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#41896 - 10° celsius cold fluid bolus does not affect hemostasis in healthy adults – A randomized crossover trial.
10° celsius cold fluid bolus does not affect hemostasis in healthy adults – A randomized crossover trial.
Background: Several studies have demonstrated favorable hemodynamic effects following the infusion of cold crystalloid fluids instead of body of room temperature. This questions the optimal temperature for fluid administration in the management of hypotensive patients, necessitating an investigation to assess its effect on hemostasis to evaluate its safety in patients requiring surgery or with active bleeding.
Objective: This study aimed to examine the effects of administering a bolus of Ringer’s lactate at a temperature of 10 °C or 22 °C on platelet function, ROTEM® and hemostasis.
Methods: A single-center, randomized crossover study was conducted in the emergency department of Odense University Hospital. Participants were randomly assigned to receive a 1000 mL bolus of Ringer’s lactate at either 10 °C or 22 °C, followed by crossover to the alternative temperature. Primary outcomes included changes in clotting time, alterations in amplitude after 5 and 10 minutes, maximum clot formation and maximum lysis measured with the ROTEM® analysis at baseline and after 30 minutes. Secondary outcomes included changes in activated partial thromboplastin time (aPTT), international normalized ratio (INR), platelet count, platelet pre-activation and fibrinogen levels.
Results: A total of 25 healthy participants were included in the study. Analysis using ROTEM® demonstrated a prolonged clotting time in the EXTEM® assay (mean difference +2.6 seconds, 95% CI 0.30 to 4.90; p=0.028) among participants who received the 10 °C bolus after 30 minutes. A post hoc power calculation demonstrated a moderate capacity to detect this difference. No other significant alterations were observed in thromboelastometry. Fibrinogen levels increased after 30 minutes in participants who received 10 °C bolus (mean difference +0.34 µmol/L, 95% confidence interval: 0.04 to 0.63; p=0.028). No significant differences were detected in aPTT (-0.52 seconds, 95% CI -1.05 to 0.01), INR (-0.02, 95% CI: -0.04 to 0.0001), platelet count (3.92 109/L, 95% CI: -4.3 to 12.15 ) or the expression of CD63 (0.19%, 95% CI: -0.14 to 0.51 ), CD62 p (1.36%, 95% CI: -2.50 to 5.22) or PAC-1 binding (2.47%, 95% CI: -3.28 to 8.22)
Conclusion: Administration of a bolus of Ringer’s lactate solution at 10 °C resulted in a marginal prolongation of clotting time after 30 minutes as assessed in thromboelastometry and had otherwise no impact on hemostasis. Additionally, it was associated with elevated fibrinogen levels after 30 minutes. This suggests that the administration of 1000 ml of cold fluids is safe in healthy adults. However, further validation is needed.
None
Peter BIESENBACH, Casper NIELSEN (Odense, Denmark), Ane Johanne DAHLBERG, Lasse Paludan BENTSEN, Camilla Schade SKOV, Line Emilie LAUGESEN, Mette Rahbek KRISTENSEN, Mette LØKKE, Christian NIELSEN, Pernille Just VINHOLT, Mikkel BRABRAND
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#41371 - A 10-Year Retrospective Study of Patients with Acquired Methemoglobinemia: Causative Substances, Clinical characteristics and Outcomes.
A 10-Year Retrospective Study of Patients with Acquired Methemoglobinemia: Causative Substances, Clinical characteristics and Outcomes.
Introduction: Methemoglobinemia occurs when methemoglobin levels rise above 1-3%, this condition impairs oxygen transport and causes several effects such as fatigue and cyanosis including deaths. Numerous substances or medications commonly encountered in daily life or used in medical practice are the causes of methemoglobinemia. Currently, there are limited data which examined on the substances or medications that induce methemoglobinemia in Asia and in Thailand.
Objective: This study aimed to describe the substances/drugs which caused methemoglobinemia, the clinical characteristics and outcomes of patients with acquired methemoglobinemia in Thailand
Methods: We performed a retrospective cohort study by analyzing data from the Ramathibodi Poison Center for 5 years (2018-2022)
Results: This study assessed 127 patients with methemoglobinemia, Most patients were male (66.1%). The mean age was 44 years with a wide age range (range 1-87years). The most common causes were food containing nitrate preservatives (34.6%), propanil herbicide (27.5%), dapsone (8.6%) and Acalypha indica (4.7%). Common clinical presentations included respiratory and gastrointestinal symptoms. Most patients had low oxygen saturation at presentation. A significant oxygen saturation gap between oxygen saturations by pulse oximetry and arterial blood gas (72%) and hemolysis (42.5%) were observed in our patients. During hospitalization, some patients developed hypotension, tachycardia, and electrolyte imbalances. Managements included oxygen therapy, intubation with mechanical ventilation, multiple dose activated charcoal (mainly for dapsone toxicity), and methylene blue administration. The median hospital stays for surviving patientswas 4 days. The mortality rate was 11%. Statistical analysis revealed that hypotension, shock, coma and metabolic acidosis during admission were associated with deaths. According to multivariate analyses, the use of inotropes during admission was only single factor which could predict deaths.
Conclusion: In this study, acquired methemoglobinemia contributed to high mortality rate of 11%. Interestingly, food containing nitrate preservatives was the most common cause following by propanil herbicide and dapsone. Preventive strategies might reduce the incidence of methemoglobinemia from these substances’ toxicities. The use of inotropes during admission was significantly associated with an increased risk of death and was indicated as a prognostic factor. Therefore, patients who exhibiting these symptoms and particularly use of inotropes, are required carefully monitoring monitored and should be extensively managed.
Phantakan TANSUWANNARAT (Bangkok, Thailand), Satariya TRAKULSRICHAI, Phitsinee BUALERD
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#42176 - A 12-year review of incidence and pattern of injuries in migrant workers presenting to a trauma centre in Singapore.
A 12-year review of incidence and pattern of injuries in migrant workers presenting to a trauma centre in Singapore.
Background
Singapore is a developed country with a total population of 5.92 million, of which 1.77 million are non-residents. 1.03 million non-residents are unskilled or semi-skilled migrant workers in sectors such as construction, marine and shipyard, process and manufacturing, as well as domestic work. Published data on work-related injuries among migrant workers is scarce and this hinders national and international policy responses to the healthcare needs of migrant workers.
The aim of this study is to gain a better understanding of the incidence, severity, mechanism and outcomes of work-related injuries among migrant workers in Singapore, in order to improve healthcare services for such injuries and enhance preventative and workplace measures to reduce the incidence of such injuries. This study also aims to compare the incidence and pattern of injuries in the migrant worker and resident populations.
Methods
This study is a retrospective cross-sectional review of patients who were registered in the trauma registry in a 1500-bed tertiary hospital in Singapore from 1st January 2011 to 31st December 2022. The trauma registry includes all patients who presented to the hospital with an eventual trauma-related Systematised Nomenclature of Medicine Clinical Terms (SNOMED CT) or International Classification of Diseases (ICD) code in their diagnoses. Patients who were less than 18 years old were excluded.
The variables studied are demographic data, residential status, whether the injuries sustained were work-related, severity of injuries (based on the Injury Severity Score (ISS)) and mechanism of injuries. The outcome measures are disposition at the emergency department, mortality, duration of hospitalisation and medical leave incurred. Continuous variables were reported as mean and standard deviation (SD), or median and interquartile range (IQR) for skewed distributions. For categorical variables, frequencies and percentages were listed. Differences between two variables were assessed using Mann-Whitney U test for continuous variables, and Pearson’s chi-square test or Fisher’s exact test for categorical variables. All analyses were performed using R version 4.1.1 (R Core Team, 2021).
Results
A total of 377,558 patients were studied during the 12-year period. 23% (86,660) of these injured patients were migrant workers. This is comparable to the national statistics which state that the non-resident population accounts for 29.9% of the total population. There was a similar proportion of severe injuries, defined as an ISS of at least 9, in both the migrant worker (1.61%) and resident (1.64%) populations. Of the severe injuries that were work-related, the distribution between migrant workers (50.7%) and residents (49.3%) was similar. Mortality at the emergency department was lower in the migrant worker population. Tools and machinery causes were more common mechanisms of injuries in the migrant worker population.
Conclusion
This is the largest study describing the incidence and pattern of injuries in migrant workers. The knowledge from this study can be used to improve current clinical pathways, resource allocation and workplace safety measures. Further study can be done to analyse the proportion and mechanism of work-related injuries in less severely injured patients, as well as the incidence of work-related injuries in each migrant work sector.
N/A
Xinyi LIN (Singapore, Singapore)
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#42234 - A bench study to minimize iatrogenic ventilator damage by flow modulation in ex vivo lung perfusion after cardiac arrest.
A bench study to minimize iatrogenic ventilator damage by flow modulation in ex vivo lung perfusion after cardiac arrest.
INTRODUCTION - Lung donation after uncontrolled circulatory death (uDCD) following a witnessed cardiac arrest presents a valuable opportunity to enhance the organ transplant program. In this process, donor lungs are assessed and resuscitated via Ex vivo lung perfusion (EVLP). This bench study explores the efficacy of expiratory flow modulation in minimizing damage caused by mechanical power during volume-controlled ventilation within the EVLP procedure.
METHODS - Donor lungs with a compliance of 40 mL/cmH₂O and an airway resistance of 5 cmH₂O/L/s were simulated using the ASL 5000 lung simulator (IngMar Medical). Ventilation was conducted in volume-controlled mode using the ViX-ventilator (KU Leuven), set at 7 breaths per minute with a positive end-expiratory pressure of 5 cmH₂O. Baseline measurements were obtained to deliver tidal volumes (VT) of 300, 400, and 500 mL. These measurements were then compared to an intervention where expiratory flow was modulated using an in-house designed device, the flow modulator. Mechanical power (J/min) was calculated using the pressure-volume curve. Differences in power between the baseline and various levels of flow modulation (10%, 30%, 50%, 70%, and 100%) were assessed using a one-sided t-test.
RESULTS - No clinically relevant differences were observed in VT delivery between baseline settings and during expiratory flow modulation. However, significant differences in mechanical power were noted between baseline and flow modulation across the three VT settings (p<0.001). The reduction in power varied from 10.9% to 58.5%, depending on the selected VT and the degree of flow modulation applied. Notably, the extent of power reduction increased with the level of flow modulation.
DISCUSSION - As demonstrated in our bench study, flow modulation in the expiratory circuit during volume-controlled ventilation does not alter VT delivery. Furthermore, it can significantly reduce mechanical power by up to 58.5% in simulated donor lungs. Mechanical power is increasingly recognized as a critical overarching parameter for ventilator-induced lung injury. These findings suggest that reducing mechanical power could potentially decrease iatrogenic damage during the ex vivo lung perfusion (EVLP) process. This reduction might extend preservation times and improve the resuscitation outcomes of uncontrolled DCD lungs. Emergency medicine has the opportunity to leverage this vital pool of donor lungs, moving towards a future with minimal transplant waitlists.
This study did not receive any specific funding.
Michiel STIERS (Leuven, Belgium), Joris GULDENTOPS, Tom SCHEPENS, Cornelia GENBRUGGE, Dieter VAN BEERSEL, Jan VERCAUTEREN, Olivier HOOGMARTENS, Benoît MARINUS, Arne NEYRINCK, Marc SABBE
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#41308 - A non-inferiority randomized controlled trial comparing nebulized ketamine to intravenous morphine for older adults in the emergency department with acute musculoskeletal pain.
A non-inferiority randomized controlled trial comparing nebulized ketamine to intravenous morphine for older adults in the emergency department with acute musculoskeletal pain.
Objective:
Our study aimed to investigate the analgesic efficacy of nebulized ketamine in managing acute moderate-to-severe musculoskeletal pain in older emergency department (ED) patients compared to intravenous (IV) morphine.
Methods:
This was a non-inferiority, double-blind, randomised controlled trial conducted at a single medical centre. The patients aged 65 and older, who presented at the ED musculoskeletal pain within seven days and had a pain score of five or more on an 11-point numeric rating scale (NRS) were included in the study. The outcomes were a comparison of the NRS reduction between nebulized ketamine and IV morphine 30 minutes after treatment, incidence of adverse events, and rate of rescue therapy.
Results:
The final study included 92 individuals, divided equally into two groups. At 30 minutes, the difference in mean NRS between the nebulized ketamine and IV morphine groups was insignificant (5.2 versus 5.7). The comparative mean difference in the NRS change from baseline between nebulized ketamine and IV morphine [(-1.96 (95% CI: -2.45 to -1.46) and (-2.15 (95% CI:-2.64 to -1.66) = 0.2 (95% CI: -0.49 to 0.89)], did not exceed the non-inferiority margin of 1.3. The rate of rescue therapy did not differ between the groups. The morphine group had considerably higher incidence of nausea than the control group (zero patients in the ketamine group vs eight patients (17.4%) in the morphine group; P = 0.006 ).
Conclusions:
Nebulized ketamine has non-inferior analgesic efficacy compared to IV morphine for acute musculoskeletal pain in older persons, with fewer adverse effects.
This non-inferiority, double-blind, randomised controlled study was conducted at a single tertiary medical centre in Bangkok, Thailand. The Thai Clinical Trials Registry (trial number TCTR20220719005) and the hospital’s Institutional Committee on Research Involving Human Participants registered and approved this trial.
Sirasa KAMPAN (Bangkok, Thailand), Jiraporn SRI-ON
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#41397 - A normal respiratory examination in drowning patients at Emergency Department presentation allows rapid discharge without further intervention.
A normal respiratory examination in drowning patients at Emergency Department presentation allows rapid discharge without further intervention.
Title:
A normal respiratory examination in drowning patients at Emergency Department presentation allows rapid discharge without further intervention.
Background:
Criteria for safe discharge following drowning have been described at 4 to 8 hours post Emergency Department (ED) presentation and have typically included results of inpatient investigations. We built a model combining clinical factors previously shown to independently predict safe discharge to determine whether drowning patients with a normal respiratory examination (NRE) at time of ED presentation are safe to be rapidly discharged.
Method
We conducted a retrospective study of drowning presentations to EDs of the Sunshine Coast Hospital and Health Service in Queensland, Australia between January 1st 2015 and December 31st 2022. A NRE was defined as a normal spontaneous respiratory rate (adjusted for age), a normal peripheral blood saturation (≥ 94%) on room air, a normal Alert, Voice, Pain, Unresponsive (AVPU) measurement (Alert), the absence of added chest sounds on respiratory auscultation and the absence of any requirement for oxygen or other ventilatory assistance from Emergency Medical Services. Primary outcome was the requirement for treatment (oxygen, ventilation or airway). Secondary outcomes included mortality and presence of pulmonary oedema.
Results:
Five hundred and seventy-seven drowning presentations were enrolled. 255 patients had a NRE at ED presentation. Patients with NRE were more likely to be younger (mean 15.6 (SD 18.33) vs mean 26.7 (SD 22.60) years, P< 0.001), have a shorter duration of drowning (mean1.13 (SD 0.60) min vs mean 1.85 (SD 2.11) min, P< 0.001) and there was an increased proportion of females with NRE (114/231 (49.4%) vs 141/346 (40.8%), P< 0.046) compared with males. There were no deaths in the NRE group (0/255 (0%) vs 17/322 (5.3%), P< 0.001), no patient with NRE required treatment (0/255 (0%) vs 145/322 (45.0%), P< 0.001) and there was no radiological evidence of pulmonary oedema (0/255 (0%) vs 81/322 (25.2%), P< 0.001) in the NRE group.
Discussion and Conclusions:
The presence of a normal respiratory exam at ED presentation in drowning patients without other injuries allows rapid discharge from the Emergency Department without further investigation or mandatory period of observation.
Funding:
The authors received grants from the Emergency Medicine Foundation (EMLE-162R34-2020-THOM) and the Wishlist Foundation (2020-05) to support the conduct of this study. The funding bodies had no role in the design, conduct or reporting of this study.
Ethics approval and informed consent:
This study received ethical approval and an exemption from obtaining patient consent from the Metro North Human Research and Ethics Committee (project number: 49754) and James Cook University Human Research Ethics Committee (H8104).
Funding:
The authors received grants from the Emergency Medicine Foundation (EMLE-162R34-2020-THOM) and the Wishlist Foundation (2020-05) to support the conduct of this study. The funding bodies had no role in the design, conduct or reporting of this study.
Ogilvie THOM (Brisbane, Australia), Kym ROBERTS, Susan DEVINE
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#42111 - A pilot study on virtual reality for pre-procedural anxiety in children.
A pilot study on virtual reality for pre-procedural anxiety in children.
Background:
Medical procedures often evoke anxiety and pain in children. Virtual Reality (VR) is a promising non-pharmacological method to manage anxiety and procedural pain and seems to be beneficial for children, although well-controlled experimental studies are pending.
This study aimed to test the feasibility of conducting a full-scale randomised controlled trial comparing VR to standard of care (SOC) on pre- procedural anxiety in children experiencing acute pain in the setting of an Emergency Department (ED).
Methods:
In this randomized controlled pilot study children with traumatic injuries, aged 6-14 years were assessed for eligibility, after institutional approval. Twenty children were randomized 1:1 to receive either SOC or VR+SOC during their visit at the ED. Anxiety was assessed three times using modified Yale Preoperative Anxiety Scale (mYPAS); at baseline, after intervention immediately before the procedure (pre- procedure) and during the procedure. Pain level was at the same time assessed using Numerical Rating Scale (NRS). The feasibility and acceptability of all study components were assessed including VR content, case report form, acceptance of video recording for blinded assessment of mYPAS and randomization procedure.
Results:
Twenty-two children were assessed for eligibility during 11 study days of 4 hours, over a period from august 2022-2023. One child declined to participate and one was excluded due to logistic reasons. Twenty children were enrolled after consent were obtained resulting in 1,8 subject recruited per day. Twenty children, median age 11 (7-14) years, were randomized and completed the full study protocol with no drop-outs.
VR decreased the level of anxiety and pain from baseline to the pre-procedural measurement: -8.33 (95%CI [-15.28; -2.38]) points, p=0.011 and -1.85 (95%CI [-2.29; -0.78]) points, p=0.002. A high level of anxiety at baseline was found to be associated with a positive effect of VR to reduce pre-procedural anxiety, spearman’s rho: 0.988.
Discussion and conclusion:
The primary goal of the current study was to assess the feasibility of a larger trial of VR for reducing anxiety and pain in children with traumatic injuries. The findings suggest that the study protocol is feasible and acceptable to children and their guardians.
The preliminary results found an effect of VR on reducing pre-procedural anxiety and pain in children with acute pain, however due to the limitation of a pilot study it is not assessed for statistical significance.
No funding
Karen Vestergaard ANDERSEN (Aarhus, Denmark), Julie Hyldgaard PETERSEN, Pedersen LINE KJELDGAARD, Stine Fjendbo GALILI, Claus Sixtus JENSEN, Marianne LISBY, Bjarne MØLLER-MADSEN, Jan Duedal RÖLFING
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#41353 - A recombinant native human anti-tetanus monoclonal antibody versus human tetanus immunoglobulin for passive immunization against tetanus: a double-blind, randomized, phase 3 trial.
A recombinant native human anti-tetanus monoclonal antibody versus human tetanus immunoglobulin for passive immunization against tetanus: a double-blind, randomized, phase 3 trial.
Background: Tetanus remains a significant public health concern in many parts of the world. Passive immunization is crucial for providing immediate protection to patients with tetanus-prone wounds who have incomplete or unknown vaccination history, as well as to immunocompromised individuals. Currently, the only recommended passive immunization therapy for tetanus prophylaxis is plasma-derived human tetanus immunoglobulin (HTIG), which is encountering a global supply shortage. Despite safety concerns, equine tetanus antitoxin (TAT) is still widely used. It is highly warranted to develop a safe and highly effective monoclonal antibody (mAb) to substitute TAT and HTIG for prevention and treatment of tetanus infection. Siltartoxatug, a first-in-class recombinant native human mAb against tetanus toxin, is being developed for tetanus prophylaxis. The objective of the phase 3 clinical trial of siltartoxatug was to compare the efficacy and safety of siltartoxatug with HTIG for passive immunization against tetanus.
Methods: This randomized, double-blind, active-controlled, phase 3 trial was conducted in 28 trial centers, mainly in Emergency Departments, across 14 provinces in China from December 2022 to July 2023. Eligible participants were adults with tetanus-prone wounds. Participants were excluded if they had received ≥3 doses of tetanus toxoid-containing vaccine, required HTIG 500 IU, or used immunoglobulins or blood products within 6 months. Participants were randomized to receive a single intramuscular injection of siltartoxatug 10 mg or HTIG 250 IU in a 2:1 ratio, stratified by concomitant administration of adsorbed tetanus vaccine. Primary efficacy outcome was the proportions of participants with an increase of anti-tetanus neutralizing antibody titers from baseline (Delta Titers) ≥0.01 IU/mL at 12 hours post dose. Secondary and tertiary efficacy outcomes included tetanus protection rates and Delta Titers at various time points post dose. Safety evaluations included adverse events (AEs), laboratory tests, electrocardiograms, etc.
Results: A total of 675 patients were randomized, and 661 received the study drug (440 in the siltartoxatug group and 221 in the HTIG group). Demographic and baseline clinical characteristics were balanced between groups. The proportion of siltartoxatug recipients with Delta Titers ≥0.01 IU/mL at 12 hours post dose was 95.4% (418/438), which was significantly higher than that of HTIG recipients (53.2%, 117/220). Both groups showed high and comparable proportions with Delta Titers ≥0.01 IU/mL at 3, 7, and 28 days post dose (all over 95%). At 90 days post dose, the proportion in the siltartoxatug group remained high at 91.5% (353/386), while HTIG group decreased to 10.1% (19/188). The geometric mean of neutralizing antibody Delta Titers in the siltartoxatug group were significantly higher than that in the HTIG group at all time points post dose. No tetanus cases occurred in both groups. AEs and treatment-related AEs were similar between groups.
Conclusions: Siltartoxatug demonstrated excellent efficacy and safety for passive immunization against tetanus. It can provide protective levels of anti-tetanus neutralizing antibodies much more quickly and at higher levels, and sustain the protective levels for a longer duration compared to HTIG. Siltartoxatug has great advantage to substitute TAT and HTIG as a safer and more effective first-line tetanus passive immunization therapy.
The trial was registered at ClinicalTrials.gov, NCT05664750. This study did not receive any specific funding. Independent ethics committees at study centers and local health authorities approved the study protocol.
Chuanlin WANG, Zijing LIANG, Si LIU (Beijing, China), Wei GUO, Xinyu LIU, Zhihua ZHANG, Jiyuan DING, Xiaohu KUANG, Meizhuo ZHANG, Huaxin LIAO, Wanmei WANG
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#41344 - A Revalidation of the GO-FAR Score in a Middle Eastern Country.
A Revalidation of the GO-FAR Score in a Middle Eastern Country.
Introduction and aim: External validations of the Good Outcome Following Attempted Resuscitation (GO-FAR) score have been in populations where Do Not Attempt Resuscitation (DNR) is practiced. Using our hospital data from 2017 to 2019, we externally validated the GO-FAR score in a population without a DNR order.
Methods: We studied patients ≥18 years old who had an In-hospital cardiac arrest (IHCA) at Al Ain Hospital from January 2017 to December 2019 excluding those who died in the emergency department. Studied variables included demography, location, response time, code duration, initial rhythm, primary diagnosis, admission vital signs, GO FAR, discharge status, and functional outcomes as determined by the cerebral performance category (CPC) score ranging from 1 (good cerebral performance) to 5 (brain death).
Results: 366 patients were studied, 66.7% were males. The median (IQR) age was 70 (55-81) years. Cardiac and respiratory causes were the primary diagnoses in 89 (24.6%) and 67 (18.5%). IHCA occurred in critical areas such as the intensive care unit, high dependency unit, and coronary care unit in 206 (80.8%) patients. The majority, 336 (91.8%), had a non-shockable rhythm, and a return of spontaneous circulation was achieved in 159 (43.4%) of the patients. Thirty-one (8.5%) patients survived hospital discharge, and 20 (5.5%) patients had CPC scores of 1 and 2. The area under the curve of the ROC for survival to hospital discharge was 0.74. The best cut-off point for predicting survival with a good neurological outcome was a GO-FAR score of 3.5, having a sensitivity of 0.81, a specificity of 0.7, a positive predictive value of 2.7, and a negative predictive value of 0.271.
Conclusions: A GO-FAR score of less than 4 predicts survival with a good neurological outcome in a healthcare system with an all-inclusive patient population with no DNR practice.
Not applicable
David ALAO (United Arab Emirates, United Arab Emirates), Hukan YAMAN, Nada MOHAMMED, Moin KINZA, Resshme SUDHA, Arif CEVIK, Abu-Zidan FIKRI
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#41983 - A specialized large language model solution to predict diagnosis in the emergency department: a real-world evaluation.
A specialized large language model solution to predict diagnosis in the emergency department: a real-world evaluation.
Background
Artificial Intelligence (AI) promises to augment clinical decision-making in emergency medicine (EM). However, existing research fails to address critical complexities of AI implementation in the high-stakes, time-sensitive environments of emergency departments (ED). This study evaluates a large language models (LLM) solution, in predicting diagnoses from initial patient presentations in real-world conditions, aiming to bridge the gap between AI potential and practical application.
Methods
We conducted a retrospective observational study using Neura (Sciense, New York, US), an LLM-driven solution based on GPT-4 (OpenAI, San Francisco, US) specialized in EM. To this end, Neura harnessed a limited domain-specific corpus of three canonical textbooks (i.e., Tintinalli's, Rosen’s, and Vincent’s). The study analyzed clinical vignettes derived from all consecutive patient admissions on a peak day in July 2023 at a Belgian university hospital. Each vignette comprised anamnesis, vital signs, medical history, and physical examination details. Neura was tasked with predicting the top five likely diagnoses from these initial clinical data, without the aid of further diagnostic tests. The final diagnoses, established by three senior emergency physicians (EPs) after a comprehensive review of full clinical workup and management, served as the criterion standard. The primary outcome was Neura's performance in including the final diagnosis among its top five predictions. Secondary outcomes were the average number of complementary exams and specialized consultations, and the diagnostic accuracy of in-charge EPs.
Results
The study evaluated 79 clinical vignettes, predominantly from orthopedics (20 cases, 25.3%), gastroenterology (13 cases, 16.5%), and urology (8 cases, 10.1%). Neura included the final diagnosis within its top five predictions in 58 cases (73.4%), ranking it first in 44 cases (75.9%), in the second or third positions in 11 cases (19%), and in the fourth or fifth positions in 3 cases (5.2%). On average, patients underwent 1.6 complementary exams (range: 0-6) and 0.4 specialized consultations (range: 0-2). In-charge EPs identified the final diagnosis in 61 cases (77.2%).
Discussion & Conclusions
Neura, leveraging preliminary clinical data, successfully proposed the final diagnosis in a significant number of cases, a remarkable achievement considering the comparable rate of final diagnosis identification by attending emergency physicians who had access to the full clinical workup. It raises the interest of AI as a clinical support system in EM, particularly for early-stage management with multipronged applications—e.g., clinical investigations guidance and diagnostic accuracy checking. However, this study was limited in predicting likely diagnoses. Further investigations are required to assess the AI system's ability to propose critical diagnoses, a distinct but equally important question for EM. Indeed, AI underperformed on so-called 'vague' diagnoses, typically diagnosis of exclusion such as 'chest pain with reassuring workup'. This should question and shape our expectations from AI-driven diagnostic applications in EM, a discipline with unique clinical constraints and requirements. Therefore, enhancing AI literacy among EPs will be crucial for steering the development of AI solutions tailored to specific applications while validating these in real-world settings.
Trial registration
Due to the retrospective nature of the work, no registration was required.
Funding
This study did not receive any specific funding.
Alexandre NISET (Brussels, Belgium), Ines MELOT, Julien FLAMENT, Nathan SCIUS, Henri THONON, Sami BARRIT
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#41482 - Acute admissions following emergency visit discharges for nonspecific abdominal pain: Frequency, causes and predictive performance of a decision tree model.
Acute admissions following emergency visit discharges for nonspecific abdominal pain: Frequency, causes and predictive performance of a decision tree model.
Introduction: Ruling out time-critical conditions is an essential emergency department (ED) task. A primary discharge diagnosis of nonspecific abdominal pain after ED stay indicates that there was no apparent or fully established cause for the patient’s symptoms. These patients might be referred for outpatient follow-up but should be at low risk of acute admissions following discharge.
We aimed to investigate the frequency and causes of acute admissions following ED visit discharges with nonspecific abdominal pain and to develop a white box model predicting acute admissions. We chose a decision tree model due to the ease of interpretation and clinical implementation.
Methods: We conducted a register-based cohort study of patients arriving in EDs across 4 of 5 regions of Denmark from March 2019 to February 2020. We included patients discharged within 3–48 hours of stay with a primary discharge diagnosis of nonspecific abdominal pain (ICD-10: R100, R101, R102C, R104). We excluded patients with registered pregnancy, palliative care, missing sociodemographic information or discharged from psychiatric departments. The main outcome was 30-day all-cause acute admission. The outcome was predicted using a decision tree model, cross validation error was used to determine the optimal number of splits. We used the following predictors: age, sex, comorbidity, socioeconomic information, previous intra-abdominal surgeries, length of stay, radiologic examinations and the 12 most frequently used biochemical analyses.
Results: We included 13,445 patients, of which 1,426 (10.6%) had a new acute admission within 30 days. Patients with admissions were more often older (median age 52 vs. 44 years), male (43% vs. 36%), of higher M3 comorbidity score (median 0.42 vs. 0.17), had previous abdominal surgery (4% vs. 2%), lived alone (37% vs. 28%), had low educational level (41% vs. 36%) and were of Danish or Western origin (90% vs. 86%); but had similar utilization of abdominal radiology (35%), time of discharge, and median values of biochemical results (C-reactive protein, leukocytes, liver enzymes, electrolytes, among others).
A preliminary decision tree model predicted readmissions for 21% of those discharged and achieved an accuracy of 78%, with sensitivity 43%, specificity 82%, positive predictive value 22% and negative predictive value 92% in internal validation. The variables used in the final model, in order of importance, were comorbidity score, proportion of abnormal biochemical results, leukocytes, alkaline phosphatase, age, estimated glomerular filtration rate, length of stay and albumin.
Of the new admissions’ primary discharge diagnoses 26% remained unchanged as nonspecific abdominal pain, 10% had other nonspecific diagnoses (ICD-10: R- and Z-chapter), 33% gastrointestinal (K-chapter), 6% genitourinary (N-chapter), and 25% remaining chapters. Cholelithiasis (6%), appendicitis (4%), ileus (3%), and cholecystitis (3%) were the most frequent gastrointestinal causes of admissions.
Conclusions: After nonspecific abdominal pain ED discharges, 10.6% were admitted within 30 days. A decision tree model identified 21% of the population with increased risk of admission at 22% and the remaining 79% with lower risk at 8%. Due to the decision tree structure, the model can easily be implemented in clinical practice. More complex models or additional clinical information might improve the predictive performance further.
The work was financed by a grant from the University of Copenhagen (2023 Strategy Funds: Data+ grant), a grant from the Research Council at Bispebjerg and Frederiksberg Hospital, and financial support from the Department of Emergency Medicine at Bispebjerg and Frederiksberg Hospital.
Rasmus GREGERSEN (Copenhagen, Denmark), Marie VILLUMSEN, Amalia Lærke Kjær HELTØ, Jakob BURCHARTH, Jens RASMUSSEN, Mikkel Bring CHRISTENSEN, Jakob Lundager FORBERG, Janne PETERSEN
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#42401 - Acute chest pain in the emergency department according to gender.
Acute chest pain in the emergency department according to gender.
Introduction: Chest pain (CT) is one of the most frequent reasons for patients to consult an emergency department. The aim of our work was to study the epidemiological, clinical and paraclinical characteristics of patients with acute chest pain according to gender.
Patients and methods: Prospective comparative descriptive study conducted over a period of 13 months in a multipurpose emergency department of a regional hospital. All patients aged 18 years or older with acute T1DM as the main complaint were included. Any DT of traumatic origin was excluded. In addition, we did not include patients with acute coronary syndrome (ACS) with ST-segment elevation. We divided the sample by gender into 2 groups.
Results: During the study period, 1261 patients consulted emergency departments for acute TD. There were 659 men (52%) and 602 women (48%), giving a sex ratio of 1.1. Of these patients, 174 (14%) were admitted to a life-threatening emergency room (LTR), 8% of whom were men (p=0.008). The mean age was significantly higher in women (54±17 years) than in men (51±16 years) (p=0.003).
:
Four hundred and twenty-four women had comorbidities compared with 354 men (p<0.0001). Cardiovascular risk factors (CRFs) were present in 68% of men versus 57% of women (p<0.0001). Smoking was present in 23% of men versus 2% of women (p<0.0001). Hypertension was more prevalent in women (40%) than in men (25%) (p<0.0001). Diabetes was present in 194 women (32%) versus 142 men (22%) (p<0.0001). Dyslipidaemia was present in 15% of women versus 5% of men (p<0.0001). Physical inactivity affected 7% of women versus 3% of men (p=0.001). Thirty-two women were obese versus 5 men (p<0.0001). Atrial fibrillation was found in 29 women versus 14 men (p=0.008). Thyroid disease was found in 38 women versus 4 men (p<0.0001). Four per cent of women were asthmatic compared with 2% of men (p=0.012).
The variety of associated symptoms was present in 402 women versus 381 men (p=0.001)-Regarding ECG abnormalities, inferior ST-segment sub-shift was found in 29 men versus 10 women (p=0.005), right bundle branch block was found in 7% of men versus 4% of women (p=0.009), conduction disorders were found in 12% of men versus 7% of women (p=0.007).
The median troponin value was 10.5ng/L IQR25%-75% [6.2-21.2] in men versus 8.9ng/L IQR25%-75% [5.3-18.2] (p=0.05).
Chest X-rays were performed in 260 men versus 149 women (p<0.0001).
Eighteen patients had a major adverse cardiac event within 30 days of their emergency visit, with an even gender distribution.
Conclusion: The age of onset of cardiovascular disease is later in women. The initial clinical presentation of DT is more misleading in women. However, the course is often similar in men and women.
AUCUN CONFLIT
Khedija ZAOUCHE, Manel KALLEL (Tunis, Tunisia), Sana SELLAMI, Emna REZGUI, Sonia AISSA, Ramla BACCOUCHE
00:00 - 00:00
#41503 - An Implementation Study of DataCryptChain: An Encryption and Blockchain Tool for Private, Secure, Shareable, and Tamper-proof Healthcare Data for Artificial Intelligence Research.
An Implementation Study of DataCryptChain: An Encryption and Blockchain Tool for Private, Secure, Shareable, and Tamper-proof Healthcare Data for Artificial Intelligence Research.
OBJECTIVES: A recent World Health Organization (WHO) document entitled “Regulatory considerations on artificial intelligence for health” — gives the highest priority to safeguarding privacy, security, and integrity of healthcare data. However, ensuring data is private, secure, shareable, and tamper-proof is a challenge as no universal standard exists. DataCryptChain is an open-source standard combining cutting-edge block chain technology with advanced encryption to ensure healthcare research data for Artificial Intelligence (AI) development remains private, secure, shareable, and tamper-proof. The objective of this study was to test the implementation of this tool using unit-testing and user experience (U/X) testing. The primary outcomes of the study were 1) sensitivity and specificity of DataCryptChain to detect tampering of data, and 2) overall satisfaction of test users. This study was approved by the Research Ethics Board at the University of Alberta (Pro00141418).
METHODS: In the unit-testing phase 10000 simulated research projects were analyzed. For each iteration, a data set was created and repeatedly modified, encrypted with DataCryptChain and then decrypted. Each iteration was randomized to be tampered with or not tampered with and sensitivity / specificity was calculated. In the U/X testing phase, participants were randomized to one of two user stories: encryption and sending a data set or receiving and decrypting a data set. Outcomes included ability to complete the designated task and results of a short user survey.
RESULTS: In the unit-testing phase, 10000 simulated research studies were created with data sets ranging from 1 to 2808 records with 1 – 101 simulated revisions. Of these data sets, 4436 were randomized to be tampered with and were intentionally corrupted by changing the value of a digit. The number of corruptions introduced ranged from 1 to 17 per project. DataCryptChain showed 100% sensitivity and specificity for detecting these intentional corruptions. In the U/X phase, all simulated users were able to install DataCryptChain and complete their assigned tasks. Mean overall satisfaction with the product was rated at 3.67/5 (SD=0.58). However, many users noted that the command-line interface would likely be a major impediment to widespread adoption of the tool among less computer-literate researchers. Most stated they found the installation difficult.
CONCLUSIONS: DataCryptChain may potentially be a useful tool in keeping research data private, secure, shareable, and tamper proof and has 100% sensitivity and specificity for detecting data tampering. However, further development will be necessary to ensure the tool remains user-friendly to encourage widespread adoption.
NONE
Dr Jeffrey FRANC (Edmonton, Italy), Manuela VERDE
00:00 - 00:00
#42151 - An innovative “patient-centered” handover model in pre-hospital emergency medical service.
An innovative “patient-centered” handover model in pre-hospital emergency medical service.
Introduction Effective handover is critical to ensure continuity and safety in different healthcare settings (1; 2). Aim of this paper is to describe the handover model used within a prehospital emergency system in the Florence metropolitan area (1.250.000 inhabitants) and to discuss preliminary results.
Methods Internal Institutional Board approved the study. EMS PSAP2 processes approximately 500 emergency calls per day. After a short training 59 doctors joined the program which required a structured handover phase at each shift. The model uses a tool designed to make communication accessible, clear, reproducible and documentable. The set of information shared was selected according to the following key points: patient-centered approach, resilience, cooperative team learning and support. The individual performance was evaluated monthly and a training CME credits program was implemented. Data were collected and analyzed using Google Sheets and Analytics.
Results The study started on April 1 2023 and adherence to the project was 98.3% (58 Dr). The quality of the report content was monitored assigning a score assessing the completeness of the digital report. 8 physicians (14%) performed the report at basic level, 16 (27%) intermediate, 35 (59%) advanced. Fifty percent of the participating physicians acquired the CFUs stipulated for the project (30 to 50 CFUs). Analyzing the 8 months before and the 8 after the introduction of the project (01.07.2022-30.03.2023 vs 01.04.2023-31.12.2023), the number of reported cases subjected to systematic reconstruction and analysis including audits and M&Ms increased significantly (2 vs 11).
Discussion&Conclusions The preliminary results obtained certainly argue in favor of the importance of using a routine and reproducible handover model. A model functional to the specific prehospital emergency care establishes a communication framework with a high clinical and organizational content effective in preventing the loss of relevant information. Furthermore it guarantees the achievement of improvement objectives including both the professionals skills and the quality and safety of care at the pre-hospital-hospital interface. Study limitations concern the short observation period and, at present, the lack of data on clinical outcomes. (1-Scand J Trauma Resusc Emerg Med 2021;29:169; 2-Am J Emerg Med 2020 Jul;38(7):1494-1503 Am. J. Emerg.Med, 2020; 38: 1494).
Elisa GUERRINI (Florence, Italy), Federico BULLETTI, Giorgio GIULIANI, Mario RUGNA, Diego SALERNO, Ilaria FEI, Cristina NANNA, Maria Gabriella SABLONE, Serena SDRAFFA, Massimo CIPRIANI, Nicola BORTOLI, Alessandro PINI, Filippo BURACCHI, Sara MAZZEI, Paolo PAMPALONI, Adriano PERIS
00:00 - 00:00
#41313 - Analysis of clinical characteristics and risk factors of central nervous system damage caused by acute bipyridine herbicide poisoning.
Analysis of clinical characteristics and risk factors of central nervous system damage caused by acute bipyridine herbicide poisoning.
Background:
It is now understood that acute poisoning with bipyridine herbicides poses a severe threat to human health, especially to the central nervous system, leading to a high mortality rate. This study aims to comprehensively outline the clinical characteristics and identify risk factors associated with central nervous system damage in cases of acute bipyridine herbicide poisoning, offering novel insights for diagnosis and treatment strategies.
Methods:
We retrospectively analyzed baseline data from 189 patients admitted to the Emergency Intensive Care Unit of the First Hospital of Wenzhou Medical University between January 2016 and October 2023, focusing on acute bipyridine herbicide poisoning. Patients were categorized into two groups based on the presence or absence of central nervous system damage following poisoning.Plasma concentrations of PQ and DQ were measured at admission using high-performance liquid chromatography coupled with mass spectrometry (Waters TQ-S UPLC-MS detector). Subgroup analyses were performed for the DQ+PQ, PQ-only, and DQ-only groups.Data were analyzed using R language version 4.2.1. Normal distribution and variance-aligned measurements were expressed as mean ± standard deviation or [M (Q1, Q3)], with comparisons using independent samples t-test or Mann-Whitney U test. Categorical data were presented as n(%) and analyzed using the χ2 test. Multifactorial Logistic regression explored independent risk factors for central nervous system damage. Receiver operating characteristic curves assessed the predictive value of factors, with p<0.05 considered statistically significant.
Results:
Among the 189 patients, 63 (33.3%) exhibited central nervous system damage, while 126 (66.7%) did not. Comparative analysis revealed that Neutrophil-to-Lymphocyte Ratio (NLR), admission plasma paraquat (PQ) concentration ≥3000 ng/ml, shock, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score were independent risk factors for central nervous system damage in acute bipyridine herbicide poisoning (OR=1.05, 95% CI: 1.00-1.10; OR=6.99, 95% CI: 1.50 - 35.9; OR=6.60, 95% CI: 1.65 - 29.39; OR=1.07, 95% CI: 1.01 - 1.14). Receiver Operating Characteristic curve analysis demonstrated an area under the curve of 0.661 (95% CI: 1.000, 1.100) for NLR, with a cut-off value of 14.62 (sensitivity, 55.6%; specificity, 74.6%) and 0.875 (95% CI: 1.010, 1.140) for APACHE II score, with a cut-off value of 16.00 (sensitivity, 77.8%; specificity, 88.9%).
Discussion & Conclusions:
Acute bipyridine herbicide poisoning leading to central nervous system damage presents distinctive clinical features, imaging characteristics, and lesion sites. The findings from this retrospective study underscore the significance of CNS damage, occurring in 33% of patients with acute bipyridine herbicide poisoning, as a serious complication. Multifactorial logistic regression analysis identified NLR, DQ concentration, shock, and APACHE II score as independent risk factors for CNS damage following acute bipyridine herbicide poisoning.
Funding：
This study was supported by the Major projects of Wenzhou Science and Technology Bureau (ZY2022023), State Administration of Traditional Chinese Medicine and Zhejiang Administration of Traditional Chinese Medicine jointly build a science and technology plan project.
Ethical approval and informed consent：
The study received approval from the Clinical Research Ethics Committee of the First Hospital of Wenzhou Medical Universit (Approval No. 2022R176）.
Hu TANG, Zhongqiu LU (wenzhou, China, China)
00:00 - 00:00
#42337 - Applying clinical decision aids in the management of febrile infant ≤ 90 days at risk of invasive bacterial infection. A prospective multicentre study across UK and Ireland.
Applying clinical decision aids in the management of febrile infant ≤ 90 days at risk of invasive bacterial infection. A prospective multicentre study across UK and Ireland.
Background
Febrile infants ≤ 90 days are at a 1 – 3% risk of invasive bacterial infection (IBI). Prompt treatment and care of these infants are paramount. However, history and exam alone are not sufficient in the identification of IBI. Clinical decision aids (CDA) have been developed to classify these infants into low risk and high risk. These CDAs utilise sequential assessment and biomarkers. Prospective validation has not been undertaken in the UK and Ireland. The aim of this study was to apply these CDAs to a UK and Irish cohort for the identification of IBI.
Method
This was a prospective multicentre study of febrile infants presenting to 35 Paediatric Emergency Research in the UK and Ireland (PERUKI) sites (emergency department and assessment units) from 6 July 2022 to 31 August 2023. Infants with a recorded temperature ≥38C at home or in a health setting within 24 hours were included. All infants received standard care as per local policy. IBI was defined as the growth of a bacterial organism in blood or cerebrospinal fluid. The diagnostic performance of the following CDAs were assessed, National Institutes for Health and Care Clinical Excellence (NICE) Sepsis NG51, Feverish illness NG143, British Society Antimicrobial Chemotherapy (BSAC), Aronson (IBI) score and American Academy of Pediatrics (AAP) CDA. AAP CDA allows for the use of CRP where PCT is not available.
Results
From 2173 patients screened, 1821 were included in the final analysis. The median age was 46 days (IQR: 30–64 days), with 1108 (61%) being male. Of the 1821 infants, 67 (3.7) had IBI. Antibiotic administration in the ED was recorded in 1242 (68%) of participants. In terms of outcomes, 247 (14%) were discharged home while 1574 (86%) were admitted to the hospital.
NICE NG51 had the highest sensitivity (100 (CI:94.6-100)) but a reported specificity of 0 (CI:0.0 – 0.2). This was followed by AAP and BSAC CDA at 98.5 (CI:91.9 -99.9) with specificities of 22.7 (CI:20.7 -24.7) and 20.2 (CI:18.3 – 22.1) respectively. NICE NG143 and IBI score both had the best specificity 29.7 (CI:27.6-31.90) and 29.6 (CI: 27.5-31.8) respectively. However, their sensitivity was lower than that of the AAP and BSAC. The AAP and BSAC CDA only misclassified 1 infant each with IBI. Infants missed by the BSAC and AAP CDA were both between 29 – 60 days and presented < 6 hours from fever onset.
Discussion/conclusion
CDAs such as BSAC and AAP with CRP could be applied in a UK and Irish setting in the evaluation of febrile infants. However, clinicians should be cautious when applying to infants with a short duration of fever.
registered on https://clinicaltrials.gov/ (NCT05259683)
Etimbuk UMANA (Belfast, Ireland), Clare MILLS, Hannah NORMAN-BRUCE, Lisa MCFETRIDGE, Hannah MITCHELL, Fiona LYNN, Steven FOSTER, Michael BARRETT, Chris WATSON, Damian ROLAND, Mark D LYTTLE, Thomas WATERFIELD, On Behalf Of PERUKI
00:00 - 00:00
#41987 - Assessing patient partnership among emergency departments in France: a cross- sectional study.
Assessing patient partnership among emergency departments in France: a cross- sectional study.
Objectives :
This study aims to describe the use of patient partnership, as defined by the Montreal Model, in emergency departments (EDs) in France and report the perception of patient partnership from both the practitioner and patient perspectives.
Methods :
This cross-sectional study was conducted between July 2020 and October 2020. First, a survey was sent to 146 heads of EDs in both teaching hospitals and non-teaching hospitals in France to assess the current practices in terms of patient partnership in service organization, research, and teaching. The perceived barriers and facilitators of the implementation of such an approach were also recorded. Then, semi-structured telephone interviews were carried out with patients involved in a service re-organization project.
Results :
A total of 48 answers (response rate 32.9%) to the survey were received; 33.3% of respondents involved patients in projects relating to service re-organization, 20.8% involved patients in teaching projects, and 4.2% in research projects. Overall, 60.4% of the respondents were willing to involve patients in re-organization or teaching projects. The main barriers mentioned for establishing patient partnership were difficulties regarding patient recruitment and lack of time. The main advantages mentioned were the improvement in patient/caregiver relationship and new ideas to improve healthcare. When interviewed, patients mentioned the desire to improve healthcare and the necessity to involve people with different profiles and backgrounds. A too important personal commitment was the most frequently raised barrier to their engagement. All the patients recognized their positive role, and more generally, the positive role of patient engagement in service re-organization.
Conclusion :
Although this preliminary study indicates a rather positive perception of patient partnership among heads of EDs in France and partner patients, this approach is still not widely applied in practice.
Geoffrey SAGNOL (Lyon), Julie HAESEBAERT, Philippe MICHEL, Anne-Marie SCHOTT, Véronique POTINET, Marie-Pascale POMEY, Karim TAZAROURTE, Marion DOUPLAT
00:00 - 00:00
#41890 - Assessment of Diaphragmatic Dysfunction in patients presenting with dyspnea: a preliminary prospective study in the Emergency Department.
Assessment of Diaphragmatic Dysfunction in patients presenting with dyspnea: a preliminary prospective study in the Emergency Department.
Diaphragmatic dysfunction (DD) is a significant contributor to respiratory insufficiency in patients presenting with dyspnea. This preliminary prospective study aimed to evaluate diaphragmatic function in patients presenting with dyspnea in the Emergency Department (ED) using diaphragm shortening fraction (DSF) measured by point-of-care ultrasound (POCUS).
DSF is defined as the measurement of diaphragmatic function, indicating the degree of diaphragmatic thickening at tidal volume. DSF is measured using POCUS in M-mode at the anterior axillary line on the right side, between the 8th and 12th ribs, from the hepatic window.
A total of 31 patients presenting with dyspnea were enrolled in the study between November 2023 and March 2024. DD was defined as DSF < 10%, while non-DD was defined as DSF > 10%. Of the 31 patients, 5 were identified with DD, all of whom required ventilatory support in the ED. Three patients received non-invasive ventilation (NIV), while two were treated with continuous positive airway pressure (CPAP). Among the remaining 26 patients without DD, only 4 required ventilatory support, with 2 patients receiving treatment in the ED and the other 2 in the general ward.
Statistical analysis revealed a significant association between the presence of DD and the need for ventilatory support (p < 0.05). Additionally, patients with DD had a significantly higher rate of ventilation requirement compared to those without DD (p < 0.05).
These preliminary findings suggest that DD is a common complication in patients presenting with dyspnea in the ED. Furthermore, the presence of DD significantly increases the likelihood of requiring ventilatory support. Early identification of DD in patients with dyspnea could facilitate prompt initiation of appropriate interventions, potentially improving patient outcomes and reducing the burden on healthcare resources.
Further research with a larger sample size and longitudinal follow-up is warranted to validate these findings and explore additional factors influencing diaphragmatic function in dyspneic patients presenting to the ED.
NCT05869045
Carmine Cristiano DI GIOIA (Modena, Italy), Lucrezia GRISAN, Alice ALAME, Geminiano BANDIERA
00:00 - 00:00
#41935 - Assessment of Transesophageal Echocardiography on Chest Compression Fraction and Clinical Outcome in Patients with Non-traumatic Out-of-hospital Cardiac Arrest.
Assessment of Transesophageal Echocardiography on Chest Compression Fraction and Clinical Outcome in Patients with Non-traumatic Out-of-hospital Cardiac Arrest.
Objectives
Transesophageal echocardiography (TEE) has become increasingly integrated into the resuscitation protocols for cardiac arrest patients; however, the benefit of TEE in cardio-pulmonary-cerebral resuscitation (CPCR) is uncertain. In this study, we aimed to explore the impact of TEE on chest compression fraction (CCF) and patient survival throughout the resuscitation process.
Methods
We conducted a retrospective cohort of video recordings of the resuscitation process in adult patients presented to emergency department of Dalin Tzu Chi Hospital with non-traumatic, out-of-hospital cardiac arrest between 15th December 2023 to 15th March 2024. Patients with cardiac arrest who underwent TEE were categorized as the TEE group, while those who did not were categorized as the non-TEE group. The primary outcome was CCF, and the secondary outcomes were pause during CPCR, rate of return of spontaneous circulation (ROSC), and survival to discharge between these 2 groups.
Results
During the study period, 27 patients with non-traumatic cardiac arrest were enrolled (mean age 70.3 [SD 15.9] years; 41% female). There were 11 patients in the TEE group and 16 patients in the non-TEE group. In the primary outcome, a better CCF performance was observed in the TEE group compared to the non-TEE group (90.4% vs 80.3%, p=0.005). In secondary outcome, the TEE group tended to have less pause number in every CPCR cycle (median, 1.2 vs 1.4 pause per 2 minutes, p=0.1) compared to non-TEE group, but there was no statistically significance. There was no significant difference of length of resuscitation, rate of ROSC lasting > 1 minute, rate of ROSC lasting > 20 minutes, and rate of survival to discharge between both groups.
Conclusions
In the observational study, the implementation of TEE in patients with out-of-hospital cardiac arrest did not impede the resuscitation process and was associated with an improvement in CCF. A possible reason for this finding is that utilizing TEE during CPCR may reduce the time required to check for a pulse compared to transthoracic echocardiography and traditional methods. However, due to the small sample size in this study, further investigation is warranted to elucidate its potential benefits.
This study was not registered and we received no funding.
Cheng-Han CHIANG (Chiayi, Taiwan), Hua LI, Tou-Yuan TSAI
00:00 - 00:00
#40801 - Association between mean platelet volume to platelet count ratio and neurological outcomes in patients with out-of-hospital cardiac arrest.
Association between mean platelet volume to platelet count ratio and neurological outcomes in patients with out-of-hospital cardiac arrest.
Background: Low platelet count and high mean platelet volume were associated with severity in critically ill patients. However, it is unknown whether mean platelet volume-to- platelet count ratio (MPR) was associated with outcome in out-of-hospital cardiac arrest (OHCA) patients. We aimed to evaluate the impact of MPR on long term neurological outcome in OHCA patients treated with targeted temperature management (TTM).
Methods: This prospective observational study included adult (≥ 18 years) OHCA patients between January 2023 and December 2023. We measured serial MPV, PLT, and MPR at admission, 24 h, 48 h, and 72 h after the return of spontaneous circulation (ROSC). The primary outcome was neurological outcome at discharge. A poor neurological outcome was defined by cerebral performance categories 3, 4, and 5.
Results: A total of 86 patients were included. Of them, 62 (72.1%) had poor neurological outcomes, whereby the median MPR levels at admission (20.7 vs. 23.2), at 24 h (15.2 vs. 18.0), 48 h (11.8 vs. 17.0), and 72 h (10.3 vs. 16.2) after ROSC were significantly lower than in good outcome group. The MPR at 72 h (odds ratio [OR], 0.789; 95% confidence interval [CI], 0.655–0.951; P = 0.013) after ROSC was independently associated with poor neurological outcomes.
Conclusion: MPR at 72 h after ROSC may be useful to assess the neurological outcomes in OHCA patients.
N-A
Seokjin RYU (, Republic of Korea)
00:00 - 00:00
#41349 - Burden of paediatric dog bite injuries on hospital emergency services of an English coastal town.
Burden of paediatric dog bite injuries on hospital emergency services of an English coastal town.
Background
Dog bite injuries can be life threatening and/or life changing for children and their families. The psychological consequences of these injuries are significant yet challenging to quantify. Prevention of these injuries is crucial with a potential role of the emergency department (ED) staff in supporting this public health issue.
We aimed to evaluate the presentations and management of dog bite injuries, with objectives to identify preventative strategies in the emergency department (ED).
Methods
A retrospective review of electronic patient records of dog bite injuries between 1 September 2021 to 30 September 2023 was performed in a district general hospital of a coastal town ED. Information on demographics, dog bite events, safeguarding concerns, management, and outcome were descriptively analysed. Variables were correlated using Chi-Squared test or Fisher Exact test where appropriate.
Results
One hundred and seventy-two cases presented with dog bite injuries. There was slight male preponderance (94; 54.7%). Injuries were commonly seen in the first decade of life (109; 63.4%). Most of the injuries occurred indoors (132; 76.7%). There was documented clear provocation preceding the bite injuries in 44.2% (76/172) of cases. The breed of dog was documented in 76.7% (132/172) with no reported banned breed.
Injuries were commonly caused by dogs familiar to their victims (137; 79.7%). Common sites of bite injuries were face (87; 50.6%) and distal upper extremities (53; 30.8%). Facial injuries were more associated with family dogs (p < 0.05). Dog bite injuries transferred for tertiary care were 14.5% (25/172). There were inconsistencies in antibiotic prescription for dog bite injuries with variations in duration of therapy.
Discussion and conclusions
The burden of dog bite injuries in our ED is evident. Although our service evaluation was limited by incomplete data given its retrospective nature, it provided incredibly insightful data to guide development of preventative strategies locally and potentially, nationally. To improve the quality of care for dog bite injuries, an electronic assessment template was launched in our ED with clear emphasis on safeguarding, incident logging with the police, and antibiotic prescription.
Kene MADUEMEM, Catherine HEY, Livi WATKINSON, Mustafa BOORENIE (Blackpool, United Kingdom), Kenechi ANAKEBE
00:00 - 00:00
#42305 - canine olfactory detection and its relevance for the medical identification of patients with COVID-19.
canine olfactory detection and its relevance for the medical identification of patients with COVID-19.
Introduction:
The assessment of Volatile Organic Compounds (VOCs) in exhaled breath or sweat represents a potential non-invasive and rapid diagnostic tool for respiratory diseases. VOCs, detectable during breathing or sweating, provide valuable information about metabolic activity, inflammation, oxidative stress, and other physiological processes within the body, contributing to the diagnostic efficacy of this method.
Objective:
By determining if properly trained dogs can reliably identify the odor associated with COVID-19, this study strives to contribute to the development of a non-invasive and potentially rapid screening method for the disease.
Methods
This is a monocentric prospective study carried out in the ED of a university hospital from july to November 2021.
COVID-19 positive and negative patients were recruited from the emergency department and its affiliated COVID-19 screening unit, in which positive patients were hospitalized until recovery. Axillary sweat samples from all patients were collected bytwo trained health care professionals using sterile gloves during the process to prevent contamination. The samples were collected in the form of sterile gauze swabs placed under the armpits for at least 4 hours for each patient included in the study and were placed in the same hermetic tube to avoid contamination. Correspondent number was attributed to each tube. Then, Tubes were shifted to the double-blind dog training center for VOC detection by two individuals.
Results:
Dogs were tested using a total of 129 axillary sweat samples following a randomized and double-blind protocol. In this study, 69 of the 107 patients who tested positive for COVID-19 based on their odors had a positive PCR/Antigen test and 19 of the 22 patients who were tested negative for COVID-19 by the dogs had a negative PCR test. The sniffer dog infection detection method had a sensitivity of 95.83% and a specificity of 33.33%. The positive predictive value was 64.49% and the negative predictive value was 86.36%. The measurement of the intensity of the connection between the two variables (disease/sign) was very strong (Q =0.84). This link is statistically significant (X²=19.13) with a probability p⩽ 0.001.
Conclusion:
Overall, the use of trained detection dogs as a screening method for SARS-CoV-2 is an interesting avenue of research that warrants further exploration and validation. If further validated through larger-scale studies and rigorous testing, these findings could contribute to the development of a reliable screening method for identifying individuals infected with SARS-CoV-2. It has the potential to complement existing diagnostic approaches and contribute to the overall efforts in preventing the spread of COVID-19.
Oumayma HWICHI, Hajer YAAKOUBI, Rym YOUSSEF, Houda BEN SALAH, Amina NAOUEL, Arij BAKIR, Imen TRABELSI (Sousse, Tunisia), Rahma JABALLAH, Asma ZORGATI, Lotfi BOUKADIDA, Riadh BOUKEF
00:00 - 00:00
#42109 - Capillary refill time paradoxically decreases in a human model of blood loss shock .
Capillary refill time paradoxically decreases in a human model of blood loss shock .
Background: The capillary refill test is used globally as a common measure of circulatory compromise. A prolonged capillary refill time (CRT) has been regarded as a sign of imminent circulatory shock. It is regarded as a measure of blood loss in trauma and taught in trauma training for civilian medical professionals and military medics. However, studies of CRT during bleeding induced hypovolemia are scarce and inconclusive. The objective of this study was to examine the relation of CRT on fingertip and hypovolemia using a blood loss shock model with lower body negative pressure (LBNP).
Method: The study was an experimental observational study. 49 voluntary, healthy subjects (29 male, 20 female) were monitored for CRT in LBNP. The study took place from September 20th to November 3rd, 2023, in the laboratory of the Emergency Research Group of the Emergency Department of Linköping University Hospital, Linköping, Sweden. The experiment continued for 40 min or until pre-syncope symptoms were experienced by the study subjects, or when vital signs indicated impending syncope.
The subjects were randomized into two groups; the stepwise group was exposed to increase in negative pressure from -20 mmHg to max -70 mmHg (n=25), and the direct group to negative pressure at -70 mm Hg (n=24) from start. The capillary refill test was performed according to a standardized protocol and capillary refill time was measured with reflectance spectroscopy on the fingertip. Blood pressure, heart rate and peripheral resistance was also measured during the experiment.
Results: The subjects presented, regardless used protocol, with two phenotypic reactions to LBNP, with shorter (70%) or longer (30%) CRT.
In the stepwise group, shorter CRT (n=16), last measured mean CR time before syncope was significantly shorter (1.18 s) compared to baseline (2.57 s), and for longer CRT (n=6) last measurement was significantly longer (1.38 s) compared to baseline (1.04 s). In the direct group, shorter mean CRT (n=14), last CRT was significantly shorter (1.16 s) compared to baseline CRT (2.85 s) and for longer CRT (n=7) last CRT (2.12 s) was significantly longer (1.2 s) compared to baseline CRT. All comparisons were made with Wilcoxon matched-pair signed rank test and a p-value below .05 was considered significant.
Mean drop in blood pressure was 51 mmHg systolic and 21 mmHg diastolic for the stepwise group, and 46 mmHg systolic and 17 mmHg diastolic for the direct group.
Discussion and conclusion: The current results, where most subjects responded with a significantly shorter CRT, contradict our previous understanding of the CRT and blood pressure relationship in blood loss shock. Our leading theory is that changes in peripheral resistance act as a far-reaching compensatory mechanism in most healthy individuals.
No special funding was granted for this study.
Frida MEYER (Linkoping, Sweden), Hugo GUSTAVSSON, Birgitta ÖLWEGÅRD, Joakim HENRICSON, Daniel WILHELMS
00:00 - 00:00
#40900 - Cardiogenic shock in prehospital care: lactate on-scene role to estimate premature mortality.
Cardiogenic shock in prehospital care: lactate on-scene role to estimate premature mortality.
Background: heart failure, with associated flare-ups, acute myocardial infarction, and other cardiac or pulmonary pathologies, account for a high number of activations and interventions by emergency medical services (EMS). In particular, the most severe form, cardiogenic shock, represents a time-dependent pathology that requires immediate advanced life support interventions (including intravenous drug therapy and non-invasive mechanical ventilation) in an attempt to reduce morbidity and mortality.
The purpose of this report is to examine the predictive ability of prehospital lactate to early mortality (2-day) in cardiogenic shock cases.
Methods: Prospective, multicentric, EMS-delivery, ambulance-based, pragmatic cohort study of adults with prehospital cardiogenic shock, referred to five hospitals (Spain), between January 2020, and February 2024. Patient treated consecutively by EMS with prehospital diagnosis of cardiogenic shock and transferred with high priority by ambulance to the ED was included in the study. Patients under 18 years of age, pregnant women, traumatic patients, risk in the scene and patients discharged on site were excluded. Demographic data (age and sex) and venous sampling were collected during the first contact with the patient in prehospital care. Analyzer epoc® (Siemens Healthcare GmbH, Erlangen Germany) was employed to perform prehospital lactate. The primary dependent variable was all-cause 2-day in-hospital mortality. The area under the curve (AUC) of the receiver operating characteristic (ROC) of the mSOFA was calculated in terms of 2-day mortality.
Results: A total of 162 patients with a prehospital diagnosis of cardiogenic shock were included in our study. The median age was 66 years (IQR: 53-80), with a range from 43 to 99 years, with 80 cases (49.3%) of females. The rate of prehospital non-invasive mechanical ventilation, ICU-admission, and 2-day mortality were 78.3 % (127 cases), 33.9 % (55 cases), and 15.4% (25 cases). The AUROC and cut-off of lactate were 0.873 (95%CI: 0.78-0.96; p<0.001) and 4.22 mmol/L, with a sensitivity of 84%, specificity of 84% and positive likehood ratio of 5.23.
Conclusions: The prehospital lactate exhibited a good predictive ability for bedside tagging of high-risk patients with cardiogenic shock. Despite being patients with a high burden of morbidities, who often suffer flare-ups of their underlying diseases, prehospital lactate was a good biomarker to identify patients with poor short-term outcomes.
This work was supported by the Gerencia Regional de Salud, Public Health System of Castilla y León (Spain) [grant number GRS 1903/A/19 and GRS 2131/A/20]
Francisco MARTÍN-RODRÍGUEZ, Raúl LÓPEZ-IZQUIERDO, Carlos DEL POZO VEGAS (Valladolor, Spain), Virginia CARBAJOSA RODRÍGUEZ, Miguel Angel CASTRO VILLAMOR, Enrique CASTRO PORTILLO, Juan Francisco DELGADO BENITO, Francisco Tomás MARTÍNEZ FERNÁNDEZ, Santiago OTERO DE LA TORRE, Daniel VIÑA GUERRA, Ancor SANZ GARCÍA, Julio Cesar SANTOS PASTOR, Irene SÁNCHEZ SOBERÓN, Ana RAMAJO SANCHEZ, Raquel María PORTILLO RUBIALES, Elena MEDINA LOZANO, Jonathan ALDEA SOTO, Alba ARROYO GONZÁLEZ, Isabel CARRILLO HERRERO, Alvaro GARCÍA ALDONZA, Ana RAMOS RODRÍGUEZ
00:00 - 00:00
#42251 - Cerebral oximetry monitoring in children presenting with neurologic emergencies.
Cerebral oximetry monitoring in children presenting with neurologic emergencies.
Introduction - Aim: Neurological emergencies are one of the common reasons for children to visit the pediatric emergency department (PED). Conditions such as coma, altered mental status, agitation, acute encephalopathies with focal deficits, status epilepticus (SE), and non-convulsive SE (NCSE) require rapid diagnosis and treatment as they are critical situations. The "Near-infrared spectroscopy (NIRS)" method can be used to determine regional dynamic physiological changes such as oxygen metabolism and release by measuring "Cerebral oximetry" tissue perfusion. Studies have shown that NIRS can demonstrate interictal epileptic discharges, predict neurological survival in cardiac arrests, and monitor cerebral oxygenation in cardiovascular surgeries. Therefore, there is a growing interest in using NIRS as a monitoring tool in recent years to provide insights into brain oxygenation and assist in the evaluation and treatment of patients.The aim of the study is to evaluate the contribution of the NIRS using in pediatric patients presenting with neurological emergencies to the PED.
Materials and Methods: Between April 1, 2023, and April 1, 2024, 28 patients presenting with neurological emergencies (altered mental status, seizures, motor deficits,) were monitored for a minimum of 15 minutes using cerebral oximetry probes (Root with O3 Regional Oximetry, Massimo) placed bifrontally. Recorded data were retrospectively analyzed to evaluate the prediction of pathology between hemispherical rSO2, Hbi, and oxi-Hb differences with EEG and cranial imaging. This study was approved by the Hacettepe Ethics Committee (GO 23/282).
Results: The average age of the participants was 8.7±6 years and boys were 51.5% of them. The most common complaints at presentation were seizures (45.5%) and followed by altered mental status (27.3%), motor deficits (6.1%), and others (6,1%). Cranial CT was performed 45.5% of the patients, 60,6% of them had cranial MRI, and 54.5% had EEG. But in 25 patients who were viewed with either CTA or MRA or both, pathology was detected in 11 patients (44%), and there was no statistical difference found among the values of interhemispherical difference of mean rSO2, Hb change, and oxiHb change for these patients (p=0.1; p=0.7; p=0.63). In 18 patients who had EEG taken, pathology was detected in 9 patients, however, there was no statistical difference found among the interhemispherical difference of mean rSO2, Hb change, and oxiHb change (p=0.3; p=0.7; p=0.58). On the other hand, in a patient who presented due to left MCA occlusion, a 21% difference between hemispheres was detected in the NIRS examination performed immediately upon admission, and an increase in Hb and oxiHB values in the left hemisphere compared to the right hemisphere was observed. Later this patient underwent thrombectomy with conventional angiography, and it was observed the occlusion was partially recanalized.
Conclusion: This study has limitations due to the heterogeneity of patient diagnoses and the time differences resulting from the monitoring with NIRS and EEG only during working hours. However, we found important clues regarding monitoring in a specific patient group presenting with stroke. Therefore, further research is needed to determine the usefulness of cerebral oxygen monitoring in specific patient groups in the PED.
This retrospetive study was approved by the Hacettepe Ethics Committee (GO 23/282).
Burcu AKBABA (Ankara, Turkey), Hande YIGIT, Ahmet Ziya BIRBILEN, Ozlem TEKSAM
00:00 - 00:00
#42287 - Characteristics of mild traumatic brain injuries and risk model for management using cranial tomography.
Characteristics of mild traumatic brain injuries and risk model for management using cranial tomography.
Background:
Population studies showed that between 50 and 60 million people worldwide (2.5 million in Europe) are affected by a new traumatic brain injury (TBI) each year. The vast majority of cases (60-95%) are mild TBI. Traumatic brain injury is the main cause of damage to the brain parenchyma. Computed tomography (CT) is primarily used to detect life-threatening abnormalities that require urgent neurosurgery and are also relevant for prognosis. We are also aware about the costs and radiation of CTs that must be analyzed, for a correct adequacy in all health systems.
Aim:
To study the characteristics of mild TBI over the course of three years and the indication for CT, assessing its prognostic value.
Methods:
This is a retrospective observational study. Hospital records from an emergency unit with a population coverage of about 220,000 people were analyzed. Data were collected from 3,606 patients with mild TBI who attended during 2019-2022. COVID pre-pandemic and post-pandemic incidence data were analyzed. A multivariate analysis was performed to identify risk factors associated with the need for radiological tests in the emergency room.
Results:
Analyzing the characteristics of the patients we observed that 46.3% were women. Median age was 77 years (IQR: 60-80). 45.3% were over 75 years old. During the pre-pandemic period, 1,339 patients went to the emergency unit, and it was observed that during the pandemic, despite the fact that the population and especially the elderly population was totally or partially isolated in their residence, the number of patients who went to the emergency room was even higher, for a similar period, 1935 patients. A risk model was developed for requesting a CT in the emergency room in patients with mild CT. The variables that were significant were: age (7 times more risk of injury in people > 75 years), suffering from DM, having a history of an arrhythmia, being an institutionalized person, being treated with anticoagulants (this was the factor with the highest OR, 49.8) and having an INR >/= 3. The protocol implemented in the unit had high efficiency and security.
Discussion & Conclusions:
Mild TBI is an increasingly common pathology due in part to population aging and population mobility. The need to implement efficient radiological testing protocols in emergency systems is indisputable. Our study establishes a safe and effective risk model, also for the vulnerable population, such as elderly people.
Carbajo Azabal SILVIA, Eunate ARANA ARRI (BARRIKA, Spain), Barrenechea Barruetabeña IKER, Ibarlucea Gorospe GARAZI, Luco Gonzalez GUILLERMO
00:00 - 00:00
#41899 - Chemical and Biological Terrorism Trends: Data form the Global Terrorism Database.
Chemical and Biological Terrorism Trends: Data form the Global Terrorism Database.
Objective: The purpose of this study was to investigate chemical and biological terrorism trends between the years 2013-2020 by reviewing and categorizing data from the Global Terrorism Database (GTD).
Methods: Data from the GTD was filtered for attacks between the years 2013 and 2020 and filtered by weapon type using the chemical weapon and biological weapon labels. Each of the cases that fell into these categories was then investigated for the types of compounds and weapons that were used. The chemical and biological agents found included acids/alkaline corrosives, chlorine, vesicant agents, pesticides, nerve agents, irritants, ricin, and cyanide. Cases in which specific compounds were not identified were categorized as either unknown gas or unknown. We described the frequency of chemical and biological agents and the number of fatalities and injuries associated with each agent.
Results: A total of 203 (chemical agents, n=198, 97.5%; biological agents, n=5, 2.5%) terrorist attacks were identified, accounting for 460 fatalities and 4,906 injuries within the 8-year time period. The largest proportion of attacks were caused by unknown agents (n=63, 31.0%), followed by chlorine (n=33, 16.2%), unknown gases (n=31, 15.3%), irritants (n=31, 15.3%), and acids/alkaline corrosives (n=26, 12.8%). Other agents that were identified in smaller proportions were vesicant agents, pesticides, ricin, nerve agents, and cyanide. Among known agents, chlorine resulted in the highest number of fatalities (n=143) and mustard agents resulted in the highest number of injuries (n=1534). During the studied period, the majority of attacks involving chlorine agents occurred in Syria and Iraq (n=31, 93.9%), with the increase in chlorine attacks aligning with conflicts that arose in 2011. Additionally, all attacks with mustard agents occurred in Syria and Iraq. Other countries that accounted for a significant proportion of incidents included Afghanistan, which accounted for 61.3% (19 out of 31) of all attacks involving an unknown gas, as well as 57.1% of attacks involving unknown compounds (36 out of 63 attacks).
Conclusion: The trends in chemical and biological terrorism identified in this study can be used to identify changes in usage of chemical agents over time, and aid in preparation against terrorist attacks in the future for emergency medicine teams.
Rita FARAH, Scott SCHMALZRIED (Charlottesville, USA), Christopher HOLSTEGE
00:00 - 00:00
#41284 - Chest discomfort without EKG and biomarkers changes, should we always look for epicardial stenosis? Cardiologic non-acute ischemia diagnoses among patients referred to a chest pain clinic in emergency room.
Chest discomfort without EKG and biomarkers changes, should we always look for epicardial stenosis? Cardiologic non-acute ischemia diagnoses among patients referred to a chest pain clinic in emergency room.
BACKGROUND: Emergency Department (ED) admissions due to non-traumatic chest discomfort are very frequent (up to 10% of visits) with a higher incidence in urban than in rural hospitals, with a mean age of 52–61 years, and with 49–57% of men, Vast majority are discharge from ED but among admissions, only 12% approx. will have a final diagnosis of acute coronary syndrome (ACS). Unluckily, approximately 2% of these patients with an ACS are erroneously discharged from the ED. This is why, although no signs of ischemia (EKG, biomarkers) are present, stress test is seldom performed, usually negative for ischemia. However, this may lead to a
longer length of stay in the ED or observation units. In our hospital, some of these patients were directly referred to stress test the next day without cardiologic examination.
METHODS: We reviewed patients referred to our new ED chest pain clinic during 17 months and selected those with cardiologic non-acute coronary syndrome as final diagnosis. Echocardiogram and pulmonary echo were performed by attendant cardiologist.
RESULTS: Among 389 patients, 7.2% had cardiac non-acute coronary syndrome as final diagnosis (39% women), with a mean age of 74 (range 43 to 93). 43% were non-smokers, 46% were ex-smokers and 11% were current smokers. 89% had hypertension, 32% diabetes mellitus, 68% hyperlipemia, 71% extra-cardiac comorbidities: 39% with one, 25% with two, 3.5% with four and 3.5% with six. These comorbidities were: chronic obstructive pulmonary disease-asthma, enolism, stroke, sleep-apnea, peripheral disease, psoriatic arthritis, Graves-Basedow disease, obesity, gout, nephropathy, cholangiocarcinoma, schizophrenia, rheumatism, pulmonary embolism, migraine, gastritis, cocaine abuse, hypothyroidism, abdominal aortic aneurism. 43% had other known cardiac disease: severe aortic stenosis (2), moderate or severe mitral regurgitation (2), mild left ventricle dysfunction (3), atrial fibrillation (5), mild pericardial effusion (1), aortic dilatation (1), atrial flutter (1), with 7% with 3 of these conditions.
In 64% of cases, no other tests were performed. Among the rest of cases, in 29% one test was performed (stress-echo (4), coronary angiography (2), angioCT (1 aortic, 1 pulmonary), and in 7% more than one test was performed (stress-echo + coronary angiography). Only in 21% of referrals, stress test was performed.
The final diagnoses were: heart failure (11 cases, 39%), symptomatic aortic stenosis (3 patients: 2 referred for surgery and 1 for trans-aortic valve implantation), symptomatic mitral regurgitation (1: referred for surgery), pericarditis, cardiac tamponade due to severe pericardial effusion, vagal syncope or reaction (2), dysautonomia+anxiety, vasospasm (3, one with ischemic torsade de pointes, and other with heart failure), acute pericarditis + heart failure (2), chronic coronary syndrome + heart failure, acute pericarditis + heart failure, atrial fibrillation + heart failure, symptomatic ventricular extrasystoles + heart failure. 60% (17) of patients had a final diagnosis of heart failure.
CONCLUSIONS: Cardiac diagnoses other than ACS are not so rare, mainly heart failure, but also other life-threatening conditions can be happened. In these selected patients, multidisciplinary approach between ED and cardiology could avoid unnecessary stress tests and misleading the correct diagnosis, probably improving the global management of this population.
Iñigo SANZ ORTEGA (Galdakao, Spain), Egoitz MARTITEGI ALBIZU, Sonia VELASCO DEL CASTILLO, Alazne URKULLU NAVEDA, Alberto ULLATE DE LA TORRE, Jose Juan ONAINDIA GANDARIAS, Angela CACICEDO FERNANDEZ DE BOBADILLA, Alberto SALCEDO ARRUTI
00:00 - 00:00
#42272 - Clinical assessment of deaf patients through two different interpretation modalities: a pilot experimental study.
Clinical assessment of deaf patients through two different interpretation modalities: a pilot experimental study.
Background:
Identifying the most effective interpretation modalities for deaf patients is crucial to guarantee a high-quality standard of care. This pilot experimental study aimed to compare the effectiveness of two different communication approaches in emergencies. We hypothesized that neither the diagnostic accuracy nor the time allocated by emergency physicians for patient history-taking would change with a remote interpreter when compared with an on-site interpreter. In addition, the preferred interpretation modality for both patients and physician was also assessed.
Methods:
This one-day pilot study was conducted in Milan (Italy) in spring 2024. It included ten deaf people acting as patients seeking emergency care. Participants were recruited by the Emergenza Sordi APS Association. Convenience sampling was used to select 10 individuals among the most vulnerable subgroup within the deaf population, namely, patients able to use the deaf Italian sign language but unable to perform lip reading or use their voice. Exclusion criteria included individuals with cochlear implants or able to read and write. The study included three arms: Group 1, where the deaf patient and physician were left alone during medical history collection, Group 2 where the physician was supported by an online Italian Sign Language interpreter, and Group 3 where an Italian Sign Language interpreter was present. A total of 30 different acute medical conditions (10 per arm) were prepared. Prior to the simulation, all cases were sent to 10 emergency physicians through a multiple-choice questionnaire to ensure equivalent complexity in all cases. One single physician, blinded to the study's objectives, examined all patients across the study arms and selected the diagnosis among 5 possible responses. Time taken for diagnosis formulation and its accuracy served as key metrics to evaluate the effectiveness of both communication methods. Data were analysed using Stata 17. Normality was tested with Shapiro Wilk test and data reported as median and IQ range (10-90). The difference between groups was performed with Kruskal-Wallis test for continuous variables and Chi2 square test for categorical variables. Statistical significancy was defined as P<= 0.05.
Results:
In terms of time employed for diagnosis formulation, Group 1 exhibited the shortest (median = 0.31 minutes, IQ = 0.23-1.22), followed by Group 3 (median = 1.15 minutes, IQ = 0.47-1.3), and Group 2 (median = 1.49 minutes, IQ = 1.23-3.04). Although the scenarios with interpreters yielded a higher rate of correct diagnoses (Group 1, 6/10 (60%), Group 2, 8/10 (80%), Group 3, 9/10 (90%)) this difference did not reach statistical significance (p 0.271). A total of 80% of participants as well as the physician reported the on-site interpreter as their preferred communication modality.
Discussion & Conclusions:
Our results did not show statistical significance in either diagnosis formulation time or diagnostic accuracy when remote versus on-site interpreters were compared. These results might suggest that, in emergency departments, on-line interpreters could be an asset during the clinical examination of deaf patients. The scenario without interpreter demonstrated a significant shorter time; insurmountable communication barriers might have prompted the physician to end the patient interview earlier than expected.
Alba RIPOLL-GALLARDO, Chiara DE LILLO (Milan, Italy, Italy), Luca ROTONDI, Davide MAURI, Riccardo FIAMENI, Andrea DUCA, Marta ZUDDAS, Gian Luca MARCONI, Ambra BERTOLA, Paola Angela Maria MAFFI, Enrico CAPIOZZO, Martina PREVITI, Riccardo STUCCHI
00:00 - 00:00
#41357 - Clinical Manifestations, Severities and Outcomes Among Patients with Guillain-Barré Syndrome and Varying the Possible Etiologies in Taiwan.
Clinical Manifestations, Severities and Outcomes Among Patients with Guillain-Barré Syndrome and Varying the Possible Etiologies in Taiwan.
Purpose:
The cause of Guillain-Barré syndrome (GBS), a rare condition that causes sudden numbness and muscle weakness, is not fully understood, but most cases follow an infection with a virus or bacteria or the vaccination. Our study aimed to describe the clinical features of GBS associated with different etiologies, including infections or vaccinations.
Materials and Methods:
We conducted a retrospective cohort study from the largest medical center in Taiwan during 2017-2022. We identified patients with newly diagnosis of GBS based on the independent clinical judgement according to the National Institute of Neurological Disorders and Stroke criteria by one emergency physician and one neurologist. We defined the possible etiology of GBS such as patients received any kinds of vaccination or experienced viral or bacterial infection 42 days prior to GBS diagnosis. We extracted the patients’ characteristics from the medical charts to collect the baseline demographics (e.g., age and sex), clinical manifestations (e.g., limb weakness and profound areflexia, autonomic dysfunction, respiratory failure, and cranial neuropathies), severities (e.g., Hughes functional grading scale and Brighton level) and outcomes (e.g., ventilator-dependent status or death) at discharge. We compared these patients’ characteristics in patients with GBS associated with vaccinations vs infections using chi-square or Fisher's exact test for categorical variables. A p-value <0.05 was considered statistically significant.
Results:
We included 189 GBS patients with a median age of 46 years and 58.2% male. Preceding the diagnosis of GBS, 25.4% (n=48) patients had the specific infection (upper respiratory tract infection: 79.2%; Herpes infections 6.3%; Cytomegalovirus (CMV) infection: 6.3%; Coronavirus disease (COVID-19): 6.3%), and 7.9% (n=15) patients received the vaccinations (COVID-19 vaccines: 66.7%; other vaccines: 33.3%). Clinical manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine related GBS included limb weakness in seven patients, facial palsy in five, sensory symptoms in nine, dysautonomia in two, and respiratory insufficiency in three. The predominant electrodiagnostic subtype of COVID-19 vaccine related GBS was acute inflammatory demyelinating polyneuropathy (n=5). Medical interventions administered for COVID-19 vaccine-related GBS encompassed ventilatory assistance for three patients at their lowest point of illness, plasmapheresis for seven individuals, and a four-person readmission rate within six months. Compared to infections, patients with GBS post-SARS-CoV-2 vaccination exhibited a higher six-month readmission rate (40% vs. 6.3%, χ2 = 8.883, p=0.014).
Nevertheless, we did not detect significant differences in clinical and electrodiagnostic subtypes, severity, or clinical outcomes at discharge between GBS occurring post-infection and post-SARS-CoV-2 vaccination.
Conclusion:
GBS cases following vaccination exhibit some differences from those triggered by infection, particularly in terms of short-term readmission rates. Conclusions remain tentative pending further research with a larger cohort to substantiate these findings more robustly.
IRB No: 202200878B0
Funding:
This study was supported by grants from Keelung Chang Gung Memorial Hospital, Taiwan (CMRPG2G0221).
Chun CHANG (Keelung, Taiwan), Shu-Chen LIAO, Shih-Chieh SHAO
00:00 - 00:00
#41208 - Comparison of Efficacy of Metoclopramide, Promethazine, and Prochlorperazine in the Treatment of Peripheral Vertigo: A triple-blind Randomized Controlled Trial.
Comparison of Efficacy of Metoclopramide, Promethazine, and Prochlorperazine in the Treatment of Peripheral Vertigo: A triple-blind Randomized Controlled Trial.
Objectives: Acute vertigo is frequently encountered in emergency departments (ED). This study aimed to assess the therapeutic efficacy of intramuscularly (IM) administered metoclopramide, promethazine, and prochlorperazine in patients with acute peripheral vertigo symptoms presenting to the ED. It sought to identify the most effective medication for vertigo treatment in this cohort, with secondary outcomes including the evaluation of the necessity for rescue medication.
Methods: We conducted a triple-blind, multicenter, randomized controlled trial. Adults aged 18–60 years experiencing peripheral vertigo with a self-assessed visual analogue scale (VAS) score of ≥5.0 were enrolled. Participants were randomly assigned to receive a single IM dose of metoclopramide, promethazine, or prochlorperazine. The primary endpoint was the reduction in VAS score at 60 minutes post-administration. Efficacy was determined by a VAS score of ≤3 at 60 minutes post-treatment, considering side effects and the reduced need for rescue medication or maneuvers. Data analysis was performed using SPSS and RStudio. This novel comparison is registered at clinicaltrials.gov (NCT05586763).
Results: A total of 77 patients were divided into three groups to receive metoclopramide, prochlorperazine, or promethazine via the IM route, with 24, 28, and 25 participants respectively, exhibiting comparable baseline characteristics. At 60 minutes, all study medications showed significant reduction in VAS from baseline with mean VAS changes of 5.30 (95% CI: 4.21–6.41) for metoclopramide, 4.60 (95% CI: 3.60–5.60) for prochlorperazine, and 4.48 (95% CI: 3.17–5.80) for promethazine when measured in a supine position. No statistically significant differences in VAS scores across supine, sitting, and standing positions were observed among the groups. The efficacy of metoclopramide (83.33%), prochlorperazine (75.00%), and promethazine (80.00%) in reducing VAS scores to ≤3 at 60 minutes post-treatment shows no significant differences between the groups. The requirement for rescue medication was similar across all groups, and no adverse drug effects were reported. Furthermore, no significant association was found between the type of medication and patient disposition.
Conclusions: This study demonstrates that intramuscular metoclopramide, promethazine, and prochlorperazine are all effective in significantly reducing acute peripheral vertigo symptoms within 60 minutes, with no differences in efficacy or need for rescue medication among them. All treatments were well-tolerated, suggesting that any can be used effectively for managing acute vertigo in emergency settings. Further research is recommended to explore long-term effects and applicability across different patient groups.
Registered at clinicaltrials.gov (NCT05586763).
Asma AL BURAIKI, Asma AL BURAIKI (Oman Muscat, Oman), Adnan AL-RAWAHI, Ahmed AL ABRI, Abdulaziz AL BAREIKI, Usama AL KHALASI, Hana AL GHUSSAINI, Fatema AL RAWAHI, Suad AL BULUSHI
00:00 - 00:00
#42391 - Comparison of Heart and Grace scores to predict major adverse cardiac events from chest pain.
Comparison of Heart and Grace scores to predict major adverse cardiac events from chest pain.
Introduction: Acute non-traumatic chest pain (ANTCP) is one of the most frequent reasons for consultation in the Emergency department (ED). Our aim was to compare whether the HEART score is more effective than the GRACE score for the diagnosis and prognosis of Major Adverse Cardiac Events (MACE) at 30 days in patients with ANTCP.
Methods: A prospective cohort study was conducted with patients with ANTCP that attended an ED in a regional hospital from August 2022 to August 2023. The primary outcome was MACE at 30 days. Diagnostic performance was calculated for each scale as the Area under the Receiver Operating Characteristic (ROC) curve (AUC), sensitivity (SE), specificity (SP), and negative predictive value (NPV).
Results: From a sample of 625 patients with ANTCP, 3% had MACE at six weeks. The AUC was 0.849 (95% CI 0.782-0.915) for the HEART score, 0.727 (95% CI 0.595-0.850) for the GRACE score. The HEART score was better than the GRACE score at predicting MACE at 30 days in patients with ANTCP. It was also a reliable tool for risk stratification in low-risk patients. For a HEART score >=4, the SE, the SP and the NPV were respectively 100%, 67% and 100%. The SE, the SP and the NPV were respectively for the GRACE score, 44%, 85% and 98% for cut-offs of > 140.
Conclusion: The results demonstrated the low specificity of HEART score comparing to the GRACE score versus the high sensitivity of the HEART score.
aucun conflit
Sana SELLAMI, Manel KALLEL (Tunis, Tunisia), Ramla BACCOUCHE, Emna REZGUI, Sonia AISSA, Khedija ZAOUCHE
00:00 - 00:00
#42193 - Comparison of two techniques of face mask ventilation in adult cardiopulmonary resuscitation after training on a simulator.
Comparison of two techniques of face mask ventilation in adult cardiopulmonary resuscitation after training on a simulator.
Background:
Artificial ventilation is part of the resuscitation maneuvers performed in case of cardiac arrest, at a rate of 30 chest compressions to 2 ventilations. The European Resuscitation Council guidelines 2021 suggest one-handed ventilation as first-line treatment and two-handed ventilation mains, in the event of failure, in case of obese patients or in case of suspected airborne contagious pathologies. It has been shown that one-handed bag-valve-mask ventilation requires prolonged training to ensure effective ventilation. To our knowledge, no study has compared the 2 standard methods taught to medical students. This study aims to evaluate the efficacy of 2-handed versus 1-handed ventilation technique by non-experienced practitioners during a simulated adult cardiopulmonary resuscitation (CPR).
Methods:
In this prospective comparative study, non-experienced medical students of the Toulouse University Hospital performed 1-handed or 2-handed bag-valve-mask technique in a 2-minute simulated adult CPR. Beforehand, the subjects received a 1-hour training course on each of the 2 techniques as part of their 2nd cycle medical studies on adult CPR. The primary outcome was the rate of effective insufflation greater than or equal to 90% during 2 minutes of CPR, measured by QCPR meter. Secondary end points included failure of ventilation (insufflation volume too low or too high), mask seal and upper airway clearance score (on a numerical scale from 0 to 10), efficacy of thoracic compression (CT) and efficacy of global CPR (effective CT combined with 2 effective ventilations in a 30/2 rhythm).
Results:
Of the 224 students trained, 94 (mean age, 22 years ; 63 women [67%]) were assessed on 1-handed ventilation and 110 (mean age, 22 years ; 70 women [63%]) on 2-handed ventilation. There was a significant difference between the 1-handed and 2-handed technique for effective insufflation rate (35 [37%] vs 65 [59%] ; p<0.05), insufficient volume insufflation rate (48 [51%] vs 35 [32%] ; p<0.05), efficacy of global CPR (33 [35%] vs 53 [48%] ; p<0.05), median upper airway clearance (7.9 vs 8.8, OR=-2.73 [-1.44 ; 0.23]). Mask sealing shows no significant difference with a score of 8.6 et 8.7 respectively (OR=-0.38 [-0.54 ; 0.36]). The effectiveness of chest compressions did not differ between the 2 groups, either in terms of depth (5-6 cm) or speed (100-120 per minute).
Discussion & conclusions:
In a simulated adult cardiopulmonary resuscitation, the 2-handed bag-valve-mask ventilation seems more efficient than the 1-handed technique in non-experienced practitioners. These results are in agreement with a recent study which showed an increase in ventilation performance between the two-handed and one-handed groups (85% versus 31% successful ventilation). It therefore seems preferable to teach a single technique instead of 2, to homogenize practices and reduce learning times.
Trial Registration: This study did not involved any patients
Funding: This study did not receive any specific funding
Ethical approval and Informed consent: According to French law, this study didn't need ethics committee approval and has been declared to the French National Commission for Informatics and Liberties.
Charles-Henri HOUZE CERFON (Toulouse), Vanessa HOUZE-CERFON, Remi COMTE, Xavier DUBUCS
00:00 - 00:00
#42171 - Compliance of Medication Reduction in Patients with Polypharmacy: A Prospective Cohort Study.
Compliance of Medication Reduction in Patients with Polypharmacy: A Prospective Cohort Study.
Abstract
Purpose
Polypharmacy, the concurrent use of ≥5 medications, poses a growing concern due to its high prevalence among the geriatric population. Multiple medications may be necessary to manage various health conditions, however they pose significant risks such as adverse drug events, unintentional interactions between medications, reduced adherence, and increased healthcare costs. An aging population with increasing frequency of chronic diseases and more medical treatment options, is thought to be responsible for this tendency. Medication reduction interventions have been proposed to mitigate these risks, but actual compliance remains uncertain. Understanding how patients respond to medication reduction interventions is critical for optimizing medication management strategies in older adults with polypharmacy.
We aim to elucidate the relationship between medication reduction in patients with polypharmacy, performed during hospitalization, and compliance after discharge.
Method
This preliminary single-center prospective cohort includes older adults with polypharmacy admitted to the emergency department (ED) at North Zealand Hospital. Patients aged 65 years or older with ≥ 5 systemic medications, who would have their medication discontinued, reduced, or replaced by a clinical pharmacist, are eligible for inclusion. Compliance assessment is conducted by reviewing the Danish Medication System: Shared Medication Record (FMK) at 14 and 30 days after discharge. Some patients will be contacted directly to evaluate compliance with FMK, not including those who have their medication managed by the municipality, as the assumption is full compliance for them. It was noted how the change would be implemented in FMK, by either pharmacist-led, ED doctor-led, or delegated to the GP. Patient characteristics include age, sex, and clinical frailty score.
Results
The preliminary study involved 22 patients undergoing a 14-day follow-up, comprised of 6 males (27.3%) and 16 females (72.7%). Overall compliance among the 22 patients was observed in 7 (31.8%). Pharmacist-led implementation resulted in a compliance rate of 60%, whereas compliance rates were 27.3% when led by ED doctors and 16.7% when delegated to GPs. For the group that was directly contacted (n=10, 45.5%), 90% of patients confirmed compliance in accordance with the FMK implementation
Discussion
Deprescribing is often a viable tactic to improve overall healthcare of older adults, yet many of the suggestions given by clinical pharmacists are not implemented, particularly when delegated to GPs. Elderly patients with polypharmacy appear capable of complying with medication reduction interventions initiated in the emergency department, but implementation seems suboptimal. Further investigation is warranted to accurately identify and address this obstacle in healthcare of the elderly.
Rune PIHL (Hillerød, Denmark), Hanne FISCHER, Charlotte VERMEHREN, Jesper LARSEN, Thomas SCHMIDT
00:00 - 00:00
#41914 - Complications of ST Segment Elevation Myocardial Infarction during out-of-hospital transport: a retrospective multicenter study.
Complications of ST Segment Elevation Myocardial Infarction during out-of-hospital transport: a retrospective multicenter study.
Introduction: ST Segment Elevation Myocardial Infarction (STEMI) are a pathology with potential rhythmic, mechanical, hemodynamic and respiratory complications. The aim of this study was to investigate the incidence of these life-threatening complications during out-of-hospital management of patients with STEMI.
Material and method:
This multicenter retrospective epidemiological study was conducted from January 1, 2022, to December 31, 2022. Analyzing patients with STEMI who were transported out-of-hospital to a coronary angiography center or cardiac intensive care unit, under the coordination of three French emergency medical service (EMS) dispatch centers. Patients experiencing cardiac arrest before STEMI diagnosis were excluded. Demographic data, duration of symptoms, transport details (type, duration, treatment received by patient), hospitalization follow up with final discharge diagnosis were collected retrospectively. Primary transport was define as transport between patient’s home and the hospital. Secondary transport was define by interhospital transfer. The primary outcome measured was the occurrence of any major complication, defined as an event necessitating an urgent therapeutic intervention. After describing the population, a multivariate logistic regression analysis was performed using data from EMS regulation and intervention records, as well as hospitalization reports.
Results: Of the 3,546 cases analyzed, 573 patients were included. Among them, median age was 64 [53-75] years, 165 (29%) were female, and 336 (59%) were active smokers. A major complication occurred for 48 (8.4%) patients, among them, 18 (37.5%) patients did not require any change in treatment. Bradycardia < 50/min was the most frequent complication (3%, n=16 ), followed by ventricular fibrillation (1%, n=6), ventricular tachycardia (1%, n=6), acute respiratory distress (1%, n=6) and hypotension (1%, n=6). One death occurred during these out-of-hospital transports. No difference was observed in the occurrence of complications depending on the cardiac territory affected by ischemia. In multivariate analysis, the factors associated with the occurrence of a major complication were primary rather than secondary intervention (ORa 2.4 CI95% 1.1 - 5.8), duration of symptoms < 2h (ORa 2.7 CI95% 1.2-5.7), and presence of left heart failure (ORa 5.2 CI95% 2.1-12.1).
Conclusion: The incidence of major complications during out-of-hospital transport for STEMI patients was relatively low at 8.4%. Patients who presented with symptoms for more than two hours and those undergoing secondary transports were found to be at a reduced risk of experiencing major events.
Antoine LEFEVRE-SCELLES, Antoine LEFEVRE-SCELLES (Rouen), Aymerick BESNARD, Mehdi TAALBA, Alix DELAMARE FAUVEL, Luc-Marie JOLY, Melanie ROUSSEL
00:00 - 00:00
#41678 - Comprehensive assessment of emergency departments in county-level public hospitals: a multicenter descriptive cross-sectional study in Henan province, China.
Comprehensive assessment of emergency departments in county-level public hospitals: a multicenter descriptive cross-sectional study in Henan province, China.
Background:
Emergency Departments (EDs) are critical components of healthcare systems, providing immediate medical care to patients in need. Despite their importance, there is a dearth of comprehensive evaluations focusing on EDs in county-level public hospitals, particularly in less urbanized regions like Henan province, China. This study aims to fill this gap by conducting a thorough assessment of EDs in county-level public hospitals in Henan province, shedding light on existing disparities and challenges.
Methods:
This descriptive cross-sectional study was conducted in 382 county-level public hospitals across Henan province, China, from July 1, 2023, to August 1, 2023. Data collection involved the utilization of an electronic questionnaire, administered to hospital administrators or designated personnel, covering various aspects such as hospital information, human resources, infrastructure, clinical capabilities, and operational capacities. The survey period encompassed data from January 1 to December 31, 2022, ensuring a comprehensive assessment of the study variables.
Results:
The findings of this study revealed notable disparities between county-level public hospitals and their provincial or municipal counterparts in Henan province, China. County-level hospitals exhibited limited medical staff, inadequate infrastructure, and constrained operational capacities compared to their urban counterparts. Specifically, the analysis indicated a shortage of emergency physicians, nurses, and support staff, as well as deficiencies in essential equipment and diagnostic facilities. These disparities pose significant challenges in delivering timely and high-quality emergency care services in less urbanized regions.
Discussion & Conclusions:
The study results underscore the urgent need for targeted interventions to address the identified disparities and enhance the quality of emergency care in county-level public hospitals. Key recommendations include increased investment in human resources, infrastructure upgrades, provision of essential medical equipment, and capacity-building initiatives for emergency healthcare professionals. Additionally, the adoption of innovative solutions such as telemedicine and mobile healthcare units could help overcome geographic barriers and improve access to emergency care services in remote areas. By prioritizing these interventions, policymakers and healthcare stakeholders can work towards achieving equitable access to emergency care services across different regions of Henan province, China.
Trial Registration:
This study did not receive specific funding and was not registered with any trial registry.
Ethical Approval and Informed Consent:
Since this study involved secondary data analysis and did not directly involve human participants, ethical approval and informed consent were not applicable.
Lijun XU (Zhengzhou, China), Yanwei CHENG, Lijie QIN
00:00 - 00:00
#41977 - Correlation between sepsis, procalcitonin and hemocoltures in E.R.: a retrospective analysis.
Correlation between sepsis, procalcitonin and hemocoltures in E.R.: a retrospective analysis.
Introduction: sepsis is considered one of the worldwide emerging diseases, with an increasingly higher impact on health care systems. Despite the relevance of this phenomenon, only scarcely is the problem acknowledged as a time-dependent disease, such as AMI, stroke or trauma.
Purpose: identifying clinical and instrumental parameters as well as laboratory tests performed on arrival at E.R. that correlate with outcomes such as death and length of hospital stay (LoS) in septic patients.
Methods: we performed a retrospective analysis of the data of all patients admitted to E.R. and Emergency Medicine Unit of San Benedetto del Tronto Hospital between 01/01/2023 and 31/12/2023 with suspected sepsis undergoing hemocultures. We carried out descriptive statistical analyses and comparisons between deceased/not deceased categories with regards to quantitative and qualitative variables (Wilcoxon test and χ²-test, respectively). We used logistic regression models (stepwise method) for variables such as death and LoS.
Results: the analysis, conducted on 529 patients (W318, 60.1%; mean age 72.6 years), showed an association (p < 0.05 for all the variables) between positive hemocultures and higher age, qSOFA score > 2, higher body temperature, HR and RR, platelet count, INR value, CRP, lactate value, LoS and lower both systolic and diastolic BP as well as GSC score. An association has also been identified (p < 0.05) between positive hemocultures, pre-existing cardiopathy and Bed Rest Syndrome (BRS). Deceased patients were older and showed qSOFA score > 2, higher HR, RR, WBC count, INR, lactate and procalcitonin values and lower systolic and diastolic BP, GCS score, hemoglobin and creatinine values and a lower platelet count. In addition, they were often affected by COPD, cardiopathies, cancer, BRS, pneumonia and sepsis (p < 0.05). Logistic regression for the dependent variable “death” has shown increased odds of dying in bedridden, older patients with lower BP and GCS score, while positive hemocultures act as a protective factor (p < 0.05 for all the variables).
Linear regression for the dependent variable “LoS” showed an increased hospitalization time for male, bedridden patients with positive hemocultures (p < 0.05 for all the variables).
Cox regression model showed an increased mortality rate in patients with cancer and pneumonia, older age and higher lactate value, while a lower mortality rate has been shown for patients with higher systolic BP, GCS score, patients with UTI and positive hemocultures (p < 0.05 for all the variables).
Conclusions: our results indicate an increased death risk related to comorbidity, older age, lower BP and GCS score and increased LoS for male, bedridden patients. Positive hemocultures represent a protective factor with respect to death, although being associated to increased LoS.
Giuseppina PETRELLI, Paolo GIORGINI, Gianluca MORONCINI, Roberto ALESSANDRONI, Osvaldo FRATINI, Federica SILVESTRI, Giorgia SESTRI, Jessica ORLANDI, Stefano NECOZIONE, Francesco LATTANZIO (Italy, Italy), Giancarlo CONCETTI, Manuela BIZZARRI, Maria Laura IACHETTI, Giorgia RUBINI
00:00 - 00:00
#42366 - CREATION OF AN ECOLOGICAL SUSTAINABILITY EVALUATION TOOL TO ASSESS MEDICAL DEPARTMENTS IN HOSPITALS AND APPLICATION OF THE TOOL IN TWO EMERGENCY DEPARTMENTS IN BELGIUM.
CREATION OF AN ECOLOGICAL SUSTAINABILITY EVALUATION TOOL TO ASSESS MEDICAL DEPARTMENTS IN HOSPITALS AND APPLICATION OF THE TOOL IN TWO EMERGENCY DEPARTMENTS IN BELGIUM.
Based on a literature review, we created a model to achieve net zero medical departments and hospitals by focussing on single use goods, waste, pharmaceuticals, chemicals, patient transport, staff commute, food, energy, water, and construction. We believe in all those 10 domains an approach involving stakeholders, using data, exploring technology, and keeping track of health economic consequences is crucial.
We applied this tool at the 2 emergency departments of GZA hospitals:
GZA ED used 943 different (unique) single use goods in 2023 costing €541 575.
We produce on an annual basis 17,6 tonnes of non-hazardous medical waste, 6 tonnes of hazardous medical waste, 4 tonnes of paper and cardboard waste and 2 tonnes of PMD. The cost of waste processing is €7985.
529 unique pharmaceuticals are used at GZA ED of which in total 124 490 doses were administered. This corresponds to an annual budget of €249 541.
The only hazardous chemical identified in our department is the cleaning agent to clean the bed pans of which we have an annual usage of 100L. This cleaning agent can cause respiratory, skin and eye irritation.
With regards to patient transport we included the effect of driving 26200 km with 2 Volvo XC90 MUG vehicles and we included an analysis of the staff commute.
Our annual energy usage is 214 371 kWh of electrical power and 328 135 kWh of natural gas, and we use 1257m3 of water.
We have no construction projects going on.
When we sum all our scope 1, 2 and 3 emissions: we arrive at 496 232 kg CO2e annual emissions
Scope 1
• Mobile combustion: 5652 kg CO2e
• Medicinal/anesthetic gases: 4,7 kg CO2e
Scope 2
• Purchase of electricity: 42 445 kg CO2e
• Purchase of steam, heating, and cooling: 75 478 kg CO2e
Scope 3
• Transport-related categories
- Employee commute: 31 482 kg CO2e
• Metered Dose Inhalers (MDI) 6 076 kg CO2e
• Electricity transmission and distribution losses: 36 357 kg CO2e
• Water: 502,8 kg CO2e
• Waste: 28 407,6 CO2e
• Extra supply chain
- Medical instruments and equipment: 204 423 kg CO2e
- Pharmaceuticals: 65 405 kg CO2e
Total GZA ED emissions: 496 232 kg CO2e
We involved a stakeholder green team and selected goods that can be reduced. This can generate annual savings of €57 921 within two years. By using our billing system correctly, we are on track to add €51 598 revenues by correctly billing the suture equipment. 108 pharmaceuticals were selected that can be removed from our ED cupboard. We recommend switching from bottled water to tap water and save an extra €7811 costs.
GZA ED has annual emissions of 496 232 kg CO2e or 783 kg CO2e per 100 patients treated at our ED. With the implementation of the green team recommendations 21 862 kg CO2e can be reduced within two years.
Brecht DE TAVERNIER (Antwerp, Belgium)
00:00 - 00:00
#41904 - Cultivating educators: simulation faculty development program for senior emergency medicine residents.
Cultivating educators: simulation faculty development program for senior emergency medicine residents.
INTRODUCTION:
Simulation-based education plays a pivotal role in the training of medical professionals, providing a safe environment to practice essential skills and decision-making in a variety of clinical scenarios. In the field of emergency medicine (EM), where split-second decisions can be a matter of life and death, the ability to effectively utilize simulation training is paramount. This abstract explores the process and outcomes of a simulation faculty development program tailored specifically for senior emergency medicine residents, aiming to enhance their abilities as educators in simulation-based training.
OBJECTIVE:
The primary objective of this study was to assess the impact of a structured simulation faculty development program on senior EM residents' simulation facilitation skills. Additionally, we sought to evaluate participants' satisfaction with the program and their perceived readiness and confidence to lead simulation sessions independently.
METHODOLOGY:
A structured faculty development program was designed, comprising didactics, workshops, peer-teaching opportunities, and hands-on practice with feedback led by experienced simulation educators. All the current senior EM residents, year 4(R4) at our institute were included. A prospective observational study was conducted from January 2023 to April 2024. A monthly simulation session was delivered to junior EM residents (R1/R2/R3) facilitated by the newly trained educators (R4) under the supervision of expert simulation faculty. Twelve such sessions were conducted during the study period. For each session, the expert faculty used Facilitator Competency Rubric (FCR) by Leighton et al. to assess the new facilitators. The FCR consists of five domains: preparation, prebriefing, facilitation, debriefing and evaluation. Each domain has sub-components which are scored on a 5-point Likert scale. The final score for each domain yields three categories; beginners to advanced beginners, competent and proficient to expert. Additionally, qualitative feedback was collected after each session to gather insights into participants' satisfaction with the program and their confidence to facilitate simulation. We divided the collected data into two groups: Phase-I(first six sessions) and Phase-II(last six sessions). We used the two-tailed paired T test to compare both phases by using SPSS. The primary outcome was considered improvement in all 5 domains of the FCR. The secondary outcome was considered improvement in satisfaction and confidence of participants in facilitating simulation.
RESULTS:
Results of the paired T test indicated that there was a significant large difference in all 5 domains of the FCR between phase-I and phase-II: Preparation(Phase-I(M=9.2,SD=3.7) and Phase-II(M=19.2,SD=1.2), p<.001), Prebriefing(Phase-I(M=5.3,SD=2.7) and Phase-II(M=15.7,SD=3.5), p=.003), Facilitation(Phase-I(M=8.2,SD=2.8) and Phase-II(M=18.8,SD=3.3), p<.001), Debriefing(Phase-I(M=8.7,SD=3.8) and Phase-II(M=24,SD=4.5), p=.002) and Evaluation(Phase-I(M=5.2,SD=1.9) and Phase-II(M=11.7,SD=2.5), p=.003). Similarly, the secondary outcome showed improvement in both satisfaction(Phase-I(M=2.2,SD=0.8) and Phase-II(M=4.2,SD=1), p< .001) and confidence(Phase-I(M=2,SD=0.6) and Phase-II(M=4.3,SD=0.5), p=.003).
CONCLUSION:
The findings of this study highlight the effectiveness of a structured simulation faculty development program in cultivating senior emergency medicine residents as proficient simulation educators. By equipping residents with the necessary knowledge, skills, and confidence to lead simulation-based training sessions, such programs contribute to the overall enhancement of medical education and patient care quality. Moving forward, continued investment in simulation faculty development initiatives is essential to ensure the ongoing professional growth and development of future healthcare educators.
Trial Registration and funding was not required.
Muhammad Saif REHMAN (Abu Dhabi, United Arab Emirates)
00:00 - 00:00
#42180 - Developing an ultra-fidelity innovative simulation center in disaster response at CHU Toulouse: An Innovative Approach for Improving Clinical Practices.
Developing an ultra-fidelity innovative simulation center in disaster response at CHU Toulouse: An Innovative Approach for Improving Clinical Practices.
Background: High-fidelity in simulation refers to a high level of realism and immersion achievable in a simulated environment. More than traditional high-fidelity simulation, ultra-fidelity takes this concept to the next level by incorporating advanced technologies and techniques to create an even more authentic experience. We developed a unique ultra-fidelity simulation center in Toulouse (SENS project) to mimic real life out-of-hospital situations and wanted to compare the requirements of ultra-fidelity with the achievement of the simulation center.
Methods: Ultra-fidelity likely involves several key features, such as advanced graphics and visuals, realistic physics and interactions, immersive audio and dynamic environments and scenarios. We designed and implemented over a 6 years period (2018-2024) a unique ultra-fidelity simulation center with the help of dedicated engineers and technicians (Cegelec defense, Toulouse, France). We made a comparative study of what we wanted and what was possible due to technical and financial constraints, concerning 13 criteria (surface, height, temperature, video projection, sound, vibrations and blast effects, explosions, rain, fog/smoke, snow, wind, heat radiation and odors. Each criterion is graded as fully reached, partially reached or not possible. Statistics are displayed as number (percentage).
Results: As a result, the center was finished on April, 25th, 2024, with 10 out of 13 criteria (77%) totally achieved and 3 (23%) partially achieved. Concerning the area of the zone, we wanted a 150 m2 working space, which was reached (final surface of 144 m2), the height requirements were also reached (4 m), the range of working temperatures was supposed to go from -5° à 30°C and was considered reached (-4°C to 40°C). The following devices were fully implemented as requested, such as sound effects from 10 to 95dB, vibrations and blast effects, explosions simulation, smoke/fog with an opacification rate from 0 to 95%, heat radiation on a wall (with ten 2000 watts heat infrared radians), snow (from 0 to 5 cm/h) and odors (+200 available such as oil, sulfur, cinder, rot, cellar, solvent, rubber, turpentine, blood, etc.). The following requirements were considered as partially reached, such as video projection (360° required versus 270° when finished, as a wall was designed to be the technical wall with the entrance gates and doors), rain which was designed to go up to 50 mm/h and was only 30 mm/h during tests, and wind, as ventilators were used in an enclosed area and could not reach the requested 50 km/h. No criterion was impossible to develop.
Conclusion: The SENS simulation tool represents a unique and significant advancement in medical education, providing learners with an immersive and effective learning experience. It offers an innovative approach to teaching and clinical practice. By providing a safe and controlled environment for learning, SENS allows learners to develop and refine their clinical skills without risking patient safety. Moreover, the flexibility of SENS enables adaptation of simulation scenarios to different levels of proficiency and specialty, making it a versatile tool for continuous medical education.
Trial Registration: This study has not been registered because it was not a clinical work
Funding: This study did receive funding from SENS project (European funds managed by the Occitanie region, REACT-EU recovery plan)
Ethical approval and Informed consent: Not needed
Léa ZERDOUD, Vanessa HOUZE-CERFON (TOULOUSE), Benoit VIAULT, Anne RAYNAUD-LAMBINET, Virginie SANGAY, Vincent BOUNES
00:00 - 00:00
#41244 - Development of a sepsis screening algorithm for the ED: can we improve on qSOFA and NEWS-2?
Development of a sepsis screening algorithm for the ED: can we improve on qSOFA and NEWS-2?
Background: Every fifth death worldwide is associated with sepsis. Patients in the emergency department with suspected acute infection must be screened for sepsis in order to identify septic patients as early as possible to improve outcome and reduce mortality. Currently, screening is performed using clinical scores calculated from vital signs, with the recommended National Early Warning Score (NEWS-2) outperforming the simpler quick Sequential Organ Failure Assessment (qSOFA). However, the complexity of the NEWS-2 reduces its clinical utility unless the vital signs are digitized, and the score is calculated automatically. If the data are already digitized, a machine learning classifier may improve on classical scoring systems. This study aimed to assess whether a simple machine learning classifier could outperform established scores.
Methods: From three prospective trial cohorts from the emergency department at Charité Campus Benjamin Franklin, Berlin, Germany, characteristics and vital signs of n=747 patients, taken at the point of presentation to the ED, were collected. An expert panel had adjudicated each case to assess whether patients had or developed sepsis within 72 hours of presentation, which n = 138 (18.5%) did. The database was randomly divided into a training cohort (70%, n = 523) and a test cohort (30%, n = 224). A lasso regularization analysis was performed to select the relevant parameters and a logistic regression classifier was trained. The Area Under the Receiver Operating Curve was used to assess the performance. A web app was built using R-Shiny to demonstrate the classifier. Further, the linearity of relationships between individual parameters and the risk of sepsis was assessed by segmenting the parameter values into 10 bands and performing a linear regression on the rates of sepsis by band.
Results: The lasso regularization resulted in the following parameters being included in the score: Glasgow Coma Scale (GCS), systolic pressure, O2 therapy, SpO2, respiratory rate, heart rate, body temperature, and age. The final algorithm identified/predicted sepsis with an AUROC of 0.87 (95% confidence interval: 0.81 – 0.92), significantly higher than NEWS-2 (0.83, 95%-CI: 0.77 – 0.90, p = 0.03) and qSOFA (0.75, 95%-CI: 0.67 – 0.84, p < 0.01). The webapp is available via sepsis-score.shinyapps.io/calculate/. While most parameters showed an overwhelmingly linear relationship, heart rate and temperature both showed parabolic tendencies with both low and high values associated with sepsis.
Discussion & Conclusions: The study above shows a proof-of-concept approach for using machine learning models for sepsis screening. While the logistic regression classifier, which assumes a linear relationship between the predictors and outcome, performed well, the analysis showed this to be an oversimplification with certain relationships being more parabolic. This indicates that better performance could potentially be achieved using more complex models, however this would require more training data to avoid overfitting. Considering classical scores have always been free and transparent, the same should apply to machine learning screening scores. However, to achieve this, hospitals and universities must collaborate and share data to develop effective classifiers.
No trial registration was required for this analysis. The trials from which the data draw were registered in the German Trial for Clinical Trials (IDs DRKS0017395, DRKS00020521).
Noa GALTUNG (Berlin, Germany), Eva DIEHL-WIESENECKER, Wolfgang BAUER
00:00 - 00:00
#42224 - Development of smart algorithms for clinical decision support in the emergency department – results of a pilot study.
Development of smart algorithms for clinical decision support in the emergency department – results of a pilot study.
In Germany preclinical and clinical emergency care represents a complex and challenging professional field of action due to a rapidly rising number of emergency cases, a high expenditure of time and costs. Under these frame conditions failure in diagnoses and treatment may especially occur in emergency departments (EDs) where trainees are engaged without direct professional supervision by medical specialist staff. To address this issue smart emergency algorithms were developed by artificial intelligence based methods to support clinical decision support for emergency diagnoses.
In the project ENSURE funded by the German Federal Ministry of Health the prototype of a clinical decision support sytem (CDSS) was developed by using a rule based system according to standard operating procedures. Furthermore, a machine learning model was trained on real patient data sets extracted from electronic health records of the ED information system and from the national registry of the medical emergency departments in Germany (AKTIN-registry). The ENSURE prototype was then tested in a clinical pilot study over a period of 9 months within three study centers to evaluate the CDSS performance for the most frequent twenty tracer diagnoses in comparison to a 9 month control phase (Trial Registration DE-22-00013946). Key performance indicators included the length of stay (LOS) within the ED and the diagnostic conformity between admission and discharge resp. transfer diagnoses
In the pilot study n=3.199 patients in the control phase and n= 1.664 patients were recruited in the interventional phase. Baseline characteristics of ED patients were comparable between these study periods. A significant reduction of the LOS was detected in the interventional group revealing a mean reduction of up to 40min (p<0.01). Furthermore, the diagnostic conformity could be improved from 75% in the control phase to over 88% of cases in the intervention ohase; furthermore, the percentage of missing diagnostic conformity could be significantly reduced (p<0.02).
In this project a CDSS for emergency diagnoses was successfully developed on the basis of explanaible AI models. Results of the pilot study revealed that implementation of this CDSS prototype may optimize both patient flow and diagnostic processes within the ED. The CDSS ENSURE thus may improve the quality of emergency care even under challenging surrounding conditions.
Trial Registration: DE-22-00013946
German Federal Ministry of Health Grant No. ZMII 2520DAT803
Sabine BLASCHKE (Germany, Germany), Frank SCHULTZE, Harald DORMANN, Katrin ESSLINGER, Zully RITTER, Michael SCHMUCKER, Faisal RASHID, Stefan RUEHLICKE, Michael DIETRICH, Martin HAAG
00:00 - 00:00
#42399 - Diabetic ketoacidosis (DKA):epiemiological aspects and caracteristcs.
Diabetic ketoacidosis (DKA):epiemiological aspects and caracteristcs.
Diabetic ketoacidosis (DKA) is a life-threatening emergency requiring appropriate and urgent management. The aim of this study was to describe the epidemiological, clinical, therapeutic and evolutionary characteristics of children admitted to the pediatrics and neonatology department of Bizerte University Hospital for DKA.
This was a retrospective study spanning five years from January 1, 2018 to December 31, 2022, carried out in the pediatrics department of the Habib Bougatfa University Hospital in Bizerte; including all children hospitalized for ACD and whose management was initiated in the department.
We included 44 cases of ACD, 68% of which were inaugural. The mean age was 9±2 years, with a female predominance (gender-ratio=0.4). Initial symptoms were dominated by a polyuro-polydipsic syndrome (n=10), asthenia (n=23), abdominal pain (n=14) and vomiting (n=26).
Clinical examination on admission revealed dehydration (12 cases), Kussmaul dyspnea (12 cases), acetonemic breath (4 cases), hemodynamic disorders (7 cases) and disturbed consciousness (2 cases).
Mean blood glucose was 25.2±10 mmol/l, with glycosuria and acetonuria averaging 3 crosses each. Mean pH and bicarbonate values were 7.17±0.14 and 8.6±0.2 mmol/l respectively. Mean corrected natraemia was 134.5 mmol/l and mean corrected kalaemia was 3.1 mmol/l. ACD was classified as moderate in 17 cases (38%). Severe forms were more frequent in patients over 4 years of age.
Patients were managed according to the ISPAD protocol. the average duration of the protocol was 24 h, with good clinical and biological evolution.
aucun conflit
Olfa HAMMAMI, Manel KALLEL (Tunis, Tunisia), A JELASSI, S GUEBLIA, I KHAMASSI
00:00 - 00:00
#42263 - Diagnostic accuracy for stroke of the STANDING algorithm in patients with isolated vertigo, a multicentre study.
Diagnostic accuracy for stroke of the STANDING algorithm in patients with isolated vertigo, a multicentre study.
Introduction
Vertigo is a frequent cause of emergency department (ED) visits. The incidence of cerebrovascular disease in patients presenting with isolated vertigo is between 2 and 6% and vertigo represents the symptom most commonly associated with a missed diagnosis of ischemic stroke. The aim of our observational prospective multicentre study (STANDING-M) was to evaluate the diagnostic accuracy of the STANDING algorithm for the diagnosis of ischemic stroke. As secondary outcomes we assessed the safety of discharge from ED for patients with a benign STANDING and its effectiveness in decreasing the number of neuroimaging tests and of ENT or neurological consultations.
Materials and methods
We enrolled a convenience sample of adult patients with vertigo or unsteadiness presenting to four EDs in Tuscany (Ethical committee n° ID 22817). The STANDING, previously validated by our group in a single-centre prospective study, is composed by four items testing for: 1) the presence of spontaneous nystagmus 2) plane and direction of nystagmus 3) head impulse test 4) upright position. After the evaluation of inclusion and exclusion criteria, the patient underwent to STANDING or to standard examination according to the presence on duty of a physician trained for STANDING. Subsequent instrumental and laboratory tests, consultations, admission or discharge were disposed by the attending physician (trained or not for STANDING) independently from the participation in the study. The reference standard was a diffusion-weighted MRI of the brain and 30-days follow-up by senior vestibologists. During follow-up we registered the occurrence of the following adverse events: all cause death, diagnosis of central vertigo in particular ischemic stroke, the need of thrombolysis or mechanical thrombectomy, neurosurgical intervention, re-admission into the ED for vertigo.
Results
Four hundred and sixty-nine patients were enrolled. Thirteen (2.8%) patients were lost at follow-up and 456 patients were finally included, 242 (53.1%) evaluated with STANDING and 214 (46.9%) with standard examination. The mean age was 60 years (range 18–99) and 62.5% were females. No difference in age, gender and prevalence of principal cardiovascular risk factors were present in the two groups. The prevalence of central vertigo was 9.6% (44 patients), with ischemic stroke as leading cause (19 patients, 4.2%) without differences between STANDING and standard group. According to STANDING, 208 (85.9%) patients were considered as having a benign disease and 34 (14%) a suspected central one. The sensitivity, specificity, negative predictive and positive predictive values of STANDING for stroke were 100% (95% CI 69-100), 89.7% (95% CI 85-93.3), 100% (95% CI 98.2-100), and 29.4% (95% CI 22.2-37.8), respectively. During follow-up, nobody dead, 2 patients (1%) with a benign STANDING had a diagnosis of central disease other than stroke and 5 (2.4%) were hospitalized. The number of head CT and of ENT/neurological consultations in the STANDING group was significantly lower in comparison to those evaluated with standard examination (51.7% vs 70.6%, p<0.001).
Discussion & Conclusions
The STANDING algorithm showed a very high negative predictive value in excluding a diagnosis of stroke in ED and is associated with a significantly lower request of radiological tests and specialist consultations.
Mattia RONCHETTI (, Italy), Paola BARTALUCCI, Giulia CANAROLI, Giuseppe PEPE, Simone MAGAZZINI, Ersilia DE CURTIS, Maurizio BARTALUCCI, Rudi PECCI, Claudia CASULA, Paolo VANNUCCHI, Andrea PAVELLINI, Cosimo CAVIGLIOLI, Peiman NAZERIAN, Simone VANNI
00:00 - 00:00
#41531 - Diagnostic Test Accuracy of the Emergency Severity Index: a Systematic Review and Meta-analysis.
Diagnostic Test Accuracy of the Emergency Severity Index: a Systematic Review and Meta-analysis.
Background: Efficient triage of emergency patients is crucial for the immediate identification of critically ill individuals and enables rapid interventions to improve patient outcomes. This review aims to comprehensively evaluate the diagnostic test accuracy (DTA) of the Emergency Severity Index (ESI) in detecting high urgency of treatment in adult patients in the emergency department (ED).
Methods: For this systematic review, we considered all studies that evaluated the DTA of the ESI in emergency care. We included case-control and cohort studies involving patients aged 14 years and older attending an ED. The outcome of a triage system is the high urgency of treatment. Accordingly, triage systems aim to identify (‘diagnose’) those in need of highly urgent treatment at the time of triage. However, as there is no generally applicable reference standard for this outcome, admission to the intensive care unit (ICU) and mortality are usually used as a reference standard. A comprehensive search strategy was applied in several electronic databases (MEDLINE, Web of Science, SCOPUS and Embase) in October 2023. Screening of the identified hits was performed independently and in duplicate using Covidence. Data extraction and assessment of methodological quality, in accordance with the QUADAS-2 instrument, was also carried out independently in duplicate. Disagreements were resolved through discussion or by involving a third person as an arbitrator.
We calculated two by two tables of triage system against the reference standard for each individual study. We calculated sensitivities and specificities and presented the results as forest plots. We aimed to summarize the diagnostic accuracy data using a bivariate random effects model.
Results: The electronic search identified a total of 2,553 studies. After removing duplicates, 1,165 studies underwent title and abstract screening and 80 fulltexts were screened. Finally, a total of 25 studies were included.
Most studies were conducted in academic hospitals (n=22; 88%) and ten studies (40%) were conducted in Europe. Twenty studies (80%) were single center, the median number of participants was 1,830 (IQR 610 to 6.859).
Nine studies (36%) had a high risk of bias in at least one domain, one study had a high risk of bias in two domains. The most common reasons for concern were type of patient selection, inclusion and exclusion criteria and type of sampling.
Pooled estimates could be calculated for mortality in 13 and admission to ICU in 5 studies. Pooled sensitivity was 0.81; 95% CI [0.68;0.89], and 0.93; 95% CI [0.57;0.99], and pooled specificity was 0.72; 95% CI [0.63;0.81] and 0.88; 95% CI [0.79;0.93], respectively, with diagnostic odds ratios of 11.20; 95% CI [5,43;23,10] and 99.97; 95% CI [5,81;1719,32].
Discussion & Conclusions: ESI showed a moderate to high diagnostic accuracy in predicting mortality and admission to ICU, risk of bias was moderate to high. Results support the use of the ESI as part of clinical decision-making, when limitations are taken into account.
Registration: The study protocol was registered with the international prospective register of systematic reviews (PROSPERO CRD42023456720), in accordance with the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy Version 1.0.0.
Funding: This research project was funded by the state of Tyrol, Austria (“Tiroler Nachwuchsforscher*innenförderung”). [Grant #: F.47908/6-2023]
Bettina WANDL (Vienna, Austria), Jan Daniel KELLERER, Verena FUHRMANN, Karina TAPINOVA, Gerhard MÜLLER, Dominik ROTH
00:00 - 00:00
#41933 - Differential effects of cold-stored and room-temperature platelets in correcting trauma-induced coagulopathy: an ex vivo spiking study in a small trauma patient cohort.
Differential effects of cold-stored and room-temperature platelets in correcting trauma-induced coagulopathy: an ex vivo spiking study in a small trauma patient cohort.
Background: Severely injured patients may develop trauma-induced coagulopathy (TIC), a haemostatic dysregulation comprising thrombocytopenia and platelet dysfunction that is associated with increased mortality. Current room-temperature platelet (RTP) transfusion regimens provide a benefit in terms of clinical haemostasis and patient survival. However, recent in vitro evidence suggests that cold-stored platelets (CSP) may be superior to RTP in supporting haemostatic functions in addition to prolonging the shelf life of platelet components. As the effect of these blood products on TIC have not been fully characterised, we aimed to compare the ability of CSP versus RTP to correct ex vivo platelet-related haemostatic parameters in patients with TIC.
Methods: Admission blood samples were collected from adult trauma patients who required activation of the major haemorrhage protocol and were enrolled into a prospective cohort study (ISRCTN12962642) at a UK major trauma center between October 2021 and April 2022. Each sample was spiked ex vivo with a volume of RTP or CSP equivalent to 2 platelet pools. ROTEM was performed on non-spiked and spiked samples. Early platelet contribution to clot strength (EXTEM-FIBTEM A5) was used as primary outcome. Platelet count was measured using flow cytometry, while aggregation and agglutination were quantified by multiple electrode aggregometry. RTP and CSP were stored at 22°C and 4°C respectively for up to two weeks. Continuous variables are reported as median and interquartile range and categorical variables as percentage. Results are reported as differences between spiked and non-spiked samples. Paired statistical tests (Wilcoxon matched-pairs signed-rank test and McNemar test) were used.
Results: Samples from 10 adult trauma patients were analysed. Patients’ median age was 32 years (22-49), 100% were male, 50% suffered a blunt injury with a high injury severity score (ISS 26, 18-40). TIC was present in 70% (EXTEM A5 <=40mm), 50% had platelet dysfunction (EXTEM-FIBTEM A5 <=30mm) and 50% died. RTP increased EXTEM-FIBTEM A5 more effectively than CSP (4 mm, 2-7, vs 2 mm, 1-5, p=0.028). Similar findings were present in terms of EXTEM A5 and other ROTEM measures of clot formation dynamics. Both RTP and CSP-spiking reduced the overall incidence of TIC, while RTP more effectively corrected platelet dysfunction. On the other hand, platelet count and aggregation were better preserved or improved by CSP-spiking. In particular, aggregation in response to arachidonic acid was significantly increased by CSP (10 AU, 3-20, vs 0 AU, 0-3, p=0.014). When spiking with RTP stored for up to a week was compared to CSP stored for up to fourteen days, a significantly larger improvement in ROTEM parameters of early clot strength and clot dynamics was present in favour or RTP, with only minimal differences in terms of aggregation.
Conclusions: When compared ex vivo, RTP and CSP have differential biological haemostatic benefits on platelet-related haemostatic parameters frequently deranged in patients with TIC, with RTP better supporting early clot strength and clot dynamics and CSP leading to higher platelet aggregation. Further investigations are required to assess the clinical haemostatic benefit of CSP over RTP before their implementation in the haemostatic resuscitation of trauma patients.
Andrea ROSSETTO (Firenze, Italy), Paul VULLIAMY, Laura GREEN, Ross DAVENPORT
00:00 - 00:00
#40705 - E(co)-health evolution: life cycle analysis of virtual fracture care and the shift from defensive to sustainable medicine.
E(co)-health evolution: life cycle analysis of virtual fracture care and the shift from defensive to sustainable medicine.
Introduction: The Virtual Fracture Care method (VFC) is designed to minimize follow-up visits for trauma patients with non-complex and stable injuries by embracing a greater risk acceptance. It poses a significant reduction in outpatient visits, follow-up imaging studies and costs, while maintaining comparable health outcomes. These reductions might contribute to less personnel and resource utilization which could contribute to the goals of the Dutch healthcare sector to cut CO2 emissions by 55% by 2030. This study aims to assess the environmental impact of the VFC by comparing its direct discharge (DD) approach the previous pre-DD over one year for the most common injury; the torus-/greenstick fracture.
Method: A process-based life cycle analysis (LCA) was used to compare the carbon footprint of the pre-DD vs DD treatment for the torus-/greenstick fracture. Data of material use, waste, packaging, material transport, energy of the building, staff- and patient travel was collected. Environmental impact was calculated using SimaPro software and the ReCiPe 2016 method. Key contributors were identified and tested for robustness via contribution and sensitivity analysis.
Results: Results show a 4.2 kg CO₂ eq [IQR: 2.7-6.9] difference per treatment between the pre-DD and DD methods, equivalent to a 1.0 ton CO₂-eq [IQR: 0.6-1.6] reduction annually.
Contribution analysis highlights raw materials as the primary contributor (1.6 kg CO₂-eq), followed by waste (0.2 kg CO₂-eq), transportation and packaging (0.1 kg CO₂-eq each). The DD method includes the highest-emitting products: wrist brace (0.7 kg CO₂-eq) and sling (0.4 kg CO₂-eq), while in the pre-DD method, the softcast ranks highest at 0.3 CO₂-eq.
Sensitivity analysis focuses on the patient travel movement (PTM), indicating a 3.9 kg CO₂-eq [IQR: 2.4-6.7] reduction with 100% car transport, translating to a 1.0-ton CO₂-eq [IQR: 0.6-1,6] annual decrease. Even with the use of an electric bus, the difference remains at 0.3 ton CO₂-eq [IQR: 0.2-0.5] annually. A mixed transport mode of 20% by foot, 25% by electric bus, and 55% by car results in a 0.6-ton CO₂-eq [IQR: 0.4-1.2] reduction over one year.
Conclusion: The life cycle assessment demonstrates a substantial reduction in the environmental footprint associated with the torus-/greenstick fracture treatment after implementing the VFC method.
Discussion: This study acknowledges limitations, including the unknown environmental impact of the VFC app due to unavailable energy consumption data. Challenges in obtaining detailed product information led to material weighing and sometime educated assumptions, while SimaPro limitations constrained uncertainty calculations. Generalized infograms influenced building and healthcare provider energy consumption estimates, and PTM data skewed by the median may lack population diversity representation. Despite these inherent uncertainties, the study provides valuable insights into the environmental impact of ED care.
Implications: This study provides valuable insights into the reduced environmental impact of the VFC method. It suggests that embracing a greater risk acceptance, as exemplified, can contribute to achieving environmental goals and alleviating pressure on the healthcare system. The potential for allowing less defensive medicine in other healthcare areas to reduce environmental impact, warrants further exploration.
Importance of the Research Question:
The research is crucial as it seeks to quantify the environmental impact difference between the traditional pre-DD method and the VFC method in the treatment of torus-/greenstick fractures. Understanding the environmental impact of healthcare interventions is vital not only for sustainability but also for fostering a transition in healthcare delivery. The findings may inspire healthcare practitioners, contributing to a more environmentally conscious approach.
By investigating the environmental consequences of the VFC method, the research indirectly addresses the intersection of ecological sustainability and healthcare efficiency. This dual perspective is critical in shaping healthcare policies that align with both environmental stewardship and effective patient care. As healthcare systems globally grapple with resource challenges and the need for eco-friendly practices, the findings from this study can make a beginning in contributing to a better understanding of the potential benefits and challenges associated with modern healthcare approaches. Ultimately, the research question delves into the potential of technology-driven healthcare solutions influencing environmental practices.
What is Already Known:
There is a limited amount of literature regarding Life Cycle Assessments within the healthcare sector, especially in the Emergency Department. The study acknowledges this gap and emphasizes the need for research in this area.
This study seeks to build upon this existing knowledge gap by focusing on the environmental implications of the Virtual Fracture Care app, providing insights into a novel and transformative healthcare approach.
Main Aim and Research Question or Major Tested Hypothesis:
The main aim of the study is to quantify the environmental footprint difference between the traditional pre-DD and the VFC method in the treatment of torus-/greenstick fractures. The primary research question involves assessing the carbon footprint associated with each method, emphasizing the reduction in patient transport as a potential contributor to environmental gains.
Trial Registration:
n.a.
Funding:
This research project was conducted without external financial support. No funding was secured for the study, and all associated costs were covered by internal resources.
Ethical Approval and Informed Consent:
Given the nature of the study, which did not involve the use of personal patient data, ethical approval and informed consent were deemed unnecessary. The research solely focused on environmental impact assessment, utilizing aggregated data and anonymized information. As a result, the study adhered to ethical standards by avoiding any involvement with sensitive patient data, thereby eliminating the need for formal ethical approval and informed consent procedures. This approach ensures the protection of privacy and upholds ethical considerations in the absence of direct patient involvement or data utilization.
Nicole VAN VLIJMEN (Utrecht, The Netherlands)
00:00 - 00:00
#40808 - Effect of Added Inhaled Corticosteroids to Systemic Steroids on Acute COPD Exacerbations Outcomes.
Effect of Added Inhaled Corticosteroids to Systemic Steroids on Acute COPD Exacerbations Outcomes.
Abstract
Background: Chronic Obstructive Pulmonary Disease (COPD) exacerbations are a major cause of morbidity and mortality. Although inhaled corticosteroids (ICS) have a role as long-term treatment, their efficacy in acute exacerbations, particularly as an adjunct to systemic steroids, remains unclear.
Methods: In this retrospective observational study, we analyzed data from 870 patients admitted with acute exacerbations of COPD (AECOPD) to a tertiary medical center in Israel from January 2018 to January 2023. We investigated the impact of adding ICS to standard systemic steroid treatment on hospital length of stay, intubation rates, and 30-day mortality using propensity score matching to account for confounders.
Results: The cohort, after matching, included 354 patients treated with systemic steroids and ICS, and 121 treated with systemic steroids alone. All characteristics were similar between the groups. Our analysis showed no differences in 30-day mortality (7.1% vs. 5.8%, p=0.63) or secondary outcomes (intubation, hospital length-of-stay, and readmission rates) between the groups. Subgroup analyses based on different eosinophil levels did not alter these findings. In multivariate analysis among the general cohort, eosinophil count <150 cells/μL (adjusted OR 0.45, 95% CI 0.21-0.87, p=0.02) and high Charlson score (AOR 1.19, 95% CI 1.02-1.37, p=0.02) were independent predictors for 30-day mortality.
Discussion: Despite the known benefits of ICS in managing chronic COPD, we did not find an added value of ICS to systemic steroids in acute exacerbations. These results underscore the necessity for individualized treatment strategies and further research into the role of ICS in AECOPD.
Noa SHOPEN (Tel Aviv, Israel)
00:00 - 00:00
#42365 - effect of gender on presentation and outcome of renal colic in the emergency department.
effect of gender on presentation and outcome of renal colic in the emergency department.
Introduction:
Pain is a widespread problem, affecting both men and women; studies have found that women in the emergency department represent some difference compared with men in the management of renal colic.
Objectives: To examine gender-related differences in the presentation, management, and outcomes of patients admitted to the emergency department (ED) with ureteral stones.
Methods: Prosrospective analysis during 01 year of all patients admitted to the ED at our institution, found to have a ureteral stone on CT. Clinical, laboratory, imaging parameters, and outcomes were collected.
Results: We collected 226 patients with renal colic. 52%% (n = 116) were males and 48% (n = 109) were females. The mean ages were 47±14 and 46±16 in males and females, respectively (p = 0.8). Female patients presented with more dyslipidemia (p=0.005) and HTA(p=0,03), a higher body temperature (p = 0.049), pulse rate (p < 0.0001), nausea and vomiting (p = 0.003), elevated serum C-reactive protein (CRP) (p = 0.002) compared to males. The prevalence of elevated serum creatinine was higher in males (p < 0.01). Analgésics were recommended on discharge without a significant difference between the two sex(p= 0.123). Spontaneous stone expulsion was significantly higher in males compared to females (p = 0.01).
Conclusions: Our results demonstrate that gender does effect presentation and outcome of patients presenting with renal colic. Females were found to have elevated infectious parameters, more nausea and vomiting and a higher incidence of positive urine cultures. Males admitted to the ED were found to have significantly higher serum creatinine levels and spontaneous stone expulsion rate
aucun conflit d'interet
Khedija ZAOUCHE, Manel KALLEL (Tunis, Tunisia), Malek CHAKROUN, Salma MARRAKCHI, Sonia AISSA, Ramla BACCOUCHE
00:00 - 00:00
#41359 - Effectiveness of urgent psychological therapy in the prevention of postpartum depression.
Effectiveness of urgent psychological therapy in the prevention of postpartum depression.
INTRODUCTION
Hormonal changes during pregnancy and the presence of obsessive traits (OT) increase the likelihood of anxiety disorders (AD) and postpartum depression (PPD). This can have consequences in the development of the newborn, so it is a priority to act urgently in a pharmacological and/or psychological way. Cognitive behavioral therapy (CBT) is a non-pharmacological intervention, which applied by an specialist with experience, has shown effectiveness in the treatment of mental disorders.
OBJECTIVE
To test the effectiveness of an urgent CBT program to minimize the risk of DPP in pregnant women.
METHOD
Pregnant women with clinical anxiety and/or depression, referred urgently to the perinatal psychology unit of the Sexual and Reproductive Health Care Program at the Hospital del Mar in Barcelona (Spain) were retrospectively included. All pregnant women underwent a first clinical visit in which the Hospital Anxiety and Depression Scale and the list of symptoms of obsessive personality from the Structured Clinical interview for DSM, Axis II were administered. Two groups were established regardless of whether they were under pharmacological treatment: Control group (CG), pregnant women without psychological follow-up and therapy group (CBTG), pregnant women with CBT. Follow-up was carried out for six months postpartum. A comparative study was carried out between both groups using the SPSS 27.0 statistical program.
RESULTS
Seventy-two patients with an average age of 33 years (standard deviation (SD) 5.23, range 20-46) and an average gestational age of 22 weeks (SD 8, range 8-37) were included. Forty per cent of pregnant women presented DPP, 60% AD and 71% clinical OT. Twenty-nine per cent of pregnant women followed pharmacological treatment with a selective serotonin reuptake inhibitor (SSRI) and/or benzodiazepines (BZD). Twenty-five pregnant women were included in the CG and 47 in the CBTG.
When comparing both groups, statistically significant differences were obtained in the development of PPD/AD postpartum (CG: 68%, CBTG: 21%; p<0.001), and in the subgroups of patients treated with SSRI/BZD (CG: 100%, CBTG: 43%; p=0.013), not treated pharmacologically during pregnancy (CG: 53%, CBTG: 17.5%; p=0.006) and in pregnant women with OT (CG: 69%, CBTG: 17%; p<0.001). There were no differences between groups in the development of postnatal hormonal syndrome (baby blues) during the first postpartum month (CG: 76%, CBTG: 64%; p=0.292).
CONCLUSIONS
Urgent psychological intervention based on CBT decreases the possibility of PPD in pregnant women with anxious and/or depressive symptoms during pregnancy and especially stabilizes the obsessive traits as a vulnerability factor. Pharmacological treatment combined with CBT is more effective than treatment with drugs alone. It would be advisable to implement CBT therapies in the perinatal units promptly.
Susana GARCIA-BLANCO (Barcelona, Spain), Daniel BERGE, Ángeles MALAGON, Ferran LLOPIS, Georgina PICAS, Luis Miguel MARTIN
00:00 - 00:00
#41965 - Efficacy and medico-economic analysis of ambulatory management of primary spontaneous pneumothorax by emergency physicians: a prospective cohort study.
Efficacy and medico-economic analysis of ambulatory management of primary spontaneous pneumothorax by emergency physicians: a prospective cohort study.
Introduction
Pneumothorax is a condition that can be managed on an outpatient basis. In France, however, hospitalization from the emergency department (ED) is still very common. Since 2015, we have developed ambulatory management of ED patients presenting with primary spontaneous pneumothorax (PSP), in collaboration with pulmonologists. The primary objective of this study is to assess the feasibility and efficacy of primary spontaneous pneumothorax ambulatory management by emergency physicians. The secondary objective is to analyse the cost of this outpatient management.
Methods
This is a prospective, single center observational study conducted from 13/03/2015 to 12/11/2020 in the adult ED of a university hospital, in a cohort of ED patients presenting with a PSP or a first non-traumatic recurrence refuted from surgical management. Approval was obtained by the hospital review board, with a waiver of written informed consent, as study was part of standard medical practice assessment.
Initial ED management for PSP includes drainage or monitoring alone, depending on the size of the pneumothorax. When the chest X-ray shows an apical detachment of more than 3 cm and/or a lateral detachment of more than 2 cm, drainage is performed using a small pigtail drain and a one-way valve. After a 6h observation in our ED short-stay unit, patients showing clinical improvement and radiographic lung reexpansion are discharged home if they meet the discharge criteria. They are followed up by telephone at day 1, and are clinically reassessed by an emergency physician at day 2 or day 3. This is followed by a day hospitalisation in the pneumology ward on day 7. Hospitalisation at the end of the ED index visit or during the 7-day follow-up is considered a failure of ambulatory management. A medico-economic analysis was conducted at the level of the health insurance system to assess the costs incurred by outpatient management as compared to hospitalisation.
Results: out of the 179 ED patients with a PSP, 159 patients eligible to outpatient management were included. Patients were mostly men (83%), mean age was 27 (9) years, mean BMI was 20 (3) kg/m2. 129 (81%) patients underwent thoracic drainage, 108 (68%) at the ED index visit, 21 (13%) during follow-up. 118 (77%) had exclusive ambulatory management, 36 (23%) were hospitalised at the end of the ED index visit (12%) or within the 7 day follow up period (12%).
The cost of PSP management by emergency physicians in collaboration with pneumologists, was 1459 euros per patient when carried out exclusively on an outpatient basis, and ranged from 1783 to 5213 euros per patient when hospitalization was required, a difference of at least 22%.
Conclusion
Ambulatory management of PSP by emergency physicians, with post ED index visit evaluation at day 2 or 3 and the possibility of secondary hospitalisation depending on progress, is safe and effective. Its tolerability is excellent and patient comfort is improved. In addition, a medico-economic approach shows that outpatient management leads to a reduction in costs, which is relevant given the scarcity of financial resources in the healthcare system.
Trial registration : observational cohort study not registered /
Funding : no specific funding, support from our university hospital
Julien PORTALES (Montpellier), Juline BERINGER, Marina MAZZIA, Sophie LEFEBVRE, Anne-Sophie GAMEZ, Arnaud BOURDIN, Mustapha SEBBANE
00:00 - 00:00
#42125 - Elderly Cerebral I/R Injury: Aggravation of Neuronal Damage by Senescent Microvascular Endothelial Cell-Derived Small Extracellular Vesicles.
Elderly Cerebral I/R Injury: Aggravation of Neuronal Damage by Senescent Microvascular Endothelial Cell-Derived Small Extracellular Vesicles.
Background: The incidence of cardiac arrest (CA) escalates with age, and elderly patients experience poorer neurological outcomes after return of spontaneous circulation (ROSC). Communication within the neurovascular unit, particularly between brain microvascular endothelial cells (BMECs) and neurons, plays a crucial role in ischemia-reperfusion injury in the elderly. Moreover, small extracellular vesicles (sEVs) derived from senescent BMECs, as a senescence-associated secretory phenotype (SASP), are involved in signal communication between BMECs and neurons during cerebral ischemia/reperfusion (I/R) injury.
Methods: Young(8-10weeks) and aged(20-24months) C57BL/6J mice were utilized to establish the CA-CPR-ROSC model via electrical stimulation through the esophagus. Primary BMECs and neurons were used in vitro experiments. Senescence in BMECs was induced in vitro using D-(+)-Galactose. sEVs were isolated by ultracentrifugation thereafter. Aging-related proteins, BMEC-sEVs secretome and neuronal damage were evaluated by western blot analysis and immunofluorescence staining.
Results: Aged mice exhibited a significantly higher rate of neuronal apoptosis after ROSC, with decreased levels of neuronal synaptic proteins. More pronounced senescence in BMECs and increased secretion of plasma sEVs were observed in age mice. In vitro, senescent BMECs secreted more sEVs compared to young BMECs. Furthermore, early intravenous administration of senescent BMEC-sEVs exacerbated neuronal apoptosis and the reduction in synaptic protein levels in young mice after ROSC, whereas young BMEC- sEVs mitigated these effects.
Conclusion: Acting as the SASP, senescent BMEC-sEVs could partly account for the worse neuronal damage in aged mice after ROSC. The regulatory effects of senescent BMEC-sEVs on neuronal apoptosis and alternations in synaptic protein levels are reflected by changes in sEVs secretion and their contents. This provides evidence for cell communication within neurovascular units after ischemia-reperfusion injury in the elderly, however, the specific regulatory mechanism requires further investigation.
Funding: National Natural Science Foundation of China (82272241)
Wen MA (Chengdu, China), Lu GAN, Yu CAO
00:00 - 00:00
#41285 - Emergency department observation unit (EDOU) in the management of acute pyelonephritis.
Emergency department observation unit (EDOU) in the management of acute pyelonephritis.
The aim of this study is to assess whether there are differences in the treatment of pyelonephritis between hospital wards and the emergency department observation unit (EDOU), particularly in terms of length of hospital stay.
Pyelonephritis, according to the European Association of Urology 2023 guidelines, is suggested by fever (> 38°C), chills, flank pain, nausea, vomiting, or costovertebral angle tenderness, with or without the typical symptoms of cystitis. It can be uncomplicated if it occurs in non-pregnant, pre-menopausal women with no known relevant urological abnormalities or comorbidities. While uncomplicated cases can be managed conservatively, complicated cases, including those with sepsis or persistent vomiting, require hospitalization for intravenous antibiotic therapy and proper hydration.
From February 27, 2021, to April 19, 2023, we collected data on all patients admitted to the Gemelli Hospital emergency department with a diagnosis of pyelonephritis. Demographic characteristics, symptoms, physical examination findings, past medical history, laboratory tests, and imaging results were analyzed.
We enrolled 183 patients, of whom 61 (48%) were males, with a mean age of 53 ± 19 years. 130 patients (71%) presented with fever, 114 (62%) with flank pain, and 94 (51%) with urinary symptoms. Upon physical examination, a positive Giordano sign was found in 55 patients (30%).
The Charlson Comorbility Index (CCI) was calculated for each patient.
78 patients had previously experienced a similar episode, and 74 were carriers of a septic focus (26 stents, 28 nephrostomies, 14 urinary catheters, 6 ureterocutaneostomies, 30 urinary lithiasis). More than 70% of patients underwent ultrasound of the urinary tract, while just over 50% underwent abdominal CT scan with contrast.
Laboratory tests revealed elevated markers of infection with an increase in white blood cell count, C-reactive protein, creatinine and procalcitonin. In 108 patients (59%), a urine culture was performed, resulting positive in 70%, and in 100 (55%), a blood culture was performed, resulting positive in 20%. The most frequently detected bacterium was Escherichia coli (32 patients, 36% of the total).
Empirical antibiotic therapy, primarily piperacillin/tazobactam, was initiated in 80% of patients, with 19 patients requiring an upgrade due to multidrug resistance. Results showed that 61 (33%) patients were admitted to the EDOU, and 122 to a ward. The average length of stay in the EDOU was significantly shorter (90 ± 47 hours) compared to the ward (240 ± 197 hours).
In the univariate analysis, age (p = 0.0001), history of previous surgeries on the urinary system (p = 0.004), CCI (p < 0.01), gender (p = 0.07), and discharge within 72 hours (p < 0.01) were significantly associated with admission to EDOU. In the multivariate analysis, only discharge within 72 hours after correction for the aforementioned factors was found to be independently associated with admission to EDOU (p < 0.001, OR 15.51, 95% CI 4.1–57.36).
In conclusion, the EDOU serves a vital role in providing both observation and treatment for pyelonephritis patients, with shorter hospital stays compared to traditional wards. This contributes to optimizing patient care and resource utilization in the management of acute medical conditions.
Ilaria BALSAMO (Roma, Italy), Marcello CANDELLI, Alberto MANNO, Angela SAVIANO, Maria LUMARE, Andrea LASSALLE, Marta SACCO FERNANDEZ, Giulia PIGNATARO, Andrea BENICCHI, Anna VASCOTTO, Camilla VALERIANO, Andrea PICCIONI, Francesco FRANCESCHI
00:00 - 00:00
#42394 - Emergency nursing competencies in the ER: expert perspectives.
Emergency nursing competencies in the ER: expert perspectives.
Background: In the emergency department (ER), contemporary nursing practice dynamically integrates three core elements: digital translation, escalating complexity within specific care contexts, and steadfast commitment to achieve health outcomes of paramount quality and excellence. The establishment of competency standards in this domain hinges on the synthesis of international, national, and institutional guidelines along with competence assessment models to inform the construction of a comprehensive professional curriculum tailored for emergency nurses. However, the heterogeneity of competencies outlined by international guidelines, coupled with the absence of clear and precise definitions at the national level regarding training needs, compromises the consensus necessary for standardization.
This study aimed to identify the level of consensus among experts regarding the training needs of nurses in the emergency room (ER). The findings of this study will inform the development of a training program aimed at operationalizing the cultivation of nursing competencies within the context of in-hospital emergencies.
Methodology: A quantitative, exploratory, descriptive, cross-sectional study design was used. A non-probabilistic convenience sample of 30 expert nurses participated in the study. Data were collected via a digital questionnaire featuring seven quick-answer, multiple-choice questions utilizing a 5-point Likert scale, encompassing characterization and agreement on 23 perceived training needs. Microsoft 365® facilitated the questionnaire construction and dissemination, Excel® was used for data compilation, and IBM® SPSS® Statistics 28 was used for statistical analysis.
Results and Discussion: To enhance comprehension, four variables pertaining to agreement on training needs were computed: approach to critically ill patients (4.67; SD±0.22), approach to the families of critically ill patients (4.30; SD±0.52), methodology and management of care provision (4.78; SD±0.22), and methodology and management of teamwork (4.50; SD±0.35), derived from the arithmetic mean of the scores for each variable surveyed. Subsequently, a composite variable was computed to reflect overall agreement on training needs (4.56; SD±0.26).
Conclusion: Given the intricate nature of the ER context and the recognized variability in competency definitions, the formal definition of a universal and contemporary emergency nursing competencies framework is deemed imperative. The alignment of expert nurses’ consensus on training needs in emergency nursing reflects the convergence of specialized knowledge, constituting a fundamental pillar for identifying knowledge and skill gaps. These findings underscore the importance of developing and tailoring content and training programs to enhance nurses’ emergency skills in clinical ER practice. This study contributes to the ongoing discourse surrounding the enhancement of emergency nursing competencies by emphasizing the importance of aligning training initiatives with the evolving healthcare demands. Collaborative endeavors are warranted to establish a robust and universally applicable competency framework that ensures excellence in emergency nursing practices. Additionally, ongoing evaluation and refinement of the competency framework should be prioritized to adapt to the changing healthcare landscape.
FCT/CINTESIS: UI/BD/151486/2021, DOI: 10.54499/UI/BD/151486/2021
João ROSA (Porto, Portugal), Paulino FERREIRA DE SOUSA, José PADILHA
00:00 - 00:00
#41291 - Enhancing Emergency Care for Older Persons: The Role and Impact of the Electronic Frailty Index.
Enhancing Emergency Care for Older Persons: The Role and Impact of the Electronic Frailty Index.
Objective: As the elderly population expands, improving Emergency Department (ED) care through research becomes crucial. A novel Electronic Frailty Index (eFI), developed from ED health records, aims to assess frailty and predict hospitalization, in-hospital mortality, ICU admissions, and 30-day ED readmissions. Materials and methods: This retrospective, single center study included patients sixty five year old or older who presented to the ED of IRCCS Humanitas Research Hospital in Milan, Italy., between January 2015 and December 2019. Frailty was assessed using a novel electronic Frailty Index (eFI), based on the cumulative deficit model, incorporating 45 health deficits to quantify frailty. Patients were divided into four quartiles based on eFI scores to explore the association between frailty levels and adverse outcomes, including hospitalization, in-hospital mortality, ICU admission, and 30-day ED readmission. Results: The study included 21,537 patients (mean age 77.4, 50.7% males). The median eFI score was 0.16. Hospitalization rates rose significantly with frailty, from 20% in the least frail quartile to 43% in the most frail. Similarly, in-hospital mortality and ICU admissions increased markedly with higher eFI scores, with mortality rates climbing from 0.44% to 5.0% across quartiles. The 30-day ED readmission rates significantly rose from 9.9% to 19.8%. For every 0.01 increase in eFI score, the odds of hospitalization, in-hospital mortality, ICU admission, and 30-day ED readmission significantly increased (P < 0.0001). Specifically, the adjusted odds ratios (OR) for hospitalization, in-hospital mortality, ICU admission and ED readmission rose to 3.55, 14.15, 4.70, and 2.22 respectively (P < 0.0001) in the most frail compared to the least frail quartile. Conclusions: The integration of the eFI into ED settings can enable more precise risk stratification and resource allocation, significantly improving patient management and healthcare delivery for older persons in these urgent care contexts.
Dana SHIFFER (Milan, Italy), Antonio DESAI, Matteo CESARI, Elena GENERALI, Massimiliano GRECO, Gabriele SAVIOLI, Mauro GIORDANO, Antonio VOZA
00:00 - 00:00
#42381 - Epidemiological and clinical characteristics of functional neurological disorder in the emergency department.
Epidemiological and clinical characteristics of functional neurological disorder in the emergency department.
Introduction:
Functional Neurological Disorder (FND), also known as conversion disorder, is a frequent reason for consultation in emergency departments. FND is now considered a "rule-in" diagnosis based on the recognition of positive clinical signs. The aim of this study is to present an overview of FND, its epidemiological and clinical characteristics.
Methods:
Monocentric and descriptive prospective study conducted in the emergency department of a regional public hospital over a period of 9 months. In this study, we included all adult patients who presented to the emergency department for the symptomatology of FND.
Results:
The study included 164 patients with FND. The mean age was 30 +/- 10 years, with a sex ratio of 0.29. Of these patients, 22(13%) had a history of psychiatric disorders particularly depression (8) and generalized anxiety disorder (6). 92 (56%) of our patients had a previous functional crisis.
Among our patients, 26% were students, 52% were employed and 22% were unemployed. We also found out that 44% had higher education and 38% had secondary education. Illiterate individuals represented only 2%. Regarding marital status, 60% were single and 38% were married, of which 28% had at least one child. The most common triggering factors were conflict (48%) and stress (45%).
Psychogenic non epileptic seizures (hyper motor 26% and akinetic 21%), Chest tightness (40%), and motor weakness (28 %) were the most frequent reasons for consultation. 21 of our patients had a histrionic personality at the medical consultation.
Conclusion:
FND is a disabling and distressing condition that commonly presents to the ED and can take many forms. This disease can occur across all ages. Although it affects more women than men, the proportion of affected males is increasing steadily. Its diagnosis has evolved over the years and its treatment is progressing.
AUCUN CONFLIT
Gabsi YASMINE, Manel KALLEL (Tunis, Tunisia), Emna KALLEL, Ramla BACCOUCHE, Sonia AISSA, Khedija ZAOUCHE
00:00 - 00:00
#42011 - Evaluation of GrandCoeur™ home monitoring system after emergency department discharge: an observational study and survey on the patient satisfaction.
Evaluation of GrandCoeur™ home monitoring system after emergency department discharge: an observational study and survey on the patient satisfaction.
Background: Follow-up of outpatients after emergency room visit remains a major issue for an optimal recovery and prevention of complications at home. Anxiety generated after a rapid discharge at home may lead to increased discomfort and healthcare utilization thus increasing the costs of emergency care. GrandCoeur™ remote monitoring is a simple easy-to-run monitoring tool using a WebApp technology and applicable at home, which allows sending the monitored vital parameters as chosen by the physician in charge consulted at the emergency department via a short message service (SMS). Following the SMS sent by the patient, the system examines the parameters sent and generates an adapted medical response sent back, according to specific algorithms pre-selected according to the patient’s morbidities and taking into account thresholds determined based on the international recommendations. Here, we aimed 1- to assess the impact of GrandCoeur™-based monitoring on the outpatients’ satisfaction and reduction in anxiety after emergency department discharge and 2- to investigate possible benefits on hospital readmission.
Methods: We conducted an observational study during 8 months (August 2023-March 2024) including all patients monitored at home using the GrandCoeur™ technology, prescribed for an average of 7 days by their physician in charge after their visit to the emergency department. The routine clinical parameters (heart rate, blood pressure, SpO2, pain scale, body temperature) were monitored twice or thrice daily at home and sent by SMS. A standardized hetero-questionnaire-based telephone survey was sent to all monitored patients. The survey assessed satisfaction (using a usual 1-10 scale), reduced anxiety, and feelings about preventing a new readmission.
Results: Three hundred and thirty five patients were monitored with the GrandCoeur™ system during eight months with the following morbidities: acute hypertension crisis (69%), acute anxiety (10%), thoracic pain (8%), bronchopneumonia (7%), COVID (4%), and cardiac arrhythmia (2%). All expected parameters were sent back with no loss to follow-up. Among these monitored patients, 115 patients (34%, mean age, 69 years; M/F ratio = 0.42) responded to the survey. Thirteen patients (11%) were re-admitted to the emergency department during the seven days post-discharge. The satisfaction rate was 95%, with 66% of the patients reporting a significant decrease in anxiety. About 36% of the participants felt that GrandCoeur™ system prevented their hospitalization.
Discussion & Conclusions: GrandCoeur™ monitoring system is easily usable in practice and appears as a promising tool to reassure outpatients discharged from the emergency department. Our findings should encourage the extending use of such home monitoring systems to strengthen the patient/caregiver link and improve the outpatient satisfaction.
Ali AFDJEI (Le Chesnay), Delphine BOUVRON, Marc BOUVRON, Antoine CONEGERO, Nicolas CROCHETON, Marc HARBOUN, Cyrus AFDJEI, Bruno MEGARBANE
00:00 - 00:00
#41395 - EVALUATION OF PREHOSPITAL SYSTEM FOR CEREBRAL INFARCTION PATIENTS IN JAPAN.
EVALUATION OF PREHOSPITAL SYSTEM FOR CEREBRAL INFARCTION PATIENTS IN JAPAN.
Background:
Japanese medical institutions have a high rate of CT and MRI installations worldwide, and patients can receive stroke diagnosis at nearby medical institutions.On the other hand, hospitals where endovascular treatment for main artery occlusion is always available are limited to urban areas. It is characteristic that Japanese tend to use medical institutions within their residential areas when seeking medical care, which may consequently hinder to realize the optimal treatment.
In recent years, the usefulness of doctor helicopters and cars with doctors and nurses on board has been widely reported, and cases are being consolidated, with patients being transported to advanced medical institutions instead of nearby medical institutions depending on the urgency and severity of their illnesses.
Shiga prefecture, where Saiseikai-Shiga hospital (hereafter referred to as “the hospital”) is located, has a total population of 1.41 million and covers an area of 4017 square kilometers. The hospital is an emergency center that provides tertiary emergency medical care, and operates both a Doctor-Helicopter and a Doctor-Car. The Doctor-Helicopter covers the entire Shiga prefecture and the Doctor-Car covers its entire secondary medical care zone. In addition, as a stroke care center with 12 beds in the SCU, endovascular treatment is always available, and about 120 cases of endovascular treatment of cerebral infarction are performed annually.
To shorten the time to start treatment by direct transport from remote area to advanced medical institution by a Doctor-Helicopter may enable patients to receive specialized stroke treatment at advanced medical institution, but there are no studies that have verified this. In this study, we examined the effectiveness of transport by a Doctor-Helicopter in patients with acute cerebral infarction.
Method:
We analyzed retrospectively the patients with cerebral infarction who were transported to the hospital for emergency treatment between January 2015 and December 2022, those who received endovascular treatment were extracted from the electronic medical record and divided into three groups by means of transport: Doctor-Helicopter(DH-group),Doctor-Car(DC-group),and ambulance-car (AC-group).The time from onset of stroke to the start of treatment, the percentage of patients with thrombectomy therapy and the effective recanalization rate were evaluated. Exclusion criteria were as follows: incomplete data, referral patient.
Result:
909 patients were enrolled, of which 88 patients were in the DH-group, 131 in the DC-group, and 690 in the AC-group.Of these, 212 patients received thrombectomy treatment: 34 (38.6%) in the DH-group, 39 (29.7%) in the DC-group, and 139 (20.1%) in the AC-group.The thrombectomy rate was higher in the DH-group and the DC-group than in the AC-group, and did not differ significantly between the DH-group and DC-group. The median time from onset to start of treatment were 159 minutes in the DH-group, 185 minutes in the DC-group, and 206 minutes in the AC-group, and they had no significant difference. The effective recanalization rate was around 90% in the groups.
Conclusion:
The results suggest that residents in remote area can receive the same level of treatment of cerebral infarction as those in secondary medical area with stroke care centers through transport by Doctor-Helicopter.
The authors have no financial conflicts of interest to disclose concerning the research.
Sho OKA (Kyoto,Japan, Japan), Manabu TAKAMATSU, Shiho HIRAIZUMI, Yoshiki OKUMURA, Ayumi TSUDUKI, Kazuma NAKAMOTO, Yuka SEGOE, Tadashi ECHIGO
00:00 - 00:00
#41967 - EVALUATION OF THE EFFECTIVENESS OF PERSONALIZED FLUID THERAPY IN SEPSIS-RELATED HYPOPERFUSION AND SEPTIC SHOCK THROUGH NON-INVASIVE ESTIMATION OF FLUID RESPONSIBILITY: PRELIMINARY DATA OF A RANDOMIZED AND PERSPECTIVE, MONOCENTRIC CLINICAL STUDY.
EVALUATION OF THE EFFECTIVENESS OF PERSONALIZED FLUID THERAPY IN SEPSIS-RELATED HYPOPERFUSION AND SEPTIC SHOCK THROUGH NON-INVASIVE ESTIMATION OF FLUID RESPONSIBILITY: PRELIMINARY DATA OF A RANDOMIZED AND PERSPECTIVE, MONOCENTRIC CLINICAL STUDY.
Fluid resuscitation plays a pivotal role in septic shock. However, there is limited data to guide the specific use of it. The Surviving Sepsis Campaign suggests that "fluid administration beyond initial resuscitation requires careful assessment”. Assessing hemodynamic response to fluid bolus is crucial, but signs of fluid responsiveness are difficult to interpret. Studies demonstrated that dynamic measurement of stroke volume (SV) after fluid bolus or passive leg raise (PLR) is safe and practical for assessing the effectiveness of fluid-induced rise of SV and cardiac-output. We evaluate the usefulness of this monitoring tool of the hemodynamic status to guide fluid administration in septic-shock.
The study was randomized and perspective monocentric, conducted over six months.
Primary endpoints were the evaluation of total amount of fluids and the length of stay in sub-intensive department; others were the need and titrating of vasopressors, use CPAP/NIV/IOT, variation of P/F, dialysis/CRR, onset of acute renal failure and water balance.
We included patients with “hypoperfusion sepsis related” or septic shock requiring fluid therapy and admitted to sub-intensive care between the third and twenty-fourth hour after diagnosis, with SOFA score ≥ 2.
Exclusion criteria were ongoing trauma, hemorrhage, pregnancy, underage, renal and hepatic end-stage disease, Myocardial infarction, or arrhythmia.
Patients were randomly assigned to:
- Cases, wherein fluid management has been guided by non-invasive hemodynamic monitoring.
- Controls, administering fluids according to guidelines and clinical judgment.
Cases who showed an increase in SV above 10% after fluid bolus or PLR were classified as "fluid responders", others as "non-responders".
We enrolled 41 patients and randomly assigned 20 cases and 21 controls. The limitations of the study are the small sample size and being a monocentric study. Cases received more fluids: no difference was observed in fluid balance, but higher diuresis; fluid responsiveness at the initial assessment were 70%, 66% remained responsive to a second assessment at 30 minutes, and 20% at 24h. The fluid balance was significantly more positive in the responder group.
Longer hospitalizations were noted in cases; however, a higher mortality was highlighted in controls.
There was no difference in requiring RRT and CPAP, although higher values were noted in the controls for NIV and IOT. No differences in delta P/F are shown but an improving trend for cases. The incidence of AKI was lower in the cases.
The use of balanced fluid therapy reduced the use of vasopressors and diuretics.
Fluid management in selected patients administered with this procedure determines a better outcome with regards to renal failure and diuresis, with lower incidence of organ failure and mortality.
This strategy led to a more positive fluid balance, in the absence of signs of overload.
This hypothesis is supported by observing the delta in arterial pressure values, significantly higher in cases.
In an era in which sepsis represents a raising cause of morbidity and mortality, it is essential having a tool to assess fluid-responsiveness in patients in order to optimize fluids and the timing of vasopressor use, minimizing fluid overload or vasopressor’s side-effects.
Daria RIGAMONTI (Rome, Italy), Julia TOLA, Ersilia CASTALDO
00:00 - 00:00
#42388 - Evaluation of the performance of the HEART Score in patients with acute chest pain in the Emergency Department.
Evaluation of the performance of the HEART Score in patients with acute chest pain in the Emergency Department.
Introduction: The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score is an easy-to-apply tool to stratify patients with chest pain according to their short-term risk for major adverse cardiac events (MACEs).
Objective: To measure the effect of use of the HEART score on patient outcomes.
Methods: Prospective and observational study conducted in an emergency department (ED) in a regional hospital from August 2022 through August 2023. Were included patients with acute non-traumatic chest pain and having a low or intermediate risk for MACEs (HEART score between 0 and 6). Were not included patients under the age of 18 years old, those who have an acute coronary syndrome (ACS), those whom troponins were positive. HEART scores were calculated for all participants. Thirty-day follow-up was conducted, assessing for MACEs (death, myocardial infarction, or coronary revascularization).
Results: A total of 588 patients were included. Only 7 patients experienced 30-day-MACEs. The mean age was 54 ± 15 years. The gender ratio was 1,15. Among these patients, 201 patients (34%) didn’t have any risk factor. The comorbidities were dominated by the arterial hypertension in 212 patients (36%) followed by the diabetes in 180 patients (31%) followed by the dyslipidaemia in 67 patients (11%). The median troponin value was 8.07 ng/L IQR [5.46; 12.82]. According to the risk stratification using the HEART score, 452 patients (77%) were at low risk. The HEART score area under ROC curve (AUC) was 0.987 (95% confidence interval, 0.975–0.999) (p<0.001). The recommended cutoff of ≥5 to identify patients at high risk of MACEs yielded a sensitivity of 100%, specificity of 96%, and NPV of 100%.
Conclusion: Among patients with acute chest pain, the HEART score has a good performance to identify patients with high risk for MACEs. However, to validate its use in ED, a multicentric study should be conducted.
aucun conflit
Sana SELLAMI, Manel KALLEL (Tunis, Tunisia), Emna REZGUI, Emna KALLEL, Sonia AISSA, Khedija ZAOUCHE
00:00 - 00:00
#41781 - Evaluation of the pre-hospital mass casualty incident plan in Milan, a prospective time series simulation analysis.
Evaluation of the pre-hospital mass casualty incident plan in Milan, a prospective time series simulation analysis.
Background. Mass casualty incidents (MCI) are often associated with a vast number of patients. Unfortunately, since MCI are rare, medical personnel is often unfamiliar with organizational internal procedures. Simulations seem to be the best way to increase exposure to these events; at the same time, they offer a priceless opportunity to test and evaluate plans. We have recently revised our local Emergency Medical Dispatch Center (EMDC) pre-hospital MCI plan in Milan city. The aim of this study was to evaluate the global performance of the dispatch center in a series of simulated MCI events. We also tested the Crisis Resource Management (CRM) skills of our staff as they have been rarely tested in this context. We added a brief case study of a real MCI (fire in a nursing home, Milan, Italy, July 7th, 2023) to test the reliability of simulations.
Methods. A prospective time series study including five simulations was conducted during a six-month period. The study population was the staff on duty at the EMDC. All exercises were designed following the Homeland Security Exercise and Evaluation Program guidelines. A set of published Key Performance Indicators (KPI) were measured using a scoring system as follows: 2 points (action correctly performed, at the right time), 1 point (action correctly performed, not at the right time) and 0 points (action not performed). The score was then proportioned to the total obtainable and converted in percentage for comparison. Actions were directly observed while time was extracted from the Emergency Management software. The published Italian version of the Ottawa CRM Global Rating Scale (GRS) (1 to 7 points scoring) was used to evaluate CRM skills; the evaluations of two independent raters were included. KPI were retrospectively calculated for the real MCI and compared with the data collected from the simulations.
Results. Regarding the KPI, an average of 81% was measured (65% - 91%, SD: 10). Out of 83 actions evaluated over the five simulations, 7 received 0 points, 18 received 1 point and 58 received 2 points. The case study of the fire in Milan received a total of 78%. This was in line with the results of the simulations (Fisher’s exact p-value: 0.039). Ottawa CRM GRS received an average of 32 points out of 42 (17 - 42, SD: 8.9), showing a good overall performance. The results from the two evaluators were aligned (agreement of 53.3%, Kappa score: 0.41).
Discussion and Conclusions. Our results suggest that our MCI procedure in Milan EMDC seems to be effective. Although the results on the Ottawa CRM GRS were overall positive, some CRM skills, such as communication skills and resource utilization, could be improved. Data collected during simulations were confirmed with the case study analysis, proving the simulations to be reliable. A strong correlation between the KPI and Ottawa CRM GRS was found (Pearson correlation coefficient: +0.93), suggesting that CRM skills strongly influence the performance.
Trial Registration: not needed.
Funding Information: this study did non receive any specific funding.
Alba RIPOLL-GALLARDO, Giovanni DE LUCA, Davide ARGHETTI, Armando STELLINI, Alessandro ZAMBELAN, Riccardo FIAMENI, Giacomo OLDRINI (Milan, Italy), Giacomo COLZANI, Andrea COMELLI, Alberto ZOLI, Giuseppe Maria SECHI, Roberto FUMAGALLI, Riccardo STUCCHI
00:00 - 00:00
#41078 - Examining the Correlation Between Positive Plasma D-dimer Result and Body Mass Index (BMI): A Comprehensive Retrospective Observational Study.
Examining the Correlation Between Positive Plasma D-dimer Result and Body Mass Index (BMI): A Comprehensive Retrospective Observational Study.
Background:
Venous thromboembolism (VTE) poses a significant burden on healthcare systems globally, with obesity identified as a potential risk factor. The correlation between obesity, assessed through Body Mass Index (BMI), and plasma D-dimer levels, a biomarker for VTE risk, remains poorly understood, particularly in non-VTE patients. This study aims to investigate this correlation, shedding light on the relationship between obesity and haemostatic markers.
Methods:
A retrospective observational study was conducted on 849 adult patients presenting to the emergency department of a UK hospital between August and December 2022. Data on D-dimer levels, BMI, and additional diagnostic tests were collected from electronic medical records. Statistical analysis, including Pearson correlation coefficient, was employed to assess the relationship between D-dimer levels and BMI.
Results:
The study population exhibited diverse demographic characteristics, with a notable proportion testing positive for D-dimer. However, the correlation analysis revealed a weak and statistically insignificant relationship between D-dimer levels and BMI. High false positive rates for D-dimer results were observed, particularly in certain BMI categories, emphasizing the need for cautious interpretation.
Discussion and Conclusion:
The findings suggest a complex interplay between BMI, D-dimer levels, and VTE diagnosis. While obesity has been linked to VTE risk, this study highlights the limitations of D-dimer testing in certain BMI categories. Clinicians should consider BMI alongside other factors when interpreting D-dimer results for VTE diagnosis.
Funding:
The research was conducted without external funding.
Ethical Approval:
As a retrospective observational study, formal ethical approval was obtained from UHNM research committee.
Importance of the Topic:
Understanding the relationship between obesity, D-dimer levels, and VTE risk is crucial for refining diagnostic strategies in emergency medicine. These findings underscore the importance of a comprehensive approach to VTE diagnosis, incorporating BMI as a contributing factor.
Originality:
This study contributes to the existing literature by examining the correlation between D-dimer levels and BMI in non-VTE patients, providing insights into the complexity of VTE risk assessment.
External Validity:
The results offer valuable insights applicable to emergency medicine settings globally, informing clinical practice and future research endeavours.
We would like to acknowledge that this research was conducted without internal or external funding.
The research was conducted as a retrospective observational study. formal ethical approval was obtained from UHNM Research committee. The project was conducted according to the Declaration of Helsinki and United Kingdom Good Clinical Practice guidelines.
Adekolawole LONGE (Stoke-on-Trent, United Kingdom), Chinazam EZE, Dayok PANKYES, Davidson ADELAKUN, Nayeem MOSTAFA, Naznin SULTANA
00:00 - 00:00
#41348 - Exploring the Need for Blood Purification Techniques: A Retrospective Study on Acute Poisoning Epidemiology in Wenzhou, China from 2012-2022.
Exploring the Need for Blood Purification Techniques: A Retrospective Study on Acute Poisoning Epidemiology in Wenzhou, China from 2012-2022.
Background：
By retrospectively analyzing a substantial number of poisoning cases, researchers can establish a robust scientific foundation for optimizing diagnostic and treatment protocols. Furthermore, such studies can inform the development of more effective prevention and educational initiatives aimed at mitigating the incidence of poisoning.
Data and Methods:
1.1.Data collection
Patient information was obtained from the Medical Storage Room of the First Affiliated Hospital of Wenzhou Medical University and the Information Service, with additional details acquired through the Electronic Case System 3.0.
Inclusion criteria comprised cases where "poisoning" was listed as a diagnosis upon hospital discharge from EICU between January 1, 2012, and December 31, 2022, and had a clear history of toxic exposure with related symptoms.
Exclusion criteria excluded diagnoses related to physiological changes due to pathological mechanisms, such as toxic shock, metabolic acidosis, metabolic alkalosis, diabetic ketoacidosis, lactic acidosis, as well as chronic and traumatic poisonings.
1.2.Research methods and data processing
The collected data were organized into an Excel database. Subsequently, statistical descriptions and analyses were performed, with results compared based on the required elements and composition ratios. SPSS 25.0 was used for statistical analysis. For data groups conforming to a normal distribution, measurement data were expressed as mean±standard deviation (X±S), with the Chi-square test employed for count data comparisons between groups. Data not conforming to normal distribution were described using the median, non-parametric tests for group comparisons, and the rank sum test for count data between groups. Statistical significance was established at P<0.05.
Results:
1.A total of 2,066 cases of suspected poisoning were identified. Among these, 2,041 cases received a definitive toxicological diagnosis.
2. The normal characteristics of all poisoning case and the distribution of toxic agents consumed by all poisoning cases(Table 3, Table 4).
3.Statistical analysis revealed a significant correlation between the use of blood purification and favorable prognosis outcomes (2=57.53, p<0.05), underscoring its efficacy in treating poisoned patients(Figure 3). And we analysed a Kaplan-Meier estimate in pesticide poisoning patients from when they took the poisons to when they were admitted to the hospital (replaced by 24h for all 24h) and the different blood purification techniques(Hemoperfusion combined with CRRT or hemoperfusion alone) used. And it shows that combined means are more effective than treatment alone (HR=0.45 (0.35-0.58), P<0.001).
4.Following blood purification, significant differences were observed in blood toxicant concentrations or cholinesterase activity, emphasizing the effectiveness of blood purification therapy in alleviating poisoning symptoms (Diquat poisoning: Z=-3.62, p<0.05; paraquat poisoning: Z=-4.08, p<0.05; organophosphorus poisoning: Z=-8.43, p<0.05) (Figure 5).
Discussion and Conclusion:
The present study comprised two parts. We first focused on cases of poisoning treated at the Emergency Department of the First Affiliated Hospital of Wenzhou Medical University, analyzing patients' overall health and the types of poisons they encountered. Besides, we assessed changes in blood toxicity levels and markers before and after initial blood purification treatment for patients exposed to three pesticide types: organophosphorus, diquat, and paraquat. Our findings highlight that blood purification treatment significantly enhances the prognosis of poisoned patients.
Ethics Statement:
This retrospective study (Issuing Number 2024,R084) was conducted in accordance with the Declaration of Helsinki and approved by Review of Ethics Committee in Clinical Research (ECCR) of the First Affiliated Hospital of Wenzhou Medical University. In addition, all patient information is collected from the hospital information system. All data were analyzed anonymously.
Funding：
The study was supported by Major projects of Wenzhou Science and Technology Bureau(ZY2022023), State Administration of Traditional Chinese Medicine and Zhejiang Administration of Traditional Chinese Medicine jointly build a science and technology plan project(GZY-ZJ-KJ-23031) and National Natural Science Foundation of China(82302482).
Yan LI (, Afghanistan), Zhongqiu LU
00:00 - 00:00
#42347 - Exploring the reality of a pediatric emergency department: Exploring the reality of a pediatric emergency department: A retrospective analysis of discharge and readmission patterns.
Exploring the reality of a pediatric emergency department: Exploring the reality of a pediatric emergency department: A retrospective analysis of discharge and readmission patterns.
Background:
Implementing data-driven interventions sourced from electronic medical records could enhance effectivity and efficacy in Pediatric Emergency Departments (PED), yet to date no comprehensive report was published from Hungary on presentations, and only limited data is available from other countries.
In our retrospective data analysis we aimed to describe the patient flow of our PED. Primary outcome was the prevalence of ward and neonatal (NICU) or pediatric intensive care unit (PICU) admissions, home discharges, readmissions, and discharge against medical advice (AMA).
Methods:
We performed a comprehensive analysis of all cases, presented between 01.01.2020. and 31.12.2023 based on anonymized electronic medical records in a tertiary level of care PED. In this PED internal medical neurologic and psychiatric cases are managed exclusively, operating 24 hours a day, and 7 days a week.
The data analysis was performed using a script written in the R programming language.
Given the low rate of missing data, no cases were excluded from analysis.
Results:
A total of 39 409 patient encounters (53,7% males) were included. Median age was 3.21 years [IQR 40 days -16 years].
A trend of lower ICU/PICU and ward admission rates were observed in higher triage categories ranging from <0.1% - 25% for PICU/NICU and 9.6% - 67% for total ward admissions of corresponding triage categories.
Home discharge was determined for 5 patients (6.9%) in triage category I, 413 (29%) in II, 3,573 (46%) in III, and 8,356 (74%) in IV, 16,904 (89%) in V.
Rates of single readmission instances (within 3 days) were varying between 0.1% and 4.7%, with the most occurrences observed in triage IV and V.
Double readmission rates (each within 3 days) fell within the range of 0.2% - 0.3%. Occurrences of three or more readmissions (each within 3 days) were not higher than 0.1% in the corresponding triage categories.
One time readmission patients were discharged home in 1,296 (72%) cases, double admissions in 56 (64%) cases and three or more admissions in 16 (76%) cases. PICU/NICU admission was observed only upon first reappearance in 8 (0.4%) cases.
DAMA occured in 370 (0.93%) cases and seldomly resulted in worsening conditions, 359 of cases (97%) were discharged home of the 8 (2,2%) that reappeared.
Discussion and Conclusion:
As anticipated, a trend of lower ICU/PICU and ward admission rates were observed in higher triage categories. The impact of patient stabilization measures in the ED is reflected as low rate of ICU/PICU admissions.
Despite being classified as triage I or II, a considerable number of patients were discharged home following successful treatment, with an acceptably low rate of reattandances, meaning that pediatric patiens usually respond well to therapies. Our practices of overtriage should be assessed further. Ward and ICU/PICU admissions could not be avoide based solely on high triage category, underlying the complexity in decisionmaking regarding admissions.
Readmissions were below 5.1%, exceeding slightly the international standard of 3%, further analysis is needed to plan interventions.
The limitations to our study includes the omission of data recording errors and missig data from consideration.
Trial registration: No trial registration was required for this retrospective analysis.
Funding: This study did not receive any specific funding.
Anna VÉGH (Budapest, Hungary), Dániel SEIDL, J. Attila SZABÓ, Péter KRIVÁCSY
00:00 - 00:00
#41964 - External validation of the modified brain injury guidelines, an observational study.
External validation of the modified brain injury guidelines, an observational study.
Introduction: The modified Brain Injury Guidelines (mBIG) propose an appropriate management of patients with complicated mild traumatic brain injury (mTBI). This algorithm has been subjected to a limited number of validations in literature. Furthermore, it does not include hygromas, lesions with a low clinical and radiological progression rate, or dubious haemorrhages, which are common findings in this patient population. The purpose of this study is to externally validate the mBIG, also considering the two types of injury mentioned above.
Methods: An observational study was performed. The study included patients who underwent a head computed tomography (CT) scan for a blunt mTBI at the Emergency Department (ED) of the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico between 1 January 2018 and 31 December 2019. The presence of polytrauma represented an exclusion criterion. Subsequently, patients with mTBI and intracranial lesions on CT were classified according to the guidelines as mBIG 1, 2, or 3. Isolated hygromas were classified as mBIG1. Dubious haemorrhages were included in the category of injury for which doubt was raised. mBIG2 and mBIG3 patients were not considered for further analyses. The variables collected included demographics, comorbidities, type of injury, number of CT repeated in the ED or post-discharge and ED length of stay. The outcomes evaluated were radiological progression, neurosurgical interventions, hospitalization and mortality due to mTBI.
Results: A total of 6,892 patients underwent a head CT for TBI during the study period. Of these, 421 patients met the inclusion criteria and were categorized into mBIG1 (234 [56%]), mBIG2 (15 [3%]), and mBIG3 (172 [41%]). Among the mBIG1 patients, 81 (35%) presented with hygroma and 91 (39%) with dubious haemorrhages.
Of the 234 mBIG1 patients included in the analysis, 165 (71%) repeated at least another head CT scan in the ED or following discharge. Radiological progression of injury was observed in 15 of the 234 patients (6%; C.I. 95% 3,6-10%).
A total of 49 out of 234 patients required hospitalization (20,9%; C.I. 95%: 16-27%), with only 11 cases being attributed to mTBI (4,7%; C.I. 95%: 2,4-8,3%). A single patient was admitted from the ED to the neurosurgery department (0,43%).
No patients required neurosurgical intervention.
Two deaths were observed, one of which was unrelated to mTBI. A single patient died as a result of a worsening hygroma, although his admission was complicated by pulmonary embolism and urinary sepsis. The mortality rate attributable to mTBI was therefore 0.43% (95% CI: 0.01-2.4%). However, it should be noted that the event was not solely caused by mTBI.
All other patients were discharged with a Glasgow Coma Scale score of 15 and an unchanged objective neurological examination.
Conclusion: The outcomes observed in our population align with findings documented in literature, showing that the implementation of mBIGs in the ED is a safe practice for patients and can optimise the allocation of resources. Our study also suggests that it is possible to include dubious haemorrhages and hygromas in the mBIG1 category, although further studies are required to confirm this hypothesis.
Giorgio COLOMBO, Anna GIULIANI (Milan, Italy), Giorgio COSTANTINO
00:00 - 00:00
#42384 - Face the facts: the green whistle is a hit! A review of consecutive emergency department use of methoxyflurane in children requiring wound care above the neck.
Face the facts: the green whistle is a hit! A review of consecutive emergency department use of methoxyflurane in children requiring wound care above the neck.
Introduction
Any Emergency Department (ED) caring for children with facial wounds find that often the child and carer will not readily cooperate or remain a non moving target.
The lack of on-site specialists (plastic, maxillofacial and 24/7 paediatric anaesthesia), presents significant challenges.
Cases requiring emergent management result in transfer, delay or consent to ED treatment.
Throughout Europe (& UK), Methoxyflurane (3ml inhaled) is licensed for relieving adult traumatic pain. However it has had extensive pre-hospital paediatric use in the Southern hemisphere. With experience in its use in ED since 2017, individual Consultants (Attendings) proposed its use in selective paediatric cases ( under 18 yo, without evidence of head injury). Informed consent was sought from parents/ carers.
Due to Covid-19 pandemic, the scope or practice was widened, as inpatient alternatives became increasingly difficult to arrange. This is a review of efficacy, safety and learning since introduction, focusing on its use as an adjunct (analgesic, anxiolytic or sedative) in the management of facial wounds and dental injuries.
Methods
Prospective collection of all methoxyflurane use in ED was audited, (2016 to date) This paper record was stored in controlled drug cupboard (with 2 nurse signatures and shift change stock count), 3 separate electronic trawls of Symphony ED database (incl. handwritten medical & nursing notes) confirmed every paediatric use, indication, additional controlled drugs, success, complications, grade of senior clinician prescribing or administering methoxyflurane. Incomplete records were cross-referenced to attendances in the preceding 24 hours. Duplicate entries (unless for different dates), was noted, as were multiple doses per patient. Using a spreadsheet (Apple Numbers) we isolated all paediatric cases of its use in head and facial wounds.
Results
105 children received (female 41%) individual administrations of methoxyflurane (mean age 5.47; range 1.25-15) for analgesia/anxiolytics and/or sedation for facial, dental or head wounds.
Indications n*
Scalp wounds 3
Forehead( incl. eyebrow) 25
Midface (maxillary) 6
Complex Cosmesis Case 26
Involving Lip/ vermillion border 9
Dental 5
* some had more than one injury
Supervision
Direct consultant involvement 71.4%.
Autonomous practitioner 96% (those in EM practice ≥ 4 years).
In all cases it was sole systemic agent. Topical, local +/- regional anaesthetic was used in the majority of cases.
No adverse incidents, nor failure to complete procedures documented.
Conclusion
After over 100 consecutive paediatric facial wounds managed exclusively in the ED, it appears the safe, effective use of methoxyflurane (outside its original license) is possible.
Unlike its use in other injuries (mostly fractures, dislocations and wounds) we have found that additional systemic agents were not necessary.
Next action
Subject to training programs, clear protocols, competency based assessments and similar review of its performance; it is proposed that its use can be extended regardless of licensing restrictions. We seek forgiveness, not permission. We wish to present our experience and how we did it.
Hugo DOWD (Antrim, ), Ian ERSKINE, David GREEN
00:00 - 00:00
#42126 - Factor Xa Inhibitor–associated Traumatic Bleed Incidence and Outcomes in the Multicountry Observational AXIOM Study.
Factor Xa Inhibitor–associated Traumatic Bleed Incidence and Outcomes in the Multicountry Observational AXIOM Study.
Background: Uncontrolled bleeding is one of the most common preventable causes of death associated with trauma and is exacerbated by the use of anticoagulants, including Factor Xa inhibitors (FXai). The use of anticoagulants, such as FXai, prior to injury is associated with an increased risk of morbidity and mortality following trauma. The goal of this multicountry study was to explore the burden of traumatic bleeds following initial use of a FXai.
Methods: This retrospective observational longitudinal cohort study involved analysis of electronic health records from new direct-acting oral anticoagulant users, specifically FXai, in Germany, the UK, the Netherlands, and Spain. The data sources were the WIG2 database for Germany (study period, 2012-2020); the Hospital Episode Statistics Admitted Patient Care and Office for National Statistics data linked to the Clinical Practice Research Datalink for the UK (2012-2020), the PHARMO Data Network for the Netherlands (2008-2021), and the BIG-PAC® database, Atrys Health, for Spain (2013-2022). This study included adult patients with a FXai prescription for a therapeutic indication (eg, venous thromboembolism, atrial fibrillation [AF], non-mechanical cardiac-valve replacement) and at least 12 months of data availability prior to study inclusion. Incidence rates of traumatic bleeds associated with FXai use and mortality were assessed and reported per 100 person-years (PYR) with 95% confidence intervals (CI).
Results: : A total of 316,792 new FXai users (Germany, N=78,086; UK, N=212,378; Netherlands, N=17,356; Spain, N=8972) were included in this analysis. Of those FXai users, 1611 (Germany, n=897; UK, n=686; Netherlands, n=18; Spain, n=10) experienced a traumatic bleed. Among patients with FXai-associated traumatic bleeds, the mean age ranged from approximately 77 to 79 years across all 4 countries. The proportion of female patients was 42.8% in Germany, 42.3% in the UK, 27.8% in the Netherlands, and 70.0% in Spain. The most common indication across all countries was atrial fibrillation (Germany, 87.2%; UK, 92.3%; Netherlands, 88.9%; Spain, 80.0%). The 1-year incidence of traumatic bleeds per 100 PYR (95% CI) was 1.03 (0.94, 1.12) in Germany, 0.24 (95% CI, 0.21, 0.26) in the UK, 0.09 (0.04, 0.16) in the Netherlands, and 0.28 (0.17, 0.39) in Spain. Rates of traumatic intracranial haemorrhage were higher than rates of other traumatic bleeds in the UK, the Netherlands, and Spain, and rates of other traumatic bleeds were higher in Germany. At 3 months after the FXai-associated traumatic bleed, all-cause mortality was reported for 24.5% of patients in Germany, 22.0% of patients in the UK, 16.7% of patients in the Netherlands, and 70.0% of patients in Spain, corresponding with incidence rates per 100 PYR of 123 (95% CI, 107, 140), 107 (91, 126), 81 (17, 237), and 922 (757, 1088), respectively. All-cause mortality rates decreased by approximately 55% to 69% across countries by 1 year after the traumatic bleed.
Discussion & Conclusions: In this observational study, FXai-associated traumatic bleed incidence rates ranged from 0.09 to 1.03 per 100 PYR across the included countries. Rates of all-cause mortality were generally highest during the first 3 months after the traumatic bleed.
This study was funded by AstraZeneca.
Alexander T. COHEN, Juan ARENILLAS, Robert C. WELSH, Jenneke LEENTJENS, Craig I. COLEMAN, Douglas C. DOVER, Jordy GASPERSZ, Ruiqi ZHANG, Jil Billy MAMZA, Godfrey GEORGE, Ali CANBAY, Eddy LANG (Calgary, Canada), - ON BEHALF OF AXIOM RESEARCH GROUP
00:00 - 00:00
#42068 - Factors influencing the perception of workplace violence - a 10 year retrospective observational study.
Factors influencing the perception of workplace violence - a 10 year retrospective observational study.
Background: Medical staff in emergency departments regularly face workplace violence (WPV), posing significant physical and psychological safety risks to themselves and patients. To respond to such incidents, factors influencing the perceived severity of incidents need to be identified. To this end, this study focused on examining the factors impacting subjective perception of WPV events in one of Germany’s largest emergency departments.
Methods: We conducted a retrospective analysis of 636 WPV incidents — aggression of patients against staff members — that occurred in our ED in a ten-year period (2014 to 2023). To investigate contributing factors, we fitted an Ordinary Least Squares regression to regress the rating of the events on a numerical rating scale (NRS) from 0 to 10, a component of the structured Revised Staff Observation Aggression Scale (SOAS-R). Independent variables included patient demographics (e.g., age, gender), incident characteristics (potential cause of the event, such as denial of medication, means of aggression, such as hands or feet), type of response to the event (e.g., forcefully restraining aggressors), and staff profession (e.g., nurse, doctor, assistant staff).
Results: The model explained 38.5% of the variance in perceived severity (Adjusted R-squared = 0.328). Significant predictors included patient gender, with males associated with higher severity ratings (beta = 4.383, p < 0.001). Also, each year in the observation period showed increasing severity perception over time (beta = 0.088, p < 0.05). Specific causes such as incidents without understandable reasons were likewise linked to higher severity ratings (beta = 0.574, p < 0.01), while nursing activity-related incidents were perceived as less severe (beta = -0.578, p < 0.05). The involvement of dangerous means and the requirement of more forceful responses significantly increased severity perceptions (p < 0.01), whereas incidents resulting in no consequences were associated with lower perceived severity (beta = -1.696, p < 0.001).
Discussion & Conclusions: The study underscores the influence of both incident and response characteristics on emergency department staff's perceptions of workplace violence events’ severity. Understanding these factors can guide the development of targeted strategies to enhance staff awareness and manage WPV incidents effectively, thereby enhancing staff safety and work-related satisfaction.
Trial Registration: The study was registered at the German Registry for Clinical Trials (DRKS00030057) and the local equivalent at the study site (FRKS004146).
Funding: LB received funding through the Berta-Ottenstein-Programme for Clinician Scientists from the Faculty of Medicine, University of Freiburg. FPH was funded by the Baden-Württemberg State Ministry for Science, Research and the Arts (as part of the multinational Clinnova consortium (GdGI)).
Leo BENNING (Freiburg, Germany), Gisbert Wilhelm TEEPE, Busch HANS-JÖRG, Felix Patricius HANS
00:00 - 00:00
#41857 - Feasibility Study on an Emergency Status Assessment System Based on Smartwatches.
Feasibility Study on an Emergency Status Assessment System Based on Smartwatches.
Background: Traditional triage systems depend on professional staff and equipment. Wearables, particularly smartwatches with pulse-tracking capabilities, present opportunities for daily health monitoring and advance self-assessment during emergencies to enhance medical care decisions, early critical condition detection, and medical resource optimization.
Objective: This study aimed to confirm the smartwatch-based system's reliability and efficacy for emergency assessment by comparing its triage results with those from standard bedside monitoring systems in the emergency department.
Method: From February 1, 2023, to April 17, 2023, 114 volunteers who visited the emergency department were recruited based on inclusion and exclusion criteria. The triage process was conducted simultaneously using both the smartwatch-based emergency status assessment system and the bedside monitoring device-based system to collect and assess vital signs, and the consistency of vital sign data and triage outcomes between the two systems was compared.
Result: The study found no significant statistical difference in the measurement of body temperature between smartwatches and traditional medical devices, showing a significant positive correlation. Measurements of heart rate, oxygen saturation, systolic and diastolic blood pressure exhibited differences between the two types of devices, but they were significantly correlated. There was a marked consistency in the triage outcomes between the smartwatch-based emergency status assessment system and the bedside monitoring device-based triage system.
Conclusion: Smartwatch-based emergency status assessment system is capable of predicting the severity of a patient’s condition, thereby supporting its potential utility in pre-hospital settings, especially those lacking professional medical staff.
Significance: This system based on smartwatches allows patients without immediate access to healthcare professionals to preliminarily assess their health, advise on medical attention, and facilitate early management of critical conditions, improving emergency patient prognosis.
Research Fund of Zhongnan Hospital of Wuhan University
Yu TIAN (Wuhan, China), Yan ZHAO, Yulin LI
00:00 - 00:00
#42118 - Feasibility study on whether Greek emergency departments can reliably measure modern quality indicators.
Feasibility study on whether Greek emergency departments can reliably measure modern quality indicators.
Background: Quality indicators are retrospectively measurable elements of the performance of a healthcare unit that can be used to assess the quality of care provided. The implementation of a carefully selected set of quality indicators by all emergency departments (EDs) in Greece can allow the identification of best practices or significant deviations and the design of long-term policies that will lead to better management of processes, increased patient safety, and, ultimately, improved quality of care. This study's main objective was to investigate Greek EDs' ability to measure modern quality indicators reliably.
Methods: We conducted a synchronous cross-sectional study in all hospitals in the country that have autonomous EDs from September 2023 to January 2024. The survey was answered by the head of each ED. The questionnaire included hospital characteristics and questions on the ability to record 144 quality indicators divided into 3 categories according to Donabedian (structure, process, and outcome indicators).
Results: Responses were received from 32 of the 40 EDs to which the questionnaire was sent. Only 19 indicators were identified, for which more than 80% of ED heads responded that they could record them. All of these indicators are structure and process indicators, while there were no outcome indicators with a high percentage of positive responses. The top ten indicators identified from the ranking are: 1) Daily census (97%), 2) Annual volume of visits (94%), 3) How many nurses are present in the ED at any given time (940%), 4) How many doctors with a specialization in Emergency Medicine work in the ED (940%), 5) The time of ordering tests (94%), 6) How many medical specialists without a specialization in Emergency Medicine who work in the ED are at any given time in the ED (90%), 7) Ability to provide paraclinical diagnostic services within the ED (90%), 8) Maximum number of beds/stretchers that can be used in the ED (87%), 9) How many doctors with a specialization in Emergency Medicine are at any given time in the ED (87%) and 10) How many residents who deal with internal medicine cases are at any given time in the ED (87%). Eleven indicators had a percentage of positive responses of less than 20%, with the main ones being 1) Detection and treatment of infectious diseases (11%), 2) Recording of patients' pain intensity (10%), 3) Ability to manage end-of-life care in the ED (10%) 4) Ability to measure and demonstrate the ED's response to complications, adverse events and risk management issues (10%) 5) Availability of a comprehensive geriatric assessment or multidisciplinary assessment for patients identified in the ED as vulnerable (7%).
Discussion & Conclusions: The Greek EDs participating in the study reported limited capacity to record reliable modern quality indicators. There is limited capacity to record structure indicators and minimal capacity to record outcome indicators, which are the most important. The lack of digitization of electronic health records in Greek EDs significantly limits the ability to record important quality indicators reliably.
Trial Registration: The study was not registered.
Funding: This study did not receive any specific funding.
Ethics committee approval and informed patient consent: The study was conducted online. Due to the nature of the study and the free choice to respond to the questionnaire, there was no need for ethics committee approval.
Georgia SIFAKI, Dimitrios TSIFTSIS, Markella CHARALAMPATOU, Stavroula ILIA, George BRIASSOULIS, Dr George NOTAS (HERAKLION, Greece)
00:00 - 00:00
#41393 - Fostering Excellence: A Ground-Breaking Peer-Mentoring Program for Emergency Residents; Transforming Education and Nurturing Residents as Future Leaders.
Fostering Excellence: A Ground-Breaking Peer-Mentoring Program for Emergency Residents; Transforming Education and Nurturing Residents as Future Leaders.
Residency stands as a pivotal period where physicians organize knowledge for patient care. The complexity of this journey may lead to cognitive challenges, burnout, or dropout. Recognizing the value of mentorship in easing this path, a unique "senior to junior" mentorship program was initiated in the Department of Emergency Medicine, spanning an entire academic year. This qualitative study aims to evaluate this program from the residents' perspective.
Conducted through semi-structured interviews with open-ended questions, the study gathered insights from twenty-one residents, including fifteen juniors and six seniors. Questions explored residents' attitudes towards the peer-mentoring program. All interviews were audio-recorded, transcripted, and transcribed. Data was analyzed and coded using Heuristic-approach.
Junior residents overwhelmingly considered the mentorship program essential for surviving residency, mitigating burnout, and enhancing academic achievement. They emphasized the close connection with senior mentors, facilitating quicker integration into the residency program. Interestingly, juniors expressed discomfort with consultants as mentors due to fear of judgment. Their ideal mentor was characterized more by interpersonal skills than academic expertise. Conversely, senior residents found mentoring juniors instrumental in developing leadership, critical thinking, and problem-solving skills. They expressed increased engagement in the residency program and a desire for greater involvement in residents' education. The majority of residents off all levels recognized significant value in a peer-mentoring program.
This study delves into residents' perceptions of mentorship, revealing preferences for senior-resident over consultants as mentors. Residents believe this choice offers better value, citing factors like approachability, openness, and more effective guidance for exams. The study highlights residents' hesitation in seeking help from consultants, perceiving knowledge gaps and a sense of idealism in their advice.
To our knowledge, this study is the first in evaluating peer-mentoring from residents' perspectives, this research contributes valuable insights into mentorship practices.
Addressing gaps and aligning mentorship strategies with residents' needs, such as through innovative approaches like peer-mentoring, holds potential for improved academic and social outcomes during residency.
Mohammed AL-ROWAIS (Riyadh, Saudi Arabia)
00:00 - 00:00
#42153 - Glial fibrillary acidic protein and ubiquitin c-terminal hydrolase-l1: potential blood biomarkers for intracranial hemorrhage in mild traumatic brain injury.
Glial fibrillary acidic protein and ubiquitin c-terminal hydrolase-l1: potential blood biomarkers for intracranial hemorrhage in mild traumatic brain injury.
Introduction: Mild traumatic brain injury (mTBI) represents a significant public health concern due to its prevalence and potential for severe consequences. Defined by a Glasgow Coma Scale (GCS) score of 13-15 and not by a normal head computed tomography (CT), mTBI evaluation may benefit from additional biomarker data. Glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1) serum levels have emerged as potential aids for emergency department (ED) clinicians in risk assessment and exhibit promise for high negative predictive value regarding serious intracranial pathology post-mTBI. However, the utility of GFAP and UCH-L1 in stratifying risk for patients presenting to the ED with mTBI and intracranial hemorrhage remains unexplored. Materials and Methods: This ongoing prospective monocentric observational study encompasses non-pregnant patients (> 18 years) presenting to the ED within 4 hours of a traumatic event, reporting mTBI (GCS >13). Eligible patients have undergone venous blood sampling and brain CT scans as part of standard emergency care per intra-hospital guidelines and clinical judgment. The primary objective is to assess the sensitivity and specificity of serum biomarkers for intracranial hemorrhage detected by head CT in mTBI patients. Continuous variables are presented as median [interquartile range], while categorical variables are expressed as absolute numbers (%). Statistical analysis employs the Mann-Whitney U test for continuous variables and the chi-square test (with the Fisher test if appropriate) for categorical variables for primary and secondary outcome comparisons. Results: Between September 15, 2022, and November 30, 2023, 412 mTBI patients were enrolled, with a median age of 68 years [53.5-82]. Median serum GFAP and UCH-L1 levels were 49.3 [25.1-91.2] and 322.8 [181.95-559.2]. Among these, 66 patients exhibited intracranial hemorrhage on head CT scans, while 346 patients did not. Median GFAP levels were 309.2 [85.2-1064.8] in patients with intracranial hemorrhage compared to 43.95 [23.45-72.05] in those with negative head CT scans. Median UCH-L1 serum values between patients with and without intracranial hemorrhage were 470.9 vs. 297.2, respectively. Utilizing thresholds derived from our population (UCH-L1>335pg/mL and GFAP >82pg/mL), combined biomarkers demonstrated sensitivity and specificity of 89.39 (74.9-95.6) and 48.27 (42.9–53.7), respectively. Conclusion: Serum GFAP and UCH-L1 measurements may enhance mTBI management in the ED by predicting intracranial injuries and facilitating risk stratification for patients without severe neurologic impairment at presentation. While current data support the potential development of a standardized serum assay, further patient enrollment is warranted.
Giacomo SPAZIANI (Rome, Italy), Marcello COVINO, Davide DELLA POLLA, Andrea PICCIONI, Gloria ROZZI, Gianluca TULLO, Valerio PICARDI, Maria LUMARE, Francesca GIANCRISTOFARO, Stefania GEMMA, Francesco FRANCESCHI
00:00 - 00:00
#42159 - Handling ED crowding by fast-tracking the Throughput component of patients less likely to need of hospitali admission.
Handling ED crowding by fast-tracking the Throughput component of patients less likely to need of hospitali admission.
Background
Emergency department (ED) crowding is a major patient safety concern and has a negative impact on healthcare systems and healthcare providers. We hypothesized that it would be feasible to control crowding by employing a multifaceted approach consisting of systematically fast-tracking patients who are less likely in need of a hospital stay as assessed by an initial nurse and treated by decision competent physicians.
Methods
108532 patients registered in a secondary care ED from the 4th quarter of 2021 to the 4th quarter of 2023. Data was drawn from the electronic health record’s (Epic) data warehouse using the SAP Web Intelligence tool and processed in the Python programming language. Crowding was compared before and after ED transformation from a uniform department into a high flow (α) and a low flow (β) section with patient placement in gurneys/chairs or beds, respectively. Patients putatively not in need of hospitalization were identified by nurse, placed in in the α setting and assessed and treated by decision competent physicians. Incidence of crowding, number of patients admitted per day and readmittances within 72 h following ED admission before and after changes were determined. Values are number of patients, mean ± SEM and mean differences with 95% CIs. Statistical significance was ascertained using Student’s two tailed t-test for unpaired values.
Results
Before and after ED changes crowding of 130% amounted to 123.8 h and 8.7 h in the latter. This is a difference of -115.3 ± 26.3 h with a 95% CI of -177.4 to -52.9, Δ% -93 (p = 0.03).
There was the same amount of patients / day amounting to 135.2 and 132.3 patients / day Δ% = -3.5 ± 1.7 patients 95% CI -7.5 to 0.5 (p >0.08)
There was no change in readmittances within 72 h before and after changes amounting to 8.9% versus 9.5%, Δ% = 0.5 ± 0.4% 95%CI -0.1 to 1.1 (p >0.09).
Discussion & conclusion
It appears feasible to abate crowding with unchanged patient admission and without an increase in readmittances by fast-track assessment and treatment of patients who are less likely to need hospitalization.
Trial Registration i s not relevant for this study.
We did not recieve funding for the study.
Halfdan LAURIDSEN (Hillerød, Denmark), Jesper Juul LARSEN, Thomas Andersen SCHMIDT
00:00 - 00:00
#41364 - HCAPPED I Study - Early Multiplex PCR on Respiratory Samples of Patients with Healthcare-Associated Pneumonia: A Novel Diagnostic Approach to Guide Antimicrobial Therapy in Emergency Department Patients with Pneumonia.
HCAPPED I Study - Early Multiplex PCR on Respiratory Samples of Patients with Healthcare-Associated Pneumonia: A Novel Diagnostic Approach to Guide Antimicrobial Therapy in Emergency Department Patients with Pneumonia.
Background: Pneumonia is the leading cause of death from infectious disease worldwide. Among these, the most challenging forms to treat are healthcare-associated pneumonia (HAP) and those associated with healthcare (HCAP), often linked to multi-drug resistant (MDR) microorganisms. HCAP represents a significant cause of Emergency Department visits and hospitalizations. Due to their often MDR nature, empirical treatment is frequently inappropriate and inadequate. Multiplex PCR applied to bronchoalveolar lavage (BAL) has demonstrated rapid and effective pathogen identification and detection of resistance genes.
Materials and Methods: HCAPPED I is a prospective, non-profit observational study conducted in the Emergency Department to evaluate the impact of early use of multiplex PCR on BAL on antibiotic therapy. The primary outcome is the percentage of cases in which multiplex PCR alters therapy (escalation and de-escalation) compared to international empirical guidelines.
Results: Seventy-two patients with HCAP were enrolled. Among these, the Film Array Pneumonia on BAL yielded positive results in 90% (65/72) of cases. The flora was multimicrobial in 63.8% (46/72) of cases, with antibiotic resistance genes identified in 36.1% (26/72). BAL culture was positive in 63.8% (46/72) of patients, with evidence of MDR or XDR (extensive drug-resistant) pathogens in 54.3% of cases (28.2% and 26.0% respectively). A change in antibiotic therapy compared to empirical guidelines occurred in 66.6% (48/72) of patients with positive film array results (66.6% escalation and 33.4% de-escalation).
The mean time from triage acceptance to BAL sampling was 18 hours (±7), with a minimum of 1 hour and a maximum of 24 hours.
Discussion: This study represents an innovation in the early etiological diagnosis of healthcare-associated pneumonia. This is particularly significant considering that blood cultures in pneumonia patients are positive only in 20% of cases (versus 90% for film array). The accuracy of multiplex PCR allows for a good estimate of whether the pathogen identified in the film array is an infectious agent or a contaminant based on the observed copy numbers. The advantage of this method lies in its rapidity. The disadvantage includes the required bronchoscopy training and the need for specific equipment, coupled with the non-ubiquitous distribution of multiplex PCR methodology.
Conclusions: In patients with HCAP, early performance of BAL in the Emergency Department and subsequent film array analysis allow for early modification of antibiotic therapy in a significant number of patients, particularly in terms of therapy escalation, enabling the targeted use of broad-spectrum antibacterials and antivirals.
CEAVC 26198
Funding none
Lorenzo PELAGATTI (Florence, Italy), Elisa MUZ, Gian Maria ROSSOLINI, Francesca MANGANI, Lorenzo CORBETTA, Sara TOMASSETTI, Alberto FARASE, Alessandro BARTOLONI, Peiman NAZERIAN, Stefano GRIFONI, Simone VANNI
00:00 - 00:00
#42120 - High acuity dispatches among the paediatric population.
High acuity dispatches among the paediatric population.
Background:
The epidemiology of out-of-hospital pediatric emergencies has gained little attention compared to other fields within emergency medical service (EMS) research. Yet, the pediatric population accounts for up to 10% of all EMS contacts and up to 30% of all emergency department (ED) visits. Although most pediatric patients seeking medical care within the emergency department do not typically arrive by traditional ambulance services, the subgroup transported by the EMS has demonstrated an increased probability of presenting with critical medical conditions. These differences from the adult population pose important challenges for EMS personnel in maintaining competencies in acute prehospital pediatric care. Elucidating pediatric medical emergencies could improve education programs for EMS personnel and better allocation of prehospital resources. The primary outcome was determining the discharge diagnosis among pediatric patients assessed by a high-acuity dispatch. The secondary outcomes were to investigate the non-conveyance rate and to examine the chief complaints among different age groups within the pediatric population.
Methods:
This retrospective registry-based cohort study included all pediatric high-acuity dispatches in Region Zealand, Denmark, between October 1, 2017, and December 31, 2022. Data was collected from the EMS administrative dispatch system, Prehospital Patient Journals, Danish Intensive Database, National Patient Register, and CPR register. Data was analyzed using descriptive statistics.
Results:
A total of 265070 high-acuity vehicles were dispatched throughout the study period. Of these, 13882 responses regarded children between 0 and 17, accounting for 5,2%. The age distribution was as follows: 3834 or 27,6% <1 year old, 2951 or 21,3 % between 1-5 years, 2461 or 17,7% between 6-12 years and 4636 or 33,4 % between 13-17 years. Females accounted for 45,6%. The three most frequent symptom categories according to Danish Index, varied by age. However, compiled in all four subgroups, seizures consisted of a total of 2373 cases accounting for 17,1 %, ill child consisted of 1828 cases accounting for 13,2 % and accidents (not traffic-related) consisted of 1258 cases accounting for 9,1%. Most high-acuity vehicles were dispatched during the evening between 15:00 – 23:00, with 6226 cases or 44,8 %. Almost one-third of the dispatches occurred during the weekend. The 30-day survival rate was 99,5% and was evenly distributed between the four age groups. There was no statistically significant difference between the 30-day and the 365-day survival rate. A total of 10365 of the 13882 dispatches were conveyed. Of these 7108 or 68,6% were downgraded from high-acuity dispatches to less acute dispatches. Of all conveyed patients 52% were admitted less than 6 hours, and 15,4% were admitted longer than 24 hours.
Conclusion:
The symptom category leading to a high acuity dispatch varied by age, but the most frequent was seizures. Non-conveyed paediatric patients represent a substantial proportion of patients assessed by ambulances following high-acuity dispatches. Of those conveyed, the majority were downgraded to a less acute dispatch, and approximately half were admitted for more than six hours.
Neelam Noorie Umar FAROOQI (Copenhagen, Denmark), Signe Amalie WOLTHERS, Stig Nikolaj Fasmer BLOMBERG, Helle Collatz CHRISTENSEN
00:00 - 00:00
#41593 - High pressure non-invasive ventilation in acute decompensation of Obstructive Sleep Apnoea/Obesity Hypoventilation Syndrome is safe and effective in improving acidosis in the hands of emergency physicians.
High pressure non-invasive ventilation in acute decompensation of Obstructive Sleep Apnoea/Obesity Hypoventilation Syndrome is safe and effective in improving acidosis in the hands of emergency physicians.
Introduction
The British Thoracic Society released guidelines in 2016 on ventilatory strategies for non-invasive ventilation (NIV). We incorporated its recommendations in our emergency department NIV protocol in 2023 and performed a one-year audit to evaluate patient outcomes. We aimed to find out if emergency physicians were able to effectively initiate high pressure bilevel positive pressure ventilation, defined as inspiratory positive airway pressure (IPAP) greater than or equal to 20cmH2O. Effective implementation encompasses avoiding intubation and improving acidosis, focusing on patients with Obstructive Sleep Apnoea/Obesity Hypoventilation Syndrome (OSA/OHS). Previous studies on the use of high-pressure NIV were done predominantly by intensive care or respiratory physicians in inpatient settings.
Methods
A retrospective single-centre observational study was performed in Singapore General Hospital’s Department of Emergency Medicine, based on internal department audit of NIV use from the period of 1 March 2023 to 30 April 2024. Managing clinicians were provided training on the use of the NIV protocol, but were given autonomy to titrate settings independently based on clinical response and physician’s comfort. Audit data was submitted by the managing clinician and included information on age, gender, diagnosis, ventilatory settings and blood gas results, which was reported on hard copy forms and transcribed into Excel. Patients selected for discussion in this review were those with OSA/OHS. Progress in the hospital was evaluated until point of discharge from the acute hospital. Outcomes assessed were change in pH within the first hour of NIV, rates of intubation, and complications of treatment including barotrauma. Statistical analysis was performed using unpaired t-test for continuous data and Fisher’s exact test for categorical data.
Results
A total of 133 patients were included in the audit, of which 10 (7.52%) patients had pre-existing OSA/OHS with acute on chronic type 2 respiratory failure. Three patients received low pressure ventilation (IPAP 15-18) while 7 patients had high pressure ventilation (IPAP 20-24), administered via Zoll EMV+ 731 portable ventilator on pressure support ventilation.
All patients survived to discharge. One patient who had good response to high pressure NIV was prematurely weaned off NIV in the ED and subsequently required intubation a few hours later because of deterioration. No patient suffered complications of barotrauma or aspiration. Improvement in pH after 1 hour was 0.038 ± 0.047 (mean ± SD), with mean initial pH 7.260 ± 0.032 and 1-hour pH 7.287 ± 0.051. Use of high pressure ventilation was significantly associated with improvement in pH at the 1-hour mark as compared to low pressure ventilation (p < 0.05).
Discussion & Conclusions
Few studies exist on ventilatory strategies of OSA/OHS patients presenting with acute decompensation, and contrary to these studies, our audit showed poor improvement in pH with use of low pressure ventilation. Our review is the first of its kind regionally to demonstrate that high pressure NIV can be administered safely and effectively in OSA/OHS patients presenting to the emergency department with decompensated respiratory failure.
Trial Registration: Not applicable; this was an internal department audit.
Funding: This study did not receive any specific funding.
Ethical approval and informed consent: Waiver of informed consent was obtained. (CIRB Ref 2019/2472)
Maehanyi RAJENDRAM (Singapore, Singapore), Evelyn WONG
00:00 - 00:00
#42156 - High sensitivity troponin and low risk patients: using the history, electrocardiogram, age, risk factors and troponin (HEART) score to improve the european society of cardiology guidelines. A prospective observational study.
High sensitivity troponin and low risk patients: using the history, electrocardiogram, age, risk factors and troponin (HEART) score to improve the european society of cardiology guidelines. A prospective observational study.
Background:
The European Society of Cardiology (ESC) guidelines suggest using a high sensitivity cardiac troponin (hs-cTn) single test to rule-out acute coronary syndrome (ACS) in patients without ST-segment elevation, who are at least 3 hours after chest pain onset (CPO). In the last two decades, many scoring systems have been developed to help the emergency physician in the identification of low risk patients presenting to the emergency department (ED) complaining of non-traumatic chest pain. The primary aim of this study is to compare the single-sample rule-out ESC strategy and its integration with the application of HEART (history, electrocardiogram, age, risk factors and initial troponin) score in the identification of chest pain patients at low risk of major acute cardiovascular events (MACE).
Methods:
This is a single centre prospective observational study, carried out at the ED of the university hospital of Bologna, Italy. 18 years or older aged patients with non-traumatic chest pain were consecutively enrolled from 25 November 2019 to 24 November 2020. Main exclusion criteria were: ST-segment elevation; consent refusal; patients admitted twice or more for the same reason. Each enrolled patient underwent electrocardiogram and a blood sample to test the Access hs-TnI (Beckman-Coulter assay; single-sample rule-out cut off: <4 ng/l). Then, the HEART score was calculated. 90-days follow up was performed to register MACE. The main outcome was a MACE missing rate < 1%. The performance of the two approaches was evaluated with the estimates of sensitivity (Se.), specificity, negative predictive value (NPV) and positive predictive value.
Results:
The study population was finally composed by 3296 patients. 90-days MACE occurred in 493 patients (prevalence 15%). 1173 patients (35.6%) had the first hs-TnI <4 ng/L and CPO ≥ 3 hours; 9 of them experienced MACE (Se. 98%, NPV 99%, p<0.05). 1140 patients (34.6%) had HEART score ≤ 3 (i.e. low risk) and the first hs-TnI <4 ng/L irrespectively of CPO; MACE occurred in 2 cases (Se. 99.5%, NPV 99.8%, p<0.05).
Discussion and Conclusions:
Both the ESC and the HEART guided approaches could correctly identify at low risk of ACS at least 1/3 of the whole population admitted to the ED for non-traumatic chest pain. MACE missing rate was below 1% in both cases. These results are consistent with the literature. By considering at low risk only patients with HEART score ≤3 and the first hs-TnI <4 ng/L, irrespectively of CPO, the 90-days MACE percentage decreased (0.17% vs 0.76%) without negatively impacting the proportion of patients at low risk. This is probably because the HEART score also considers age and cardiovascular risk factors, elements relevant to identify the group of patients with a low pretest probability of disease. Data obtained from this prospective study suggest that the integration between the single-sample rule-out strategy and the HEART score could improve the accuracy in the correct identification of chest pain low risk patients in the emergency department.
Study approved by ethics committee with registration number 480/2019/Oss/AOUBo.
This study did not receive any specific funding.
This study contemplated informed consent.
Dr Eleonora TUBERTINI (Bologna, Italy), Gabriele FARINA, Luca SANTI, Benedetta PERNA, Fabrizio GIOSTRA
00:00 - 00:00
#41539 - How accurate is and how compliant are paediatric patients with the NHS11 advice given from clinically trained compared to non-clinically trained call-handlers?
How accurate is and how compliant are paediatric patients with the NHS11 advice given from clinically trained compared to non-clinically trained call-handlers?
Background
NHS 111 is a United Kingdom wide 24/7 telephone advice and triage service for urgent but non-life threating conditions. The purpose of the NHS111 telephone service is to direct patients to the most suitable level of care and reduce pressures on urgent and emergency care (UEC) services. However, there is evidence showing 111 has had little impact on reducing demand for NHS UEC services. Our previous research in adults showed patient compliance with NHS 111 advice is often low. It has also been suggested that non-clinically trained call-handlers may be risk averse and tend to ‘over-triage’. The aim of this study was to explore the accuracy of the advice regarding paediatric patients given by clinically trained vs non-clinically trained call handlers, and the level of compliance with that advice.
Methods
Using a linked regional routine UEC dataset containing NHS 111 calls and subsequent visits to an Emergency Department (ED) within 48 hours we performed retrospective observational analyses. The data was from the entire Yorkshire region in North England, during 1/4/2013-31/3/2017, for paediatric patients aged 0 to 15 years. Analysis included descriptive summary measures and adjusted logistic regression to determine the association between call-handlers clinical skill level and the accuracy of advice given and patient compliance.
Results
Our analysis found that clinically trained call-handlers were more likely to recommend self-care (OR=10.75) compared to non-clinically trained call handlers. They were also less likely to recommend ambulance conveyance (OR=0.43), ED attendance (OR=0.76) or primary care (OR=0.18). Patients who received advice to self-care from a clinical call-handler were less likely to attend ED compared to those receiving the same advice from a non-clinical call handler (OR=0.06).
In terms of accuracy, patients who attended ED following an NHS 111 triage with a clinically trained call-handler were more likely to receive a low-urgency ED classification if they received NHS111 advice to self-care (OR=1.25) or seek primary care (OR=1.09), but less likely to receive a low-urgency classification if advised to attend ED (OR=0.947) compared to a non-clinically trained call-handler.
Discussion & Conclusions
We found that clinically trained call-handlers were more likely to recommend lower-acuity dispositions for paediatric patients. ED urgency classifications suggest clinically trained call-handlers triage more accurately, and consequently that this lower-acuity triaging style is not likely to be unsafe. ED attendance patterns also suggest that patients have more likely to follow decisions made by clinically trained call-handlers. The results from this study have implications in terms of managing the trade-off between employing clinically trained call-handlers vs accurate triaging and reducing unnecessary UEC use.
Ethics
This CUREd Database study has approval from the UK National Health Service (NHS) Research and Ethics Committee (Ref: 18/YH/0234). CUREd also has approval from the UK Confidentiality Advisory Group (Ref: 18/CAG/0126, previously 17/CAG/0024), to receive health and social care data without patient consent for patients of emergency and urgent care services in Yorkshire and Humber.
This report is independent research funded by the National Institute for Health and Care Research, Yorkshire and Humber Applied Research Collaborations NIHR200166.
Jen LEWIS, Rebecca SIMPSON (Sheffield, ), Tony STONE, Colin O'KEEFFE, Nicola ENNIS, Nicola KAY, Susan CROFT, Suzanne MASON
00:00 - 00:00
#41860 - How is Same Day Emergency Care (SDEC) Being Implemented Across England?
How is Same Day Emergency Care (SDEC) Being Implemented Across England?
Introduction
In 2019, NHS England announced that every major hospital would provide “Same Day Emergency Care” (SDEC) by the end of the year. SDEC is the provision of same day care for patients who would otherwise be admitted to hospital, such that patients with appropriate conditions can be rapidly assessed, diagnosed and treated on a dedicated unit, and if clinically safe to do so, go home the same day their care is provided. The aim of this model is to reduce avoidable hospital admissions, an important issue facing all acute care services. Adoption and utilisation has been variable and so this national study aims to gain an insight into the varying methods of SDEC implementation and subjective workforce opinions on its use.
Methods
An electronic survey was designed using evidence-based methods, available literature and discussions with those working in the field. 60 hospitals with type 1 emergency department (ED) and SDEC services in England were selected using simple randomisation and the survey distributed via email to relevant staff members. Follow-up interviews were conducted for those consenting participants to expand on their survey responses and key themes identified.
Results
44 responses have been received to date, 28 from ED staff and 16 from SDEC leads, representing 36 hospitals. Responses covered 74 SDEC units, 47% providing care to acute medical patients, 23% surgical, 14% geriatric and 16% other subspecialty patients. These units operated a mean of 12 hours during weekdays and 10 hours during weekends.
The average SDEC unit comprised 12 staff members including a senior decision-maker (consultant or registrar) and utilised advanced care practitioners or physician associates in 85% of units. However, doctors in training were not well-represented, deployed in only 46% of units. Only 2 units (15%) employed a physiotherapist or occupational therapist.
Regarding resource availability, average staff to computers ratio (4:3) was good, with all units having an average of 9 stations. Assessment space availability was mixed, with an average unit comprising 5 bed or trolley spaces, 13 chair spaces and 1 side-room.
Patient attendance was high, with 87% of units managing ≥31 patients per day, the majority of which were referred from ED rather than community services. Despite this, the average unit admitted 10% of patients assessed per day, equivalent to less than 10 patients in surveyed units.
Five interviews have been undertaken so far, with key themes highlighting a poor understanding of the purposes of SDEC by staff members working in and referring to SDEC and the suboptimal staffing and resources available. There was agreement that frailty SDEC should be further developed nationally, more community referrals should be taken and that SDEC units should be co-led by both Emergency and Acute Medicine.
Conclusions
Despite variable staffing, resources and methods of delivery, the SDEC units surveyed have the capacity to see large numbers of patients whilst admitting few. However, the true impact on reducing admissions is unclear. More research is needed to identify the optimum model of service and in the national dissemination of this.
N/A
Joshua WREN (Sheffield, United Kingdom), Suzanne MASON, Susan CROFT
00:00 - 00:00
#41473 - Identifying the walk-in wounded: a case series of paediatric major trauma patients self-presenting to a paediatric major trauma centre.
Identifying the walk-in wounded: a case series of paediatric major trauma patients self-presenting to a paediatric major trauma centre.
Background:
Injury is one of the commonest presentations for children being brought to the emergency department (ED). Children who self-present to the ED may not be seen as promptly or receive trauma team activation compared to those arriving by ambulance. Little is known about this patient group, the injuries that bring them to the ED, or their level of injury. This case series reports patient characteristics, time to be seen and TTA, injuries, and operative interventions received.
Methods:
This study is a case series of paediatric patients presenting with injuries consistent with major trauma to an inner-city level 1 major trauma centre in the UK. Consecutive paediatric patients (<16 years of age) who self-presented to the ED between 5th August 2020 and 6th May 2022 who sustained injuries significant enough to be added to the national Trauma Audit and Research Network (TARN) database were included. Information was collected on demographics, time to be seen, trauma team activation, mechanism of injury, clinical signs and observations, injuries sustained, concerns for non-accidental injury, surgical interventions received and mortality. Descriptive statistics were analysed using SPSS 28.0 and injuries were classified according to the 2015 revision of the Abbreviated Injury Scale (AIS), which was used to calculate the Injury Severity Score (ISS).
Results:
153 major trauma patients presented to the ED throughout this period, with 24 self-presenting who were eligible for inclusion. The mean age of patients was 6.22 years (SD 5.1 years) and 18 (75%) were male. Mean time to be seen was 58.5 minutes (SD 48.4 minutes) and no patients received trauma team activation. The mechanism of injury was primarily falls (12, 50%), sporting injuries (6, 25%), bicycle injuries (2, 8.3%), being dropped (1, 4.2%) and 3 in whom injuries were unexplained (12.5%).
Nearly all (23, 95.8%) experienced single body region injuries, with the majority (54.2%) being head injuries. 8 (33.3%) had extremity injuries and 3 (12.5%) had intra-abdominal injuries. Median AIS was 3 (range 2-5) and median ISS was 9 (range 4-25) with 6 patients (25%) scoring >15 and classified as major trauma. Most (22, 91.6%) patients had obvious external evidence of injury, most notably either a boggy swelling to the head, abdominal bruising or thigh swelling /deformity and most had relatively unremarkable clinical observations. Concerns for non-accidental injury was confirmed in 3 (12.5%) of patients, all under the age of 1. 10 children (41.6%) required surgical intervention. No children died.
Discussion and conclusions:
In the time period studied 15.7% of all children who self-presented met the criteria for major trauma. Adoption of simple triage alerts for the three key features identified to prompt immediate senior clinician review might improve management of this group by triggering appropriate trauma team allocation and appropriate allocation of resources for this high risk population.
This study was a service evaluation using routinely collected data and so did not require trial registration or ethical approval. This study did not receive any specific funding.
Robert HIRST (Bristol, ), Ashwini SRIDHAR, Anne FRAMPTON
00:00 - 00:00
#40921 - Immobilization or non-immobilization for toddler's fracture: a systematic review and meta-analysis.
Immobilization or non-immobilization for toddler's fracture: a systematic review and meta-analysis.
Toddler fractures, first described by Dunbar in 1964, describe isolated, non-displaced, spiral or oblique fractures of the tibia. Any displacement is often less than 2mm, rendering it difficult to discern on X-ray. Consequently, clinicians frequently depend on the patient/carer’s history and physical signs to diagnose a fracture, and often treat these presumptively with immobilisation, regardless of the initial x-ray appearances. Increasingly, clinicians opt to treat suspected fractures without immobilisation, and there is a suggestion that even in those subsequently confirmed with a fracture, outcomes are similar to those who are immobilised at the index presentation. There is consequently a lack of consensus on whether toddler’s fractures require any immobilisation at all. The aim of this systematic review is to compare outcomes from immobilisation versus non-immobilisation in children with toddler’s fractures.
The primary objective was to explore fracture and non-fracture-related adverse outcomes observed in children under the age of 6 years treated with immobilization versus non-immobilization for toddler fractures.
Studies were included based on predefined criteria focusing on the management of toddler’s fracture (PROSPERO CRD42023461206). The searches were conducted on Ovid via Medline, Web of Science and Embase independently by two reviewers. Additional records were identified through reference screening, grey literature, conference proceedings and google searches. No language or setting restrictions were used. The meta-analysis was conducted using Review Manager 5.4. The risk of bias and certainty of evidence were assessed using the ROBINS-I tool, and GRADE respectively. Reporting followed the PRISMA 2020 checklist.
We identified 8 studies (7 retrospective case series, and 1 randomised controlled trial) that fit the inclusion criteria, with a total of 776 participants (566 immobilised vs 211 non-immobilized). The reported immobilization techniques included long/short leg casts, rigid splints, ankle boots, and backslab. No significant difference was observed in fracture-related adverse outcomes (displacement, angulation or delayed union) between the groups (Risk Difference 0; 95% CI, -0.02, 0.02, P = 0.96). 12.7% (72/566) of immobilised participants experienced non-fracture adverse events (pressure sores, fitting issues, breakage, pain, skin-related issues) Absolute risk difference 0.12; 95% CI, 0.04, 0.20, P=0.002). Three studies provided evidence regarding discomfort or pain; no significant difference was observed between the two groups (Odds ratio 0.89; 95 CI%, 0.25, 3.24, P=0.86). Participants with confirmed toddler’s fractures were more likely to be immobilised compared to suspected cases (78% vs 46% Odds ratio 1.78; 95% CI, 1.25, 2.52, P=0.001). Other outcomes that were reported narratively included time to clinical discharge, length of immobilisation, subjective assessment (questionnaire) unplanned and planned outpatient visits and time to weight-bearing/ambulation.
This updated systematic review considers new parameters/outcomes that are relevant in assessing the need for immobilisation. Overall, several limitations were identified, including the lack of validated classification for the severity of toddler’s fractures, heterogeneity in immobilisation techniques, and small sample sizes. Arguments against the use of immobilisation include increased rates of immobilisation-related adverse events. Furthermore, immobilisation did not provide additional benefits in reducing fracture-related events. Future research should focus on generating higher quality studies encompassing larger sample sizes and further utilising randomised controlled trials.
None
Sxe Chang CHEONG (United Kingdom Sheffield, Malaysia), Rishna RAMSINGH, Samlal SHIVANI, Shammi RAMLAKHAN
00:00 - 00:00
#41079 - Impact of Early Fascia Iliaca Compartment Block on 30 and 90 days Postoperative Mortality and Readmission in Elderly Individuals with Neck of Femur Fracture: A Retrospective Observational Study.
Impact of Early Fascia Iliaca Compartment Block on 30 and 90 days Postoperative Mortality and Readmission in Elderly Individuals with Neck of Femur Fracture: A Retrospective Observational Study.
Background:
Fractures of the femoral neck pose significant challenges in elderly populations, often leading to adverse outcomes and increased healthcare costs. Managing pain in these patients is crucial yet complex, particularly due to the limitations of standard analgesic approaches. Early fascia iliaca compartment block (FICB) presents a potential solution to address pain effectively, but its impact on postoperative complications and mortality remains understudied.
Methods:
A retrospective observational study was conducted at the University Hospital of North Midlands NHS Trust, including 376 elderly individuals with neck of femur fractures. Data on demographic characteristics, co-morbidities, time to FICB administration, postoperative readmissions, and mortality at 30 and 90 days were collected from electronic medical records. Statistical analysis was performed to evaluate the association between early FICB and postoperative outcomes.
Results:
The majority of patients were female (66%) with a high prevalence of comorbidities such as dementia and atrial fibrillation. While no statistically significant differences were observed, there was a trend suggesting reduced postoperative readmissions and mortality rates in the early FICB group compared to the late FICB group at both 30 and 90 days.
Discussion and Conclusion:
Despite the limitations of a retrospective design, this study provides preliminary evidence supporting the potential benefits of early FICB in reducing postoperative complications and mortality in elderly individuals with femoral neck fractures. Further prospective studies are warranted to validate these findings and elucidate the underlying mechanisms.
Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Ethical Approval: As a retrospective observational study, formal ethical approval was obtain from the UHNM research committee.
Importance of the Topic and Relevance for Emergency Medicine Practitioners and Researchers:
The findings underscore the importance of optimizing perioperative pain management strategies, particularly in high-risk elderly populations. Early FICB has the potential to improve outcomes and reduce healthcare costs associated with femoral neck fractures.
Originality of the Reported Research:
This study contributes to the limited literature on the impact of early FICB on postoperative outcomes in elderly individuals with neck of femur fractures, addressing a significant gap in knowledge.
External Validity:
While conducted in a specific healthcare setting, the results are applicable to emergency medicine practitioners globally, providing insights into the potential benefits of early FICB in improving outcomes for patients with femoral neck fractures. Further research in diverse settings is warranted to enhance external validity.
Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Ethical Approval: As a retrospective observational study, formal ethical approval was obtain from the UHNM research committee.
Adekolawole LONGE (Stoke-on-Trent, United Kingdom)
00:00 - 00:00
#41337 - Impact of Smoking on Premature Acute Coronary Syndrome in Code Heart Patients- A Retrospective Observational Study in Riyadh, Saudi Arabia.
Impact of Smoking on Premature Acute Coronary Syndrome in Code Heart Patients- A Retrospective Observational Study in Riyadh, Saudi Arabia.
Abstract
BACKGROUND: The major risk factors for coronary artery disease (CAD) include hypertension, dyslipidemia, diabetes mellitus, family history, and smoking. It may take years of exposure for CAD risk factors to manifest as atherosclerosis. Generally, premature CAD is defined as CAD occurring in men and women younger than 55 and 65 years respectively. Smoking is a social determinant of health and a modifiable risk factor for CAD. Acute Coronary Syndrome (ACS) includes ST- elevation myocardial infarction (STEMI), non-STEMI, and unstable angina; conditions which critically impair coronary blood flow. ‘Code Heart’ is a burst page sent to all hospital staff involved in emergency cardiac catheterization.
OBJECTIVES: To investigate the association between CAD risk factors and premature ACS occurrence in ‘Code Heart’ patients presenting to a single chest pain center in Riyadh, Saudi Arabia.
DESIGN: Retrospective observational cohort study.
SETTING: Tertiary care referral hospital, Chest Pain Centre in Riyadh, Saudi Arabia.
PATIENTS AND METHODS: All patients for whom a “Code Heart” was activated at the King Faisal Specialist Hospital and Research Centre, Riyadh (KFSH&RC) from 2010-2018 were included. Patient demographics and risk factors including age, sex, family history, hypertension, diabetes, coronary artery disease, dyslipidemia, and smoking history were obtained from the electronic medical records (EMR) and the patient care reports (PCR) compiled by the paramedics’ staff. ACS was considered premature in male patients aged ≤ 55 years and females aged ≤ 65 years. We analyzed the dataset using descriptive statistics, Chi-square, univariate, and multivariable logistic regressions. The association between the risk factors and premature ACS was reported as an odds ratio with a 95% confidence interval. A p-value of <0.05 is considered significant.
RESULTS: During the study period of 7 years, 354 “Code Hearts” were activated. 134 patients were smokers (37.8%). 50% of the cohort had suffered from premature ACS. The mean ages for premature and mature ACS were 46 and 65 years, respectively (p<0.001). The average age of non-smokers was 58.7 years while the average age of smokers was 50.5 years (p<0.001). Smoking and hypertension history remained statistically significant after multivariable logistic regression analysis. In our ACS patients, the odds ratio for smoking was 2.14 (95% confidence interval 1.36, 3.38), indicating that smokers were two times more likely to experience premature ACS than nonsmokers (p<0.01).
CONCLUSION: In this Code Heart population, smokers were more than twice as likely to experience a premature ACS (p<0.01). Smoking is a major modifiable risk factor for developing premature ACS. Concrete efforts should be made to prevent smoking in younger individuals.
LIMITATIONS: Patient data from a single center, lack of secondhand smoke exposure patient history.
COMPETING INTERESTS: None declared.
Maha BUTT (Riyadh, Saudi Arabia), Mohamed GAMAL, Taimur BUTT
00:00 - 00:00
#42130 - Impact of Vitamin C on the Reduction of Opioid Consumption for Acute Musculoskeletal Pain: A Double-Blind Randomized Control Pilot Study.
Impact of Vitamin C on the Reduction of Opioid Consumption for Acute Musculoskeletal Pain: A Double-Blind Randomized Control Pilot Study.
Introduction Recent evidence has shown that vitamin C has analgesic and opioid sparing properties in the immediate postoperative context. However, these properties have not been studied for acute musculoskeletal injuries (MSKI), which are often seen in the ED. The aim of this pilot study is to evaluate the feasibility of conducting a randomized placebo-controlled pilot study to determine the opioid sparing and analgesic effect of vitamin C compared to placebo, in MSKI-ED patients.
Methods: A double-blind randomized trial (RCT) distributed in two arms, stratified for fractures, was performed in a tertiary care center, one group receiving 1 g of vitamin C twice a day for 14 days and another receiving placebo. Participants were ≥18 years of age, treated in ED for MSKI present for less than two weeks, and discharged with an opioid prescription of 20 morphine 5 mg pills. Participants completed a 14-day paper or electronic diary to document their analgesic use, vitamin C consumption, and pain intensity. As a mitigation strategy, they were also contacted by phone at 2 weeks for the same information.
Results: 137 patients were screened; 44 (32%) were excluded, 38 refused to participate, leaving 55 participants (9.2 per month and 59.1% consent rate) with fractures as stratification variable (12 in each arm). Mean age was 53 (SD=16) and 45% were women. Fourteen (25%) participants were lost to follow-up and 83% of patients complied with treatment. For the per-protocol analysis, the median (Q1-Q3) morphine 5 mg pills consumed was 6.5 (3.3-19.5) for the vitamin C and 9.0 (1.5-16.0) for placebo group. The median (IRQ) naproxen 500 mg pills consumption was 0 (0-9.8) for vitamin C and 20 (0-27) for placebo group.
Conclusion: This pilot study supports the feasibility of a larger RCT on the opioid sparing and analgesic properties of vitamin C for MSKI-ED participants. However, strategies to reduce the refusal and lost to follow-up rate should be established.
NCT05555576, ClinicalTrials.Gov PRS
This research was supported by the « Fonds Alma Mater et Chaire Docteur Sadok Besrour de l’Université de Montréal », the « Association des spécialistes en médecine d’urgence du Québec » and the « Fonds des Urgentistes de l’Hôpital du Sacré-Cœur de Montréal ».
Raoul DAOUST (Montréal, Canada), Jean PAQUET, David WILLIAMSON, Verilibe HUARD, Caroline ARBOUR, Jeffrey PERRY, Marcel EMOND, Simon BERTHELOT, Patrick ARCHAMBEAULT, Dominique ROULEAU, Alexis COURNOYER
00:00 - 00:00
#41881 - Implementation of an emergency department consultant for general practitioners reduces the number of ED referrals from primary care -an interventional pilot study.
Implementation of an emergency department consultant for general practitioners reduces the number of ED referrals from primary care -an interventional pilot study.
Background
In Finland, 20% of patients are referred to the emergency department (ED) from primary health care, mostly by general practitioners (GP) working in health care centers. However, the referral process lacks coherence due to knowledge gaps in referral criteria, local practical differences, high turnover rates of GPs, and scarce interaction between the referring units and the EDs. This may result in unnecessary ED visits at the wrong time and place and consequently decrease patient satisfaction and safety. We provided a telephone ED consultant for primary care GPs, hypothesizing that it would result in fewer referrals to the ED.
Methods
We conducted an interventional unicenter pilot study between 3rd of October 2022-15th of December 2023 in Espoo, Finland. As intervention, we provided a specialized ED physician as a telephone consultant to whom the GPs were instructed to call before referring an adult patient to the ED. The primary study outcome was the number of ED referrals. The study was divided into two phases. In phase 1 (7 months) the consultant was available for two study health care centers and in phase 2 (6 months) for all primary health care units in the area. In phase 1, we compared the number and proportion of referrals made from the study health care centers and the number of referrals made from other health care centers between the study period and a 7-month control period before the study. In phase 2, we compared the total number of ED referrals between the study period and a 6-month control period before the study. A qualitative analysis was conducted from the feedback received from the GPs and ED consultants. Statistically, we used Student’s t-test. P-values of <0.05 were considered statistically significant.
Results
The ED consultant received 1524 calls during the whole study period. Of all calls, 58% (n=882) resulted in an ED visit and 3% (n=38) in a non-urgent visit in secondary care. Over one-third (n=550) of the calls did not result in a referral, and 3% (n=44) of the calls missed a decision. During phase 1 study period, the total number (165 vs. 217, p=0.026) and the mean proportion (7.6% vs. and 9.2%, p<0.001) of referrals from study health care centers decreased significantly. Furthermore, the referrals from other health care centers decreased, but the result was nonsignificant (1999 vs 2162, p=0.250). During phase 2 study period, there was a significant reduction in the total number of referrals (4307 vs. 4794, p=0.021). Of GPs, 79% regarded the intervention as functioning, 78% as effortless and 58% as beneficial. All ED consultants agreed on the advantages of the intervention.
Discussion & Conclusions
Implementation of an ED telephone consultant resulted in significant reductions in both the number and proportion of ED referrals from primary health care. The intervention received mainly positive feedback from all participants. For further implementation, more research is needed regarding patient-specific outcomes.
This study was funded by Helsinki University Hospital.
Ria HOLSTEIN (Helsinki, Finland), Kimmo SUOJANEN, Johanna KAARTINEN, Veli-Pekka HARJOLA, Arja KOBYLIN, Minna HALINEN, Kati MARTTINEN, Minna KONTTINEN, Maaret CASTRÉN
00:00 - 00:00
#42265 - Improving confidence at performing ‘high acuity, low occurrence’ procedures, a longitudinal study of a mixed methods educational programme.
Improving confidence at performing ‘high acuity, low occurrence’ procedures, a longitudinal study of a mixed methods educational programme.
Background: Emergency Physicians must be able to perform High-Acuity Low-Occurrence (HALO) procedures, to do this requires psychomotor skills, personal cognitive ability and team ability. HALO procedures are time critical, high stake interventions that by their very definition occur relatively rarely. This makes training physicians and maintaining confidence in HALO procedures difficult to achieve. Our primary aim was to use a mixed methods educational programme to improve and maintain confidence in three key procedures; Resuscitative Thoracotomy (RT), Lateral Canthotomy (LC), Front of Neck Access (FONA).
Methods: This longitudinal study, ran from May 2021 to April 2024, was set within the Emergency Department at Bedford Hospital, a Trauma Unit within the East of England Trauma Network in the United Kingdom. Participants included Consultants, Specialty Doctors, Senior Clinical Fellows and Emergency Medicine Trainees whilst employed or on rotation at the hospital. To cover psychomotor skills, personal cognitive ability and team ability a mixture of educational methods were used. This began with high fidelity simulation in May 2021 & low fidelity ‘in situ’ simulation. This was followed by procedural skills training every 6 months using animal & synthetic training models which started in September 2021. In October 2022 we launched a peer to peer web based interactive teaching package for HALO procedures. Participants had access to complete the HALO procedure modules through the departmental app, completion was set to expire at 6 months to prompt re completion of the modules on a regular basis. The online resource, simulation topics and procedural skills sessions were expanded to include a wider range of HALO procedures during the project. Feedback was sought from participants after each session to improve quality of the educational programme. All participants were asked how confident they felt to perform each specific HALO procedure on a simple 1-10 opinion scale survey at the beginning of the study, with surveying of all current staff repeated at various intervals, mean scores were rounded to the nearest whole number and presented with the interquartile range (IQR).
Results: Initial confidence scores were 3(IQR 1-4), 4(IQR 2-5) & 4(IQR 3-7) for RT, LC and FONA respectively, before implementing the educational programme. Confidence improved immediately after educational sessions to 7(IQR 6-9) for RT, 8(IQR 7-9) for LC and 8 (IQR 7-10) for FONA. Confidence reduced to 5(IQR 4-7) for RT, 6(IQR 5-8) for LC and 7(IQR 6-9) just prior to each procedural skills session. Over the course of the study RT has been performed 3 times by the department and LC once.
Discussion & Conclusions: Our study did not analyse subgroups of staff by prior experience and took a pragmatic approach in regards to staff turnover. It was also not possible to analyse the individual impact of each educational method. However, our mixed methods educational approach has led to emergency physicians in our department having increased and maintained confidence in performing HALO procedures. We believe this approach is reproducible for other departments.
This study was unfunded and did not require ethical approval.
Ka-Wing NG, Sebastian CLARK, Dr Richard AUSTIN (Bedford, )
00:00 - 00:00
#41330 - Improving Emergency Department Staff Satisfaction and Work-Life Balance through Rota Optimisation: A Quality Improvement Project.
Improving Emergency Department Staff Satisfaction and Work-Life Balance through Rota Optimisation: A Quality Improvement Project.
Introduction:
A well-balanced rota is essential for ensuring the well-being and job satisfaction of Emergency Department (ED) staff. Dissatisfaction with rota schedules can lead to increased burnout rates, reduced job satisfaction, and challenges in maintaining a healthy work-life balance. This quality improvement project aimed to improve satisfaction and work-life balance by optimisation rotas for Senior House Officers (SHOs) at Our Lady of Lourdes Hospital's Emergency Department (ED).
Methods:
To understand SHOs' expectations and perceptions of the existing rota system, a survey was distributed to 20 SHOs who worked from July to November 2023. The survey assessed SHO preferences for ideal number of consecutive workdays, consecutive weekends off, number of off days per week, and preferred schedule notice. Based on the identified expectations, an online semi-automated rolling rota with leave and swap manager features was developed. The new rota system was implemented on January 12th, 2024. Evaluation of the new rota system was conducted on March 25th, 2024, using a Likert scale survey to assess SHO satisfaction with various aspects of the rota.
Preferences:
The analysis of SHOs' preferences revealed insights into their ideal number of consecutive workdays, consecutive weekends, number of off days per week, and preferred schedule notice. A majority (66.7%) preferred no more than 5 consecutive workdays, while the remaining 33.3% favoured no more than 4 consecutive days. Regarding consecutive weekends, 83.3% preferred no more than 2 consecutive weekends, while 16.7% were comfortable with more than 2 consecutive weekends. Notably, 100% expressed a preference for at least 2 days off per week, and a significant proportion (66.7%) favoured a two-week notice period for schedule notification.
Results:
The results highlight a significant shift in SHO satisfaction levels pre- and post-implementation of the new rota system. Initially, dissatisfaction was prominent among 50% of SHOs, while only 16% expressed satisfaction, with 34% remaining neutral. However, following the implementation, substantial improvements were noted, with 60% of SHOs reporting being very satisfied, and an additional 40% expressing satisfaction.
Specifically, regarding consecutive workdays, 60% of SHOs reported being very satisfied, with an additional 20% expressing satisfaction and 20% remaining neutral. Similarly, concerning consecutive weekends off, 40% were very satisfied, while 40% remained neutral, and 20% were satisfied. The analysis also revealed that 40% of SHOs expressed very satisfaction with the number of off days per week, while 40% were satisfied, and 20% were neutral. Additionally, 60% were very satisfied with the advance notice of rota release.
In terms of work-life balance, 60% of SHOs were very satisfied, 20% were satisfied, and 20% were neutral.
Conclusion:
The improvements observed in satisfaction levels highlight the effectiveness of the intervention in optimising the rota system for SHOs in the ED. Continuous monitoring and potential adjustments will be necessary to ensure sustained satisfaction and well-being among SHOs in the department.
Kishan INDRAKUMAR (Ireland, Ireland)
00:00 - 00:00
#42131 - International Comparison of Ambulance Time Intervals for Stroke/Transient Ischaemic Attack Across Seven Countries Before and During the COVID-19 Pandemic.
International Comparison of Ambulance Time Intervals for Stroke/Transient Ischaemic Attack Across Seven Countries Before and During the COVID-19 Pandemic.
Background
Prehospital management of stroke/transient ischemic attack (TIA) aims to shorten time to diagnosis and treatment. International reports have acknowledged the wide-ranging impact of the COVID-19 pandemic on acute stroke services including a marked decline in acute stroke presentations. As time critical conditions, acute stroke/TIA care are potential indicators of the impact of the pandemic on care access and delivery. Thus, we aimed to investigate if ambulance time intervals for adults with suspected stroke/TIA differed before and during the COVID-19 pandemic across seven countries.
Methods
We conducted a secondary data analysis with a quasi-experimental design, using data from seven international ambulance services. These services include those from: the Republic of Ireland, Northern Ireland, Scotland, New Zealand, Netherlands (Tilburg), Austria (Vienna) and Australia (Queensland). Although included countries have different underlying healthcare systems they all use the Advanced Medical Priority Dispatch System (AMPDS). Thus data harmonisation and comparison was possible and appropriate. We included all cases assigned AMPDS code 28 (suspected stroke/TIA) by the emergency call-taker, between 2018-2021. We compared five ambulance time intervals: “allocation performance”, “mobilisation performance”, “response time”, “on scene time” and “conveyance time” between the pre-COVID-19 and COVID-19 periods using descriptive and regression analyses. We also compared call volume for suspected stroke/TIA between the pre-COVID-19 and COVID-19 periods using time series and regression analysis. Due to differing populations served by the included services, call volume is reported in “number of suspected stroke/TIA calls per 1,000 emergency calls” for each service.
Results
We included 263,319 adults with suspected stroke/TIA from 1st January 2018 to 31st December 2021 in this analysis. Of these, 118,443 occurred during the pre-COVID-19 period and 144,876 occurred during the COVID-19 period. Mean allocation performance significantly increased across five services. Whilst response performance and on-scene time significantly increased across six services during the COVID-19 period. In all seven included regions, an initial decrease in suspected stroke/TIA call volume per 1,000 emergency calls occurred during the initial COVID-19 period.
However, mean monthly suspected stroke/TIA calls per 1,000 emergency calls significantly increased for all services apart from the Netherlands, between the pre-COVID-19 and COVID-19 periods.
Conclusion
These findings underscore the dynamic nature of prehospital stroke management amidst the evolving challenges posed by the pandemic. Further research is warranted to delve deeper into the underlying factors driving these international differences and to optimise strategies for enhancing stroke care delivery in the context of ongoing public health crises.
Health Research Board Ireland [CDA-2019-001; Collaborative Doctoral Award (CDA) 2020-2024].
The funders had no role in study design, data collection and analysis, decision to submit, or preparation of the abstract.
Edel BURTON (Cork, Ireland), Rory QUINN, Emma BOSELEY, Conor DEASY, Craig HENDERSON, Heather HUTCHINSON, Mario KRAMMEL, Adam LLOYD, Wayne LOUDON, Terence QUINN, Siobhán MASTERSON, Neelesh C. MUPPARAPU, Cathal O'DONNELL, Jerry OVERTON, Harm VAN DE PAS, David WILLIS, Julia Helen WOLFE, Kieran CROSBIE-STAUNTON, Áine MERWICK, Vera Jc MCCARTHY, Patricia M. KEARNEY, Claire M. BUCKLEY
00:00 - 00:00
#41063 - Is Admission Hypocalcaemia Associated with Haemodynamic Instability in Paediatric Major Trauma? - A Retrospective Single-Centre Pilot Study.
Is Admission Hypocalcaemia Associated with Haemodynamic Instability in Paediatric Major Trauma? - A Retrospective Single-Centre Pilot Study.
Aims
Haemorrhage is the predominant cause of potentially survivable death in trauma. The lethal triad of hypothermia, acidosis and coagulopathy is now considered a diamond of death, with a fourth component, hypocalcaemia, contributing to acute cardiovascular decompensation and worsening coagulopathy. Ionised hypocalcaemia may be associated with haemodynamic instability and adverse outcomes in paediatric major trauma patients. However, current data is limited.
This pilot study aims to report the association between admission ionised hypocalcaemia (iHypoCa) and hypotension in a cohort of paediatric major trauma patients. Secondary aims include reporting the incidence and differential determinants of iHypoCa and the association with adverse outcomes.
Methods
This study is a retrospective analysis of prospectively collected paediatric major trauma patients (<16 years old) admitted to a single major trauma centre between August 2016 and August 2023. Patients with an admission ionised calcium level taken before the administration of blood products were identified from local site Trauma Office records with matched patient data obtained from the electronic medical records. Secondary transfers and repatriations were excluded.
Demographics, mechanism of injury, injury time, and Injury Severity Score (ISS)), 24-hour and 30-day mortality, Glasgow Outcome Scale, and length of stay data were obtained from the local Trauma Office records. The presence of hypotension, laboratory data, and details of pre-hospital and hospital treatments (fluids, blood, calcium, vasoactive agents, invasive intervention (interventional radiology (IR) or operative)) were obtained from the electronic medical record.
The Student t-test compared normally distributed parameters. The Mann-Whitney U test compared non-normally distributed variables. The χ2 test was used for categorical variables. Multivariable logistic regression was used to assess the dichotomous endpoint of hypotension for association with hypocalcaemia and adjusted for other potential variables of interest (age, gender, injury severity score, pre-hospital fluids, acidosis).
Results
Admission iHypoCa was observed in 8/45 (17.7%) patients. Median age was 10.8 years [IQR 5.6 – 14.9], 25/45 (55.5%) were male. Median ISS was 25 [20 -35], the majority were blunt mechanism (44/45 (97.7%)). Other than the adolescent age group (p <0.05), there were no statistically significant differences in baseline characteristics.
The odds of haemodynamic instability were two to three times higher for patients with hypoxia (OR 2.77 (95% confidence interval 0.35 to 23.56) p=0.33). However, this was not statistically significant. In the first 24 hours, ten-fold increased odds of invasive management (interventional radiology/operation) were observed (OR 10.94 (95% confidence interval 1.37 to 159.4) p=0.04). While trends towards other adverse outcomes were observed, they were not statistically significant in this cohort.
Conclusion
In this pilot study, admission ionised hypocalcaemia was present in approximately one-in-six paediatric major trauma patients. This was associated with two to three times increased odds of haemodynamic instability and tend-fold odds of requiring invasive management. Larger multi-centre studies are recommended to further clarify trends in treatment requirements and adverse outcomes.
Trial Registration
Queen Mary University of London sponsored the study. Integrated Research Application System (IRAS) project number 328924.
Funding
This study did not receive any specific funding.
Ethical Approval
Research Ethics Committee (REC) reference 23/PR/0876. Informed consent was not required as this involved a retrospective dataset collected as part of routine care.
Owen HIBBERD (Cambridge, United Kingdom), Edward BARNARD, Matthew ELLINGTON, Stephen THOMAS, Tim HARRIS
00:00 - 00:00
#41310 - Is multimorbidity associated with readmissions in older patients acutely admitted with a potentially preventable hospitalisation? A nationwide register-based study from Denmark.
Is multimorbidity associated with readmissions in older patients acutely admitted with a potentially preventable hospitalisation? A nationwide register-based study from Denmark.
Background:
The emergency departments encounter significant resource challenges due to the demographic trend with an ageing population and escalating multimorbidity burden. Consequently, identification and prioritisation of patients at higher risk of unnecessary hospital use becomes a key task. Multimorbidity is related to increased emergency care utilisation. However, little is known about the group of patients who are admitted due to a potentially preventable hospitalisation, and whether the complexity related to their chronic diseases influence their pathway. The aim of this study is thus to investigate the association between multimorbidity and readmissions in older patients acutely admitted with a potentially preventable hospitalisation.
Methods:
Using data from Danish health care registries, we conducted an observational cohort-study spanning January 2013 to December 2018. Patients were included in the study upon an acute hospital admission due one of the following diagnoses: Gastroenteritis; Nutritional anaemia; Dehydration; Pneumonia, bronchitis, chronic obstructive pulmonary disease; Constipation; Decubitus; Urinary tract infections; Fractures; and Socioeconomic/psychosocial circumstances, care provision/medical facilities. Eligibility criteria were Danish citizen, 65 years or older at the time of inclusion, and sampling was consecutive. The primary exposure variable was multimorbidity status; defined as having ≥2 chronic diseases out of 39 possible concurrently. The study assessed hospital readmission within 30 days of discharge from the index admission. To determine the association between multimorbidity and hospital readmission, we applied the Fine and Gray approach to estimate the subhazard ratio (SHR), and modelled cumulative incidence curves.
Results:
227,016 patients were included in the final analysis. 192,291 (84.7%) were multimorbid with a median number of chronic diseases of 5 (3;6). Median age was 78 years (71;74) and 61 years (68;77) for patients with and without multimorbidity, respectively. Top three index diagnoses were fractures (39%); pulmonary diseases (34%), and dehydration (9%). Overall, 41% of the patients experienced a readmission within 30 days after discharge. Multimorbidity was negatively associated with readmissions (aSHR 0.93 [0.91;0.94], adjusted for age, sex, previous hospitalisations). 4% of the patients died during their hospital stay.
Discussion and conclusion:
Our findings underscore the prevalence of multimorbidity among acutely admitted older patients, with the majority exhibiting a significant burden of chronic diseases. Despite the complexity associated with multimorbidity, our results surprisingly reveal a negative association between multimorbidity and hospital readmissions within 30 days of discharge.
This study sheds light on the interplay between multimorbidity and hospital readmissions among older patients with potentially preventable hospitalizations. While multimorbidity is highly prevalent in this population, it appears to be associated with a decreased risk of readmission within 30 days. A nuanced look at differences in index diagnosis groups, and multimorbidity combinations, should be applied in future research, and clinical approaches.
This project was supported with research grants from Helsefonden and Forsknings- og Udviklingspuljen. Ethical approval was not needed.
Trine THØGERSEN (Aarhus N, Denmark), Eskild BENDIX KRISTIANSEN, Deidre CRONIN FENTON, Marianne LISBY
00:00 - 00:00
#41949 - Leveraging AI for Enhanced Fracture Detection in Medical Imaging: A Path Towards Improved Healthcare Outcomes.
Leveraging AI for Enhanced Fracture Detection in Medical Imaging: A Path Towards Improved Healthcare Outcomes.
Aims and objectives.
Fractures are a common reason for attendance at emergency departments (EDs) and missed or delayed diagnosis of fractures is common, with potentially serious implications. The present-day healthcare system faces a multitude of challenges. Incorporating artificial intelligence (AI) tools into clinical decision-making has the potential to address a number of those challenges and deliver potential benefits, including improved diagnostic accuracy. The use of AI to identify fractures on adult skeletal radiographs in the acute trauma setting is a relatively unexplored area. Although the technical performance characteristics of the algorithms are important, it is assessing the accuracy of AI in a real-world context that allows its translation into clinical use.
AI as a clinical decision support has been shown to improve image interpretation performance in controlled diagnostic accuracy studies (Meng et al., 2023; Eng et al., 2021; Noguerol et al., 2019). The greatest benefit is seen for less experienced readers, with smaller improvements for experts (Lee et al., 2022). ED clinicians perform a preliminary review of imaging as part of their clinical assessment, yet many lack confidence or have limited experience in image interpretation (Kelly et al., 2012; Jimah et al., 2020). This suggests there could be significant productivity benefits from integrating AI in an ED setting where reporting turnaround times are a challenge, and where clinicians may fail to identify subtle radiological findings (Jones et al., 2020).
The aim of the proposed investigation is to evaluate AI musculoskeletal (MSK) fracture detection in a single ED setting in the UK.
Method and design
AI functionality for fracture detection in limb x rays was rolled out in phases from October 2022 till July 2023. MDT Group oversight the clinical trials to gain system performance assurances (both technical and clinical).
AI decisions are compared to formal clinical reports produced by Radiographers. Any discordant cases identified and sent for adjudication.
Aim of studies were to see:
If AI model has comparable performance to human reporters
If AI enhance the performance of clinicians as a technical supplement.
If AI impacts on patient flow and reduce errors in fracture detection
Number of Audits were done focusing on,
• Impact on A&E workflow and patient’s safety
• Referrals to fracture clinic
• Impact on Radiology reporting
• End user service Experiences.
Results and conclusion:
The results provided useful insight in several educational and clinical applications for AI in fracture detection.
Radiographic fracture recognition performance and efficacy of the AI tool increased overtime with significant reduction in False positive and Negative cases (Machine Learning).
Number of false positive results impacted fracture clinic referrals.
Impact on reduction of length of stay in the department.
Decrease in Complaints and Datix incidents.
AI enhances the performance of clinicians as a technical supplement rather than as a replacement for natural intelligence, with a huge potential for further collaboration (Duron et al., 2021).
Asim HABIB (Wigan, UK, ), Muhammad Saleem NASIR, Muzamil CHAUDHARY
00:00 - 00:00
#41483 - Long-term mortality among sepsis patients: A prospective single-center study.
Long-term mortality among sepsis patients: A prospective single-center study.
Background
According to a global report from the World Health Organization (WHO) on the epidemiology and burden of sepsis, there are limitations and knowledge gaps in sepsis estimates. Heterogeneous study designs, differences across data sources, and the use of different sepsis definitions have produced estimates of incidence and mortality that differ considerably. It has been criticized that most sepsis epidemiological analyses are based on systematic reviews of the literature that include primarily retrospective observational cohort or cross-sectional studies, and WHO has emphasized that long-term outcome data among sepsis patients still needs to be improved. They advocate for prospective studies based on chart- or electronic health records as the preferred method for evaluating sepsis epidemiology.
Aim
To examine long-term all-cause mortality and predictors for mortality in a prospective study of adult patients admitted to an emergency department (ED) with sepsis.
Methods
We conducted a prospective study of all ED patients admitted with suspected infectious diseases from 1.10.2017 to 31.03.2018. Sepsis was defined as a Sequential Organ Failure Assessment Score ≥ 2. The primary outcome was all-cause mortality (time to death) within the long-term follow-up period. We obtained mortality data from The Regional Zealand Patient Registration System, which is linked to the Danish Civil Registration System and provides daily updated information on the vital status of all Danish citizens. Demographic information, comorbidities, triage variables, laboratory tests, infectious sources, other diagnostic procedures, and the clinical progression during hospitalization were retrieved from a database containing prospectively collected data on all ED patients with suspected infection in the study period. Proportions are presented with 95% confidence intervals (CI). We used Cox regression analyses to estimate adjusted hazard ratios (aHR) with a 95% CI for mortality. A Nelson-Aalen cumulative hazard function plot against the Cox-Snell residuals was used to check the overall model fit, and the predictive power of the Cox model was evaluated by Harrell’s C concordance statistic.
Results
A total of 2,110 patients with suspected infections were included, and 714 (33.8%; 31.8-35.9) patients (58.4% male) with a median age of 75 years developed sepsis. After a median follow-up of 2 years, 361 (50.6%; 46.8-54.2) patients had died. Factors independently associated with increased risk of mortality included age (HR 1.04;1.03-1.05), a history of cancer (HR 2.21;1.70-2.87), ischemic heart disease (HR 1.39;1.05-1.85), dementia (HR 1.90;1.41-2.57) and previous admission with sepsis (HR 1.48;1.19-1.84) within the last six months before the index admission. A model without age produced the best model fit. The Harrel’s C for that model was estimated to be 0.488.
Conclusions
Half of the sepsis patients admitted had died within a median follow-up period of 2 years. Age, cancer, ischemic heart disease, dementia, and previous sepsis admission were independent predictors for mortality. However, the predictive ability of the model was poor.
This study was funded by the Regional Zealand Research Foundation.
Osama Bin ABDULLAH, Lana CHAFRANSKA ANDERSEN, Rune H. SØRENSEN, Thomas ANDERSEN SCHMIDT, Finn Erland NIELSEN (Aarhus, Denmark)
00:00 - 00:00
#42115 - Longer emergency department length of stay is associated with longer in-hospital length of stay in the elderly patients, a monocentric retrospective study.
Longer emergency department length of stay is associated with longer in-hospital length of stay in the elderly patients, a monocentric retrospective study.
Background : Numerous studies found an association between a long emergency department length of stay (EDLOS) and a higher mortality as well as a higher rate of adverse events in the older patients. Those studies also found a higher a longer in-hospital length of stay (HLOS) tendency for patients with long EDLOS, but none specifically both studied this effect in the older patient and use HLOS as primary endpoint.
This study aims to show an association between a long EDLOS and a prolonged HLOS specifically in older patients.
Methods : This was a mono-centric retrospective study on medical records from patients age 75 and older admitted on site to a medicine ward after emergency department (ED) consultation in a suburban hospital from July 1st 2023 to September 30th 2023. Patients admitted to intensive care, surgery ward or transferred to another hospital were not included in this study.
A total of 425 patients were included and divided in two groups: a group for patients that had spend 24 hours or more in the ED and those who spent less than 24 hours in the ED
EDLOS and HLOS were extracted from the digital records of the patients.
Their respective HLOS were then compared using Mann Whitney test and Kruskall Wallis test (the EDLOS was not included in HLOS calculation)
Results : A significative association was found between EDLOS and HLOS. Patients with EDLOS >24h had a 19h longer HLOS compared to patients with EDLOS <24h (p<0.0378), and had a 36h longer HLOS compared to patients with EDLOS <12h (p<0.0248). A strong association was found between patient orientation and HLOS strongly suggesting a patient profile with high risk of longer HLOS. Besides, patient frailty and final diagnosis at the end of the emergency department care was not taken into consideration in the statistical analysis representing potential confounding factors.
Conclusion : Elder patients are exposed to longer EDLOS and its’ consequences on morality and adverse events. This study finds that a longer EDLOS is also associated with longer HLOS in these patients. A patient profile with high risk of long HLOS in emergency setting to be determined. These results incentivize the creation and developpement of dedicated care pathways for fragile older patient.
Non registered
No specific funding
Clément MONTABORD (Paris), Maxime GAUTIER
00:00 - 00:00
#41905 - Necessity of 24-hour neurological observation in anticoagulated patients with mild traumatic head trauma: A single center observational study.
Necessity of 24-hour neurological observation in anticoagulated patients with mild traumatic head trauma: A single center observational study.
Title: Necessity of 24-Hour Neurological Observation in Anticoagulated Patients with Mild Traumatic Head Trauma: A Single Center Observational Study
Background/Objectives: Patients with mild traumatic head trauma (mTHT) who are on anticoagulant therapy face a heightened risk of intracranial hemorrhage (ICH). The benefits of hospitalizing these patients following a normal initial cranial CT scan is currently debated. Our study aimed to evaluate the necessity of 24-hour neurological observation in this patient group.
Methods: We conducted a single center prospective cohort study involving all adult patients aged 18 or older admitted to our emergency department. To be eligible for participation, the patients had to had suffered a mild head trauma while on anticoagulation therapy (Warfarin, Eliquis, Xarelto, Brilique or Pradaxa). Only patients with an initial head CT without abnormalities and an initial GCS-score above 9 were included. All included patients were admitted to the emergency department of Northern Zealand Hospital between January 19th – February 24th 2024. The primary endpoint was development of symptomatic ICH within the 24 hour observation period. Data was reported as simple percentage.
Results: A total of 19 patients (average age 81 years (50-97 years), 47% male) met the inclusion criteria. During the observation period, no instances (0%) of delayed ICH were recorded, and none of the patients showed neurological deterioration due to ICH within the first 24 hours.
Conclusions: Delayed diagnosis of intracranial hemorrhage (ICH) within 24 hours is remarkably rare in patients with mild traumatic head trauma (mTHT) receiving anticoagulants and presenting with a normal initial head CT scan.
Routine hospitalization of these patients may be unnecessary when the initial scan is thoroughly assessed. Our study demonstrates a 0% incidence of delayed ICH in anticoagulated mTBI patients, consistent with prior research (1) reporting a 0.2% incidence rate.
The trial was conducted as a quality control study, and does therefor not require ethical approval or written consent from participating patients in accordance with danish law.
Minna BABAZADEH (Copenhagen, Denmark), Shira HENDIN
00:00 - 00:00
#41255 - Non-invasive versus arterial pressure monitoring in the pre-hospital critical care environment: a paired comparison of concurrently recorded measurements.
Non-invasive versus arterial pressure monitoring in the pre-hospital critical care environment: a paired comparison of concurrently recorded measurements.
BACKGROUND
Blood pressure monitoring is important in the pre-hospital management of critically ill patients. Non-invasive blood pressure (NIBP) measurements are commonly used but the accuracy of standard oscillometric cuff devices may be affected by extremes of physiology and adverse conditions (e.g. noise and vibration) during transport. This study aimed to quantify the accuracy of NIBP measurements amongst patients requiring pre-hospital critical care.
METHODS
A retrospective cohort study was undertaken using data from patients treated by a pre-hospital critical team between 1st May 2020 and 30th April 2023 that had NIBP measured concurrently with invasive blood pressure (IBP) arterial manometry. An acceptable difference was determined a priori to be <20mmHg for systolic blood pressure (SBP) and diastolic blood pressure (DBP), and <10mmHg for mean arterial pressure (MAP). The primary outcome was “pairwise agreement”, i.e. the proportion of paired observations that fell within this range of acceptability. Bland-Altman plots were constructed together with 95% limits of agreement to visualise differences between pairs of data. Associations with patient age, reason for critical care, transport status, haemodynamic shock, severe hypertension, and arterial catheter position were explored in univariate analyses and by fitting multivariable logistic regression models.
RESULTS
There were 2,359 paired measurements from 221 individual patients with a median age of 57. The most frequent reason for transport was cardiac arrest (79, 35.7%). Bland-Altman analyses suggested unacceptably wide limits of agreement with NIBP overestimating both SBP and MAP during hypotension and underestimating these values during hypertension. Haemodynamic shock (SBP <90mmHg) was independently associated with reduced pairwise agreement for SBP (adjusted odds ratio [aOR] 0.52, 95% CI 0.35 to 0.77), DBP (aOR 0.65, 95% CI 0.42 to 0.99) and MAP (aOR 0.53, 95% CI 0.36 to 0.78) and severe hypertension (SBP >160mmHg) with reduced pairwise agreement for SBP (aOR 0.17, 95% CI 0.11 to 0.27). There was no association between patient transport and pairwise agreement for SBP, DBP, or MAP.
CONCLUSIONS
Non-invasive blood pressure measurements are often inaccurate in the pre-hospital critical care setting, particularly in patients with haemodynamic instability. Clinicians should be cautious when interpreting NIBP measurements and consider direct arterial pressure monitoring when circumstances allows.
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Yanithra PERERA, David METCALFE (Oxford, ), James RAITT, Asher LEWINSOHN, Kurtis POOLE
00:00 - 00:00
#41557 - Non-steroidal or opioid analgesia for children with acute musculoskeletal injuries: the No OUCH trials.
Non-steroidal or opioid analgesia for children with acute musculoskeletal injuries: the No OUCH trials.
Background: Musculoskeletal (MSK) injury is associated with moderate to severe pain in most children. While ibuprofen is recommended as first-line therapy for children’s mild-moderate MSK pain, optimal management for more severe pain remains unclear, especially when considering family concerns surrounding opioids.
Methods: Using a novel preference-informed complementary trial design, we conducted 2 simultaneous randomized, double-blind, controlled trials. Children 6-17 years, presenting to one of six Canadian pediatric emergency departments with an acute MSK injury (<24 hours) of a single limb and a verbal numerical rating scale (vNRS) score >5/10 were recruited from April 2019 to March 2023. Our primary objective was to determine the effectiveness of a combination of oral opioid and non-opioid analgesic medications [ibuprofen (IBU-10mg/kg) + acetaminophen (ACET-15mg/kg); IBU (10mg/kg) + hydromorphone (HM-0.05mg/kg); IBU (10mg/kg) alone]. The primary outcome was self-reported vNRS score at 60 minutes. Secondary outcomes included the proportion with a vNRS pain score < 3 and score reduction at least 2 points, between group vNRS scores, caregiver and child satisfaction with analgesia, length of stay, rescue analgesia, time to effective analgesia, and adverse events.
Results: A total of 699 children were randomized and 653 were included in the primary analyses (IBU+ACET=295, IBU+HM=110, IBU alone=294). Mean (SD) age was 11.5 (3.5) years, 47.4% (331/699) were female, and initial mean (SD) vNRS score was 6.4 (1.8); demographic characteristics were similar across the three study groups. The most frequent injury location was the upper limb 43.3%, 302/698). Mean (SD) vNRS scores 60 minutes post drug administration were 4.6 (2.4) IBU+ACET, 4.8 (2.6) IBU+HM, and 4.6 (2.3) for IBU alone. Mean (SD) pain reduction at 60 minutes was -1.9 (2.2) IBU+ACET, -1.7 (2.1) IBU+HM, and -1.8 (1.9) for IBU alone. Mean (SD) pain reduction at 120 minutes was -2.0 (2.4) IBU+ACET, -1.6 (2.2) IBU+HM, and -2.0 (2.3) for IBU alone. Proportions of children achieving a VNRS <3 were 19.9%, 23.4%, and 19.3% for IBU+ACET, IBU+HM, and IBU alone. The proportion of children achieving a vNRS score reduction of >2 were 53.0%, 55.1%, and 51.3% for IBU+ACET, IBU+HM, and IBU alone. Adverse events occurred most frequently in IBU+HM (28.2%) compared to IBU+ACET (6.1%) and IBU alone (6.1%). No serious adverse events occurred.
Discussion & Conclusions: Combining ibuprofen with either acetaminophen or hydromorphone did not provide better analgesia than ibuprofen alone for children with an MSK injury. Adverse events were over 4-fold more frequent with hydromorphone use. These trials’ results do not endorse adding oral hydromorphone or acetaminophen to ibuprofen for moderate-severe MSK injury pain in children.
Clinical trials.gov NCT03767933
Funding: Canadian Institutes of Health Research
Ethics approval was obtained by the institutional review boards at each participating site
Samina ALI, Maala BHATT, Serge GOUIN, Scott SAWYER, Antonia STANG, Maryna YASKINA, Anna HEATH, Petros PECHLIVANOGLOU, Terry KLASSEN, Martin OFFRINGA, Amy DRENDEL, Serena HICKES, Naveen POONAI (London, Canada)
00:00 - 00:00
#42336 - NT-PROBNP: INDEPENDENT FACTOR OF MORTALITY DURING ACUTE DYSPNEA.
NT-PROBNP: INDEPENDENT FACTOR OF MORTALITY DURING ACUTE DYSPNEA.
Introduction: NT-proBNP is a reliable diagnostic and prognostic biomarker in certain cardiac conditions. In the emergency department, its diagnostic utility in severe acute dyspnea has been demonstrated, but its prognostic value remains understudied. This study aimed to assess the prognostic value of NT-proBNP during severe acute dyspnea.
Patients and Methods: Prospective study conducted over 6 months. Inclusion of patients over 18 years old presenting with severe acute dyspnea. Exclusion of post-traumatic dyspnea, those associated with acute coronary syndrome, and those secondary to recent surgery. Mortality study at Day 30.
Results: N=108, Mean age=64+/-13 years, Sex ratio=0.83. Mean NT-proBNP concentration=1193+/- 178 pg/mL. It was higher in patients with acute heart failure (2116 vs 70; p<0.001). This concentration also varied by gender, with higher values in the female patients (1593 vs 1238 pg/mL; p=0.043). It also varied by age, BMI, and renal function. In-hospital mortality was observed in 29.6% of cases. It was correlated with high levels of NT-proBNP, with a mean of 2322 pg/mL in the death group vs 1058
pg/mL in survivors (p=0.01). Multivariate analysis revealed that an NT-proBNP level ≥1300 pg/mL was an independent predictor of mortality at Day 30. Kaplan-Meier survival curve analysis based on the threshold value of plasma NT-proBNP ≥1300 pg/mL showed that the difference in mortality rates became evident after 6 days of admission. Survival distribution was significantly different in the two groups (p<0.001). Median survival was 12 days (95% [CI], 3-20 days) in the NT-proBNP≥1300 pg/mL
group vs 32 days (95% [CI], 22-41 days) in the other group (p<0.001).
Conclusion: The prognostic value of NT-proBNP has been demonstrated in cardiology settings for chronic heart failure and ischemic heart disease. In the emergency department, it is primarily useful in the positive diagnosis of acute heart failure. In this study, NT-proBNP was an independent factor of mortality during acute dyspnea, highlighting the importance of better understanding its prognostic value in emergency settings.
Fatma HEBAIEB, Syrine TROJETTE, Saloua HOUIMLI (la Marsa, Tunisia), Nour El Houda MAATOUG, Mohamed ASSADI, Hajer HAMZAOUI, Sarra AKKARI
00:00 - 00:00
#41645 - Opioid prescription patterns for patients discharged from a Dutch Emergency Department: a retrospective cohort study.
Opioid prescription patterns for patients discharged from a Dutch Emergency Department: a retrospective cohort study.
Background:
Pain is a common complaint of patients visiting the Emergency Department (ED), frequently resulting in an opioid prescription upon discharge. The opioid epidemic in the United States and Canada has led to increased numbers of patients suffering from Opioid Use Disorder and rising numbers of opioid related deaths. While the Netherlands does not have the same levels of opiod use or abuse, we do see a growing number of opioid prescriptions. Therefore, it is important to provide emergency physicians with insights in their prescription patterns and associated factors.
We aimed to investigate the prescribing patterns of opioids and non-opioids in patients discharged from the ED. Furthermore, we sought to describe both patient and physician characteristics that were associated with opioid prescription.
Methods:
This retrospective cohort study was conducted at a single teaching hospital in the Netherlands. We obtained data from patients who visited the ED between July 2017 and June 2018. All consecutive adult patients that presented to the ED with pain as main complaint and were discharged from the ED with a new diagnosis were included. Exclusion criteria were admission to the hospital, pre-existent chronic pain or pain syndrome, age <18 years, pain accompanying a malignancy, or use of opioids in the previous 6 months.
Baseline patient characteristics, analgesics provided in the ED and prescribed at discharge, location of pain, cause of pain, pain score and physician characteristics were documented.
T-test and Chi square analyses were used for continuous and categorical variables, respectively. Logistic regression analyses were used to evaluate associations with patient and physician characteristics with opioid prescription at discharge from the ED.
Results:
A total of 2,530 patients were included. At discharge, 21.1% received an opioid prescription. Older patients were more likely to receive a prescription for opioids (OR 1.03, 95%CI 1.02-1.03). There were no statistical significant differences at discharge based on patient gender.
Trauma resulted in lower odds of being prescribed opioids compared to non-traumatic complaints (OR 0.80, 95%CI 0.65-0.99). Patients presenting with complaints of the upper extremity or head/neck also had higher odds of receiving an opioid prescription upon discharge (OR 1.57, 95%CI 1.28-1.93 and OR 1.80, 95%CI 1.22-2.66, respectively). Patients who underwent a reduction in the ED were also more likely to receive an opioid prescription (OR 2.896, 95%CI 1.48- 5.68).
Nurse practitioners in training prescribed significantly less opioids than emergency physicians (p=0.002). There were no significant differences between emergency physicians, EM-residents, general practitioners in training and interns.
Discussion and conclusions:
Over one fifth of patients that presented with pain received an opioid prescription when they were discharged from the ED. There are numerous patient and physician related factors influencing opioid prescriptions upon discharge.
This supports the need for further research to gain more insight in methods to reduce opioid prescriptions, such as educational programs, pre-populated default quantities in electronic prescribing systems and prescription guidelines.
Trial registration
The trial was not registered because it was not subject to the Medical Research Involving Human Subjects Act (WMO) due to the retrospective nature.
The Medical Ethical Committee Leiden-Den Haag-Delft decided that the study was not subjected to the Dutch Medical Research with Human Subjects Law. Informed consent was waived due to the sample size and the retrospective nature of the study.
Maaike VAN DEN HAMER (Delft, The Netherlands), Sjef BULDER, Daphne VAN RIJSSEL
00:00 - 00:00
#41576 - Osmolarity and Mortality in Patients with Extreme Hyperglycemia: A Danish Cohort Study.
Osmolarity and Mortality in Patients with Extreme Hyperglycemia: A Danish Cohort Study.
Objectives: Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the two most acute hyperglycemic emergencies. The diagnostic criteria of HHS are blood glucose ≥33 mmol/L, effective plasma osmolarity (2x sodium + glucose) ≥320 mmol/L, mild or no ketoacidosis, and dehydration, whereas DKA is defined by hyperglycemia, acidosis and ketosis. Some patients will present with a combined condition of HHS and DKA. The association between osmolarity and mortality remain unclear in patients with extreme hyperglycemia. The current osmolarity criteria in HHS of 320 mmol/L is based on case series results. Our objectives were to determine the 30-day mortality of patients acutely admitted with blood glucose ≥33 mmol/L, to examine the association between the degree of osmolarity and mortality , and to estimate the optimal cut-off point of osmolarity, when considering mortality risk .
Method: In this etiological population-based register study, we present preliminary data. We included all acutely admitted patients aged ≥18 years from Danish hospitals in the period 2016–2018 with plasma glucose ≥33 mmol/L taken 2 hours prior to 6 hours after arrival and calculated the effective plasma osmolarity (2x sodium + glucose). We estimated the 30-day mortality from arrival and computed an unadjusted spline regression to assess the 30-day mortality probability associated with osmolarit y . We evaluated the predictive performance of osmolarity by estimating the area under a receiver-operating characteristic curve (AUROC) and calculated a Youden index to find the optimal osmolarity cut-off point for mortality.
Results: A total of 2723 persons were acutely admitted with hyperglycemia ≥33 mmol/L. Osmolarity at arrival was distributed as follows <275 mmol/L=1%, 275-295 mmol/L=22% and >295mmol/L=77%. Thirty days after arrival, 275 (10%) persons had died. The median age was lower among survivors compared to non-survivors (64 years vs 74 years), and the proportion of females was higher among non-survivors (44% vs 37%). The best fitted spline regression was a linear spline model with three knots at osmolarity values 270, 290, 310 mmol/L. The spline curve resembled a U-shape, in which the probability of death was increasing with osmolarity of more or less than 290 mmol /L. When considering patients with osmolarity >275 mmol/L, the AUROC was 0.64 (95% CI: 0.60-0.67) and the maximum value of the Youden index was at 309 mmol/L with a sensitivity of 0.61 and specificity of 0.62.
Conclusions: The mortality for patients with hyperglycemia ≥33 mmol/L at acute hospital arrival was high. In a spline regression, we identified a U-shaped curve with the lowest mortality risk at osmolarity 290 mmol/L, with increasing mortality from this set-point of osmolarity. The predictive performance of osmolarity was poor. The optimal osmolarity cut-off when considering mortality differentiation in persons with hyperglycemia was 309 mmol/L, challenging the classic osmolarity criteria in HHS. This argues for reevaluation of the threshold of osmolarity for HHS and for more studies to detect this threshold.
The project was approved by Statistics Denmark (project number: 707838), Danish Health Data Authority (FSEID-00004732 and FSEID-00005777), and the Data Protection Agency (P-2019-616).
Funds: None.
Emilie Vangsgaard ROSAGER (Copenhagen, Denmark), Janne PETERSEN, Finn Erland NIELSEN, Steen Bendix HAUGAARD, Rasmus GREGERSEN
00:00 - 00:00
#41616 - Patient hours of care provided: Can it be a new metric to determine staffing in a post Covid-19 environment?
Patient hours of care provided: Can it be a new metric to determine staffing in a post Covid-19 environment?
Objectives :
Previous studies have shown that Emergency Departments (ED) have had increased Length-of-Stay (LOS) and Boarding times following the COVID-19 pandemic, it is unclear how temporal fluctuations in patient volume have been affected. Further, we suspect that EDs are seeing fewer patients but are having to provide more patient hours of care with the same staffing levels. We intend to demonstrate how differences in the daily ED volume and the patient hours of care delivered impact ED operations and to advise regarding staffing levels.
Methods:
This is a retrospective study of patient encounters in the ED at a single urban tertiary care hospital in the years 2018 (baseline) and 2022 (comparator). ED volume was quantified as the current treatment census over a twenty-four hour period over the course of the year and the median, 75th, and 90th percentiles were plotted for both years. The treatment census value was measured as the median and excluded waiting room census. Patient hours of care (PHOC) was derived by multiplying the median daily treatment census by the LOS and calculated for each hour of the day. Median patient hours of care was plotted for both years. Data was collected retrospectively from our electronic medical record (EPIC). The research was reviewed by our hospital’s IRB and deemed exempt, and non-human subject research. This study did not receive any funding.
Results :
In 2018, the median census in the Emergency department was as low as 38 patients at 07:00 and peaked between hours of 15:00 till 23:00 where the median census was 77. In 2022, the median census in the ED was 75 at 07:00 and the peak census occurred between 12:00 until 23:00 at 90 patients. In 2018, the median number of per day PHOC provided was 1,434 hours per day versus 2022 where it was 2,023 PHOC per day. That is 589 PHOC per day more hours of care delivered in 2022 than in 2018 despite an annual census of 101,132 patients in 2022 and 78,872 patients in 2018. In 2018, the total PHOC was 524,000 hours which per patient, was 5.2 hours per patient versus in 2022, where the PHOC was 740,000 hours which was 9.3 hours per patient.
Conclusions :
In a post-COVID-19 era, our ED cared for fewer patients, delivered more patient hours of care per patient and experienced less throughput and maintained higher censuses at every point throughout the day. These findings suggest that while most decisions on staffing utilize annual ED volume, that patient hours of care delivered model could be a more accurate metric to determine amount of work performed in the ED. Additionally in the post COVID-19 era, in our ED we have shown minimal fluctuation in the ED census throughout the day. Therefore, staffing levels should be adjusted to reflect this new reality.
Peter VAJDA (Detroit, USA), Howard KLAUSNER, Ronald GOUBERT, Mit PATEL, Nicole WANIS, Britany BETHAM
00:00 - 00:00
#42116 - Patients near death being transported to emergency care despite receiving specialized palliative home care - A registry study.
Patients near death being transported to emergency care despite receiving specialized palliative home care - A registry study.
Background: A significant proportion of patients who receive palliative home care express a preference for dying at home, even when the symptoms of their disease deteriorate. Despite this, a large number of patients die in hospital, suggesting that patients are transported from home to emergency care. These transports can mean that dying patients end up in the emergency department, a place that is less suited to end-of-life care. The emergency department environment poses great challenges for emergency nurses trying to care for patients near death. Lack of space, time and staff are cited as the main barriers.
The aim of this study was to map data on patients near death who had received specialized palliative home care and were transported to hospitals in Sweden.
Method: A national retrospective cross-sectional study was conducted using data from the Swedish Register of Palliative Care. The study included patients aged 18 years or above who were enrolled in specialized palliative home care and who died between 1 November 2015 and 31 October 2022 (n=39,698). Descriptive statistics were utilized to contrast patients who were transported to hospital and subsequently died within seven days of arrival, with patients who were not transported or transported earlier than seven days before death.
Results: A total of 7,383 patients were identified as having died within seven days of being transported from specialized palliative home care to a hospital or other care unit. The majority (74%) were admitted to a specialized palliative inpatient care unit, 23% to a non-specialized palliative inpatient care unit, and 3% to additional care units. The majority of these patients died within one to two days of arrival at the hospital. No clinical relevance was observed in the comparison of transported patients with non-transported patients with regard to sex, age, or diagnosis. However, transported patients exhibited a higher prevalence of dyspnoea (31% vs. 23%, p <0.001) and anxiety (60% vs. 57%, p <0.001). The simultaneous occurrence of multiple symptoms (e.g., confusion/anxiety, pain/severe pain, dyspnoea/respiratory secretion) was significantly more prevalent in the transported group (27% vs. 25%).
Discussion & Conclusions: A significant proportion of patients enrolled in specialized palliative home care were transported to hospital and subsequently died there. The majority of patients died within one or two days of admission. Complex symptoms were present, and not all patients were admitted to a specialized palliative inpatient care unit. Some commonalities, such as symptoms and symptom burden, can be observed in the patients who were transported. However, further studies are required to identify the causal relationship between these transports. Our study visibilises a phenomenon that can be experienced by the involved patients, relatives, and healthcare personnel as a major event in a vulnerable situation. We see a necessity to gain a deeper understanding of the underlying reasons for this type of transport and whether they are compatible with good palliative care and a dignified death.
Trial Registration: The study has not been registered due to non-clinical work.
Funding: The study is externally funded by the Swedish Cancer Society and internally funded by ALF funding, Region Örebro County.
Camilla WALL (Hallsberg, Sweden), Karin BLOMBERG, Elisabeth BERGDAHL, Helena SJÖLIN, Fredrik ALM
00:00 - 00:00
#41014 - PEAChY-O: Pharmacological Emergency management of Agitation in Children and Young people a randomised controlled trial of Oral medication.
PEAChY-O: Pharmacological Emergency management of Agitation in Children and Young people a randomised controlled trial of Oral medication.
Background: Acute behavioural disturbance in children and adolescents is becoming a more common reason for emergency department (ED) attendance. If non-pharmacological strategies fail, there is variation and uncertainty on the optimal oral medication.
Objectives: To determine whether oral olanzapine would be more effective than oral diazepam in achieving behavioural containment for acute behavioural disturbance.
Methods: In this investigator-initiated, open-label, multi-centre, superiority, randomised trial, we recruited young people aged between 9-17 years presenting to nine Australian EDs with acute behavioural disturbance deemed to require oral medication. Participants were randomly assigned to a single weight-based oral dose of olanzapine or diazepam. The primary outcome was achieving successful sedation (Sedation Assessment Tool score ≤0) without the need for additional sedatives one hour post randomisation. A range of secondary outcomes, including adverse events, were assessed.
Results: Three hundred and forty-eight participants were recruited, with 176 assigned to olanzapine and 172 to diazepam. Successful sedation without the requirement for additional sedatives occurred in 103/168 (61%) in the olanzapine group and 90/158 (57%) in the diazepam group (adjusted risk difference 0.036, 95% confidence interval -0.067 to 0.139). No serious adverse events were reported.
Conclusions: In young people presenting to the ED with behavioural disturbance, there was little evidence that oral olanzapine resulted in a greater proportion of participants achieving successful sedation at one hour post randomisation than oral diazepam. Neither medication resulted in any serious adverse events, however, approximately 40% of participants in each group did not achieve successful sedation.
Trial registration number: ACTRN12621001236886
Funding: Medical Research Futures Fund Grant Million Minds Mission (GNT1179137), Western Australian Child Research Fund, Emergency Medicine Foundation, National Health and Medical Research Council postgraduate scholarship
Elyssia BOURKE (Melbourne, Australia), Amit KOCHAR, Deborah SHELLSHEAR, Chris SELMAN, Simon CRAIG, Franz BABL
00:00 - 00:00
#42074 - People experiencing homelessness in the emergency department: admission, triage, diagnostics.
People experiencing homelessness in the emergency department: admission, triage, diagnostics.
Background: People experiencing homelessness (PEH) face lower health status, higher frailty and lower life expectancies compared to people not experiencing homelessness (PNEH). PEH tend to either not utilize medical services or to opt for low-barrier primary healthcare services due to often lack of health insurance, residence permit, and previous experiences of shame and discrimination. Medical emergencies, chronic somatic or psychiatric diseases cannot be covered by these structures, resulting in higher utilization of emergency departments (EDs). Little is known about this patient group. The aim of this analysis was to identify PEH from ED routine data and to analyze sociodemographic and medical characteristic of PEH in comparison to PNEH.
Methods: The routine data of all adult ED cases (≥18 years) from 27.11. – 3.12.2023 of a tertiary care hospital in Berlin (Germany) were retrospectively captured. Socio-demographic characteristics, administrative and medical parameters were recorded from the clinical information systems of the ED into an electronic database (RedCap). Medical documentation was screened for hints of homelessness: e.g., missing address data, social help organization’s address, documentation of “without fixed residence” in the initial nursing assessment or in the medical history/findings, ICD-10 codes Z59, Z65. Descriptive statistics are used for a comparison of PEH with PNEH.
Results: A total of n=943 cases were recorded. We included n=918 in the analysis (exclusion of n=25 due to age <18 years, or missing age information). In Total, n=71 patients (8%) showed hints of homelessness. While 70% of PEH were male, in contrast to 47% male in PNEH. PEH arrived twice as often by ambulance than PNEH (44% vs 22%). The mode value in the triage (Manchester triage system) was "urgent" in both groups (PEH: 52% vs PNEH: 49%). Most patients were treated and discharged from ED. In PEH 27% (n=19) of patients discharged themselves against medical advice or left before any doctor was seen. Blood sampling and x-rays were the most common diagnostic procedures performed in the PEH group. The most prevalent reasons for medical treatment were injuries (ICD-10 chapter S and T). Diagnoses of mental and behavioural disorders were 8-times more frequent in PEH than in PNEH (32% vs. 4%).
Discussion & Conclusion: PEH in urban EDs are not a marginal phenomenon, and represent a significant proportion of the patient population. In comparison, PEH were more likely to attend the ED by ambulance and to leave the ED before treatment was completed. The high number of psychiatric treatments presents a challenge in the ED. This underscores the importance of enhanced further research and interdisciplinary collaboration both within the hospital and with local stakeholders. Such efforts will be essential, for example, to develop social work approaches to the ED
Funding: This study did not receive any specific funding.
Ethical approval and informed consent: The ethics committee of the Charité University Medicine Berlin approved the ethics vote (EA1/082/18). As this is a retrospective secondary data analysis with routine data no separate patient consent was required.
Renate KARPENKO, Dorothee RIEDLINGER (Berlin, Germany), Anna C. SLAGMAN, Martin MÖCKEL, Liane SCHENK, Daniel SCHINDEL
00:00 - 00:00
#41205 - Perceptions and impact of Clinical Simulation training for Emergency Physicians.
Perceptions and impact of Clinical Simulation training for Emergency Physicians.
Background
The Emergency Department(ED) is a dynamic, busy clinical environment with multiple critically ill patients, time constraints in diagnosis and treatment and large interdisciplinary teams of varying experience. Continuous education and training for all staff members are crucial to optimize patient outcomes.
Clinical Simulation Training(CST) offers comprehensive education covering all aspects of care: clinical skills, knowledge, communication and teamwork.[1]
In a tertiary hospital in Greece, CST has been part of the training curriculum for Emergency Medicine Trainees since 2021. This educational method was introduced to the Emergency Physicians(EP) of the Department, for the first time
This study aimed to describe EP perceptions and attitudes toward CST and the impact of such training on their knowledge on specific topics.
Methods
In March 2024, 9/12 EPs of the ED of a tertiary referral hospital in Athens, Greece were enrolled; 2/12 were excluded for being Clinical Simulation Facilitators(CSF) and one declined to participate.
Participants were allocated to teams and progressed through three CST Scenarios: Eclampsia, Tricyclic Antidepressant Overdose and Peri-arrest Anaphylaxis. Each team received pre-briefing and debriefing by a single external CSF for each scenario
To assess changes in knowledge, perceptions and attitudes toward CST, a pre-and a post-survey(7 days after completion) were administered electronically with Cloud-based software, SurveyMonkey. Surveys consisted of a total of 78 questions (Table 1) Knowledge questions were scored correct or incorrect by a CST trainer; partial answers were deemed incorrect. All responses were anonymous.
Results
1 EP did not respond to the questionnaire.
Knowledge:
Regarding the 5 scenario-related questions, they answered correctly to 38% (15/40) before CST vs 45% after. After the CST the incorrect answers percentage lowered (28% after vs 55% before) with a concurrent increase of unanswered questions (28% after vs 8% before). They scored much less in the general knowledge questions (21%)(Table 2).
CST prompted 66% to read further on the conditions presented. 86% felt more confident (“strongly agree”, “agree”) in dealing with acute and complex emergencies overall but also for each of the 3 scenarios separately.
Perceptions and Attitudes
Figure 1 represents questions on perceptions and attitudes regarding CST before and after the training. The respondents’ opinions shifted in favour of the CST once the training was completed. Specifically, respondents felt that the CST increased their clinical and communication skills, ability to be a team member and confidence in dealing with acute and complex emergencies more than they had initially anticipated before the CST.
Conclusion
This study identified knowledge gaps among EPs in a tertiary hospital in Greece. Respondents’ knowledge increased with CST. EPs reported improvements in their clinical and communication skills, as well as their ability to work as part of a team. Furthermore, their confidence in handling acute and complex emergencies exceeded their initial expectations before the CST. This merits further research with validation of the questionnaire before administration, repetition of learning content per current educational theories and consideration of timing of the administration of the post-CST questionnaire.
Did not require ethics approval.
No funding was received.
Dr Anastasia SFAKIOTAKI (Melbourne, Australia), Ioannis KOPSIDAS, Christos GEORGIOU, Dimitrios MAVROLIAS, Effie POLYZOGOPOULOU, John PARISSIS
00:00 - 00:00
#41909 - Point-of-care bio-adrenomedullin at the emergency department: an early predictor of diuretic response in patients with acute heart failure.
Point-of-care bio-adrenomedullin at the emergency department: an early predictor of diuretic response in patients with acute heart failure.
Background: Despite progress in prevention and management of heart failure, acute heart failure (AHF) remains a common cause of patient presentation at the emergency department (ED), and the leading cause of hospitalization in elderly individuals. Inadequate diuretic response (DR) during hospitalization is associated with increased length of stay, short-term mortality, and readmission rates. Bio-adrenomedullin (Bio-ADM), a vasoactive peptide reflecting residual congestion, has recently emerged as a promising prognostic biomarker in patients with AHF. We aimed to investigate the role of point-of-care bio-ADM measured upon presentation at the ED as an early predictor of DR in patients hospitalized for AHF.
Methods: Forty-four patients with AHF were prospectively enrolled upon ED presentation. Clinical, echocardiography, standard laboratory and cardiac biomarker assessments were performed. Bio-ADM was measured at the ED from whole blood sample using a commercially available point-of-care immunoassay. DR was evaluated using total urine output per 40mg of furosemide equivalents during the first 3 days of hospitalization. Patients were categorized as having high or low DR if their urine output per 40mg furosemide was ≥ or < the median value, respectively. We examined the utility of bio-ADM as an early predictor of DR.
Results: Study population were 55% males, of median(IQR) age 76(65-83)years with AHF phenotype of 13(30%) pulmonary edema, 27 (61%) decompensated chronic HF, 1(2%) cardiogenic shock and 3(7%) right-sided HF. Patients with low DR consisted 50% of the population and had more frequently decompensated chronic HF (82% vs 41%, p=0.013); lower systolic blood pressure (SAP) [125(108-140)mmHg vs 150(123-180)mmHg, p=0.026), lower eGFR [44(30-67) vs 66(48-88)ml/min/1.73m2, p=0.041], and higher estimated pulmonary artery systolic pressure (PASP) [50(45-60) vs 43(29-51), p=0.038] and bio-ADM levels [104(59-263) vs 45(44-56), p=0.001]. In ROC analysis, bio-ADM showed good ability to predict DR (AUC 0.783, p<0.001). A cut-off of ≥60.1pg/ml could predict low DR with a sensitivity of 77% and a specificity of 82%. In logistic regression analysis, after adjustment for SAP, eGFR, and PASP, log(bio-ADM) independently predicted low DR during hospitalization (OR, 95%CI; 21.7, 1.05-446.1, p=0.046).
Conclusions: Point-of-care bio-ADM measured upon presentation to the ED in patients with AHF is associated with DR during hospitalization. Patients with increased bio-ADM may benefit from a more intense diuretic regimen to achieve optimal decongestion.
Dionysis MATSIRAS (Athens, Greece), Vasiliki BISTOLA, Christos VERRAS, Sofia BEZATI, Antonios BOULTADAKIS, John PARISSIS, Effie POLYZOGOPOULOU
00:00 - 00:00
#41908 - Point-of-care ultrasound to assess hydronephrosis in patients presenting with acute kidney injury in the emergency department: a prospective comparative pragmatic study.
Point-of-care ultrasound to assess hydronephrosis in patients presenting with acute kidney injury in the emergency department: a prospective comparative pragmatic study.
Background: While point-of-care ultrasound (POCUS) is recommended to exclude renal tract obstruction in the context of acute kidney injury (AKI), the diagnostic performance of POCUS performed by emergency physicians (EP) compared with central radiology examination for the diagnosis of hydronephrosis in ED patients presenting with AKI is poorly evaluated. Study objectives were to assess the performances of renal POCUS for the diagnosis of hydronephrosis, and explore factors associated with POCUS misclassification in ED patients with AKI.
Methods: We conducted a prospective, single-center, pragmatic diagnostic study, in the ED of a urban university hospital from July 2020 to June 2023. We obtained Institutional review board approval, with a waiver of written informed consent. We included ED patients presenting with AKI who underwent both a renal POCUS and a central imaging study (renal US and/or computed tomography (CT)) by a radiologist, as part of standard care. Patients with polycystic kidney disease, known renal tumor, horseshoe kidney, and urinary globes were excluded. Diagnosis of AKI was defined according to Kdigo criteria based on increase in serum creatinine level. Renal POCUS was performed by a trained attending EP, blinded from central imaging results using a Vivid S60 or a LOGIQ E (GE Healthcare, Medical System Israel Ltd, Israel). POCUS results were recorded as hydronephrosis present (present or suspected) or hydronephrosis absent. The presence or absence of hydronephrosis as diagnosed by the radiologist was defined as the gold standard. Agreement between POCUS and central imaging results were analyzed according to Gwet’s coefficient. Performances of POCUS were calculated along with their 95% CI. Multivariate analysis was carried out to identify factors associated with POCUS misclassification.
Results: One hundred fifty-five patients with confirmed AKI were analyzed (60% male, mean age: 70 (19) years, mean BMI:26 (6) kg/m2, 45% Kdigo1). Sixty-four (73%) EPs and 9 (27%) emergency residents were involved in the study with a median POCUS of 1 [1; 3] per EP, and a previous expertise > 50 POCUS for 63 (41%) of them. 99 patients (64%) underwent CT, median time between POCUS and central imaging study was 1.8 (0.8; 3.2) hours. Hydronephrosis was diagnosed in 35 (22 %) patients. POCUS misclassified 30 patients (19%), including 8 (23%) false negative. Agreement between POCUS and central imaging results was 68 % [95CI: 56 ; 79]. POCUS sensitivity was 87% [95CI: 69;100], negative predictive value (NPV) was 96% [95CI: 91 ;100]. A vascular history (odds ratio: 4,6 [95CI: 1,7-12,6], p=0,001) and flank pain at palpation (OR: 6,2 [95CI: 2,2-17,2], p=0,001) were independent risk factors for misclassification at POCUS.
Conclusion: EPs can accurately rule out hydronephrosis at POCUS patients presenting with AKI in the ED. Caution should be considered in patients with a vascular history or flank pain at palpation. Central imaging is required in case hydronephrosis is visualized or suspected at POCUS.
Trial registration : observational study no registration required /
Funding : no specific funding, supported by our university hospital
Solenn CORBINAIS, Yann INSERRA, Emmanuelle ESTIVES, Marie-Christine PICOT, Martin DARLET, Bruno LEHODEY, Sophie LEFEBVRE (Montpellier), Mustapha SEBBANE
00:00 - 00:00
#42170 - Predicting complications in elderly patients with acute coronary syndrome in the emergency department.
Predicting complications in elderly patients with acute coronary syndrome in the emergency department.
Introduction
Due to fear of complications, patients with acute coronary syndrome (ACS) are often admitted to wards with advanced cardiac monitoring. Several risk prediction models for ACS patients exist but their use in the emergency department (ED) is limited and their accuracy is unclear.
Objective
We aimed to compare the ability of existing scores to predict complications in ACS patients and ultimately to create an improved risk prediction algorithm.
Methods
This was a secondary analysis of data from the ESC TROP trial (NCT03421873). In the present study, we included consecutive ACS patients aged 75 and above who visited one of 5 EDs in Region Skåne in southern Sweden from February 1st to November 30th 2017 and 2018. All patients’ medical records were manually reviewed, and complications were identified via diagnosis (ICD10) and/or intervention codes (Swedish KVÅ codes) and confirmed during the manual review. Complications were defined as the following: Death, cardiac arrest where cardio-pulmonary resuscitation was provided, cardiogenic shock, pulmonary edema, ventricular arrythmia, high-degree AV-block that required a pacemaker implantation, and mechanical complications such as cardiac tamponade, papillary muscle rupture or ventricular septum defect. GRACE, TIMI risk index, ACTION ICU, HEART and CHA2DS2VASc scores were calculated for each patient. Logistic regression identified factors predicting high risk, and the area under the receiver operating characteristic curve (AUROC) was used to compare the different risk prediction models. This study was approved by the Swedish Ethics Review Authority.
Results
Of all 831 patients with a verified ACS diagnosis after chart review, 110 (13%) had complications and 50% of these were male. Compared with patients without complications, those with complications were on average older (85.7 vs 82.6 years), more often had dementia or mild cognitive impairment (15.4% vs 7.6%, p=0.007), and more often a Do-Not-Resuscitate order (60.9% vs 19.0%, p<0.001). In the logistic regression, lactate at admission (OR 23.78, CI 4.83 – 116.98), shock index (OR 12.94, CI 2.81 – 59.62), new ischemic ECG changes (OR 3.21, CI 1.40 – 7.32), Killip class (OR 2.68, CI 1.60 – 4.49) and ST elevation myocardial infarction (OR 2.38, CI 1.11 – 5.14) were statistically significant predictors of complications, and this model had an AUROC of 0.87. The AUROCs of the published risk prediction scores were all smaller than this - ACTION ICU 0.80, GRACE 0.78, HEART 0.65, TIMI risk 0.76, CHA2DS2-VASc 0.52.
Conclusions
About 13% of elderly ACS patients had a serious complication. None of the previously published risk prediction scores were accurate at predicting complication risk. A logistic regression model based on simple variables provided superior prediction of complications in this study.
Tsvetelina NILSSON (Lund, Sweden), Alicia TRÄGÅRDH, Ulf EKELUND
00:00 - 00:00
#42158 - Predictive value of nt-probnp for early recurrence of atrial fibrillation post-cardioversion at the emergency department.
Predictive value of nt-probnp for early recurrence of atrial fibrillation post-cardioversion at the emergency department.
Background: Atrial fibrillation (AF) is a common arrythmia encountered in the emergency department (ED). Cardioversion is frequently performed to restore sinus rhythm in patients with acute AF in the ED. It has been shown to be a safe and effective treatment strategy that allows direct discharge from the ED thereby reducing avoidable hospitalizations. However,early AF recurrence may present a limitation, therefore necessitating the identification of predictors of AF recurrence post-ED cardioversion.
Methods: This prospective, observational, single-center study was conducted in the ED of Attikon University Hospital, between December 2021 and April 2024. We enrolled 148 adult patients with new onset AF (first detected or recurrent paroxysmal), managed by pharmacological (PC) or electrical cardioversion (EC) at the ED, either acutely (if AF duration <48h) or on a scheduled basis after ≥3 weeks treatment with anticoagulants. Clinical, echocardiography, routine laboratory and NT-proBNP assessments were performed upon presentation. We investigated the role of NT-proBNP, a biomarker in heart failure, as a predictor of acute success of cardioversion to restore sinus rhythm and early AF recurrence at the 8th and 30th day post-cardioversion. Predictive ability of NT-proBNP was tested with univariate and multivariate regression after adjustment for left atrial diameter and receiver operating curve (ROC) analysis. Results: Study population consisted of 53% males, of median(IQR) age 68(58-75) years, with 56% paroxysmal AF, 85% managed with acute cardioversion, 72% received direct current cardioversion, with LVEF 55 (50-60)% and left atrial diameter (LAD) 38 (35-44)mm. Patients who were acutely successfully converted to SR (Day 0) as well as those who remained on SR on the 8th day (D8) after cardioversion had lower NTproBNP levels compared to patients in whom cardioversion was not successful or showed AF recurrence on D8 [D0: SR vs non-SR, 387(127-1095)pg/ml vs 1262(595-2295), p=0.004; D8: SR vs non-SR, 370(127-1095) vs 1366(718-2295), p=0.002]. In multivariate regression analysis, higher logNT-proBNP levels were associated with higher rates of unsuccessful acute cardioversion [OR, 95%CI: 4.8 (1.6-14.5), p=0.006] as well as higher risk of AF recurrence at D8[OR, 95%CI: 3.6 (1.0-12.4), p=0.043]. Using ROC analysis, high NTproBNP showed good predictive ability for non-successful acute conversion as well as early AF recurrence at D8 (D0: AUC 0.735, p<0.001; D8: AUC 0.761, p<0.001). Conclusion: NT-proBNP may serve as a useful biomarker for identifying patients at higher risk of AF recurrence, allowing for closer monitoring in the ED setting. In acute AF managed by cardioversion in the ED, NT-proBNP may predict acute non-response to cardioversion as well as early AF recurrence up to 8 days post-cardioversion
"This study did not receive any specific funding"
Antonios DIAKANTONIS (ATHENS, Greece), Vasiliki BISTOLA, Sofia BEZATI, Christos VERRAS, Antonios BOULTADAKIS, Christos GEORGIOU, Ioanna RITA, Lambros MARKOS, Maria VELLIOU, Ignatios IKONOMIDIS, John PARISSIS, Effie POLYZOGOPOULOU
00:00 - 00:00
#42157 - Prognosis of traumatic brain injury patients with coagulopathy in the emergency department.
Prognosis of traumatic brain injury patients with coagulopathy in the emergency department.
Introduction:
Traumatic brain injuries (TBI) are a major cause of morbidity and mortality worldwide. Patients with traumatic brain injuries may develop hemorrhagic complications, including coagulopathies, which can worsen their clinical condition and affect the prognosis.
This study aims to investigate the association between the presence of coagulopathy and in-hospital mortality among patients admitted to the Vital Emergency Reception Service for a head injury.
Methods:
A prospective study among patients admitted to the emergency department for traumatic brain injury was conducted over a defined period (From January 2022 to December 2023). Demographic data, clinical characteristics, coagulation test results, and in-hospital mortality outcomes were collected. The association between the presence of coagulopathy upon admission and in-hospital mortality was analyzed using the appropriate statistical methods.
Traumatic Coagulopathy was defined as thrombocytopenia below 120,000/mm³, prothrombin levels below 70%, or an international normalized ratio above 1.3.
Results:
In total, 273 patients with TBI were included in our study, with a mean age of 39 ± 17.6 years, and a male predominance (in 81.3% of cases) with a sex ratio of 4.3. Therefore, 193 (70.7%) patients suffered a TBI due to a car accident whereas 17(6.2%) were physically assaulted. The in-hospital mortality rate was 18.3% (50 patients) due to traumatic brain injury. Forty-eight patients (17.6%) with TBI presented coagulopathy on admission: 26(9.5%) had an international normalized ratio above 1.3, 17(6.2%) had thrombocytopenia below 120,000/mm³ and 37(13.6%) had prothrombin levels below 70%.
Results suggest a significant association between the presence of coagulopathy upon admission and in-hospital mortality among traumatic brain injury patients. Those with coagulopathy showed an increased risk of in-hospital death compared to those without (43.8% vs 12.9%, p<10-3)
Conclusion:
This study highlights the importance of coagulopathy as a potential prognostic factor in traumatic brain injury patients admitted to the Emergency Room. Early detection and appropriate management of coagulopathy could improve clinical outcomes and reduce in-hospital mortality for these patients.
Kais CHEOUR, Wiem DEMNI, Wided BAHRIA, Khaireddine JEMAI (Tunis, Tunisia), Yesmine WALHA, Arij KLAI, Sirine BACHROUCH, Nour Elhouda NOUIRA
00:00 - 00:00
#40557 - Prognostic factors in shock patients.
Prognostic factors in shock patients.
Introduction: Early predictable factors and preventive drugs are important, as secondary sepsis, multiple organ failure, despite appropriate treatment during shock, leads to poor prognosis. Recently, macrophage migration inhibitory factor (MIF), toll receptor 4 (TLR4) and T cell viability, factor of infection and immunity, have been known for their usefulness in nonclinical experiments. Our study aims to explore the significance of TLR, MIF and T cell viability as predictors of sepsis in shock patients.
Methods: In hemorrhagic shock patients who visited a single emergency centers between 2018 and 2020, MIF in serum, TLR4 in polymorphonuclear neutrophils, and T cell viability and interleukin 2 in T lymphocytes were measured. The associations were identified by comparing the measured factors with patients mortality and the incidence of sepsis.
Results
1. Relationship between MIF, TLR4, T cell viability and sepsis in shock patients
In 180 shock patients, MIF (2633±710pg/mL) was higher than MIF (588±485pg/mL) in normal people and higher than MIF (1460±680pg/mL) in non-occurrence groups. In addition, TLR4 (16.27±2.05 (FACs), 5.05±1.94 (TLR4/Actin) in the sepsis group were higher than TLR4 (7.78±0.59 (FACs), 0.63±0.11 (TLR4/Actin) in the non-occurrence group. In the MTT for the measurement of T cell viability, the sepsis group (0.52±0.25) was lower than that of the non-occurrence group (0.78±0.45), and the IL-2 measured in FACs was significantly higher in the sepsis group (4.68±3.36) than in the non-occurrence group (2.41±2.58).
2. Relationship between MIF, TLR4, T cell viability and mortality in shock patients
In shock patients, MIF in the death group were over 3000 pg/mL, and TLR4 measured in FACs was 12.67 in the death group, higher than 9.74 in the survival group, but had no statistical significance. In the MTT for the measurement of T cell viability, the death group (0.66±0.46) was lower than the survival group (0.80±0.43). The IL-2 measured in FACs showed no difference between the survival group (2.84±3.15) and the death group (2.62±2.04).
Conclusions
The lower T cell viability, higher MIF and TLR4 values were shown in the death group in shock patients, but only T cell viability had statistical significance. However, in the development of sepsis, higher MIF, TLR4 and lower MTT values are shown which may be useful for the initial diagnosis of sepsis development.
no
Sung-Hyuk CHOI (korea, Republic of Korea), Lee SUN-HONG, Ko BYUNG-CHUL
00:00 - 00:00
#41325 - Prognostic role of the A-PVpCO2 calculated on peripheral venous blood, in patients with sepsis in the Emergency Department.
Prognostic role of the A-PVpCO2 calculated on peripheral venous blood, in patients with sepsis in the Emergency Department.
Introduction and Objectives: The arteriovenous pCO2 gap (A-VpCO2 gap) is considered an indicator of tissue perfusion,reflecting cardiac output (CO). It is considered normal when <6 mmHg, calculated using central (or mixed, if available) venous blood. Several studies have shown that an A-VpCO2 gap <6 mmHg, calculated using central venous blood, is associated with unfavorable prognosis in septic patients. Preliminary studies suggest the reliability of peripheral venous blood, much easier to obtain in a rapid and crowded setting such as the Emergency Department (ED), to assess the A-VpCO2 gap. The aim of our study was to evaluate whether the A-VpCO2 gap, calculated using peripheral venous blood (A-PVpCO2 gap), correlates with 7-day mortality in patients presenting to the Emergency Department with sepsis.
Materials and Methods: This is a monocentric, observational, prospective study.Patients aged >18 years, of both sexes, presenting to the Emergency Department of the "Agostino Gemelli" University Hospital in Rome between May 2021 and May 2023 with sepsis of varying origin and severity were enrolled. Upon arrival, each patient underwent simultaneous arterial and peripheral venous blood gas analysis. Vital signs, laboratory tests, routine exams, and inflammation indices were analyzed for each patient. Based on the SOFA score and APACHE-II score, patients were divided into two groups: low risk (<7 for SOFA, <15 for APACHE-II) and medium-high risk (patients not classified as low risk). Differences between groups were considered significant if the p-value was ≤ 0.05.
Results: A total of 121 patients were recruited, with a mean age of 72.6 ± 13.2, 71.5% male. Seven-day mortality was statistically associated with the following factors: lower systolic (101.1 ± 24.0 vs 118.5 ± 24.6) and diastolic (59.9 ± 13.0 vs 70.1 ± 14.1)blood pressure (p=0.02); lower CRP (93.8 ± 50 vs 185.3 ± 119.1; p < 0.001);higher lactate levels (5.9 ± 3.3 vs 2.3 ± 4.4, p=0.02); higher APACHE-II and SOFA scores (respectively 93% vs 51% and 71.4% vs 30.5%, p=0.003). A-PVpCO2 gap was higher in patients with worse outcomes (10.3 ± 4.7 vs 7.8 ± 5.7), although not statistically significant (p=0.08). From the ROC curve analysis (AUC=0.65 indicating poor accuracy), the most accurate A-PVpCO2 gap value as a prognostic marker for 7-day mortality was found to be 6.75 mmHg (sensitivity 92.9%, specificity 50.5%). Finally, Pearson correlation analysis between ΔA-VpCO2 and other variables included in the study showed a significant association only between ΔA-VpCO2 and lactate (R 0.235, p=0.01).
Conclusions: Our study suggests that A-PVpCO2 gap is generally higher in patients with worse outcomes, albeit not statistically significant,while a cut-off value of <6.75 identifies patients with better outcomes. The cut-off we found is very close to that indicated in the literature (<6 mmHg) when A-VpCO2 gap is calculated using central venous blood, and to that described by Wei Gao et al (2018), whose A-PVpCO2 gap was significantly associated with 28-day mortality when exceeding 7.1 mmHg. The main limitations of the study were: small sample size, lack of simultaneous measurement of A-VpCO2 gap on central venous blood, and heterogeneity of septic patients in the ED.
Maria LUMARE (Rome, Italy), Michele Cosimo SANTORO, Maurizio GABRIELLI, Roberta DI LUCA, Licia SCATÀ, Martina MALASPINA, Alberto MANNO, Maria Rita MORABITO, Dario GIANI, Ilaria BALSAMO, Andrea PICCIONI, Marcello CANDELLI, Marcello COVINO, Francesco FRANCESCHI
00:00 - 00:00
#42174 - Prognostic value of clinical scores in patients with acute community-acquired pneumonia in the Emergency Department.
Prognostic value of clinical scores in patients with acute community-acquired pneumonia in the Emergency Department.
Introduction:
Acute community-acquired pneumonia (CAP) is a frequent reason for admission to the emergency department and is responsible for a high morbidity and mortality rate. Several studies have demonstrated the prognostic value of clinical scores such as quickSOFA and CRB-65.
we aimed to investigate the prognostic value of CRB-65 and qSOFA in patients with CAP admitted to the emergency department.
Methods:
A prospective, descriptive, and analytical study was conducted over one year. Inclusion of all patients with CAP admitted to the emergency department. The epidemiological, clinical, and evolutionary data were collected, and CRB-65 and qSOFA scores were calculated on admission. We conducted a univariate analysis to determine the factors predictive of early mortality and to study the prognostic contribution of these scores by analysis of the areas under the ROC curves.
Results:
Inclusion of 173 patients. The mean age was 65±17 years. A male predominance was observed (sex ratio=1.43). Patients' main comorbidities were: arterial hypertension (48.6%), diabetes (41%), chronic respiratory pathologies (20.8%), and coronary artery disease (13.3%). The main reasons for consultation were: dyspnea(87.3%), fever(36%), cough(34.1%), purulent sputum(23.7%) and asthenia(22%). The median CRB-65 score was 1[0-5]. Over 2/3 of patients (66.4%) had a CRB-65 score≥1. The median qSOFA score was 1[0-3]. Seventy-one patients (41%) had a qSOFA≥2. Early mortality in the emergency department was 24.3%. In univariate analysis, predictive factors for early ED mortality were: qSOFA≥2 (p<0.001; OR=8.7; CI95%=[3.88-19.6]) and CRB-65≥1(p=0.007, OR=3.88, CI95%=[1.24-12.71]). The areas under the ROC curves for qSOFA and CRB-65 scores were 0.87 (p<0.001,CI95%=[0.79-0.95]) and 0.75 (p<0.001;CI95%=[0.64-0.85]) respectively.
Conclusion:
The qSOFA score outperforms the CRB-65 score in predicting early mortality in the emergency department of patients with CAP. Further multicenter studies with larger samples are needed to support this hypothesis.
Wiem DEMNI, Wided BAHRIA, Khaireddine JEMAI (Tunis, Tunisia), Mariem REBHI, Yesmine WALHA, Intissar BOUSSAID, Nour Elhouda NOUIRA
00:00 - 00:00
#42138 - Prospective observational study of prognostic factors for difficult peripheral vascular access in emergency department patients.
Prospective observational study of prognostic factors for difficult peripheral vascular access in emergency department patients.
Background: Placing a peripheral venous catheter in the emergency department (ED) is crucial for rapid testing and supporting patients with necessary medications and fluids. Failure to place a peripheral intravenous catheter and repeated attempts cause patient discomfort, delays in their management, and additional costs in resources. Identifying factors associated with difficult venous access in the ED can lead to interventions that will reduce the phenomenon of multiple failed attempts. Our study aimed to identify patient prognostic factors and healthcare professional characteristics associated with an increased risk of failure in the first attempt to place a peripheral intravenous catheter.
Methods: It was a prospective observational convenience sample study of adult patients who came to the ED of a Greek tertiary hospital from July to November 2023 and required the placement of a peripheral intravenous catheter. The characteristics of the patients and nurses who performed each venipuncture were recorded. Statistical analysis was performed using x2 and Fisher's Exact test for qualitative values. The study of correlations was performed using the Pearson correlation.
Results: 1007 patients and 28 nurses participated in the study. The venipuncture success rate on the first attempt was 69.5% (20.3% required two attempts, 6.5% three, and the remaining 3.8% four or more attempts). The nurse age group of 20-30 years had a success rate of 57.9%, which was lower than the other age groups (p<0.001). Nurses with at least two years of experience in the ED had low failure rates (25.6-28.8%) compared to nurses with less experience in this department (41.2%). However, nurses with more than two years of experience in another department or clinic outside the ED, who had recently moved to this department, also had high failure rates before completing two years in the ED. Failure on the first attempt often led to using a smaller diameter catheter on subsequent attempts. As for the patients, statistically significant risk factors for difficult venipuncture were found to be female sex (65% vs. 75% in men, p<0.001), chronic bedriddenness, the presence of edema, the use of intravenous drugs, history of diabetes mellitus, the presence of agitation or non-cooperation during venipuncture, the presence of shock, a history of difficult venipuncture in the past, low or high weight (less than 60 or more than 100 kg) or body mass index (BMI less than 20 or more than 30). Increasing failure was also observed with increasing patient age, especially in patients with recent hospitalization less than 14 days before the visit to the ED.
Discussion and Conclusions: Nurse experience in the ED is the most important factor for successful peripheral venipuncture from the healthcare professional's perspective. Identifying patients with characteristics that put them at risk for difficult placement of a peripheral intravenous catheter may allow for the design and development of protocols and interventions that will improve the rates of successful venipuncture on the first attempt in these patients, such as the use of ultrasound guidance from the first attempt.
Trial Registration: The study is not registered.
Funding: This study did not receive any specific funding.
Ethics committee approval and informed patient consent: The study was approved by the Administrative and Scientific Council of the University Hospital of Heraklion and the Ethics Committee (Protocol No.: 19280 EI 2023 Date: 20/07/2023). Due to the use of anonymized data, there was no need for patient consent.
Valentina MASAOUTI, Iro TSOUROU, Athina KOUNETAKI, Zoe KANELLI, Georgia SIFAKI, Ioanna GIAKOUMAKI, Stavroula ILIA, George BRIASSOULIS, Dr George NOTAS (HERAKLION, Greece)
00:00 - 00:00
#41583 - qSOFA and MEWS have similar abilities to predict ICU admission and hospital death in the emergency department: a retrospective study.
qSOFA and MEWS have similar abilities to predict ICU admission and hospital death in the emergency department: a retrospective study.
Objective: The Quick Sepsis-related Organ Failure Assessment (qSOFA) score is widely used for prognostic prediction in sepsis, but its prognostic ability in whole visits in emergency department (ED) remains unclear. In this study, we aimed to compare the accuracy of qSOFA and modified early warning score (MEWS) in predicting hospital mortality and intensive care unit (ICU) transfer in patients admitted to the ED.
Methods: All patients admitted to ED from January 2015 to May 2022 were retrospectively included. Data for qSOFA and MEWS calculation were collected after triage. The primary outcome was in-hospital mortality, and the secondary outcome ICU transfer. The assessment of discrimination was conducted using the area under the receiver operating characteristic curve (AUROC).
Results: A total of 106,800 patients were included in this study. The median age was 45 years old (interquartile range, 30-62), with 55,574 (52.0%) being women. Among all the patients, 1,017 (1.0%) died in the hospital, and 6,091 (5.7%) experienced ICU transfer. qSOFA was significantly correlated with MEWS in patients who died in hospital (R2 = 0.46) or admitted to ICU (R2 = 0.50) rather than those survived (R2 = 0.30) from hospital or discharged (R2 = 0.23) from ED. Approximately 25.4% of patients with a qSOFA score of 1 or higher. qSOFA had a greater discrimination for ICU transfer (AUROC, 0.696; sensitivity, 62.4%; specificity, 76.8%) than MEWS (AUROC, 0.649; sensitivity, 71.7%; specificity, 58.1%). Consistently, qSOFA also had a similar discrimination for hospital mortality (AUROC, 0.769; sensitivity, 78.8%; specificity, 75.1%) than MEWS (AUROC, 0.720; sensitivity, 70.6%; specificity, 73.4%).
Conclusion: Both qSOFA and MEWS can categorize the high-risk patients in ED. A qSOFA score of 1 or more had a higher prognostic accuracy for hospital death or ICU transfer than MEWS.
Study protocol and methods of data collection were approved by Medical Ethical Committee of Zhongnan Hospital of Wuhan University (approval number 2022248).
Yu TIAN (Wuhan, China), Shaoping LI, Yan ZHAO
00:00 - 00:00
#41183 - Qualitative study to explore the acceptability of an accelerated syncope strategy to patients and staff involved in the ASPIRED syncope trial.
Qualitative study to explore the acceptability of an accelerated syncope strategy to patients and staff involved in the ASPIRED syncope trial.
Objective: The BHF funded ASPIRED study (https://www.isrctn.com/ISRCTN10278811) is aiming to determine whether immediate, enhanced (14-day) ambulatory ECG monitoring decreases the number of episodes of syncope at one year compared to standard care monitoring in Emergency Department (ED) patients presenting acutely with unexplained syncope. This embedded qualitative study (ASPIRED-Q study) aimed to explore the experiences of patients and healthcare professionals (HCPs) with respect to syncope episodes, acute care pathways, and the acceptability of the 14-day remote monitoring intervention for undiagnosed syncope.
Methods: Semi-structured interviews were conducted with forty-three participants (30 patients and 13 HCPs) recruited from four hospitals (two in England and two in Scotland). 30/43 (69.8%) completed interviews (20 patients, 10 HCPs). Thematic analysis was employed to identify key themes.
Results: Three overarching themes emerged.
(1) Experiences of syncope; revealed diverse perceptions and reactions among patients, including reluctance to seek medical attention, confusion about the event, and embarrassment especially if they perceived that they had caused an inconvenience in public.
(2) Acute Care Journey; highlighted the importance of patient-HCP communication, resource allocation challenges, and the value of local syncope pathways in decision-making. Delays in follow-up monitoring influenced discharge decisions, with concerns raised that syncope was ‘overlooked’ or ‘underplayed’ compared with other ED presentations and suggested further clinician education regarding syncope management was required in ED settings.
(3) Acceptability of the intervention; both the patients and HCPs liked the 14-day monitoring. Patients found it easy to use and non-obtrusive, but occasionally encountered challenges with battery failure, interpreting device signals, and understanding instruction manuals. HCPs believed that the device would enhance decision-making and improve patient experience. However, they worried about future over use and emphasised the need for a protocol to manage practice.
Conclusion: The ASPIRED-Q study provided valuable insights into the multifaceted experiences of syncope patients and HCPs within acute care settings, alongside the acceptability of remote monitoring interventions. Findings underscore the importance of patient-centred communication, streamlined acute care pathways, and adequate resource allocation. Challenges such as delays in follow-up ECG ambulatory monitoring and concerns regarding overuse of remote monitoring strategies were identified, necessitating protocolised approaches for effective future implementation. Future research should focus on translating these findings into actionable strategies for improving the management of syncope in clinical practice.
This study was funded by a BHF Project Grant (PG/21/10805). Qualitative study to explore the acceptability of an accelerated syncope strate-gy to patients and staff involved in the ASPIRED trial (£22,004.11); Chief Investigator Matt Reed. Matt Reed is supported by an NHS Research Scotland Career Researcher Clinician award.
Matthew REED (Edinburgh, ), Alice PEARSONS, Coral HANSON, Ellise CLARKE, Caroline BLACKSTOCK, Lis NEUBECK
00:00 - 00:00
#41219 - Rapid Recognition of Aortic Dissection Based on Peripheral Pulse Oximetry Waveform in Emergency Setting.
Rapid Recognition of Aortic Dissection Based on Peripheral Pulse Oximetry Waveform in Emergency Setting.
Background: Aortic dissection (AD), a life-threatening cardiovascular emergency frequently misdiagnosed as other chest pain conditions, may induce abnormalities in peripheral blood flow detectable through pulse oximetry waveforms. This study sought to evaluate the feasibility of recognizing AD based on pulse oximetry waveforms.
Methods: This study employed two separate emergency department datasets: the initial dataset was enriched with AD patients (n=258, 47% AD) for model development, and the second was a cohort of chest pain patients awaiting angiography (n=71, 25% AD) used for external validation. For each patient, pulse oximetry waveforms from the four extremities were collected. Following data preprocessing, the recognition model based on random forest algorithm was trained by using patients’ gender, age and waveform difference features that were extracted from the pulse oximetry waveforms. The performance of the recognition model was assessed using receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA).
Results: The recognition model performed well, achieving high accuracy of identifying AD in the training and external validation set, with areas under the ROC curves of 0.979 and 0.855, sensitivity of 0.918 and 0.889, specificity of 0.949 and 0.698, precision of 0.947 and 0.746, and accuracy of 0.947 and 0.746, respectively. DCA also demonstrated that the model provided a substantial net benefit for identifying AD.
Conclusions: This study demonstrated the feasibility of identifying AD based on peripheral pulse oximetry waveforms. The approach exhibited good performance and clinical benefit among chest pain populations in the emergency setting who were at risk of AD.
NCT05699395/National Natural Science Foundation of China (12071086)
Jing-Chao LUO (Chengdu, China), Feng SUN
00:00 - 00:00
#41343 - Re-analysis of damage assumptions in Osaka city caused by a Nankai Trough earthquake using mobile spatial statistics.
Re-analysis of damage assumptions in Osaka city caused by a Nankai Trough earthquake using mobile spatial statistics.
Background The government of Osaka prefecture, the main prefecture in the center of western Japan with a population of more than 8 million, has publicized a damage estimation for a Nankai Trough earthquake with a probability of recurrence of about 70% within the next 30 years. We have assessed manageability of the designated “disaster coping” hospitals in Osaka City using geographic information system (GIS)-based analysis combined with data on inpatient care capacities of these hospitals and casualty distributions for both high and low tsunami evacuation rates. However, the casualty distributions officially reported nationally and by Osaka prefectural government were based on a national census (NC), which may diverge from actual patient distributions. Mobile Spatial Statistics (MSS) are the actual population statistics for all of Japan that are generated continuously from mobile terminal network operational data. In this study, we re-calculated the casualty distribution caused by a Nankai Trough earthquake using MSS and investigated the difference from that calculated from NC-based data.
Methods MSS data at 18:00 during December were obtained from a mobile phone company. We calculated the number of injured patients in each 50×50-m mesh in Osaka city caused by a Nankai Trough earthquake in accordance with the methods provided by Osaka prefecture, based on either NC or MSS. We calculated the number of patients based on damage estimations for high and low evacuation rates from the tsunami-affected zone. These data were expanded on the GIS to analyze casualty distribution.
Results We compared the population based on MSS with that based on NC. The MSS-based population of Osaka city was 3.47 million, whereas the NC-based population was 2.67 million, indicating a 30% higher population based on MSS. The MSS-based population was distributed more in the center of the city. The respective numbers of MSS-based patients injured for low and high evacuation rates were 30,960 and 4,294, whereas those of NC-based patients injured were 31,620 and 4,452. With a high evacuation rate, the difference in the number of patients between MSS and NC revealed more MSS-based patients in the center and fewer patients in the periphery of Osaka City. With a low evacuation rate, the number of injured patients based on both MSS and NC were high on the coast and northeastern part of the city. Our comparison showed the number of MSS-based patients to be higher in the urban and industrial areas of the city and lower in the residential area than those of NC-based patients.
Discussion & Conclusions The number and distribution of injured patients based on MSS was different from those based on conventional NC data. By using MSS, we can estimate manageability of the medical system accurately in conformity with an actual situation.
This work was supported by JSPS KAKENHI Grant Number JP20K09292
Pr Hiromasa YAMAMOTO (Osaka, Japan), Yoshinari KIMURA, Yasumitsu MIZOBATA
00:00 - 00:00
#41575 - Real-world cost-effectiveness of targeted temperature management in out-of-hospital cardiac arrest survivors: Results from an academic medical center.
Real-world cost-effectiveness of targeted temperature management in out-of-hospital cardiac arrest survivors: Results from an academic medical center.
Background: Out-of-hospital cardiac arrest (OHCA) is a global health challenge, with survival rates and neurological outcomes varying widely. Our study stands out as one of the few to conduct an economic evaluation of targeted temperature management (TTM) using clinical patient-level data. This unique approach not only provides a comprehensive understanding of TTM's cost-effectiveness but also engages the audience in a novel perspective. Our aim is to explore the real-world cost-effectiveness of TTM compared with conventional supportive care for OHCA.
Methods: We conducted a retrospective cohort study at a single academic medical center in the United States to assess the cost-effectiveness of TTM in adult (≥18 years) non-traumatic OHCA survivors. Individuals who were transferred to the emergency department between 1 January 2019 and 30 June 2023 were included. We excluded those with presumed traumatic cardiac arrest and died in the ED. Clinical outcomes and total costs were compared between patients receiving TTM (intervention group) and those receiving conventional care (control group) using a net benefit regression framework. The primary outcome (effect) was survival to hospital discharge status (yes/no). Total costs were extracted from the hospital billing records, including direct (services to the patients) and indirect (non-patient related) costs. Incremental cost-effectiveness ratios (ICERs) were calculated and compared to a variety of decision-maker willingness to pay (WTP) values. Incremental net benefit analysis and cost-effectiveness acceptability curves (CEACs) were utilized to evaluate the economic attractiveness of TTM. Uncertainty about the incremental cost and effect was explored with a 95% confidence ellipse.
Results: Among 925 non-traumatic OHCA survivors, only 30 (3.2%) received TTM. The TTM group had fewer White, Black, and Asian and more Hispanic patients. Additionally, the TTM group had a lower prevalence of malignancy and lower Charlson Comorbidity Index scores compared to the control group. After adjusting for potential confounders, the TTM group had a 6% (95% CI: -11% to 23%) greater probability of survival and a $-5,141 (95% CI: $-35,347 to $25,065) lower expected costs. The adjusted ICERs suggested TTM was cost-saving and provided the additional chance of survival to hospital discharge. The CEAC demonstrated that the probability of TTM being cost-effective was 70%, 74%, and 78% if the WTP threshold was $50,000, $100,000, and $250,000 per additional survival to hospital discharge, respectively. The 95% confidence ellipse suggested a high level of decision-making uncertainty with evidence that the true value of the ICER could be in any of the quadrants of the cost-effectiveness plane.
Conclusions: While TTM did not demonstrate a significant improvement in survival to hospital discharge for OHCA survivors, it may represent good value for money. TTM was associated with comparable costs, suggesting that its implementation may not result in additional financial burden. Despite limitations resulting from its retrospective nature and relatively small sample, this study sheds light on the cost-effectiveness of TTM in real-world OHCA care, emphasizing evidence-based decision-making for resource allocation. The findings underscore the urgent need for further research to clarify TTM's optimal use and address the uncertainty surrounding its effectiveness.
The project described was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant number UL1 TR001860. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The travel grants were supported by the Faculty of Medicine, Chiang Mai University.
Wachira WONGTANASARASIN (Chiang Mai, Thailand), Daniel K. NISHIJIMA, Wanrudee ISARANUWATCHAI, Jeffrey S. HOCH
00:00 - 00:00
#42160 - Revisits among frail and non-frail older patients in the Emergency Department - a Prospective Observational Multicenter Study.
Revisits among frail and non-frail older patients in the Emergency Department - a Prospective Observational Multicenter Study.
Background
The population of individuals aged over 65 in emergency departments (EDs) worldwide is steadily increasing, reflecting the growing number of older adults needing emergency care. The rate of revisits has been suggested as an emergency care quality indicator, but the characteristics of revisits to the EDs among elderly patients and its association with frailty is unknown. Our aim was to investigate the prevalence of ED revisits among patients over 65 years of age, living with or without frailty, and its association with rate of hospitalization, and mortality.
Methods
This was a prospective, multicentre study carried out in three EDs in southeast Sweden. The data collection was made during 6 weeks at each ED respectively, between may to november 2021. An assessment of the patient's level of frailty was added to standard triage, using the 9-level Clinical Frailty Scale (CFS-9) with a CFS score of ≥ 5 as the cut-off for frailty. Patients ≥65 who made an index ED visit during the study period and got a CFS score of 1 to 8, were eligible for inclusion. Data on index visits, revisits, admissions and mortality were obtained via the electronic medical records.
The primary outcome (1) was the prevalence of ED revisits at 7, 30 and 90 days, described as the proportion (%) of revisits in relation to index visits. Secondary outcomes were: (2) the rate of admission at the revisit at 7, 30 and 90 days, expressed as the proportion (%) of admitted patients; and (3) difference in mortality rate among patients who revisited the ED within 90 days in relation to the non-revisiting patients.
Categorical variables were analyzed with the Yate’s Chi2-test. The significance level was set at p-value < 0.05.
The study was approved by the Swedish Ethical Review Authority (permit no. 2021-00875)
Results
A total of 1835 index visits were included, and out of those, 595 patients made a revisit within 90 days of index visit. Patients living with frailty (CFS ≥ 5 - 8) were more likely to make a revisit to the ED at 8 to 30 days (10,7% vs 16,8% diff 6,1%, 95% CI 2-10%, p<0,001) and at 31 to 90 days (11,9% vs 18,6% diff 6,7%, 95% CI 3-10%, p<0,001) and be hospitalized during the revisit than non-frail patients (56,5% vs 47,3%, diff 9,2%, 95% CI, 0,8-18%, p<0,05). Results also show that patients living with frailty had a higher overall mortality rate than non-frail patients (17,1% vs 4,6%, diff 12,5%, 95% CI 7-18%, p<0,001).
Conclusions
Frail patients made more revisits, were more often admitted, and had a higher overall mortality rate than non-frail patients. The higher rates of revisits, admissions and mortality in frail patients are likely explained by their having more complex medical needs that must be addressed not only in the ED, but requires a more holistic approach throughout the healthcare system.
Helena JOHANSSON (Linköping, Sweden), Sara FAHLANDER
00:00 - 00:00
#40274 - RISK FACTORS FOR POST-CONCUSSION SYNDROME IN PATIENTS WITH MILD TRAUMATIC BRAIN INJURY. A SYSTEMATIC REVIEW.
RISK FACTORS FOR POST-CONCUSSION SYNDROME IN PATIENTS WITH MILD TRAUMATIC BRAIN INJURY. A SYSTEMATIC REVIEW.
Background / Introduction: Up to 25% of patients with mild traumatic brain injury (mTBI) develop a post-concussion
syndrome (PCS), with persistent physical, neurological and behavioural complaints.[1,2] PCS has a great impact on a
patient’s quality of life, often decreases the ability to return to work, and henceforth has a great economic impact.[3]
Recent studies show that early treatment can greatly improve prognosis and prevent long-term effects in these
patients.[4] However, early recognition of patients at high risk of PCS remains difficult.
Objectives: The objective of this systematic review is to assess the risk factors associated with the development of PCS
in non-hospitalized patients presenting with mTBI at the Emergency Department (ED).
Method / Description: We searched PubMed/MEDLINE, Cochrane Library and EMBASE on 23-09-2022 for prospective
studies which assessed risk factors for the development of PCS. Exclusion criteria: retrospective studies, >20% CT
abnormalities, <18 years of age, follow-up < four weeks, severe trauma, and study population <100 patients. A quality check
was conducted on the identified studies using the Newcastle Ottawa Scale Quality Assessment Tool.[5]
Results / Outcomes: The search strategy identified 1628 articles, of which 17 studies met eligibility criteria (cohort size
varied between 103 and 1151). Risk factors found in this systematic review are pre-existing psychiatric history (OR
between 2.1 and 3.6), headache at the ED (OR between 1.5 and 7.7), neurological symptoms at the ED (OR between 1.5
and 4.2), female sex (OR between 1.6 and 3.2), CT abnormalities (OR between 4.4 and 7.6), pre-existent sleeping
problems (OR between 2.2 and 3.8), and neck pain at the ED (OR between 2.5 and 3.4).[6-22]
Conclusion: This systematic review identified seven risk factors for development of PCS in patients with mTBI. Future
research should assess if implementation of these risk factors into a risk stratification tool will assist the emergency
physician in the identification of patients at high risk of PCS.
Barbra BACKUS, Barbra BACKUS (Rotterdam, The Netherlands)
00:00 - 00:00
#42175 - Risk stratification in young patients with acute coronary syndrome in the emergency department.
Risk stratification in young patients with acute coronary syndrome in the emergency department.
Introduction
Patients with acute coronary syndrome (ACS) are routinely admitted to wards with high-level monitoring because of the risk of complications. However, complications in younger ACS patients are rare and improved risk stratification for these patients is desirable. There are several risk scores for ACS patients but their value for predicting complications in young ACS patients is unknown.
Aim
We aimed to analyze the accuracy of published risk scores in ACS patients, and to ultimately create an improved risk prediction algorithm.
Methods
This was a secondary analysis of data from the ESC TROP trial (NCT03421873), and we included consecutive ACS patients aged 18-65 years presenting to one of five emergency departments in Region Skåne, Sweden from February 1st to November 30th 2017 and 2018. Complications were identified by diagnosis (ICD10) and intervention codes (Swedish KVÅ codes) using register data and manual review of the patient records in all patients was then performed. Complications were defined as the following: Death, cardiac arrest where cardio-pulmonary resuscitation was provided, cardiogenic shock, pulmonary edema, ventricular arrythmia, high-degree AV-block that required a pacemaker implantation, and mechanical complications such as cardiac tamponade, papillary muscle rupture or ventricular septum defect. The following scores were calculated for all patients: GRACE, TIMI risk index, CHA2DS2-VASc, ACTION ICU and HEART. Logistic regression analysis for complication prediction was performed and included sex, the logarithm of high-sensitivity troponin T and lactate, ST-elevation myocardial infarction (STEMI), ST segment deviation on ECG, Killip class, and ejection fraction on echocardiography. The area under the receiver operating characteristic (AUROC) curve was used for comparisons. This study was approved by the Swedish Ethics Review Authority.
Results
Out of 788 patients with ACS, 79% were male and a total of 37 (4.7%) suffered one or more complications. Interestingly, patients with complications had numerically less often hypertension (10.8% vs 20.4%), less often diabetes (10.8% vs 18.6%) or a previous myocardial infarction (2.7% vs 12.3%), and were on less medications than patients without complications, but none of these differences were statistically significant. In the logistic regression, lactate at arrival (OR 14.5, CI 2.0 – 119.2), ejection fraction (OR 2.1, CI 1.3 – 3.4), STEMI (OR 3.5, CI 1.4 – 9.1) and Killip class (OR 3.4, CI 1.6 – 7.1) were significant predictors of complications. The AUROC of this model (0.84) was higher than those of all studied scores (ACTION ICU 0.73, GRACE 0.69, HEART 0.61, TIMI risk 0.59, CHA2DS2-VASc 0.44).
Conclusions
Less than five percent of adult ACS patients <65 years had any complication. Simple factors available at the ED appeared to be useful predictors of complications using logistic regression. Existing risk scores did not provide satisfactory risk stratification.
Tsvetelina NILSSON (Lund, Sweden), Ivar LIDSTRÖM, Ulf EKELUND
00:00 - 00:00
#42367 - SAD PERSON at risk in the Emergency Department.
SAD PERSON at risk in the Emergency Department.
Suicide is a major public health issue, and a priority requirement is accurately identifying high-risk individuals in the Emergency Department.
The SAD PERSONS (SP) and modified SAD PERSOSN (mSP) scales are simple tools for an attempt to assist non-psychiatrists assess suicide risk. It may help as a guide regarding the need for referral or admission.
Objectives
To asses the SP and mSP performance detecting suicide risk in clinical scenario of ED.
Methods
Patients presented to the ED with suicidal ideation/attempt were retrospectively recruited of a single tertiary hospital between January 1st 2023 and June 30th 2023.
Patients under 14 and those without information in the electronic medical record were excluded.
Variables analyzed: demographics, triage level, provenance, destination, type of event. Main dependent variable: severity of the attempt or ideation (referred/admitted to psychiatry).
The continuous quantitative variables are described as median and interquartile range (IQR), the qualitative variables are explained by relative frequencies (%). Comparison of means: quantitative variables: the Mann-Whitney test, qualitative variables: Chi-square test. The predictive capability of SP and mSP scores was by calculating the area under the curve (AUC) of the receiver operating characteristic (COR). A confidence level of 95% (95% CI) (p<0.05) is considered significant. Data analysis with IBM SPSS 27.0 software
The SP and the mSP scales were calculated following the variables:
S: Male sex, A: Age (<19 or >45 years), D: Depression, P: Previous attempt, E: Excess alcohol or substance use, R: Rational thinking loss, S: Social supports lacking, O: Organized plan, N: No spouse, or social support, S: Sickness.
SP score is calculated from ten yes/no questions, with one point for each affirmative answer:
Risk score. 0–4: Low, 5–6: Medium, 7–10: High
The mSP differs with SP rating with 2 points D: Depression, R: Rational thinking loss, O: Organized plan and in addition, (+ S: Stated future intent) also scoring with 2 points.
Risk score. 0–5: Safe to discharge, 6–8: Probably psychiatric consultation, >8: Probably admission.
Results
Two hundred and nineteen patients met inclusion criteria. Females 138(63,01%), mean age 39 yo (24-52)ICR, 166(75,80%) referred from primary care. Destination: 99(42,21%) discharged by the emergency physician.
SP vs mSP: 147(67,12%) vs 160( 73,06%) low risk, 60(27,40%) vs 50(22,83%) medium risk, 12(5,48%) vs 9(4,11%) high risk.
A total of 104(47,49%) were serious attempts or ideation.
Provenance*serious attempt: own means/ambulance 18,3% vs 29,3% (p<0,001), Destination*serious attempt: discharge/admission 15,5% vs 29,2% (p<0,001),
Urban*serious attempt: country/urban16,4% vs 31,1% (p<0,03),
Sex male*serious attempt: female/male 23,3% vs 24,2% (p<0,01)
Organized plan*serious attempt: yes/no 8,7% vs 38,8% (p<0,01)
Stated future intent*serious attempt: yes/no 8,2% vs 39,3%(p<0,01)
The highest odds with the attempt severity were Organized plan OR 16,00(4,53-56,49) and Stated future intent OR 44,22(5,74-340,14)
The AUC ROC for the SP and the mSP scores were 0,769 and 0,830 respectively (p<0,0001)
Conclusions
The reliable identification, by emergency physicians, of those with suicide severe attempt/ideation is crucial, to discharge patients safely, but also to coordinate with psychiatrist to provide the best care for the patient.
No fund for this study
Carlos DEL POZO VEGAS, Dr Raúl LÓPEZ IZQUIERDO (Valladolid, Spain), Cayetana GONZÁLEZ CHAMORRO GIL, Francisco MARTÍN RODRÍGUEZ, Leyre PINILLA ARRIBAS, Pedro DE SANTOS CASTRO, Alberto GÓMEZ DE DIEGO, Raúl ALONSO AVILÉS, Nuria DIEZ MONGE, Ana María GARCÍA RODRÍGUEZ, Ana GIL CONTRERAS, María BLANCO GONZÁLEZ, Alberto CORREAS GALÁN, Pablo GONZÁLEZ IZQUIERDO, Miguel POSADAS MUÑOZ, Pilar VELASCO DIAZ-SALAZAR, Lourdes CORISCO SÁNCHEZ, Fernando PICÓN SERRANO, Álvaro LAGO LESTAYO, Javier DE SANTIAGO LÓPEZ
00:00 - 00:00
#40932 - Salbutamol for Analgesia In Renal Colic.
Salbutamol for Analgesia In Renal Colic.
Study objective: The pain of renal colic is severe and often difficult to control; the pain is caused in part by ureteral spasm and subsequent inflammation. Salbutamol has been shown to cause ureteral relaxation, but its effects on the pain of renal colic have never been studied. The objective of the trial was to investigate whether the use of intravenous salbutamol in addition to standard analgesia was associated with greater pain reduction compared to standard analgesia alone in patients presenting with renal colic.
Methods: This was a single centre, phase II, randomised, placebo-controlled trial. The study population comprised adult (≥18 years) emergency department patients with clinically suspected renal colic. Participants were randomised 1:1 to receive either 250mcg of intravenous salbutamol or placebo (sodium chloride 0.9%). The primary outcome was the difference in the change in pain scores (measured on an 100mm Visual Analogue Scale) from baseline to 30 minutes following trial treatment administration in participants with subsequently confirmed renal colic.
Results: In participants with confirmed renal colic, analysed on a modified intention-to-treat basis, the median change in pain score for participants in the salbutamol group was -18mm (IQR -25 to -3) vs. placebo group change of -13mm (IQR -33 to -1), difference 5mm (95% CI -16 to 6, p=0.575).
Conclusions: This trial has not identified a clinically significant benefit from the addition of intravenous salbutamol to standard care for patients presenting to an emergency department with pain caused by renal colic.
Funding: This project was funded by the National Institute for Health and Care Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0817-20044). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
The preparatory work for this project was supported by the Royal College of Emergency Medicine Young Investigator Award.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Protocol: A trial protocol, published prior to study completion, is available: Johnson G, Tabner A, Fakis A, et al. Salbutamol for analgesia in renal colic: study protocol for a prospective, randomised, placebo-controlled phase II trial (SARC). Trials. 2022;23:352. doi:10.1186/s13063-022-06225-9
Trial registration
The trial was registered with the European Union Drug Regulating Authorities Clinical Trials Database (EudraCT), reference 2018-004305-11. It was also registered with the ISRCTN Registry, reference 14552440.
Graham JOHNSON (Derby, United Kingdom), Andrew TABNER, Apostolos FAKIS, Rachelle SHERMAN, Victoria CHESTER, Andrew SKEGGS, Fran GANE, Richard JACKSON, Suzanne MASON
00:00 - 00:00
#41923 - Seizures in Single Substance Pediatric Exposures: Analysis from the United States National Poison Data System.
Seizures in Single Substance Pediatric Exposures: Analysis from the United States National Poison Data System.
Background: We aim to describe the characteristics of single substance exposures that resulted in seizure in the pediatric population (age less than 20 years) as reported to United Sates poison centers between January 1, 2009, and December 31, 2023.
Methods: We conducted a retrospective review of the National Poison Data System (NPDS) over a 15-year period, between January 1, 2009, and December 31, 2023. We queried single substance exposures with seizure reported as a clinical effect, among the pediatric population (age < 20 years). We included single and multiple seizures and status epilepticus. We calculated trends in frequency and rates (per 100,000 exposures). We described changes in the most frequently reported substances.
Results: During the studied period, 30,985 exposures with seizure, in patients less than 20 years, including 1,712 with status epilepticus, were reported to poison centers. The number of exposures with seizure increased between 2009 and 2023 from 1418 to 2749 cases, with an average of 5% yearly increase. During the studied period, the number of exposures with seizure doubled in age groups 6-12 years and 13-19 years with a 6% yearly increase. The increase (45%) was less pronounced among children younger than 6 years of age, with a yearly increase reaching 3%. The rate of exposures with seizures reported increased from 88 cases per 100,000 exposures in 2009, to 237 cases per 100,000 exposures in 2023, with an average yearly rate increase of 7.5%. The increase is in part driven by diphenhydramine-related exposures that increased from 85 cases in 2009 to 404 cases in 2023. In addition, bupropion related exposures increased from 162 exposures in 2013 to 431 exposures in 2023. Between 2009 and 2012, tramadol and diphenhydramine ranked, respectively, first and second most frequently substance reported in single substance exposures with seizure, every year. Between 2013 and 2023, every year, bupropion and diphenhydramine were the first and second most frequently reported substance, respectively. Synthetic cannabinoids ranked third between 2012 and 2015. Bupropion, diphenhydramine, synthetic cannabinoids and amphetamines were the most frequently reported substances in status epilepticus.
Conclusion:
Seizures associated with pediatric single substance exposures are steadily increasing. The substances most responsible for this increase include, diphenhydramine, an over-the-counter drug, tramadol, bupropion, and synthetic cannabinoids. Preventative measures need to be instituted to prevent a further rise.
Rita FARAH, Conner T. MCDONALD (Charlottesville, USA), Sandra NIXON, Christopher HOLSTEGE
00:00 - 00:00
#41635 - Should patients with a traumatic cardiac arrest be transported to trauma centers?
Should patients with a traumatic cardiac arrest be transported to trauma centers?
Introduction
Patients with major trauma benefit from a direct transport to a specialized trauma center. Trauma network has helped to reduce trauma associated mortality associated. However, patients suffering from traumatic cardiac arrest are excluded from these systems and are generally transported to the nearest hospital. The aim of the present study is to evaluate the association between the level of trauma designation of the receiving hospital (tertiary trauma center vs. any other hospital) and in-hospital mortalitý amongst patients with traumatic cardiac arrest.
Methods
This retrospective cohort study was based on data collected in the Montreal (Canada) region between 2010 and 2020 by the Corporation d'Urgences-santé. We included patients aged 18 and over suffering from a prehospital traumatic cardiac arrest. Patients who were not transported to hospital (death declared on the field) or with missing critical data were excluded. We separated patients into two groups according to their hospital destination (tertiary trauma center vs. any other hospital). The primary outcome measure was survival to hospital discharge. Chi-square tests and a multivariate logistic regression model were used to assess the association of interest.
Results
Among 818 patients in the initial registry, 411 patients (Male=81%; mean age=47 years) were included, of whom 129 (31%) were transported to a tertiary trauma center and 282 (69%) to another hospital. Being transported to a tertiary trauma center was associated with survival to discharge (Tertiary trauma center: 7.8%; Any other hospital: 1.4%, p=0.001). The low number of events (14) prevented us from generating a multivariate logistic regression model due to the risk of overfitting.
Conclusion
Patients with a traumatic cardiac arrest may benefit from a direct transport to a tertiary trauma center. The maximum tolerable redirection time for this remains uncertain. A larger study should first assess this and perform a multivariable model, which should be follow by a prospective trial.
This research project has received research subventions from the 'Département de médecine familiale et de médecine d'urgence' and the 'Association des spécialistes en médecine d'urgence du Québec'.
This research project has received in-kind support from the ‘Fonds des urgentistes de l’Hôpital du Sacré-Coeur’ in the form of logistical support.
Laramée PHILIPPE, Samuel BLAIS, Luc DE MONTIGNY, Thérésa CHOISI, Eli SEGAL, Raoul DAOUST, Justine LESSARD, Véronique CASTONGUAY, Mathieu TOULOUSE, Vérilibe HUARD, François DE CHAMPLAIN, Martin VINCENT, Luc LONDEI-LEDUC, Dr Alexis COURNOYER (Montréal, Canada)
00:00 - 00:00
#42128 - Single-center retrospective study of changes in antimicrobial resistance of microorganisms isolated from urine cultures of the emergency department of a tertiary hospital during the five-year period 2018-2022.
Single-center retrospective study of changes in antimicrobial resistance of microorganisms isolated from urine cultures of the emergency department of a tertiary hospital during the five-year period 2018-2022.
Background: The choice of empirical antibiotic therapy in the Emergency Department (ED) should be based on a good knowledge of the local flora. Antimicrobial resistance (AMR) is a significant public health problem with global dimensions. This study aimed to investigate the changes and characteristics of AMR in urine samples ordered from the ED of a tertiary hospital during the five years 2018-2022, to identify local resistance, and the appropriate empirical treatment of UTIs in the ED.
Methods: We conducted a single-center retrospective observational study. Information was collected on all urine cultures ordered from the University Hospital Heraklion ED from 2018 to 2022. The diagnostic yield, the microorganism species isolated, the types of resistance identified, and their change during the study period, which also included the COVID-19 pandemic period, were assessed. Differences in resistance due to gender or age were also investigated.
Results: Information was collected on 20,321 cultures (6,180 positive, diagnostic yield 30.4%, stable over the years). The most common microorganisms isolated differed depending on age. Patients over 35 years of age more frequently had infections from E. coli (54%), K. pneumoniae (12%), P. mirabilis (6%), E. faecalis (5%), and P. aeruginosa (4%), while patients under 35, from E. coli (63%), St. saprophyticus (10%), P. mirabilis (8%), K. pneumoniae (7%), and E. faecalis (4%). A gradual increase in resistance of E. coli to the amoxicillin/clavulanate combination was observed from 24% to 47% (28% to 54% over 35, 16 to 28% under 35) with a simultaneous decrease in resistance to nitrofurantoin (from 13% to 6%). The difference in E. coli resistance to many antibiotics was significant between the two age groups (e.g., 2nd generation cephalosporins 27% vs. 9%, 3rd generation cephalosporins 18% vs. 5%, quinolones 30% vs. 4%, in over 35 vs. under 35 respectively). Kl.Pneumoniae showed a statistically significant decrease in resistance to piperacillin/tazobactam (from 33% to 22%). On the contrary, Pr. Mirabilis showed an increase in resistance to amoxicillin/clavulanate (from 25% to 38%), piperacillin/tazobactam (from 6% to 12%), carbapenems (from 2% to 19%) and fosfomycin (from 0% to 8%), with more pronounced changes in the older age group, which also showed significantly higher resistance to almost all antibiotics. The resistance of E.Faecalis to carbapenems increased from 0% to 21%. For patients over 35 years of age with UTI from an unknown microbial agent, the cumulative probability for empirical therapy failure with ciprofloxacin, ceftriaxone, piperacillin/tazobactam, or carbapenems was 26%, 24%, 10%, and 5%, respectively.
Discussion and Conclusions: Within the five years 2018-2022, we observed a significant change in the AMR of the common microorganisms that cause UTIs. Our study highlights age as an important factor when choosing the initial empirical antibiotic therapy in the ED. The very high resistance we observed in older patients is a dangerous indicator of the course of the AMR phenomenon in the study area.
Trial Registration: The study is not registered.
Funding: This study did not receive any specific funding.
Ethics committee approval and informed patient consent: The study was approved by the Administrative and Scientific Council of the University Hospital of Heraklion and the Ethics Committee (Protocol No.: 25699 Date: 02/10/2023). Due to the use of anonymized retrospective data, there was no need for patient consent.
Vasiki KOUTSOUROUMBI, Stavroula ILIA, Dimitra STAFILAKI, George BRIASSOULIS, George HAMILOS, Dr George NOTAS (HERAKLION, Greece)
00:00 - 00:00
#40696 - Socially marginalized patients’ perspectives on hospital transition: A qualitative study.
Socially marginalized patients’ perspectives on hospital transition: A qualitative study.
Background: Socially marginalized patients often have several contacts with healthcare and social service workers. Their healthcare needs are often complex as they often struggle with chronic diseases, multimorbidity, and severe social issues. Emergency departments serve an essential role in healthcare for socially marginalized patients, as proper care and support at the beginning of their patient pathways are vital for a coherent healthcare trajectory. Research has shown that social nurses with specialized knowledge and experience working with marginalized patients provide patient-centered care and coherence during hospital admission. However, limited research on the hospital transitions of socially marginalized patients has been undertaken. Therefore, this study aimed to explore the experiences of the transition from hospital to home of socially marginalized patients who receive social nursing during their hospital stay.
Methods: This is a qualitative study performed with a phenomenological and hermeneutic approach at Odense University Hospital in Denmark. Adult patients who had contact with a social nurse during hospital admission were purposely sampled between January 2023 and March 2023. Sixteen patients were interviewed during hospital admission, and thirteen of the patients participated in a follow-up interview 7–22 days after discharge. The analysis was performed using systematic text condensation, and data storage and coding were supported by Nvivo 12. The analysis was synthesized in a workshop by the research group and afterward qualified by two patient representatives, who shared their reflections on the results.
Ethical approval and informed consent: The study is registered with the Danish Data Protection Agency (22/47509). Participants gave oral and written consent to participate.
Results: The participants' experiences of the transition from the hospital to home depended on three aspects: 1) how the discharge was planned, 2) their living circumstances after discharge, and 3) the level of support after discharge. While clear communication and a well-prepared discharge were important for a successful transition from the hospital to home, the participants experienced being rushed at discharge and many felt left out of the decision-making process. The hospitalization was a turning point for many participants’ daily lives as their physical condition required changes in their lifestyle to achieve the best possible recovery. The participants had interactions with many different social and healthcare services and many needed additional healthcare and support after discharge. However, many participants experienced poor multidisciplinary cooperation and standardized care options, which did not always match their needs.
Discussion and conclusions: The findings revealed a silo-divided healthcare system, which is especially problematic for the care of patients with coexisting social and healthcare issues. This study identifies transitional care gaps in socially marginalized patients’ pathways related to poor multidisciplinary cooperation and standardized care. Knowledge of the hospital transitions of socially marginalized patients is important to provide early identification of healthcare needs and sufficient support in the emergency department and improve the patient pathway of patients with social vulnerability.
Funding: This study was supported by the University of Southern Denmark, the Region of Southern Denmark, Novo Nordisk, Østifterne, and the Department of Emergency Medicine at Odense University Hospital.
Lisa KVIST ANTONSEN (Odense, Denmark, Denmark), Annmarie TOUBORG LASSEN, Dorthe NIELSEN, Christina ØSTERVANG
00:00 - 00:00
#41361 - STAR-EM: Summer training and research in emergency medicine for medical students: five year program review.
STAR-EM: Summer training and research in emergency medicine for medical students: five year program review.
Background: Research training programs for students, especially in emergency medicine (EM), may be difficult to initiate due to lack of protected time, resources, and mentors. We developed a ten-week summer program for medical students aimed at cultivating research skills through mentorship, clinical enrichment, and immersion in EM research culture through shadowing and project support.
Methods: The STAR-EM program was established in 2019 at University Health Network, a University of Toronto teaching hospital. This is a 10 week structured program in which pre-clerkship medical students work with a dedicated project supervisor, engage in weekly group collaborative project reviews guided by an ED faculty member, and participate in a structured education program on core topics in academic emergency medicine. Program design followed review of existing summer research programs and literature regarding challenges in EM research. Curriculum development is collaborative and iterative and informed by Kern’s six-step model for curriculum development. All projects are approved by the hospital research ethics board (REB). Program evaluation by students and faculty occurs at the end of week ten.
Results: The program has completed five successful years. Program evaluation is informed by Kirkpatrick’s model of learning evaluation: reaction, learning, behavioural change, organizational performance. At the reactions and learning level, student evaluations have reflected a uniform impression that course material and mentorship were excellent (63.2%, 12/19) or very good (36.8%, 7/19). At the level of behavioural change, increased interest in pursuing academic EM as a career was identified by most students (15/19, 78.9 %). All respondents have rated the program as excellent (13/19, 68.4%) or very good (6/19, 31.6%) and have indicated that they would recommend the program to others (19/19, 100 %). At the level of organizational performance, faculty researchers who served as mentors rate the program as effective in terms of enhancing their own research productivity and scholarly output. The program has been a consistent catalyst for student and faculty research productivity and scholarly output, with 16 related scholarly conference presentations and 8 published peer-reviewed manuscripts to date.
Conclusion: The STAR-EM program provides a transferable model for other academic departments seeking to foster the development of future clinician investigators and enhance ED research culture.
Steven Marc FRIEDMAN (Toronto, Canada), Jennifer BRYAN, Konika NIRMALANATHAN
00:00 - 00:00
#42185 - Structured triage via intelligent assistant service OPTINOFA - Results of a multicenter, randomized and controlled interventional study.
Structured triage via intelligent assistant service OPTINOFA - Results of a multicenter, randomized and controlled interventional study.
Background:
In Germany a substantial reform of emergency care is strictly recommended. Regulation of patient flows into the ambulatory and stationary sectors remain one of the major issues.
Methods:
In the OPTINOFA project funded by the Innovationsfunds a new triage system was developed for a structured primary evaluation of both urgency and care level of emergency cases. OPTINOFA was evaluated in a randomized, controlled multicenter trial in eleven emergency departments (ED) during July 1st 2019 until May 31st 2021. The primary study endpoint represented the increase of patient transfer to the ambulatory sector; secondary endpoints included the outcome, process and quality indicators as well as mean emergency care costs.
Results:
In the study control period (CP) n=46.558 and in the interventional period (IP) n=37.485 emergency cases were included. Concerning the primary endpoint a significant increase of transfers to the ambulatory sector were detected in the per-protocol EDs (p<0.001, RR=2.48). Waiting times were significantly reduced by on average 20 min in the IP. Furthermore, a stable admission rate was found within three days after initial ED presentation. Cost analysis revealed no increase of treatment expenses within 28 d after ED admission.
Conclusions:
In this project a valid assistant service for structured primary evaluation of urgency and care level was successfully developed for emergency cases and served as a digital triage instrument with interoperable format. Clinical trial results revealed a big potential for the OPTINOFA triage system to control patient flows in emergency and acute medicine.
German Innovationsfunds Grant No. 01NVF17035
Sabine BLASCHKE (Germany, Germany), Haraldd DORMANN, Rajan SOMASUNDARAM, Christoph DODT, Ingo GRAEFF, Hans-Jörg BUSCH, Bernadett ERDMANN, Katrin ESSLINGER, Elisabeth NYOUNGUI, Patrik DRÖGE
00:00 - 00:00
#42149 - Study of self-reported work-life balance among emergency medicine and nursing professionals in Greece.
Study of self-reported work-life balance among emergency medicine and nursing professionals in Greece.
Background: Work-life balance (WLB) is a significant issue in the workplace. Emergency Medicine and Nursing include stressful work environments, and achieving WLB is difficult. Like other European countries, Greece experiences a loss of healthcare workforce, with healthcare professionals leaving healthcare for less stressful environments. This study aimed to investigate the current WLB of Emergency Medicine professionals in Greece, compare it with workers in other healthcare settings, and associate it with their personal and workplace characteristics.
Methods: We conducted a synchronous study using an online questionnaire for healthcare professionals working in emergency departments (EDs) and non-emergency care settings (outpatient departments and clinics) throughout Greece from June to September 2023. The questionnaire included demographics, working conditions, and self-reported job satisfaction and was validated on 30 healthcare workers before its use in the study. Data analysis was performed using chi-square and Spearman's rho, with Bonferroni correction for multiple comparisons.
Results: The sample comprised 312 healthcare professionals (78.8% women, 53.5% married, and 55.8% with at least one child). 58% were nurses, 21.2% residents, and 13.1% attending physicians. 63.8% of the sample worked in an inpatient clinic or an outpatient department, and 36.2% in an ED. No differences were observed in any of the parameters studied between ED workers and those working in other departments. Overall, 70% of healthcare workers reported having insufficient time for themselves and their families, half reported that work interferes with family formation, and 73% reported having seen a mental health professional. 77.6% reported experiencing work-related health problems, and 15.2% reported daily discomfort. 76.9% reported sleeping less than 7 hours daily, and 73.1% reported poor sleep quality. 77.6% reported receiving complaints from family members about their working hours. 68.9% reported decreased enjoyment, 70.2% poor mood, and 76.3% that their work affects their diet. 83.0% reported that the staff in their workplace is insufficient, resulting in them performing non-assigned duties (90.1%) and working overtime (54.5%), but 54.2% reported not being paid for this. 76.3% reported making a significant mistake at work, mainly due to fatigue (44.8%). 23.2% reported sexual harassment from patients (61.4%) or colleagues (53.9%). 84.3% reported that they are not adequately compensated, resulting in 26.0% working an additional job. Finally, 52.6% of workers reported thinking often or daily about changing their department, and 26.6% about changing their profession.
Discussion and Conclusions: At this stage, achieving a Work-Life Balance for healthcare workers in Greece is difficult regardless of whether they work in the ED or another hospital department. The severely disrupted Work-Life Balance may explain, to some extent, the wave of resignations from the National Health System.
Trial Registration: The study is not registered.
Funding: This study did not receive any specific funding.
Ethics committee approval and informed patient consent: The study was conducted anonymously online. Due to the non-use of personal data and the free choice to respond after consent to the questionnaire, there was no need for ethics committee approval.
Iro TSOUROU, Stavroula ILIA, Eleni PEITSIDOU, George BRIASSOULIS, Dr George NOTAS (HERAKLION, Greece)
00:00 - 00:00
#41312 - Successful kidney transplantation from donation after cardiac death according to chest compression methods (mechanical versus manual) applied. A systematic review and meta-analysis.
Successful kidney transplantation from donation after cardiac death according to chest compression methods (mechanical versus manual) applied. A systematic review and meta-analysis.
Introduction: There are patients who have suffered a cardiac arrest outside hospital, and after failed cardiopulmonary resuscitation (CPR) attempts are then transferred with continued CPR to hospital for organ donation. For kidney transplantation, maintaining circulation to the kidneys after cardiac arrest is key to successful transplantation.
Objective: The objective of this study was to assess whether the use of the mechanical chest compression (CC) is superior to the manual CC in the successful transplantation of kidney after cardiac death outside hospital.
Methodology: A systematic review and a meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The systematic search was carried in PubMed and SCOPUS databases up until 01 April 2024. We used the following keywords: kidney transplant and chest compression. Two independent reviewers conducted title and abstract screening, identified potentially eligible articles for the full-text review, extracted data and assessed risk of bias using Newcastle-Ottawa Scale. Discrepancies were resolved by agreement with the third reviewer.
For meta-analysis, articles reporting data to calculate Odd Ratio (OR) and its 95% confidence interval (95% CI) were included. The pooled effect size and their 95% CI to estimate using inverse variance method. Heterogeneity was assessed using the I2 statistic, which was interpreted accordingly as follows: modest (0%-25%), moderate (25%-50%), substantial (50%-75%) and considerable (75%-100%). We estimated a random-effect model because substantial to considerable heterogeneity was present. Meta-analysis was conducted using Review Manager software (RevMan V.5.3.5) and we considered p<0.05 statistically significant.
Results: The systematic search detected 29 references through keyword search. Of these, 9 were duplicates, resulting in 20 papers. After titles and abstracts revision, 10 articles were excluded. Ten studies were selected for review after full-text evaluation. Of these, 3 papers were excluded. Therefore, seven articles fulfilled the inclusion criteria and three were incorporated in the systematic review and meta-analysis.
The seven papers included in the systematic review were retrospective cohort studies. All included studies were published between 2010 and 2022 (5 were article, 1 letter to editor and 1 was abstract congress). These studies were performed in two countries including Spain (n= 6), and United States (n= 1). The number of participants ranged considerably (from 48 to 458) between the articles with a median 122 and an average of 159. Five papers actually belonged to the same study.
A total of three papers met criteria for meta-analysis, including 490 individuals. Four articles that shared the same cohort were excluded and the most current article was included in the meta-analysis. In a random effects meta-analysis, our results showed no significant differences in the successful transplantation according to CC by mechanical devices or manual, with a pooled OR (95% CI) of 0.83 (0.31-2.22); p=0.71. Considerable heterogeneity was identified among studies (I2=82%; p<0.001)
Conclusion: Mechanical CC was not statistically superior to manual CC in the successful transplantation of kidney after cardiac death outside hospital.
Not applicable
Sergio RICO MARTIN (Caceres, Spain), Gonzalo DE LA OSA ANDRÉS, Esperanza SANTANO MOGENA, Fidel LÓPEZ ESPUELA, Ana Teresa DOMINGUEZ MARTÍNEZ, Julián F CALDERÓN GARCÍA
00:00 - 00:00
#41898 - Symptoms and Referral Patterns of Patients with a Missed Acute Ischemic Stroke: A Danish Multicentre Cohort Study.
Symptoms and Referral Patterns of Patients with a Missed Acute Ischemic Stroke: A Danish Multicentre Cohort Study.
Background: Stroke is one of the leading causes of morbidity and mortality worldwide, affecting millions of people each year. The efficacy of acute ischemic stroke (AIS) outcomes relies on rapid access to suitable care, particularly acute reperfusion therapy, which demands promptness. In Denmark, a meticulous stroke treatment infrastructure was established to ensure swift and efficient management. It features a nationwide pre-hospital pathway directing potential stroke patients to specialized stroke centres through the hospital referral center. However, the challenge of identifying AIS in patients presenting with non-specific stroke symptoms can often complicates the referral process. Consequently, a high proportion of AIS patients are initially referred to a non-stroke department, causing delays and potential barriers to evidence based acute stroke care. This study aims to describe symptom characteristics and outcomes of AIS patients initially admitted to emergency departments (ED) compared to patients admitted directly to a stroke center (SC) in Denmark.
Methods: This retrospective cohort study utilized data from a regional stroke database (DDSC) and review of electronic medical records (EMR) in the period from April 1st, 2020, to January 31st, 2022. Data was collected from one SC and one ED at a university hospital, and two EDs at a regional hospital within the eastern part of the Central Denmark Region. Eligible patients were aged ≥18 with a confirmed diagnosis of AIS, admitted to either an ED or directly to a SC. A random sample of 300 patients was selected from each group: "Direct admission at a stroke centre" (SC group) and "Admission at an emergency department" (ED group). The exposures of interest were the decision regarding department referrals, focusing on which department AIS patients were admitted to, based on their baseline clinical features. Outcome measures included symptom prevalence, patient demographics, and stroke severity assessments comparing AIS patients in EDs versus direct admissions to SC. Secondary outcomes compared treatment trajectories between ED and SC admissions, focusing on delay duration and reperfusion therapy utilization. Data were analyzed using descriptive analysis, and chi-square or Fisher's exact tests were applied for comparisons.
Results: In the study period a total of 3204 patients were diagnosed with AIS, of which 19.1% were initially referred to an ED, and 80.9% were directed to a SC. The median patient age was 74 years (IQR 64, 82), with 42.8% female patients. Gender and age distributions were similar between groups. A cohort of 435 patients (235 ED, 200 SC) underwent detailed review of the EMR. Non-specific stroke symptoms, such as dizziness (ED 25.1% vs. SC 8.5%), nausea/vomiting (ED 18.3% vs. SC 3.0%), and headache (ED 18.3% vs. SC 8.0%), were more prevalent in the ED group, while the SC group had higher rates of focal neurological deficits. Patients referred to the ED experienced longer delays (30.6 [12.65,76.75] hrs. vs. 3.9 [1.51, 13.72] hrs.) and lower reperfusion therapy rates (8.1% vs. 39.5%).
Conclusion: AIS patients referred to the ED more frequently exhibited non-specific stroke symptoms, experienced prolonged delays, and had lower reperfusion rates compared to those directly referred to a SC.
Approvals and Registration: The present study is considered a quality improvement study, and according to the Danish Health Act section 42d, subsection 2, no additional approvals or registration of the study were required. (34) However, as a review of the electronic medical records was conducted, approvals were obtained from the management of Aarhus University Hospital, Randers Regional Hospital, and Horsens Regional Hospital.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Disclosure: We declare no conflict of interest.
Line BILGRAV NISGAARD (Aarhus, Denmark), Rolf ANKERLUND BLAUNFELDT, Niels HJORT, Marianne LISBY
00:00 - 00:00
#41457 - Symptoms at STEMI presentation is associated with short-term and long-term outcomes: a retrospective cohort study.
Symptoms at STEMI presentation is associated with short-term and long-term outcomes: a retrospective cohort study.
Introduction:
Atypical presentations of acute myocardial infarction may lead to delayed diagnosis, suboptimal treatment, and increased in-hospital mortality. However, it is still unclear which segments of the door-to-balloon time in ST-elevation myocardial infarction (STEMI) treatment are affected by symptoms at presentation and how these symptoms influence long-term mortality outcomes. This study aims to investigate the impact of typical and atypical symptoms presented initially at the emergency department (ED) in STEMI patients on outcomes such as delays in various time segments from door to balloon, and 30-day,1-year, 3-year mortality rates.
Method:
A retrospective cohort study was conducted at a tertiary teaching hospital. Patients diagnosed with STEMI in the ED who underwent primary percutaneous coronary intervention were identified from January 1, 2013 to December 31, 2022. Atypical symptoms were defined as initial presentations on ED arrival other than chest pain. Data collected included patient demographics, medical history, initial troponin levels, ECG findings, and coronary angiography reports. Various time segments within the door-to-balloon time, as well as the dates of mortality, were also collected. Multivariable logistic regression was used to assess the impact of atypical symptoms on the delays across different time intervals within the door-to-balloon time frames. Multivariable Cox proportional hazards analysis was employed to evaluate the association between atypical symptoms and survival outcomes, including 30-day, 1-year, and 3-year mortality.
Results:
A total of 807 STEMI patients were included, with 109 patients presenting atypical symptoms upon arrival. For outcomes of delays in various time segments from door to balloon, multivariable logistic regression analysis revealed that STEMI patients with atypical presentation had significantly higher odds of door-ECG time > 10 minutes (aOR:11.35, 95% CI: 6.22-20.72, P<0.001), catheter lab-arrival-to-balloon > 30 minutes (aOR:1.99, 95% CI: 1.25-3.14, P=0.003), and door-to-balloon time > 90 minutes (aOR:3.98, 95% CI: 2.30-6.90, P<0.001) than those with typical presentation. For the survival outcomes, 46 patients died within 30 days, 69 patients died within 1 year and 87 patients died within 3 years. Multivariable Cox proportional hazards analysis showed that atypical presentation was also an independent predictor of 30-day (aHR: 2.29, 95% CI: 1.13-4.66, P=0.022), 1-year mortality (aHR: 1.82, 95% CI: 1.04-3.20, P=0.036), and 3-year mortality (aHR: 1.77, 95% CI: 1.07-2.94, P=0.026).
Discussion and Conclusion:
Atypical symptom presentation significantly exacerbates delays in specific segments within the door-to-balloon timeline and is associated with higher short-term and long-term mortality rates. This study reinforces the importance of developing strategies to better recognize and promptly address atypical presentations of STEMI. Enhanced training for emergency department staff to recognize non-classical presentations of myocardial infarction, coupled with protocols that expedite the diagnostic and treatment processes for these high-risk patients, could potentially improve clinical outcomes.
Trial registration: This study is not a clinical trial.
Funding: This research did not receive external funding
Jeng-Fu HUANG (Chiayi City, Taiwan), Yu-Ting HSIAO, Ya-Ni YEH, Shi-Quan ZHANG, Ming-Jen TSAI
00:00 - 00:00
#41682 - Targeting STING/FSP1 to Reduce Septic Vascular Permeability : The Protective Role of H-151 in Preserving Vascular Endothelial Cells from Ferroptosis.
Targeting STING/FSP1 to Reduce Septic Vascular Permeability : The Protective Role of H-151 in Preserving Vascular Endothelial Cells from Ferroptosis.
Background
The vascular endothelium has been investigated as an integral organ in the field of sepsis over the past two decades. Researchers have indicated that vascular endothelial injury occurs in the early stage of sepsis and plays a crucial role in the development of multiple organ dysfunction syndrome (MODS). Therefore，effectively treating vascular endothelial injury is of great significance to block the progression of MODS.
Methods
A murine model of cecal ligation and puncture (CLP) sepsis was established, and either the STING inhibitor H-151 or the ferroptosis inhibitor liprostatin-1 was employed for intervention. The degree of vascular leakage was evaluated by EB staining and VE-cadherin IF staining. Western blot and IHC staining were used to compare the differences in STING and FSP1 protein levels in mouse vascular endothelial cells. The therapeutic effect of H-151 was assessed by tissue HE staining and observation of 7-day mortality. Subsequently, HUVECs pretreated with H-151 or the FSP1 inhibitor iFSP1 were stimulated with LPS. STING1 knockdown HUVECs were also constructed through siRNA interference. The levels of MDA, Fe2+ and lipid ROS were detected, and the localization and expression of STING and FSP1 were compared by IF staining.
Results:
STING is significantly activated in vascular endothelial cells of septic mice and induces ferroptosis by inhibiting the expression of FSP1, leading to severe vascular leakage. Treatment with H-151 can inhibit the activation of STING in vascular endothelial cells, reverse the reduction of FSP1 to inhibit ferroptosis, and improve vascular leakage and organ damage in septic mice. In vitro, both H-151 and siRNA inhibition of STING promoted FSP1 expression, reduced ferroptosis and promoted the repair of adhesion junctions in HUVECs. However, all these therapeutic effects of inhibiting STING can be reversed by iFSP1 treatment, indicating that FPS1 was located downstream of STING and regulated by it during this process.
Discussion ＆ Conclusions:
This study confirmed that STING activation in sepsis can promote ferroptosis of vascular endothelial cells by inhibiting the expression of downstream FSP1, destroy intercellular adhesion junctions, and lead to vascular endothelial injury. This result further confirms the importance of STING-FSP1-ferroptosis pathway in sepsis-induced vascular endothelial injury, and provides a new target for the treatment of sepsis. STING specific inhibitor H-151 can effectively improve vascular endothelial injury and reduce organ damage in septic mice, which provides a new strategy for the treatment of vascular endothelial injury in sepsis.
All animal experiments were conducted in accordance with the Guide for the Care and Use of Laboratory Animals, and all protocols were approved by the Animal Ethics Committee of Tianjin Medical University General Hospital.
Songtao SHOU (Tianjin, China), Tianyi ZHANG
00:00 - 00:00
#40785 - The association between C-reactive protein to albumin ratio and 6-month neurologic outcome in patients with in-hospital cardiac arrest.
The association between C-reactive protein to albumin ratio and 6-month neurologic outcome in patients with in-hospital cardiac arrest.
Background: Prior research has established a connection between C-reactive protein (CRP), CRP to albumin ratio (CAR), and neurological outcomes in out-of-hospital cardiac arrest patients. However, the association between CAR and neurological outcomes in individuals with in-hospital cardiac arrest (IHCA) remains understudied. This study aimed to examine the relationship between CAR following the return of spontaneous circulation (ROSC) and neurological outcomes in IHCA patients undergoing targeted temperature management (TTM).
Methods: A retrospective observational study was conducted on adult comatose IHCA patients, treated with TTM between January 2017 and December 2022.Post-ROSC CAR was computed from CRP and albumin levels. The Good Outcome Follow Attempted Resuscitation (GO-FAR) score was determined based on age and pre-cardiac arrest clinical parameters. The primary endpoint was defined as poor neurological outcome at six months, represented by cerebral performance categories 3, 4, and 5. Multivariate analysis and area under the receiver operating characteristic curve (AUC) were applied to evaluate a poor neurological outcome.
Results: The study included 141 patients, with 112 (79.4%) demonstrating poor neurological outcomes. These patients exhibited elevated CRP levels (2.4 vs. 0.2 mg/dL), higher CAR (0.9 vs. 0.0), and reduced albumin levels (3.0 vs. 3.4 mg/dL) in comparison to patients with positive neurological outcomes. Upon controlling for confounders, CAR displayed significant independent association with poor neurologic outcomes (odds ratio 1.662; 95% confidence intervals [CIs], 1.107–2.496).The AUC of CAR for poor neurological outcomes stood at 0.774 (95% CI, 0.696–0.840).
Conclusions: Elevated CAR following ROSC was associated with poor neurological outcomes in IHCA patients undergoing TTM.
Yong Deok LIM (, Republic of Korea)
00:00 - 00:00
#41637 - The Effect of Deep Learning-Based Assistive algorithm of Brain Computed Tomography for intracranial hemorrhage on the Interpretation and Decision Making of Emergency Medical Professionals: A Simulation-Based Prospective Interventional Study.
The Effect of Deep Learning-Based Assistive algorithm of Brain Computed Tomography for intracranial hemorrhage on the Interpretation and Decision Making of Emergency Medical Professionals: A Simulation-Based Prospective Interventional Study.
Objectives: Intracranial hemorrhage is a critical neurological emergency requiring prompt attention and accurate diagnosis in the emergency department (ED). Deep learning technology may be able to assist with interpreting non-enhanced brain computed tomography (CT) scans. However, its impact on clinical decision-making in real-world settings remains uncertain. This study evaluated the effect of a deep learning-based assistive intracranial hemorrhage detection algorithm (DLHD) on interpreting CT scans and decision-making in a simulated clinical environment.
Methods: The study involved a simulation-based prospective interventional design. Ten emergency medical professionals participated in the study, including emergency physicians, emergency medicine residents, and emergency medical technicians from a tertiary hospital’s ED. CT scans with patients’ clinical information were reviewed in two steps, without and with DLHD. Diagnostic performance measures were calculated, including sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve. Consistency in clinical decision-making was assessed using the Kappa statistic.
Results: Our findings indicated that DLHD minimally influenced diagnostic performance and clinical decision-making in experienced participants. Inexperienced participants showed significantly increased sensitivity (59.33 (95% confidence interval (CI) 53.78–64.89) to 72.67 (95% CI 67.62–77.71), p<0.001) and decreased specificity 65.49 (59.66–71.33) to 53.73 (47.61–59.85), p<0.001) when assisted by the algorithm. Clinical decision-making was moderately consistent among inexperienced professionals (k=0.425, (0.362–0.488), with higher agreement among experienced professionals (k=0.738, (0.687–0.789)) (p<0.001). Changes in clinical decisions occurred more frequently in the inexperienced group, mainly due to the algorithm’s false positives.
Conclusion: The utilization of a DLHD had variable effects on emergency medical professionals’ diagnostic performance and decision-making. This study underscores the importance of comprehensive evaluation and careful integration of deep learning solutions in the clinical workflow, particularly for inexperienced professionals. Further research is warranted to assess the algorithm’s impact on patient outcomes and its generalizability across diverse clinical settings.
This work was supported by Medical AI Clinic Program through the National IT Industry Promotion Agency, funded by the Ministry of Science and ICT (Project number S1313-22-1003, H0124-23-1006).
Arom CHOI (Seoul, Republic of Korea)
00:00 - 00:00
#41320 - The impact of arterial blood pH on short-term mortality in adult medical emergency department visits: a population-based, multicentre study.
The impact of arterial blood pH on short-term mortality in adult medical emergency department visits: a population-based, multicentre study.
Background
The acid-base balance in arterial blood is critical in determining patient outcomes during emergency care. Although acid-base imbalances are common, the impact of pH levels on short-term mortality in emergency department (ED) settings is not well studied. Most evidence comes from intensive care unit settings where interventions can affect pH levels and outcomes, raising concerns about these findings' generalisability to the ED setting.
The objectives were to examine the correlation between arterial blood pH and 0–2- and 3–7-day mortality in adult medical ED visits.
Methods
This population-based, multicentre cohort study included all adult medical ED visits of 18 years or older from seven departments in the Region of Southern Denmark from January 1, 2016, to March 19, 2018. The inclusion criteria required an arterial blood gas (ABG) analysis within four hours of arrival. The outcomes were 0–2- and 3–7-day mortality rates stratified by pH levels and adjusted for confounders with hazard ratios (HRs) compared to normal pH levels.
Results
The study included 64,725 adult medical ED visits and 31,650 unique individuals with ABG testing. Most patients had normal pH (54.2%), followed by alkalosis (31.8%), acidosis (11.3%), and severe acidosis (2.7%). Dyspnoea was the most common symptom (29.5%), and 64% of patients were aged ≥65. The largest group of patients had no comorbidities. The most frequent discharge diagnoses were respiratory diseases (29.2%), unspecific findings (18.6%), and circulatory diseases (12.4%).
The mortality rates for patients within 0–2 days and 3–7 days of the index visits were 2.4% and 2.1%, respectively. Patients with severe acidosis (pH < 7.20) had the highest risk, with mortality rates of 20.8% and 8.9% (HR 9.6 and 5.2, respectively). Acidosis (pH 7.20–7.34) was associated with mortality rates of 7.4% and 5.2% (HR 4.1 and 2.7, respectively). Within two days, nearly 60% of patients with pH < 6.90 died. In the adjusted analysis, lower pH levels, increased burden of comorbidities, and advanced age were associated with increased risk of short-term mortality.
Discussion and conclusions
Our study highlights that lower pH, increased comorbidities, and older age are linked to higher short-term mortality risk in the ED. Notably, 40% survival among patients with pH < 6.90 challenges the prevailing medical consensus, suggesting a critical re-evaluation of prognostic values and treatment approaches for acute patients may be necessary.
Trial Registration
Permission to obtain and store data was obtained from the regional authorities (identifier 3-3013-2272/1 and identifier 17/24904, amendment identifier 20/24502).
Funding
This study did not receive any specific funding.
Ameer Jamal IVERSEN, Marius Moen CHRISTIANSEN, Annmarie Touborg LASSEN, Isik Somuncu JOHANSEN, Flemming ROSENVINGE, Michael Dan ARVIG (Odense M, Denmark)
00:00 - 00:00
#41880 - The impact of Point-of-Care Ultrasound on the diagnosis and management of Small Bowel Obstruction in the Emergency Department: a retrospective observational single-center study.
The impact of Point-of-Care Ultrasound on the diagnosis and management of Small Bowel Obstruction in the Emergency Department: a retrospective observational single-center study.
Small bowel obstruction (SBO) represents a critical condition that requires rapid diagnosis and intervention. This retrospective observational study conducted at a single center aims to evaluate the impact of point-of-care ultrasound on the diagnosis and management of SBO in the emergency department.
Currently, the diagnosis of SBO relies on clinical evaluation and imaging modalities such as plain radiography and CT scans. POCUS offers advantages including rapidity, repeatability, cost-effectiveness, and lack of radiation exposure. This study compares the diagnostic efficacy of POCUS against traditional methods for diagnosing SBO.
Patients older than 18 years with a final diagnosis of SBO assessed at our Emergency Department between November 1, 2021, and December 31, 2023, were retrospectively included in the research. All patients underwent computed tomography (CT) imaging as part of their diagnostic evaluation, given its established status as the gold standard for accurately identifying the etiology and precise anatomical location of intestinal obstruction. Subsequently, patients were stratified into two cohorts: the POCUS group that comprised individuals examined by a physician through intestinal point-of-care ultrasound, and the non-POCUS group consisting of patients evaluated using conventional clinical examination methods. In the POCUS group, an intestinal obstruction diagnosis was confirmed if at least three of these ultrasound signs were present: dilatation of the bowel loops (>2.5 cm), thickening of valvulae conniventes (typical in jejunum and ileum), alternating peristalsis (to-and-fro sign), or free fluid among loops (tanga sign). Out of a total enrollment of 328 patients, exclusion occurred for 129 due to incomplete data or having an encoded diagnosis as solely being related to intestinal obstruction because other types weren't coded. The POCUS group consisted of 99 patients, compared to the non-POCUS group which had a total of 100 patients.
In the POCUS group, the median diagnostic time was 52 minutes, which was notably shorter than the 190 minutes observed in the non-POCUS group (p < 0.05). Notably, within the POCUS group, the time for diagnosis was 172 minutes when confirmed by abdominal CT with contrast, compared to 190 minutes in the non-POCUS group (p < 0.05), highlighting the significance of POCUS in expediting decisions for CT imaging.
Furthermore, the average length of hospital stay was shorter in the POCUS group (10.4 days) compared to the non-POCUS group (11.22 days), although this difference was not statistically significant (p > 0.05). Similarly, there was no significant difference in mortality rates between the two groups (p > 0.05). In the POCUS group, 6 patients died, while in the non-POCUS group, 9 passed away.
These results emphasize the practical value of POCUS in assisting with SBO diagnosis and influencing subsequent management decisions. Although POCUS reduces diagnostic time compared to conventional approaches, it does not significantly affect hospital stays or mortality rates, likely due to the individual presentation timing in the emergency room and the natural progression of the condition.
Further investigation is warranted to explore the long-term outcomes and cost-effectiveness of integrating POCUS into routine ED practice for SBO diagnosis and management.
NCT05864378
Carmine Cristiano DI GIOIA (Modena, Italy), Alice ALAME, Lucrezia GRISAN, Geminiano BANDIERA
00:00 - 00:00
#42250 - The implementation of an emergency medicine specialist organisation: association with reduced admission rates without compromising safety - a 10-year perspective.
The implementation of an emergency medicine specialist organisation: association with reduced admission rates without compromising safety - a 10-year perspective.
Background: Over the last few decades, the organisation of emergency departments (EDs) in Europe has increasingly been built on emergency specialist staffing and management rather than multispecialty involvement. In Sweden, Emergency Medicine (EM) was finally recognised as a specialty in 2014. The same year Region Skåne, serving a population of 1.3 million, implemented a EM specialty training and leadership program to provide its five major EDs with resident- and specialist physicians as primary workforce. Among several objectives, this transition aimed to enhance early diagnosis and treatment, risk stratification, and reduce admissions. However, there remains a lack of knowledge regarding the impact of EM implementation on admission rates and patient safety. This study aimed to evaluate the effects of a decade-long implementation of an EM specialist organisation on admission rates and safety measures.
Method: A retrospective before-and-after analysis was conducted comparing data from 2013 (pre-implementation) to 2023 (post-implementation) in Region Skåne, Sweden. Data from the Swedish Emergency Department Register (SVAR) for the respective years were utilised. The primary outcome measure was the admission rate, while safety measures included 7-day mortality and unplanned in-hospital admissions within 72 hours. ED length of stay was also analysed. Changes in patient characteristics, such as age, ambulance arrivals, and triage priority levels, were examined to understand potential shifts in the patient population.
Results: In 2013, the five EDs had a total of 258,985 visits, increasing to 274,440 visits in 2023. Post-implementation, there were significant increases in median patient age (from 55 to 57 years), higher acuity triage (from 28.5% to 29.2% of patients triaged to level 1 or 2 out of five), as well as ambulance arrivals and referrals from general practice (from 26.0% to 28.5%). The admission rate decreased significantly from 30.1% (95% CI: 30.08-31.13%) to 24.2% (95% CI: 24.03-24.35%; p < 0.001), representing a relative decrease of 22%. While there was a non-significant increase in crude 7-day mortality (from 0.85% to 0.90%; p = 0.054). Unplanned in-hospital admissions within 72 hours decreased significantly from 2.26% to 1.96% (p<0.0001). The length of stay in the ED increased from a median of 2 hours and 57 minutes to 3 hours and 54 minutes.
Discussion: Despite a rise in patient volume and complexity post-implementation, the study observed a 22 % relative reduction in admission rates, indicating more effective resource allocation. This reduction in admissions seemed not associated with compromised safety, as indicated by stable re-visit, and overall mortality rate. However, the longer ED stays suggest that the decrease in admission rate, probably related to increased ED diagnostic processes, comes with the price of longer stays in the ED. While the study demonstrates a strong association between emergency medicine specialty-based organisation and improved admission rates, a causal relationship cannot be proven from this observational study.
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Andreas LINDEGREN (Helsingborg, Sweden, Sweden), Katarina LOCKMAN-FROSTRED, Daniel JANSON-THORFINN, Jakob LUNDAGER-FORBERG
00:00 - 00:00
#41323 - The mental health and well-being of helicopter emergency medical service clinicians: A systematic literature review and national survey of organisational provision.
The mental health and well-being of helicopter emergency medical service clinicians: A systematic literature review and national survey of organisational provision.
Background
Recent evidence has indicated high levels of mental health problems in ambulance service staff in the UK and worldwide. A systematic review of qualitative research found that several aspects of ambulance work impact significantly on mental health and well-being, with increased risk of conditions such as post-traumatic stress disorder, anxiety and depression. Helicopter Emergency Medical Services (HEMS) work alongside ground ambulance services in delivering prehospital care, however, unlike ground ambulance staff, routinely attend the most critically ill and injured patients requiring enhanced levels of care. HEMS clinicians are therefore frequently exposed to highly traumatic incidents and may face even greater risks to mental health and well-being than those working within ground ambulance services. However, little is known about the mental health and well-being of this population within the UK or more widely. The project aims were to identify, synthesise and critically appraise the international literature on mental health and well-being of HEMS clinicians, and to explore provision for mental health and well-being of clinicians in UK HEMS organisations.
Methods
A systematic literature review was conducted to determine types of mental health and well-being outcome that have been investigated for HEMS clinicians, and to identify, synthesise and critically appraise literature on prevalence of mental health and well-being outcomes, risk and protective factors, and experiences of HEMS clinicians. Ten databases of published literature were searched from inception to 2023. Reference lists of included studies were checked and a grey literature search was conducted. Narrative synthesis was employed due to the heterogeneity of studies. Alongside the systematic review, a national online survey was conducted of UK HEMS regarding clinician sickness absence and provision for clinician mental health and well-being. The survey was sent to Human Resources Leads or staff members nominated by Chief Executive Officers. Ethical approval was obtained from Anglia Ruskin University.
Results
From the initial 6,973 unique records identified for screening, nine papers were included from the database searches. Three further studies were identified from reference lists of included studies and the grey literature search. Findings indicated that HEMS clinicians can experience detrimental outcomes such as burnout, but protective factors including peer support and job control may mitigate this. The survey was completed by 11 UK HEMS organisations, a response rate of 52.4%, with sickness absence data provided for two further organisations. Findings showed considerable variability in mental health-related sickness absence rates across 10 organisations that provided this data. There was also heterogeneity in provision for mental health and well-being and several barriers to providing support were identified.
Discussion & Conclusions
There is a scarcity of literature on the mental health and well-being of HEMS clinicians. UK HEMS organisations reported that clinicians have sickness absences related to mental health but there was a high level of missing data. Provision for mental health and well-being varies across organisations and the effectiveness of the provision has not yet been evaluated. Future research should be conducted with HEMS clinicians to explore their mental health and well-being, and to determine effectiveness of organisational provision.
The systematic literature review was registered on PROSPERO in May 2023, ref: CRD42023425560. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023425560
The project was funded by the Health, Performance and Wellbeing Theme at Anglia Ruskin University, UK.
Sarah MCLACHLAN (Chelsmford, United Kingdom), Alexandra POWER-MASON, Hilary BUNGAY, Nigel LANG, Aswinkumar VASIREDDY, Christopher LAND
00:00 - 00:00
#41979 - the power of P.
the power of P.
Background: The inter-atrial block (IAB) is a delay in atrial conduction defined as a wide p wave (WPW) on an electrocardiogram (ECG) recognized as a high specificity prediction factor for supraventricular tachycardia (SVA) prediction but weak for stroke prediction. New criteria for IAB (NIAB) appeared as the increase wide of p wave in the inferior leads, which has increased its predictive value. Objective to find a relationship between new NIAB and IS.
Method: A retrospective study of 356 total patients: 178 cases admitted to the hospital for ISUSi (A group) and 178 controls admitted with no stroke history (B group) both groups had no prior arrhythmias and the same cardiovascular risks factors (cases and controls were matched1 to 1 by age, gender and CHA 2 DS 2 -vasc score). Defining the NIAB as: IABi: p bimodal ≥ 120 ms in I, I or III and IABc: p biphasic ≥ 120 ms in II, III and AVF. NIAB finding on the ECG was assessed in both groups at admission to the hospital. Data analysis was made to find IAB differences between groups in relation to age (<75; ≥75).
Results: 356 patients (51% men; mean age 73,1+13,8; Barthel index 80,49+24,36 were included in study. WPW and NIAB findings were significantly more prevalent in group A (p≤0.000). Significant differences were found in age (<75; ≥75): stronger association WPW vs IABi and IABc in the younger group (OR 26,8(11,9-60,9) vs 21,5(7,27-63,5) and 25,43(3,3- 194) in contrast with a stronger association IABc and IABi vs WPW in the oldest group (OR 27,07(6,25-127,3) and 2,3(1,2-4,7) vs 9,6(4-23,2).
Conclusions: WPW and NIAB were significantly related to ISUCi. Relevant differences were found considering age, being more prevalent WPW and IABi in younger and IABc in elder. Although more studies are needed, in the future these outcomes could justify primary prophylaxis with anticoagulation before SVA appears
No funding
Martínez Rivas JUAN JOSÉ (Granollers, Spain), Duems OSCAR
00:00 - 00:00
#41276 - The prognostic role of comorbidities on survival and neurological outcomes at hospital discharge after adult out-of-hospital cardiac arrest: a retrospective cohort study.
The prognostic role of comorbidities on survival and neurological outcomes at hospital discharge after adult out-of-hospital cardiac arrest: a retrospective cohort study.
Background: Out-of-hospital cardiac arrest (OHCA) is a critical public health issue that causes millions of deaths globally. Though survival and neurological outcomes after OHCA remain poor, differences exist between patient groups. Whether comorbidities play a prognostic role in outcomes following OHCA is still unclear.
Methods: This retrospective cohort study included non-traumatic OHCA adult survivors who received targeted temperature management (TTM) in 10 medical centers via the TaIwan network of targeted temperature ManagEment for CARDiac arrest (TIMECARD) Registry from January 2014 to September 2019. Patients were divided into 4 groups by individual comorbid burden based on modified Charlson Comorbidity Index (mCCI). Prognostic effect of mCCI and specific comorbidities contained in mCCI on survival and neurological outcomes at discharge are identified by Kaplan-Meier survival curve analysis and logistic regression.
Results: A total of 383 OHCA survivors were analyzed with 82 patients in mCCI 0-1 group, 90 patients in mCCI 2-3 group, 124 patients in mCCI 4-5 group and 87 patients in mCCI >=6 group. The mean age of all enrolled patients is 64.3 years, and 256 (66.8%) patients were male. The overall average mCCI was 3.7, and most patients scored between 4 (16.7%) and 5 (15.7%). Only 150 patients survived at hospital discharge, and 80 of whom had favorable neurological outcomes. The most common comorbidities were hypertension (210, 54.8%), diabetes mellitus (147, 38.4%), coronary artery disease (112, 29.2%) and hyperlipidemia (71, 18.5%). Liver cirrhosis (hazard ratio [HR] 2.87, 95% CI 1.52-5.42), heart failure (HR 1.66, 95% CI 1.22-2.26), end stage renal disease (HR 1.57, 95% CI 1.08-2.27) and diabetes mellitus (HR 1.35, 95% CI 1.04-1.75) were associated with worser survival at hospital discharge. The mCCI 2-3 group, the mCCI 4-5 and the mCCI >=6 group possessed worser survival at hospital discharge with HR 1.73 (95% CI 1.1-2.73), HR 2.08 (95% CI 1.36-3.18) and HR 2.34(95% CI 1.51-3.61) respectively in comparison with the mCCI 0-1 group. Compared with the mCCI 0-1 group, the mCCI 2-3 group, the mCCI 4-5 group and the mCCI >=6 group also tended to acquire poor neurological outcomes at hospital discharge with odds ratio (OR) 2.48 (95% CI 1.28-4.81), OR 3.47(95% CI 1.83-6.61) and OR 11.62(95% CI 4.26-31.71) respectively.
Conclusion: This nationwide multicenter retrospective study puts forward that increased comorbid burden is related to both worser survival and neurologic outcomes at discharge. Specific comorbidities also have undesirable prognostic effect on survival at discharge.
Trial registration:
NCT03578328
The TaIwan network of targeted temperature ManagEment for CARDiac arrest (TIMECARD) Registry
Funding:
No funding to declare.
Ethical approval and informed consent:
This study was approved by the Research Ethics Committee of National Taiwan University Medical College. The requirement for informed consent was waived.
Wan-Ru HUANG (Hualien, Taiwan), Kuo-Liong CHIEN, Chien-Hua HUANG, Bo-Yu HSIAO
00:00 - 00:00
#42409 - The Race Against Sepsis: Are Helicopters Always Necessary When Transporting Sick Children? An Outcome Analysis of Transporting Children with Sepsis.
The Race Against Sepsis: Are Helicopters Always Necessary When Transporting Sick Children? An Outcome Analysis of Transporting Children with Sepsis.
Background
Several studies focus on the utilization of ground versus air transportation for pediatric traumatic injuries, but there are limited studies on the best mode of transportation for children with sepsis to tertiary care facilities. The aim of this study is to determine if there is a significant difference in transport time, length of stay, and mortality in ground versus rotor wing transport of pediatric patients with sepsis.
Methods
A retrospective chart analysis of electronic medical records was completed at a 255 bed tertiary care children’s hospital that functions as the region’s primary level 1 pediatric trauma center with ~81,000 visits annually to the pediatric emergency department. The study included patients from January 1, 2010- January 1, 2020 between the ages of 0-18 years who were transported by Pedi-flite, a neonatal and pediatric critical care transport team that utilizes ground and rotor wing transport. Patients included were those assigned International Classification of Diseases (ICD)-10 codes specific for a diagnosis of sepsis. Data collection included age, diagnosis, average distance traveled, receiving unit (ED, PICU), length of stay, discharge location, and time of transport.
Results
In our study of 149 patients diagnosed with sepsis, 113 patients were transported via ground and 36 by rotor wing. There was no statistical difference in time to dispatch and time to patient (156 minutes for rotor vs 199 minutes for ground, p = 0.11), and no statistical difference in length of stay between ground versus rotor wing (average length of stay for ground, 9.22 days vs 10.78 days for rotor, p = 0.6). Additionally, there was no statistical difference in survival when comparing ground and rotor wing (90% ground, 97% rotor, p= 0.4).
Conclusion
When comparing ground and rotor wing transport of patients with sepsis, our study indicates that there is no significant difference between transportation time to tertiary care facility, length of stay, or mortality. Although statistically insignificant, rotor wing resulted in faster arrival to patients compared to ground. At our institution, the rotor wing is a shared asset resulting in a time delay due to equipment loading and unloading prior to transport. Ground transport has an average cost of ~$2500 compared to rotor wing which can exceed $40,000.
Recognition and treatment of pediatric sepsis is a priority in decreasing morbidity and mortality in pediatric patients. Transporting a pediatric patient with sepsis is optimized when performed by a specialized neonatal and pediatric critical care team. Critical care that is initiated in the emergency department is continued when the critical care team arrives and throughout transport. While rotor wing gets the team to bedside sooner, this mode of transport does not improve the overall outcome for the patient.
Rudy KINK (, USA)
00:00 - 00:00
#41440 - The Totaled Health Risks in Vascular Events (THRIVE) Score Predicts Successful Revascularization Status Post Intra-Arterial Thrombectomy: Analysis On Emergency Medical Service Database in Taipei City.
The Totaled Health Risks in Vascular Events (THRIVE) Score Predicts Successful Revascularization Status Post Intra-Arterial Thrombectomy: Analysis On Emergency Medical Service Database in Taipei City.
Background
The Totaled Health Risks in Vascular Events (THRIVE) scoring system, which encompasses age, NIHSS score, and 3 risk factors of atrial fibrillation, diabetes mellitus, and hypertension, was developed to predict the mortality at 90 days of stroke patients intra-arterial thrombectomy (IAT). The association between THRIVE score and reperfusion status after IAT has not been addressed. We aimed to investigate the association between the THRIVE score, measured in emergency department (ED), and successful intra-arterial revascularization, in terms of the modified Treatment in Cerebral Ischemia (mTICI) score.
Methods
This retrospective cohort study evaluated the performance of THRIVE score on short-term outcome of successful revascularization in acute large-vessel occlusion stroke patients treated after IAT. We conducted an analysis on the ASSST (Acute Stroke Surveliance System of Taipei City) dataset, which covered 11 Advanced Emergency Responsibility Hospitals in Taipei City. Participants treated with IAT were retrieved from January 1, 2017, to June 30, 2022. Successful revascularization was defined as mTICI of 2b to 3. The logistic regression models are conducted to evaluate odds ratios (ORs) and 95% confidence intervals (CIs) for successful revascularization. The receiver of operating characteristic (ROC) curve was used to explore the optimal threshold of THRIVE score, namely the Youden’s index, on predicting successful revascularization and the 90-day functional outcome status (i.e., the mRS 0-2 versus 3-6). The sensitive analysis evaluated selected patients of Taipei Medical University Hospital (TMUH) for the linear association between Thrive scores and both mTICI and mRS.
Results
A total of 485 participants treated with the IAT were enrolled into the analysis. On univariate logistic regression model, female sex (OR: 1.81, 95% CI: 1.15 to 2.87), and higher THRIVE score (OR: 2.04, 95% CI: 1.24 to 3.34) were significantly associated with higher odds of poor reperfusion. The multivariable logistic regression model consistently showed THRIVE ≥5 (adjusted OR: 1.93, 95% CI: 1.17 to 3.18) was significantly associated with unfavorable revascularization. In the Youden’s index analysis, the optimal cutoff was THRIVE ≥5 as well. In the participants of TMUH, the ROC curve analysis showed the THRIVE had moderate performance on predicting successful revascularization (AUC: 0.68, 95% CI 1.2 to 15.84) and the functional outcome status (AUC: 0.71, 95% CI 0.57 to 0.89). In addition, we found a significant correlation between mTICI and mRS (coefficient -0.38, 95% CI: -0.63 to -0.11).
Discussion and Conclusion
The THRIVE score has shown good performance to predict the mortality at 90 days with a first-generation IAT device[1], and is found correlated with the functional outcomes status and occurrence of hemorrhagic transformation.It was an easy-to-use tool on assessing stroke patients treated after IAT and assisted to predict the reperfusion degrees in terms of mTICI, and the functional outcome status on 90 days.
Funding: This study was supported by Taipei Medical University, Taipei, Taiwan (reference number: TMU111-AE1-B07)
Ethics approval and Informed Consent
This study was approved by the Joint Institutional Review Board of Taipei Medical University (reference number: N202110064) and the informed consent was waived due to the de-identified and anonymous data were used.
This study was supported by Taipei Medical University, Taipei, Taiwan (reference number: TMU111-AE1-B07)
Hui-An LIN (台北, Taiwan), Chyi-Huey BAI, Sheng-Feng LIN
00:00 - 00:00
#41900 - Thrombo-inflammatory Prognostic Score (TIPS) Improves A2DS2 for Predicting Stroke-Associated Pneumonia: A Retrospective Cohort Study.
Thrombo-inflammatory Prognostic Score (TIPS) Improves A2DS2 for Predicting Stroke-Associated Pneumonia: A Retrospective Cohort Study.
Background: Stroke-associated pneumonia (SAP) is a common complication of acute ischemic stroke (IS), significantly increasing patient mortality and disability rates. Therefore, early prediction of SAP is crucial. The A2DS2 score is commonly used in clinical practice to predict SAP, but it focuses on assessing the overall risk of post-stroke pneumonia, potentially overestimating the actual risk of SAP and leading to insufficient specificity. Previous studies have confirmed that inflammation and thrombosis play important roles in the development of SAP. Thus, our aim is to assess whether the novel and simplified Thrombo-inflammatory Prognostic Score (TIPS), combined with the A2DS2 score, can improve early diagnosis and prognostic evaluation of SAP in the emergency department.
Methods: This was a multicenter retrospective cohort study. TIPS was derived from inflammatory and thrombotic biomarkers at admission. We used receiver operating characteristic (ROC) curves, integrated discrimination improvement (IDI), net reclassification improvement (NRI), and decision curve analysis (DCA) to assess whether TIPS could improve the predictive and prognostic performance of the A2DS2 score for SAP and 90-day mortality risk.
Results: A total of 915 patients with IS were included, of whom 294 were diagnosed with SAP. The area under the curve (AUC) of TIPS plus A2DS2 for predicting SAP (0.815) was significantly higher than that of TIPS (0.758) or A2DS2 (0.750) alone (p < 0.001). TIPS plus A2DS2 was significantly associated with stroke severity and mortality in ischemic patients. The improvement in discrimination was confirmed by an IDI of 0.087 (p < 0.001). Adding TIPS to A2DS2 resulted in an NRI of 0.529 (p < 0.001). DCA showed that the net benefit of TIPS plus A2DS2 was higher than that of TIPS or A2DS2 alone at any threshold probability.
Conclusion: The prognostic value of the A2DS2 score for patients with SAP was enhanced by adding the TIPS score at admission for early risk prediction in the emergency department.
Our study was registered at www.chictr.org.cn (ID: ChiCTR2100052025). The methods of the study were conducted following the tenets of the Declaration of Helsinki and were approved by the institutional review boards of Sichuan University West China Hospital and other participating hospitals.
Peng YAO, Li DONGZE, Yarong HE, Liang LIANJING, Liu PENG, Pr Yu CAO (Chengdu, China)
00:00 - 00:00
#41992 - Trauma that does not bleed: An Assessment of Mental Health Services.
Trauma that does not bleed: An Assessment of Mental Health Services.
Patients with mental health concerns present to the emergency department (ED) when they are in crisis. Mental health services have evolved to decrease stigma and improve access to these services by co-locating liaison psychiatry self-harm nurse specialists in the ED. Portiuncula University Hospital (PUH) is a level 3 community hospital with approximately 32000 ED presentations. Unlike most hospitals PUH does not have an approved psychiatry admission unit. Patients are seen and assessed by the ED clinician, then referred to the liaison and psychiatry team on call. Patients’ deemed for admission need to be referred to another hospital. They often may wait in the ED until a bed is available.
This study was a prospective review of the patients’ recorded on the referral excel who presented to the ED at PUH in 2023 in mental health crisis and were referred to the psychiatry service. The data was then analysed in context of previous studies.
There were 446 presentations to the ED in 2023, with men:women(232: 214), an increase since 2022(187:210). and previous trends in which there were more women. These numbers are similar to 2016 when data was first collected. 349(78%) were discharged from the ED and 90 were referred from admission. The previous age group that attended most were 30–39-year-olds followed by 20-29- and 40–49-year-old, also recorded in 2016 and subsequent years. Results for 2023 however showed that most amongst 40-49 years(93) followed by 30-39(85) and < 20(73). Numbers were also high amongst other groups 20-25(69); 50-59(51) and >60(40). 201 lived with family, 74 unknown living status, 73 lived alone, 67 student accommodation and 29 were homeless/supported accommodation. The majority of patients 411 were referred to hospital by family and friends, continuing previous trend. 345 were seen within 2 hrs of referral and 61 between 2-6hrs. 227 had suicidal ideation alone, 70 had overdosed with prescribed drugs, 55 cut themselves, 40 non-prescribed drugs; 31 recreational/alcohol and 17 had attempted hanging. 144 had no previous self-harm acts, 128 declined to advise, 6 had >5 self-harm presentations in the previous year, 38 had 2-4 attempts in the previous year and 50 had at least one self-harm episodes in the previous year. Alcohol(82) was the most associated with self-harm followed by a combination of alcohol and drugs(52).
There was an increase in cases of mental health crisis and deliberate self-harm to the ED as compared to previous years. The collocated liaison psychiatry service improved assessment times for those in crisis. Further study will be required to review reason for this increase. It is very noteworthy that there is an increase of DSH amongst the younger population, those of employable age and in the elderly. The increase in use of recreational drugs like cocaine in combination with alcohol to deliberately self-harm is concerning. The easier accessibility to the drug and experimentation in the former group and loneliness and co-morbidities in the latter. Mental Health Issues certainly plagues many in our society and affects all socioeconomic.
Kiren GOVENDER (Galway, Ireland), Kathleen GAFFEY
00:00 - 00:00
#41061 - Trends in psychological-related presentations at the emergency department during the COVID-19 pandemic.
Trends in psychological-related presentations at the emergency department during the COVID-19 pandemic.
Background
Singapore saw our first imported case of COVID-19 on 23 Jan 2020. At the initial phase of the pandemic, the focus was predominantly on the pathogenicity and transmissibility of this novel virus, proposing measures for preventing, containing and treating the disease. As such, the psychological and psychiatric implications tend to be under-estimated, both on an individual and collective level. Many countries reported an increase in psychological disorders presenting to the hospital. The aim of this study is to examine the trends in psychiatric presentations to the Emergency Department (ED) of a tertiary hospital during the initial 5 months of the COVID-19 pandemic.
Methodology
We conducted a retrospective audit of patients who presented to the ED with specific International Classification of Diseases (ICD) codes related to psychological conditions between January to June 2020 (COVID group) and compared them to the control group of January to June 2019. Patient demographics, past medical history and attendance-related data were studied and classified. Data was analysed using Chi-square and independent T tests where appropriate.
Results
A total of 2595 visits in 2019 (control group) and 2367 visits in 2020 (COVID group) were studied.This constituted 4.17% and 4.40% of total ED visits in 2019 and 2020 respectively (p=0.060) within the same period of time. There was no significant difference in demographics of patients in both groups, including age, sex and presence of existing psychiatric history. There were however more healthcare workers (HCWs) in the COVID group, with 48 out of 2367 (2.03%) in the COVID group being HCWs as compared to 35 out of 2595 (1.35%) ED attendances in the control group (p=0.040).
There was no significant difference in the number of patients with ED attendances for psychological-related diagnoses. However, patients with psychological-related ED attendances were significantly younger (p<0.001) and tended to present to the ED outside of working hours (p=0.004).
Discussion
Results of our audit differs from what is reported in other published literature. In the global scene, EDs have seen increased presentations of psychiatric complaints during the first year of COVID-19 pandemic. We highlight 3 possible reasons for this variance - fear of contracting COVID-19 keeping patients away from the ED, increased emphasis on use of telemedicine for non-life threatening complaints which would include psychological symptoms, as well as relative drastic changes in the active outgoing lifestyle of youths as compared to the older population resulting in more apparent difficulty in coping with imposed social restrictions.
Conclusion
Past tragedies/pandemics have shown that the mental health implications can last longer and have greater prevalence than the epidemic itself. Although our study results differ, there was an increase in psychiatric complaints of the younger population which concur with other studies. There are implications to workflow and crowd control strategies in the ED.
Nil
Magneline ANG (Singapore, Singapore), Krishin NANDWANI, Wenjian CHAN, Georgina KWEK, Clara SEAH, Shu Woan LEE
00:00 - 00:00
#42162 - Triage of patients presenting to the Emergency Department with presumed organ dysfunction: Performance of Manchester Triage System in early sepsis identification.
Triage of patients presenting to the Emergency Department with presumed organ dysfunction: Performance of Manchester Triage System in early sepsis identification.
Introduction
The triage process in Emergency Departments (EDs) plays a critical role in identifying patients at risk of sepsis promptly. Assigning individuals with pre-septic and septic conditions to the highest urgency categories facilitates rapid intervention by emergency physicians, aligning with guideline-recommended early sepsis management (1). Among the widely employed triage systems, the Manchester Triage System (MTS) stands out for its reliability in prioritizing patients with life-threatening conditions, boasting low levels of undertriage (2). However, there is limited data on the efficacy of MTS in early sepsis identification. In this study, we aim to evaluate the performance of the Manchester Triage System in identifying patients likely to develop sepsis among adult patients presenting to the Emergency Department with presumed organ dysfunction.
Methods
From December 2016 until March 2017 we performed a prospective observational multicentre study across three major hospitals in Germany (two sites at the Charité University Hospital in Berlin and the university hospital in Jena). Adult patients presenting to the ED with presumed organ dysfunction, defined by an elevated qSOFA score of more than 1, were included, while those with acute trauma, stroke, myocardial infarction, pregnancy, and limited life expectancy (<28 days) were excluded (3). The primary endpoint was sepsis within 96 hours of ED presentation based on the sepsis 3 definition. This analysis focused solely on patients recruited at the Berlin sites excluding those who developed sepsis after 24 hours. Assignment of septic patients to urgent triage levels 1-3 was defined as accurately triaged in the sense of early sepsis identification, whereas assignment with low triage categories were defined as mistriaged.
Results
Among the 721 included patients, 187 developed sepsis within the first 24 hours. Notably, the majority of septic patients were assigned to the second triage category (49%, n=93), followed by the third category (33%, n=36). Only a small percentage of 5.3% (n=10) of patients were assigned to the highest urgency triage level of one, while 11% (n=22) were undertriaged in the fourth category. No septic patients were assigned to the fifth category. MTS demonstrated high sensitivity (88.9%) in predicting sepsis in the study population, with a negative predictive value of 80.9 %. The reported specificity was relatively low with 17%.
Conclusion
MTS showed a high sensitivity in early sepsis identification among patients presenting to the ED with presumed organ dysfunction and demonstrated low undertriage levels. Integrating the qSOFA score into MTS could enhance early sepsis screening in the ED, potentially improving outcomes for septic patients.
Ethical approval and informed consent
This study was performed in accordance with the ethical guidelines of the Helsinki Declaration (WMA Declaration of Helsinki), approved by the Institutional Review Board of the University Hospital Jena (4892-08/16) and registered in the German registry for clinical trials DRKS00011188. Written informed consent was obtained from all patients or their legal representatives where appropriate.
Philipp SCHONDELMAIER, Martin MÖCKEL, Anna SLAGMAN, Antje FISCHER-ROSINSKÝ, Michael BAUER, Johannes WINNING, Angelicka STACKE, Myrto BOLANAKI (Berlin, Germany)
00:00 - 00:00
#41332 - Tromboelastography’s Diagnostic Validity In Suspected Patients With Acute Coronary Syndrome.
Tromboelastography’s Diagnostic Validity In Suspected Patients With Acute Coronary Syndrome.
Background
Acute coronary syndrome (ACS) is one of the reasons of life-threatening emergency department admissions. In some patients diagnosis can be delayed, missed or resulted with death because of a wide spectrum of ACS’s clinical view. Diagnosis is made by combination of patient’s history, electrocardiography (ECG), biomarkers and cardiac catheterization. Early diagnosis and treatment of ACS would lower mortality and morbidity. Besides, early exclusion of ACS may prevent unnecessary further follow-up or procedures and result with low hospital fees. Thromboelastography (TEG) has used to show hypercoagulability in clinically, thrombosis, anticoagulation, response to antithrombotic treatment, thrombocyte function analysis and follow-up procoagulant treatment. It may show hypercoagulable state to ease the diagnosis of ACS. Diagnosis of hypercoagulability is assessed with a decrease in reaction time (R) and an increase in maximum amplitude (MA) via TEG. ACS is one of the complications of hypercoagulable state and the similar results in TEG parameters are expected in patients with ACS.
Objectives
The aim of our study was to investigate the effectiveness of TEG in diagnosis of ACS, in suspected patients with ACS.
Methods
The study was performed in Zonguldak Bülent Ecevit University Hospital within 01.0.2019 and 31.12.2019. Patients with suspected ACS who are 18 years old and over, applied to the hospital were included in the study. Associated parameters were evaluated via TEG. Data were evaluated via SAS 9.4 statistical analyses programs.
Results
In 65.3 (n=64) % of all patients were men. The mean age of all patients was 58 ± 15.8 years, the youngest patient was 19 and the oldest patient was 90 years old. In 66.3 (n=65) % of all patients were diagnosed with ACS. MA was higher in patients with ACS compared to patients without ACS; but the result was not statistically significant (p=0.61). It has been found that each unit decreasing in R was related to increase the likelihood of the diagnosis of ACS by 5%. Thus, this parameter might be used in patients who are followed up with chest pain.
Conclusions
This study is one of the few studies about using TEG parameters in early diagnosis of ACS and the data were not compatible with the other studies in the literature. More studies are needed about using TEG parameters in early diagnosis of suspected ACS patients or follow-up care of patients with ACS.
The thromboelastography device and the study kits which were used in this research, were funded by Scientific Research Project (2019-50409025-01).
Hasan Can TAŞKIN (Zonguldak, Turkey), Hilal HOCAGIL, Abdullah Cüneyt HOCAGIL, Şükran KOCA
00:00 - 00:00
#41248 - Ultrasound-Guided Peripheral Intravenous Access: A Survey of Emergency Medicine Clinicians.
Ultrasound-Guided Peripheral Intravenous Access: A Survey of Emergency Medicine Clinicians.
Background
Ultrasound-Guided Peripheral Intravenous (UGPIV) access is a commonly performed skill in the Emergency Department (ED). There are numerous studies looking at which method for performing UGPIV access is better. None, however, have looked at how clinicians are actually performing this skill and their reasons for doing so. The aim of this survey is to explore ED clinicians’ current practice in performing UGPIV access and identify barriers to its use.
Methods
A survey was created using Google Forms and distributed via RCEM Specialty Tutors to ED clinicians across the Yorkshire deanery.
Results
A total of 171 responses were received from doctors and Advanced Clinical Practitioners (ACPs) across different grades.
The most common technique for performing UGPIV access was the transverse (out-of-plane method) (64.3%), followed by the combined method, in which the clinician starts with a transverse view and rotates to a longitudinal view during the procedure (28.1%). Only 4.1% of respondents said they used the longitudinal method. The most commonly cited reasons for clinicians’ preferred methods were having ‘more success with this method’ (60.8%), thinking ‘it is easier to perform’ (57.3%) and feeling that they ‘visualise the needle tip better’ (44.4%). 71.4% of clinicians who use the longitudinal method stated they visualise the needle tip better, compared to 30.9% who use the transverse method.
The most commonly reported complications of UGPIV access were posterior vessel wall puncture (40.4%), dislodgement (37.4%) and extravasation (22.8%). Arterial puncture or cannulation was reportedly higher in the combined (8.3%) and transverse (6.4%) methods compared to the longitudinal method (0%). 88.3% of respondents stated they most commonly use a standard cannula, with 9.9% stating they use a midline or other type of long cannula. 71.9% strongly agreed or agreed that UGPIV access can reduce the need for central venous access. The most common barriers to performing this skill were difficulties in accessing an ultrasound machine (35.6%), lack of access to other equipment (28.1%) and a lack of time to perform the skill (20.5%). Only 2.9% stated lack of training or supervision as a barrier.
Conclusions
This survey provides a snapshot of how ED clinicians perform UGPIV access. Numerous studies have looked at which method for performing UGPIV access is better, however no method has been shown to be superior. This survey shows that clinicians’ preferred techniques are based on factors such as the perceived ease of using the method as well as their experience of success and risk of complications.
A number of barriers to UGPIV access were identified including lack of access to appropriate equipment. Lack of training was not a commonly cited barrier. Barriers may prevent UGPIV access from being undertaken, thus delaying peripheral access being gained. It is well recognised that the use of ultrasound increases the success rate of peripheral venous access, with this survey finding that the majority of clinicians are in agreement that UGPIV access can reduce the need for central venous access. Departments should identify and reduce potential barriers to ensure UGPIV access can be performed when required.
This study did not receive any specific funding
Ethical approval: Not needed
Aaron MADHOK (Rotherham, )
00:00 - 00:00
#40745 - Unlocking the stroke code: Machine learning predicts large vessel occlusion stroke before arrival, a prospective observational studio.
Unlocking the stroke code: Machine learning predicts large vessel occlusion stroke before arrival, a prospective observational studio.
Introduction
Acute ischaemic stroke (AIS) is the leading cause of death in women and disability in adults in most European countries. Pre-hospital emergency medical services (EMS) have a critical role to play in reducing the time from symptom onset to reperfusion treatment. However, while intravenous fibrinolysis (IVT) is widely available in most hospitals in our region, mechanical thrombectomy (MT) for large vessel occlusion (LVO) is only available in a few hospitals that rotate on call. For EMS, selecting the destination hospital using only clinical scales to detect LVO is a challenge.
Machine learning (ML) techniques have been successfully used in stroke units to identify patients who may benefit from mechanical thrombectomy (MT) using clinical variables and data from an electrocardiographic (ECG) monitor. The research question is: Can a ML algorithm, trained with clinical and ECG variables of stroke code (SC) patients from an EMS, improve the accuracy of a prehospital clinical scale for detecting LVO?
Methods
This is a prospective observational study. Patients fulfilling SC criteria (sudden onset of neurological symptoms within the last 24 hours, mRS score <3) who underwent at least one ECG and vital signs measurement with an ECG monitor (Lifepak 15) were included. Patients with haemorrhagic stroke and those who did not have all the required variables recorded were excluded. Four datasets were collected: clinical characteristics, vital signs, trends, and electrocardiographic measures (last three from EMS ECG monitor). Hospital diagnosis at discharge was recorded. The main outcome was the detection of LVO ischaemic stroke.
The sample was divided into two subsets: 70% for training and 30% for testing. The first subset was used to iteratively train the ML algorithm with the four described datasets. The second subset was used to evaluate real performance, calculating ROC and confusion matrix to assess algorithm's diagnostic accuracy for each iteration. Parameters were compared with prehospital scales such as Madrid-Direct and RACE.
A sample size of 120 patients was calculated based on previous experience. All consecutive patients were included to limit bias.
Results
A cohort of 816 patients enrolled during 2022 is used for preliminary results. The number of patients and variables may vary depending on the data source. The best results for detecting LVO were obtained using a combination of three data sources (clinical features, haemodynamic parameters, trends) and a cohort of 98 patients. Results evaluated on the test sample show an area under the curve (AUC) of 70%, with an F1 score of 79%. The positive predictive value is 68% and the sensitivity is 93%.
Using the same population, the Madrid Direct scale showed a positive predictive value of 80% and a sensitivity of 62%.
Discussion & Conclusion
In this preliminary analysis using clinical and ECG data, ML techniques showed promising accuracy (between Madrid-Direct and RACE scales) for detecting LVO. The main limitations are the selection bias introduced by the observational design and the large proportion of losses due to missing variables. These data may be generalisable to other EMS using the same type of ECG monitor.
FUNDING
This study has been partially funded by STRYKER
ETHICS
The ethics committee of the Princesa University Hospital (Madrid) approved the study protocol with registration number: 22-07-21, act CEIm 14/21. The informed consent waiver was authorised.
María RIOS DELGADO, Maria RIOS DELGADO (Madrid, Spain), Jose Luis AYALA RODRIGO, Gemma REIG ROSELLO, Nuria RODRÍGUEZ-RODIL, Jose MARTINEZ-GOMEZ, Nicolas RIERA-LOPEZ
00:00 - 00:00
#42106 - Unraveling Sepsis-Associated Encephalopathy: A Retrospective Dive into Emergency Department Admissions.
Unraveling Sepsis-Associated Encephalopathy: A Retrospective Dive into Emergency Department Admissions.
Background:
Emergency departments are often the first point of contact for patients presenting with severe infection symptoms. This provides an opportunity for a thorough examination of patients with symptoms of sepsis, specifically analyzing its development, associated symptoms, and laboratory test results. The emergency department is also a setting where there is the possibility of initiating sepsis treatment in accordance with sepsis survival guidelines, which is crucial for improving patient prognosis. Sepsis-associated encephalopathy (SAE) is a common complication of sepsis, significantly increasing mortality among patients and potentially leading to long-term neurological deficits.
Aim of the study: The study aimed to determine the frequency of SAE occurrence, SAE predisposing factors, and to assess whether inflammatory markers could be use as indicators of the likelihood of SAE occurrence.
Methods: The study was conducted at the Emergency Department of a tertiary university hospital. We examined the records of patients admitted to the ED with a diagnosis of sepsis from January 1st, 2021, to December 31st, 2022. All patients included in the study were adults. Sepsis was diagnosed based on a SOFA scale score equal to or greater than 2. SAE was assessed based on information regarding neurological deficits documented in the medical records.
Results: A total of 450 cases of sepsis were identified. Among them, 250 exhibited neurological dysfunction indicative of SAE. In both years, the most common neurological impairments were deterioration of communication (97.6%), confusion (76.8%), and drowsiness (60%), while coma, agitation, seizures, and hallucinations were less frequent. Overall, 119 patients died, including 111 with SAE. Additionally, the values of inflammatory markers such as CRP, PCT, and neutrophil to lymphocyte ratio (NLR) were examined in each patient group. Procalcitonin levels were higher in patients with SAE in both years and were also correlated with mortality, whereas no such correlation was found for CRP and NLR. Chronic comorbidities of patients who developed SAE were analyzed, with the most probable correlation found between heart and kidney failure and the occurrence of SAE.
Discussion & Conclusions:
Studying patients with sepsis in the emergency department yields many insights into the uncertainties in available knowledge regarding SAE. Primarily, the frequency of its occurrence is often underestimated in scientific research, and moreover, the range of its values is considerable (9-70%). The study revealed how perilous the complication is – 93% of deceased patients exhibited symptoms of SAE. Knowledge regarding diagnostic and predictive methods is still limited, although new, more specific markers of encephalopathy are emerging. Nonetheless, clinicians currently must rely on more widely available indicators, such as procalcitonin, which in this study is the most effective in predicting the occurrence of SAE and death. Furthermore, the study demonstrated that based on a patient's chronic burdens, a more predisposed group can also be identified.
While retrospective studies have inherent limitations due to their retrospective nature, the results obtained from such analyses show promise. However, to corroborate these findings and establish causality, further prospective studies are deemed essential.
This study did not receive any specific funding.
Klaudia KRZYZANIAK (Gdansk, Poland), Aleksandra SZYMCZYK, Anna WSCISLAK, Sonia ZEMBRZUSKA, Aleksandra LOSINSKA, Natalia SZCZYGIEL, Robert KRION, Mariusz SIEMINSKI
00:00 - 00:00
#41969 - Use of emergency services in response to a flood: an account of the aftermath of the May 2023 flood in Romagna, Italy.
Use of emergency services in response to a flood: an account of the aftermath of the May 2023 flood in Romagna, Italy.
Background:
The acceleration of extreme weather events due to anthropogenic activities has significantly increased the frequency and severity of hydrological disasters like floods, impacting human health and healthcare systems worldwide. Previous research has highlighted the immediate and direct impacts of such events on healthcare systems, including loss of life and a range of medical emergencies inflicting several diseases on patients. This study investigates the effects on public health of the May 2023 flood in Romagna, Italy, focusing on patterns of emergency service use and adapting them to the needs of specific patient populations.
Methods:
A retrospective cohort study was conducted on 813,724 citizens of Romagna, Italy, from May 15 to August 31, 2023. The study differentiated between individuals in flood-affected (Exposed) and non-affected (Not Exposed) areas, assessing emergency room (ER) access rates (overall and by disease category), hospitalization odds, and mortality. Data were analyzed using Poisson regression models, adjusting for demographic variables, and clinical and social frailty.
Results:
Of the study population, 227,287 individuals were not exposed to the flood, while 586,437 were exposed. ER visits totaled 11,055 for the unexposed group and 27,948 for those exposed to the flood (HR 0.97; 95%CI 0.95 – 1.0). The rate of access with the highest triage scores was higher among those exposed to the flood, as well as the rate of hospitalization after ER visits. The rate of ER admission was lower for ophthalmology diseases (HR 0.85; 95% CI 0.71-1.00) and general disorders (HR 0.87; 95% CI 0.79-0.96), and higher for trauma (HR 1.22; 95%CI 1.08-1.22), gastrointestinal diseases (HR 1.09; 95%CI 1.01-1.18), and mental health disorders (HR 1.80; 95%CI 1.37-2.34). Exposed individuals had an increased - although approximating statistical significance - risk of death in the subsequent weeks (HR: 1.09; 95% CI: 0.99 – 1.19).
Discussion & Conclusion:
In the wake of the May 2023 flood in Romagna, our study seeks to evaluate the health impacts of such extreme meteorological events, particularly through the lens of emergency service usage and the role of clinical and social frailty. Our findings show the heightened vulnerability among those directly affected by the flood, revealing an increase in the likelihood of hospitalizations and a tentative rise in mortality rates. The observed increase in ER visits, especially for injuries/trauma, gastrointestinal and other acute medical issues, and mental health disorders, echoes the aftermath of other weather catastrophes, which similarly spurred a surge in critical healthcare demands. Such insights underscore the need for a robust healthcare infrastructure capable of a sustained response in the aftermath of natural disasters that is tailored to the specific problems of patients with selected needs.
In conclusion, the May 2023 flood in Romagna forced us to reevaluate health strategies in the face of an evolving climate narrative. As we step into an era where extreme weather events loom larger and strike more frequently, the insights of this study are not just reflective assessments of a singular event but an advocation for heightened preparedness that highlight the need for prospective healthcare planning and intervention strategies.
Trial Registration:
It was not appropriate or possible to involve patients or the public in the design and conduct of our research.
Funding Information:
This study did not receive any specific funding.
Ethical approval and informed consent:
This study was approved by the Ethics Committee of Romagna (CEROM), Registration Trial n. 3708, Protocol 443/2024, I.5/224.
Andrea PORTORARO (Ravenna, Italy), Gabriele FARINA, Andrea STRADA, Giorgia VALLICELLI, Roberto DE GIORGIO, Davide GOLINELLI, Simona ROSA, Eleonora TUBERTINI, Michele Domenico SPAMPINATO, Roberto GRILLI
00:00 - 00:00
#42359 - Utility of the Heart score calculated with a high-sensitivity troponin measured through a point of care in an emergency department.
Utility of the Heart score calculated with a high-sensitivity troponin measured through a point of care in an emergency department.
Background
The Heart score has been developed to assist in clinical decisions among patients with not traumatic chest pain in emergency departments. Point-of-care (POCT) devices that measure high-sensitivity troponin (hs-cTn) have been developed in recent years. Currently, a reliable determination of a hs-cTn can be obtained in less than 10 minutes after the patient arrives at the emergency department.
AIm.
To know the usefulness of the Heart scale calculated with the determination of hs-cTn with a POCT upon arrival of the patient to the emergency department.
Methods.
A prospective, non-interventional, multicenter cohort study was conducted in adult patients presenting with non-traumatic chest pain between August 1, 2023-December 31, 2023. The study included two university hospitals. Patients with acute coronary syndrome with ST elevation were excluded. Patients who met the inclusion criteria underwent hs-cTn measurement using a POCT (Siemens Atellica® VTLi hs-Tn POC assay) and in the central laboratory upon arrival to the emergency department. Variables: age, sex, Charlson index, calculation of the hs-cTn-POCT heart score (Heart-POCT) and with hs-cTn from the central laboratory (HEART-Central). Main dependent variable: diagnosis of acute coronary syndrome (ACS). Calculation by risk levels of the Heart scale: 0-3: low risk, 4-6: medium risk, 7-10 high risk. Description of the sample: quantitative variables: median and interquartile range (IQR), qualitative variables: frequency and percentage. Univariate study through comparison of quantitative (U-Man-Whitney) and qualitative (Chi-square) variables. The area under the curve (AUC) of the receiver operating characteristic (ROC) of each of the scales was calculated. Calculation of sensitivity and specificity, positive predictive value (PPV), negative predictive value (NPV), positive likehood ratio (LH +), negative likehood ratio (LH -) for a score of 3 or more points and 7 or more points. Logistic regression was used to assess the probability of ACS diagnosis. 95% confidence interval (95% CI). SPSS 29.0 software. Statistical significance p<0.05
Results.
N: 201. Median age 65 (55-76); Female: 40.3%; Charlson index: 3 (1-4). median age male: 62 (51-73), female: 68 (58-78) (p<0.05). SCA: 9%. AUC COR Heart-POCT: 0.959 (95% CI 0.913-1.00, p<0.0001) and Heart-central: 0.967 (95% CI 0.926-1.000, p<0.0001). Heart POCT: low risk: ACS: 0%, medium risk: 4.1%, high risk: 73.7% (p<0.0001). Heart-central: low risk: 0%, medium risk: 4.4%, high risk 77.8% (p<0.0001). Heart-POCT: > 3 points: sensitivity: 100 (95% CI 82.4-100) specificity: 46.4 (95% CI 39.4-53.7), PPV: 15.5 (95% CI 10.0-23.2), NPV: 100 (95% CI: 95.7-100), LH+: 1.87 (95% CI: 1.63-2.14), LH-: 0.00. Heart-POCT: > 7 points: sensitivity: 77.8 (95% CI 54.8-91.0) specificity: 97.3 (95% CI 93.8-98.8), PPV: 73.7 (95% CI 51.2-88.2), NPV: 97.8 (95% CI 94.5-99.1), LH+: 28.47 (95% CI 11.58-69.95) LH-: 0.23 (95% CI 0.10-0.54. Multivariate: Age, sex, Charlson (p>0.05), Heart-POCT: OR: 5.228 (95% CI 2.696-10.137, p <0.001).
Conclusions:
The Heart score using a high-sensitivity troponin by POCT has an excellent predictive capacity for ACS comparable to the use of central laboratory troponin. Therefore, currently it would be possible to determine the risk of these patients within a few minutes of their arrival at the emergency department.
This study was supported by unconditional funding from BIOTEC MEDICA.
Dr Raul LOPEZ IZQUIERDO, Carlos DEL POZO VEGAS (Valladolor, Spain), Daniel ZALAMA SÁNCHEZ, Francisco MARTÍN RODRIGUEZ, Ancor SANZ GARCIA, Javier PRESENCIO DOMINGUEZ, Ana GIL CONTRERAS, Susana SANCHEZ RAMÓN, Miguel POSADAS MUÑO, Manuel BALADRÓN SEGURA, Blanco BLANCO GONZALEZ, Maria FERNANDEZ GARCIA, Pablo GONZALEZ IZQUIERDO, Mario RODIL MUÑOZ
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#42398 - VALUE OF ULTRASOUND IDENTIFICATION OF THE LUMBAR PUNCTURE SITE IN EMERGENCY DEPARTEMENT.
VALUE OF ULTRASOUND IDENTIFICATION OF THE LUMBAR PUNCTURE SITE IN EMERGENCY DEPARTEMENT.
Introduction: The anatomical landmarks used to determine the correct intervertebral space for lumbar puncture (LP) are misleading in 30% of cases.
Lumbar puncture may be complicated by post-lumbar puncture syndrome or traumatic damage to the terminal cone of the spinal cord.
Ultrasound has become an important tool in anaesthesia and emergency medicine, particularly for locating the correct intervertebral space to be catheterised; it is easy to learn and use. We compared the location of the chosen lumbar puncture site by conventional anatomical location and by ultrasound location.
Methods: Single-centre prospective observational study in medical and surgical emergency department. The primary endpoint was the mean distance in millimetres between the puncture site chosen after anatomical location and after ultrasound location.
Patients admitted between 02/02/2023 and 04/03/2023 with a potential indication for LP were included. The observed distance was expressed as the mean with a 95% confidence interval after verification of the normality of the distribution.
Results: Ultrasound location differed from conventional anatomical location, with a mean distance of 32 mm (95% CI 27 - 37). The mean vertical distance was 29 mm (95% CI 24 - 34). The mean horizontal distance was 8 mm (95% CI 6 - 10). There was a 59% rate of intervertebral space change.
Conclusion: Ultrasound identification of the lumbar puncture site differs from anatomical location. The average distance separating the two methods is equal to one intervertebral space. There is mainly a vertical variation in the puncture point depending on the marking method used. These results could explain at least in part the low failure rate of lumbar puncture when performed after echolocation.
Hamza TOBI (RABAT, Morocco), Aziz BERTUL, Naoufel CHOUAIB, Ahmed BELKOUCH, Saad ZIDOUH, Lahcen BELYAMANI
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#41091 - Vocal Cords Position as a Predictor of Intubation Difficulty in Video Laryngoscopy: A Retrospective Study of Laryngoscopy Videos.
Vocal Cords Position as a Predictor of Intubation Difficulty in Video Laryngoscopy: A Retrospective Study of Laryngoscopy Videos.
Background: The application of the video laryngoscope has markedly reduced the difficulty of intubation compared to direct laryngoscopy. However, a real-time, quick assessment method to judge the difficulties during intubation with video laryngoscopy remains lacking. Direct visualization of the vertical position of the vocal cord displayed on the screen following blade tip engagement may serve as an indicator for intubation difficulty. This study aimed to investigate the correlation between the position of the vocal cords, as visualized during video laryngoscopy-guided intubation, and the success rate and timing of first-attempt intubation.
Methods: We retrospectively reviewed laryngoscopy recordings from adult intubations performed by emergency physicians using the C-MAC video laryngoscope (Karl Storz). The vertical position of the vocal cords, indicated by the arytenoid cartilage’s location on the monitor following the blade insertion and engagement, was categorized into upper and lower locations for analysis. The primary outcome was the success of first-attempt intubation within 90 seconds. Kaplan-Meier survival curves and multivariable Cox proportional hazard analysis were employed to assess the impact of arytenoid location on the success rate of first-attempt intubation within 90 seconds.
Results: Analysis of 209 laryngoscopy records revealed that 113 showed the arytenoid located in the lower field of view, while 96 were in the upper field. Kaplan-Meier survival analysis indicated a significantly lower cumulative success rate for intubations with upper arytenoid location (log-rank test, P < 0.001). After adjusting for factors such as modified Cormack-Lehane grade, blade tip engagement location and other intubation findings, multivariable Cox models confirmed the arytenoid's location as a significant predictor of successful intubation within 90 seconds, with an adjusted hazard ratio of 0.56 (95% confidence interval, 0.39–0.81) for the upper location group compared to the lower (P = 0.002).
Discussion & Conclusions: The position of the vocal cords, as determined by the arytenoid cartilage’s location during video laryngoscopy-guided intubation, significantly predicts the success rate and timing of the first intubation attempt. An elevated arytenoid location is associated with decreased success rates. Evaluating the arytenoid location after blade engagement provides a simple and quick method to anticipate intubation challenges.
Trial registration: This study is not a clinical trial.
Funding: This research didn’t receive any funding.
Ethical approval and informed consent: The Institutional Review Board of the Ditmanson Medical Foundation Chia-Yi Christian Hospital (IRB 2023028) has approved this study to be exempted from informed consent due to the retrospective nature of the study.
Ming-Jen TSAI (Chiayi city, Taiwan), Yung-Cheng SU, Kai-Yuan CHENG
00:00 - 00:00
#42114 - What could motivate patients to return unused opioids to the pharmacy after an emergency department acute pain visit?
What could motivate patients to return unused opioids to the pharmacy after an emergency department acute pain visit?
Objectives
The main objective of this study was to determine what could motivate patients to return unused opioids to the pharmacy. Secondary objectives were to assess the quantity of unused opioids, their storage and disposal methods at two weeks and three months post-receipt of an opioid prescription following an ED visit for acute pain.
Materials and Methods
In this planned sub-study of a prospective multicentre cohort study, we included consecutive patients aged ≥18 years with an acute pain condition discharged from the ED with an opioid prescription. Two weeks and three months after their ED visit, participants were asked about their unused opioids, as well as their storage and disposal. At three months, we inquired about the factors that could motivate participants to return unused opioids to the pharmacy. Descriptive statistics were employed to report the percentage of participants with unused opioids as well as the methods of storage and disposal during each follow-up period.
Results
A total of 2,047 and 1,837 participants were included at two weeks and three months respectively, with a mean age of 51 (±16) years and 48% were female. At two weeks, 84% (95%CI: 82%-86%) of the participants had unused opioids and 68% stored them in an unlocked area or within reach of children or teenagers. At three months, 62% (95% CI: 59%-64%) of participants still had unused opioids at home. The majority (58%) kept them in case of possible future pain, while 29% cited forgetting or not having time to return them to the pharmacy. Regarding motivations to return unused opioids to the pharmacy; 20% would do it for a cash refund, 17% if they can retrieve them later, and 39% of the participants would keep them regardless of incentives.
Discussion
In summary, a high percentage of participants had unused opioid medication at home at two weeks and three months. Inappropriate opioid storage and the propensity to keep their opioids even three months after an acute pain ED visit may contribute to opioid misuse. Since a significant portion of patients will not return unused opioids regardless of incentive, it's essential to tailor the quantity of opioid pills in prescriptions to the specific painful conditions to minimize unused.
NCT03953534, ClinicalTrials.Gov PRS
CIHR: 159808
Raoul DAOUST (Montréal, Canada), Jean PAQUET, Marcel EMOND, Iseppon MASSIMILIANO, Williamson DAVID, Justin YAN, Jeffrey PERRY, Verilibe HUARD, Gilles LAVIGNE, Jacques LEE, Justine LESSARD, Eddy LANG, Alexis COURNOYER, Research Group OPUM
00:00 - 00:00
#42277 - What data is gathered in Mass Casualty Incidents?
What data is gathered in Mass Casualty Incidents?
Background
Mass casualty incidents (MCIs) are overwhelming events which generate a surge in casualties, exceeding local capacity and stressing emergency services. Significant mortality, morbidity and economic impact is often caused. They can attract responses from both local and international governmental and non-governmental medical responders. To improve professional standards and accountability, there has been much recent focus on record keeping by teams in these contexts. We therefore sought to understand what data is gathered during MCIs, in order to outline current practice and help move towards improved minimum standards of care.
Methods
We first conducted a structured database search and abstract screening process utilising PRISMA guidelines for scoping reviews. Data was then collected from all papers included in this study. To ensure we had gathered all relevant data, we then contacted the authors of each included study to clarify their approach to data collection for their work.
Results
From 175 included manuscripts 64 data points per paper were recorded, capturing MCIs over a period of 32 years located in 48 countries from Africa, Asia, Europe, North America, Oceania, South America and the Arctic. 400,625 casualties are recorded, including 21,209 deaths. There was a roughly even split between retrospective and contemporaneous data collection. In hospital or research team data collection was most common, pre hospital collection was rare. The ten most common data categories collected were number of injuries (89.3%), number of deaths (82.6%), injury type (74.2%), cause of Injury (72.5%), sex (58.4%), severity of injury (58.4%), age (57.9%), treatment (55.1%), outcome of injury (51.1%), investigations/treatments given (49.4%). 29 of contactable authors responded. 16 reported either reviewing notes retrospectively or using follow up patient interviews. Eight utilised bespoke contemporaneous data collection forms.
Discussion & Conclusions
There is significant variety in what data is collected, who collected it and the methodology employed to do so. It is notable that the most common data categories are descriptive pieces of information or relate to demographics. Only half of papers discussed treatments given, and both pre-hospital care and longer term rehabilitation were much less prevalent.
MCIs relating to terrorism and shooting were the largest by paper number. Mass gathering and shooting MCIs had the highest reported percentage mortality. Predominantly made up of more recent MCIs in higher income countries, these findings potentially reflect more organised healthcare systems with better methods of data collection.
Contacted authors highlighted the challenging nature of record keeping in MCIs. One commented that casualty influx rendered IT systems inoperable. Another, that continuity of record keeping was challenging as prehospital and in hospital patient ID systems for MCIs differed. This may explain the heavy reliance on retrospective data collection.
Overall, data collection in MCIs is challenging and heavily reliant on retrospective analysis. Data is often descriptive or demographic in nature. Current practice lacks standardisation. If professionalism and accountability for healthcare delivery in MCIs is to be improved, so must methods of data collection and minimum standards of practice.
Funding
None needed
Ethical approval and informed consent
Not needed
Michael PALLOT (Swansea, ), Alvi SARAH, Hanley JADE, Jafar ANISA
00:00 - 00:00
#42410 - “Outcomes in Fluid Resuscitation Alone Versus Fluids with Insulin During Transport of Pediatric DKA Patients: A Retrospective Chart Review”.
“Outcomes in Fluid Resuscitation Alone Versus Fluids with Insulin During Transport of Pediatric DKA Patients: A Retrospective Chart Review”.
Background: DKA is a life-threatening complication of diabetes mellitus and can be classified as mild, moderate, or severe. Although inpatient management has evolved, protocols for transporting these patients to a tertiary care center (TCC) vary widely, especially from an outside hospital (OSH). This increases unnecessary healthcare spending, such as using air instead of ground transport. Additionally, there are increased risks for adverse events. For example, paramedics cannot administer or titrate insulin, heightening the risk for hypoglycemia. This can cause a longer length of stay (LOS), expose patients to more complications, and require a higher level of care than what would have otherwise been needed. Currently, International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines dictate that insulin should be given at least one hour after initiation of fluid resuscitation. Therefore, we have two hypotheses: first, pediatric patients in DKA transported from an OSH to Le Bonheur Children’s Hospital (LBCH) with fluid resuscitation alone will have similar outcomes in LOS and rates of ICU admissions and cerebral edema (CE) as those transported with fluids and insulin. Second, no difference exists between those transported via air or ground, regardless of DKA severity and treatment group.
Methods: We conducted a retrospective chart review of pediatric patients transported via air or ground from an OSH to LBCH with mild, moderate, and severe DKA from January 1st, 2011, to January 1st, 2021. We then used Pearson's chi-square, Fisher's exact test, and Kruskal-Wallis rank sum tests to assess if there was a significant difference for each variable across each group. We excluded the missing values from the comparison between the groups. The statistical significance was determined with two-sided p<0.05. Our primary endpoint was the length of stay at LBCH. Our secondary endpoints were rates of CE, transport method, and admission to either the PICU or the floor.
Results: 238 pediatric patients 0-18 years of age were included in this study. Patients given fluids alone during transport had no statistically significant differences in length of stay compared to those transported with fluids and insulin. This was found when controlling for males in mild (p=0.89), moderate (p=0.56), or severe (p=0.54) DKA and females in mild (p=0.08), moderate (p=0.45), or severe (p=0.07) DKA. No statistically significant differences were found with rates of ICU admissions or CE. This finding was similar when looking at transport methods.
Conclusion: Regardless of DKA severity, transportation with fluid resuscitation alone has similar outcomes in length of stay and rates of CE and ICU admissions as those transported with insulin and fluids. Additionally, helicopter transport has no clinical improvement in patient outcomes compared to ground transport. The combination of using only fluids with ground transport reduces the costs to patients, families, and the healthcare system.
Rudy KINK (, USA)
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#41551 - “Pump, pleura, pouring blood”: Evaluation of a novel point-of-care ultrasound protocol for major trauma patients in a helicopter emergency medical service.
“Pump, pleura, pouring blood”: Evaluation of a novel point-of-care ultrasound protocol for major trauma patients in a helicopter emergency medical service.
Background:
Critically injured patients can present with shock due to various mechanisms. Physical examination has limited accuracy in diagnosing the type of shock and underlying aetiology. Point-of-care ultrasound (PoCUS) allows detailed examination and various PoCUS shock protocol can identify the underlying pathology. However, the shock protocols used in hospital are detailed and can lead to delay in care. Hence, we have developed a bespoke prehospital PoCUS shock protocol.
Methods:
A retrospective review of consecutive patients on whom the full 'Pump,pleura and pouring blood' (PPPB) protocol was performed from Sep 2021 to March 2023 was conducted. Patients with missing documents were excluded. Prehospital data was collected from the London air ambulance (LAA) database and REDCap while in-hospital data were collected from all the four Major Trauma Centres in London. A complete case analysis was utilised for this study. The primary analysis was the diagnostic accuracy of the PPPB protocol compared to definitive in-hospital findings. Secondary analysis evaluated the inter-rater reliability between clinicians and expert reviewers. Variables collected included: timings of the prehospital incident, age, sex, mechanism of injury, suspected injuries, PoCUS windows obtained, prehospital PoCUS findings, ‘code red’ (defined as any trauma patient with a systolic blood pressure <90 mmHg with suspected or confirmed haemorrhage and no response to fluids) declared at any time, in-hospital findings, patient outcome. Data abstractors used the following sources to establish the patients’ definitive injury burden: clinical examination, consultant radiologist reports (CT and chest radiography), in-hospital ultrasound reports (both PoCUS and formal sonography) and intra-operative findings. A pre-defined significance values of p<0.05 was used. Data were described using number (percentage) for categorical variables and mean ( standard deviation (SD)) or median [interquartile range (IQR)] for continuous variables as appropriate. Shapiro-Wilk normality tests were applied to confirm normality. Sensitivity, specificity and positive and negative likelihood ratios were calculated using standard formulae. The 95% confidence interval (CI) is reported where appropriate. Inter-rater reliability was assessed using the Cohen’s kappa (Κ) statistic.
Results:
52 cases were reviewed and 46 were included. The median age was 28 years and majority (83%) were male. Majority had penetrating injuries (55%) to the thorax (65%). The average scene time was 22.4 minutes and PoCUS was mostly performed by physicians (74%). The sensitivity and specificity for diagnosis of pericardial effusion was (100% & 98%), pneumothorax (56% & 96%) and free-fluid (26% & 91%). The overall sensitivity and specificity of the protocol for diagnosis of life-threatening injuries was 56% and 90% respectively which increased to 75% in patients with massive haemorrhage. Only a small percentage of major injuries requiring intervention were missed using this protocol in prehospital.
Discussion and Conclusion:
Various in-hospital shock scanning protocols have been used in prehospital. eFAST has been used and has been shown to have similar accuracy for diagnosing pneumothorax and free-fluid. PPPB protocol is feasible in prehospital with no impact on scene times for patients and shows that is fairly sensitive in diagnosing life-threatening pathologies and cause of shock in hyper-acute trauma patients.
Salman NAEEM (Maidstone, ), Shadman AZIZ, Jamin MULVEY, Johannes STROBEL, Alexander SMITH, Ka Jun CHENG, Jankee PATEL, Michael CHRISTIAN, Matthew MAK, Daniel NEVIN
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#42133 - "e;I'm itchy and my ECG shows ST elevation"e;: Kounis Syndrome?
"e;I'm itchy and my ECG shows ST elevation"e;: Kounis Syndrome?
Kounis syndrome (KS) is an acute coronary syndrome resulting from a hypersensitivity reaction, a medical emergency that is frequently under-diagnosed or mistaken for “conventional” myocardial ischemia resulting from coronary artery disease. Recognition of both anaphylactic and cardiac pathophysiology is important in the Emergency Department (ED) setting so as to initiate potentially life-saving treatment.
We present a likely case of KS in an elderly gentleman with no apparent allergen exposure, whose investigations subsequently revealed triple vessel disease.
A 65-year-old male chronic smoker with no significant medical history presented to the ED following a pre-syncopal episode after returning home from his usual breakfast joint. His wife had found him slumped on the ground in their bedroom, conscious but weak. He reported generalised pruritus but denied chest pain, breathlessness and abdominal pain. There was no known exposure to any new food, drugs or insect bites. On examination, he was profoundly hypotensive with a BP of 58/35 and HR of 97. He was afebrile but his peripheries were warm and he appeared flushed. There was no urticarial rash, angioedema or respiratory rhonchi. An electrocardiogram (ECG) showed sinus rhythm with global ST-segment elevations.
He was treated for anaphylactic shock with IV diphenhydramine 25mg, IV hydrocortisone 100mg and 1 litre of crystalloids. He was administered boluses of IV epinephrine in aliquots of 20-50mcg (total 200mcg) and was subsequently put on an IV epinephrine infusion. His BP and ECG changes improved in tandem, and he stabilised sufficiently to be admitted to the High Dependency ward.
The first serum Troponin-T sent 1 hour after symptom onset was 251 ng/L, with subsequent trend 251 > 197 > 195 > 225 ng/L showing a rise and fall indicative of an acute myocardial injury. The patient’s other laboratory results were unremarkable, with no renal impairment, anemia or elevated infective markers. A transthoracic echocardiogram (TTE) showed a dilated left ventricle with an estimated ejection fraction (EF) of 35-40% and regional wall motion abnormalities. A cardiac angiogram revealed underlying triple vessel coronary artery disease. A serum tryptase done approximately 9 hours post-event was elevated at 14 mg/L (reference level <11.4mg/L) but this is not specific for anaphylaxis.
The patient was weaned off epinephrine after 27 hours and discharged after 7 days, with outpatient referrals to an Allergist and Cardiothoracic Surgery for consideration of cardiac bypass graft surgery.
This case presented a diagnostic difficulty. Cardiogenic shock secondary to an acute myocardial infarction was an obvious differential given the patient’s age, cardiovascular risk factors and ECG changes. However, the lack of classical anginal symptoms and presence of peripheral vasodilation stood out. It is important not to miss the diagnosis of anaphylactic shock as the emergent management of these two conditions differ. The use of antiplatelet medications and morphine can lead to greater histamine release. Conversely, adrenaline, the mainstay of anaphylaxis treatment, can worsen coronary vasospasm and ischemia if used liberally. Our patient’s progress makes a diagnosis of KS type II (anaphylaxis occurring in pre-existing atheromatous disease, causing vasospasm or infarction) likely.
Julia JAFFAR (Singapore, Singapore), Ting Wen YEOW
00:00 - 00:00
#42029 - "e;Nothing fine, I'm torn"e;: a case of axillary artery tear secondary to anterior shoulder dislocation.
"e;Nothing fine, I'm torn"e;: a case of axillary artery tear secondary to anterior shoulder dislocation.
Here we are presenting the case of a 62 years old man, presenting to ED following traumatic anterior dislocation of right shoulder. Patient was pre-alerted by ambulance service due to discoloration of the limb. On examination upon arrival, patient was showing dusky coloured skin, prolonged capillary refill time (CRT) of 4 seconds, despite palpable radial pulse. Neurologically, patient showed reduced sensation on axillary and radial nerve territory, with associated wrist drop. Hence, orthopaedic team was involved, and manipulation was performed rapidly.
Despite successful procedure, no neuro-vascular improvement was achieved, and it was found that radial pulse was disappearing on arm elevation.
CT angiogram (CTA) of upper limb was then performed to investigate for vascular injury; CTA demonstrated right proximal axillary artery tear with significant haematoma.
Patient underwent vascular surgery with stenting to repair the tear; in the immediate post-operatory phase, patient suffered with STEMI and was transferred to cardio-thoracic centre for Percutaneous angioplasty and coronary stenting.
At moment patient is recovering well, all neuro-vascular functions of right shoulder are restored, with mild weakness in abduction.
DISCUSSION
Axillary artery injury (AAI) represents 15-20% of the arterial injuries of upper limb, predominantly subsequent to penetrating injury (94%). Blunt injuries gives account of 6% AAJ, with less than 1% occurring with glenohumeral joint dislocation without associated fracture. Brachial plexus associated injury occurs in 60% of cases and is the most important factor of long-term disability.
Isolated brachial plexus injury in context of shoulder dislocation is relatively rare – around 6% - but when AAI is present, this incidence raises up to 50%. Vast majority of AAIs associated with shoulder dislocation happens above age of 50.
Clinical presentation might vary, with the described pathognomonic triad of proximal shoulder dislocation, expanding haematoma and reduction of volume of radial pulses. Our patient had two elements of the triad, whereas the radial pulses were preserved. This can happen due to efficient collateral circulation, but also – as in our case – due to intimal tears with intra-arterial hematoma formation and thrombosis.
Gold standard for diagnosis is CT angiography, but doppler ultrasound is a useful tool, with very high sensitivity and specificity.
CONCLUSION
In presence of shoulder blunt trauma with dislocation - regardless of associated fracture – thorough neurovascular assessment needs to be performed, especially in patient above 50 years of age. Assessment needs to be repeated after closed reduction, as sometimes signs can develop on a later stage. However, if AAI is suspected, with or without brachial plexus involvement, closed manipulation should be avoided, and operative procedure should be performed instead.
In spite of an intact radial pulse, axillary artery injury needs to be suspected in case of expanding haematoma in the area, fluctuating haemoglobin, fluctuating blood pressure.
Early imaging and surgical exploration with involvement of vascular surgeons is recommended, as prompt intervention increases chances of full recovery.
CONFLIC OF INTEREST
None of the authors has any conflict of interest in regards of this case
Rupa CHATTERJEE (United Kingdom, ), Daniel STANCIU, Mattia KOLLETZEK
00:00 - 00:00
#41416 - "e;SODIUM FLUOROACETATE POISONING CASE REPORT"e;.
"e;SODIUM FLUOROACETATE POISONING CASE REPORT"e;.
SODIUM FLUOROACETATE POISONING CASE REPORT
Introduction
Sodium fluoroacetate is an odorless, tasteless, water-soluble compound used as a rodenticide; the lethal dose 50 in humans is 2 to 4 mg/kg; 1 Its toxicodynamics consist of irreversible inhibition of the citric acid cycle (Krebs cycle) interacting with Acteil-CoA forming the fluoroacetyl-CoA complex, which binds to citrate synthase producing monofluorocitrate which binds to aconitase resulting in depletion of substrates and finally cell death. Most of these types of poisonings are due to intentional exposures for self-harming purposes. 2
Clinical Case Report
A 53-year-old woman, who ingested 1 vial of rodenticide 1080 (sodium fluoroacetate) in an unspecified amount, presented syncope in public so she was taken to the first contact clinic where gastric decontamination was performed, later she presented tonic-clonic seizure and neurological deterioration, for which airway protection was performed and she was transferred to our unit. On admission with vital signs; blood pressure 64/40 mmHg, mean arterial pressure 53 mmHg, heart rate 40 bpm, respiratory rate 17 rpm, SpO2 92%, temperature 36ºC, sedation was optimized and ventilatory parameters were adjusted, management with norepinephrine was started at a dose of 0.2 mcg/kg/min, treatment with vodka (40% ethanol) was started orally calculated at 800 mg/kg in a single dose and then 80 mg/kg/hour for approximately 10 hours.
Laboratories were requested with results: hemoglobin 13.2, hematocrit, 38.2%, platelets 163 000, leukocytes 10 300, neutrophils 56%, glucose 435, urea 32.1, BUN 15, creatinine 1.43, protein phosphokinase 330, total bilirubin 0.50, AST 178.8 IU, alkaline phosphatase 100, venous blood gases pH 7.37, pCO2 28, pO2 46, HCO3 16.4, BE- 9.0 SO2c 82.
The patient was admitted to intensive care, a second vasopressor was added at supra-optimal doses without achieving perfusorial mean arterial pressure, asystole was presented and advanced cardiovascular resuscitation was initiated for 5 cycles and he died 12 hours after admission.
Discussion:
Sodium fluoroacetate poisoning describes a wide variety of signs and symptoms, these appear from 30 minutes to 20 hours after ingestion, the most common symptoms are nausea, emesis, abdominal pain, muscle weakness and can progress to agitation, seizures, arrhythmias and death of the patient, as was the case in our case.1 There are few studies in reference to this intoxication, mostly series and case reports, where the proposed antidote is ethanol since it increases acetate levels acting as an alternative substrate for the Krebs cycle reactivating cellular respiration, the recommended doses are 800 mg/kg loading dose and 80 to 150 mg/kg/hour of oral maintenance to achieve serum concentrations of 100 to 150 mg/dL within 12 to 24 hours.1,2,3 However, despite treatment, mortality can reach up to 90% of cases, as happened with our patient.2
Conclusion:
Sodium fluoroacetate poisoning is relatively uncommon in the emergency department, however, poisoning is lethal, which is why we must know that ethanol, electrolyte correction, as well as control of arrhythmias and seizures are the basis of treatment. Finally, we should consider conducting further case series or review studies to support this treatment.
Alejandra BLAS HERNANDEZ (Veracruz, Mexico), Del Angel Gonzalez NATANAEL, Manuel Josimar ORTEGA DOMINGUEZ
00:00 - 00:00
#41414 - "e;STEVEN JOHNSON IN THE EMERGENCY DEPARTMENT: A CLINICAL AND THERAPEUTIC CHALLENGE"e;.
"e;STEVEN JOHNSON IN THE EMERGENCY DEPARTMENT: A CLINICAL AND THERAPEUTIC CHALLENGE"e;.
STEVEN JOHNSON IN THE EMERGENCY DEPARTMENT: A CLINICAL AND THERAPEUTIC CHALLENGE
Introduction:
Stevens-Johnson syndrome (SJS) is a reactive dermatosis consisting of erythema multiforme with the presence of vesicles and/or blisters in mucous membranes (especially oral). Its most severe presentation is toxic epidermal necrolysis (TEN). The most common cause is hypersensitivity to multiple drugs, followed by infections, connective tissue diseases, and neoplasms.
Both are intense and extensive reactions that are characterized by necrosis of the dermal and mucous tissues, based on the same pathophysiological principle based on a type IV hypersensitivity to keratinocytes whose difference lies in the affected body surface. When it is less than 10% of the body surface area, it is known as SSJ;while an affectation of 30% or more is called NET; if this affectation is between 10 and 30%, we call it SSJ/NET overlap SSJ/NET.
We present the case of an 85-year-old male with a history of chronic kidney disease, who began with fever of 39°C, malaise and diarrheal bowel movements, self-medicating with Trimethoprine-Sulfamethoxazole 160/800mg in a single dose, on the same day he started treatment with Ciprofloxacin 1g a day for 3 days. He went to the Emergency Department due to progressive worsening of his general condition with a fever of 40°C and the appearance of disseminated skin lesions on the trunk, back, face and upper limbs. On arrival, hemodynamically stable with blood pressure 133/88, temperature 37.5°C, oxygen saturation 98% and heart rate of 70 bpm. A complete physical examination was performed, presenting multiple erythematous skin lesions on the trunk, back, face and upper limbs, presence of Nikosly's sign on the extremities. Cardiopulmonary auscultation and abdominal examination were normal.
Complementary studies were carried out reporting: leukocytes: 10.66 (neutrophils 76%); hemoglobin 11.6; platelets 148,000; normal clotting; glucose 120; urea 116; creatinine 4.67; GOT 89; GPT 56. The chest x-ray showed no significant abnormalities. Assessment was carried out using the Parkland scheme with a total score of 60%, so it was classified as toxic epidermal necrolysis SCORTEN 4 points and transferred to the Intensive Care Unit (ICU). Initiating management with administration of fluids, glucocorticoids and cyclosporine;resulting in lesion limitation and lowering criteria for acute treatment.
Conclusion:
The SSJ/NET is an urgency that requires immediate attention due to the systemic commitment it represents. Although they originate from the same pathophysiological principle, the extent of the affected body surface area is the main point that we must consider for the classification of these events. The SCORTEN scale stratifies severity and prognosis, especially in toxic epidermal necrolysis, and if the involvement of the body surface is very significant, it would be indicated to admit the patient to an intensive care unit, since renal function and hydroelectrolyte balance must be closely monitored to avoid multi-organ failure.
Alejandra BLAS HERNANDEZ (Veracruz, Mexico), Enrique Alejandro COLORADO PEÑA, Karent Isela MENDEZ VERDEJO
00:00 - 00:00
#41725 - "e;Time is Tissue"e; not only in the heart and brain. Interdisciplinary care of acutely inflamed diabetic foot in the emergency department.
"e;Time is Tissue"e; not only in the heart and brain. Interdisciplinary care of acutely inflamed diabetic foot in the emergency department.
Introduction: Diabetic foot syndrome represents a significant and potentially life-threatening complication of diabetes, characterized by an acutely inflamed foot with rapidly progressing skin and tissue necrosis, accompanied by pronounced systemic symptoms. This acute manifestation is commonly termed a "diabetic foot attack," reflecting the urgency and severity of the condition.
Objectives: The primary aim of this study is to emphasize the critical importance of promptly recognizing diabetic foot attacks, which signify severe infection, and initiating immediate surgical and medical interventions, including broad-spectrum antibiotic therapy. The ultimate goal is to ensure limb salvage and enhance patient survival rates.
Materials: We conducted a thorough retrospective analysis of clinical data obtained from 17 consecutive patients who presented to our emergency department in 2022 with an acutely inflamed diabetic foot. The data encompassed demographic information, medical history, laboratory findings, and treatment outcomes.
Results: Among the 17 patients included in the analysis, 80% were male and 20% were female, with an average age of 77 years. Peripheral arterial disease (PAD) was prevalent in 76% of patients, and 44% had a history of chronic coronary artery disease. Upon admission, 19% exhibited a glomerular filtration rate below 30, indicating impaired renal function, while 4% were dependent on dialysis. Poorly controlled diabetes was observed in 91% of cases, as evidenced by elevated glycated hemoglobin levels, with 23% exceeding 8. In terms of infections, 49% of patients had elevated C-reactive protein levels between 10-20 mg/dl, while 11% had levels above 20 mg/dl. Subsequent hospitalization revealed that 88% of patients underwent partial or major foot amputation, with 3 fatalities recorded, yielding a mortality rate of 17%.
Summary: Our study underscores the multifaceted nature of diabetic foot care, highlighting the imperative of comprehensive and timely intervention beyond localized foot treatment. The observed high mortality rate underscores the presence of pre-existing multi-organ pathology in these patients upon admission, necessitating urgent and coordinated medical management. We embrace the fundamental principle of "Time is Tissue," drawing parallels between diabetic foot attacks and other time-sensitive medical emergencies such as acute myocardial infarction and stroke. Effective collaboration among interdisciplinary emergency physicians, surgeons, and intensivists is paramount in optimizing patient outcomes, with critical therapeutic decisions often initiated in the emergency department. Ultimately, the success of surgical interventions hinges not only on the technical aspects of the procedure but also on the perioperative correction and stabilization of systemic organ dysfunction.
Dumitrita TIGLA (Burghausen, Germany)
00:00 - 00:00
#41761 - A 10-Year Retrospective Analysis of Fatal Poisonings Presenting to the Emergency Department.
A 10-Year Retrospective Analysis of Fatal Poisonings Presenting to the Emergency Department.
Introduction and Aim:
Poisoning cases are an important social problem that can often cause mortality and morbidity. Although survival and healing in poisoning cases can be achieved with antidote application and symptomatic treatment, it is still important since it can lead to health problems that can lead to the death of young healthy individuals. Emergency services are clinics where treatment of poisoning patients is diagnosed and patients can result in healing or morbidity and mortality. In this study, our aim is to retrospectively examine the mortality of poisoning patients and to provide the literature with the data of diagnosis, treatment and results.
Material and Methods:
This study was performed as a retrospectivly in the Department of Emergency Medicine at Balcalı Hospital with the approval of Çukurova University Faculty of Medicine Ethics Committee. 59 patients who admitted to the Adult Emergency Medicine Service between 2009 - 2019 years, who are over 18 years of age, who exposed to toxic substances or drugs through oral, intravenous, inhalation or skin absorption, by accident, forced or suicidal purposes and were resulted in morbidity or mortality, were included in the study. The data of the cases included in the study were retrospectively researched through the hospital information management system and patient files and were recorded in the previously prepared study sheet. Research data was uploaded and analyzed on computer via “IBM SPSS 22 for Windows (SPSS Inc, Chicago, IL)”.
Results: A total of 59 patients were included in the study. The average age of all patients was 45.12 ± 15.83 years and 72.9% (n = 43) of the patients were male. 45.8% of the patients included in the study were in the form of poisoning for suicide. 86.4% of the cases had oral exposure to toxic substance or drug. 49.2% of the patients included in the study applied to the hospital in the first 6 hours after poisoning. In mortal poisonings, the mean age was found lower statistically significantly in patients who had purpose of suicide than patients who was poisoned accidentally (p = 0.006). In mortal poisonings, suicide attempts were also found in the background of patients who received medication or substance for suicide purposes compared to the group of patients who were poisoned by accident as a statistically significantly (p = 0.040).
Discussion and Conclussions:
In our study, it was found that poisoning for suicide was more common in young people and accident poisoning was more common in the elderly. It was observed that patients who took toxic substances or drugs for suicide had similar attempts in their CVs. Due to the fact that patients who took substances or drugs for suicide attempts were taking stronger and more toxic drugs, arrival vital signs could be unstable. For whatever reason, the majority of poisoning patients were found to be admitted to the hospital within the first 6 hours. Clearer data on mortality and factors affecting mortality can be obtained through more comprehensive and multicenter studies.
Keywords: Emergency room, poisoning, mortal poisoning, retrospective, mortality, morbidity
Ahmet SEBE (adana, Turkey), Ayca AKPINAR ACIKALIN, Dr Nezihat Rana DISEL, Ozge BAKISKAN
00:00 - 00:00
#41673 - A 74-year-old male of Leriche Syndrome mimicking acute stroke: A case report.
A 74-year-old male of Leriche Syndrome mimicking acute stroke: A case report.
A 74-year-old man presented to the ED complaining of new-onset ambulation difficulty with left extremity weakness for approximately 6 hours. At presentation, he had no headache, diplopia, slurred speech, or chest, abdominal, limb pain. Medical history revealed an old infarction at the right putamen, coronary artery disease with triple-vessel disease post percutaneous coronary intervention and coronary artery bypass grafting, sick sinus arrhythmia post pacemaker implantation, hypertension, and congestive heart failure. He had a history of smoking and social alcohol drinking. On arrival, blood pressure, heart rate, respiratory rate, oxygen saturation, and body temperature were 107/77 mmHg, 79 beats/min, 20 breaths/min, 99% (room air), and 35.8°C, respectively. Physical examination revealed alert and focused consciousness. There were no traumatic wounds or tenderness over the trunk, neck, or limbs. Neurological examination revealed decreased muscle power in the left lower limb (hip flexion, score 4; knee extension, score 3+). No extraocular motion abnormality, light reflex impairment, hemianopia, diplopia, or tongue deviation was observed. Suspecting the new-onset cerebrovascular accidence, head computed tomography (CT) was performed, revealing hypodense changes over the right basal ganglion. However, re-evaluation before ward admission revealed findings inconsistent with acute ischemic stroke (AIS). First, the patient had left lower limb weakness and left lumbar soreness. In AIS, single-limb weakness is less common 2. Second, the blood pressure was 107/77 mmHg on arrival. Blood pressure may rise in patients with AIS to compensate for decreased cerebral brain perfusion. The left dorsalis pedis pulse was undetectable. The blood pressure values for the right upper, right lower, left upper, and left lower limbs were 102/70, 106/70, 138/90, and 50/32 mmHg, respectively. Aorta CT angiography was performed on suspicion of limb ischemia resulting from vascular occlusive disease or dissection. It showed a segment of total occlusion at the left common and external iliac artery, recanalization at the left femoral artery, and multifocal moderate stenosis at the left proximal femoral artery. Thus, LS was diagnosed. Unfractionated heparin was subcutaneously administered, and the patient was transferred to a hospital where mechanical thrombo-embolectomy could be performed. This case with hypotension initially, which is incompatible with AIS presentation. Moreover, presenting only with single-limb weakness and numbness is also unusual for AIS patients. Therefore, the complaint of left extremity weakness was most likely caused by previous stroke. According to the history, physical and examination findings are inconsistent, re-examination is important to avoid misdiagnosis.
Chih-Chieh WU (Taipei city, Taiwan)
00:00 - 00:00
#41955 - A case of alcoholic ketoacidosis (AKA) and its complication – an approach to diagnosis and management in the Emergency Department.
A case of alcoholic ketoacidosis (AKA) and its complication – an approach to diagnosis and management in the Emergency Department.
Background:
A 55-year-old male, known for heavy alcohol intake, presented to the Emergency Department (ED) with acute on chronic hiccups, nausea, and vomiting persisting for the last 48 hours. These symptoms had worsened recently as the patient attempted to reduce alcohol consumption. He reported consuming at least a bottle of whiskey daily, with poor food intake but increased thirst and urination. He denied any other symptoms.
On arrival, the patient was lucid and alert but appeared anxious and sweaty, with ongoing hiccups and retching. He exhibited coarse tremors in his hands but was not psychotic. Initial vital signs were within normal limits, and systemic examination was unremarkable. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score was 7. Despite ongoing management, the patient experienced a cardiac arrest and was successfully resuscitated after 20 minutes.
This case highlights the atypical presentation of alcoholic ketoacidosis (AKA) and underscores the importance of timely recognition and management to prevent fatal complications such as cardiac arrest. Additionally, it demonstrates a straightforward yet effective clinical approach to diagnosing and managing AKA in the ED.
Results & Discussion:
Upon presentation, the patient underwent venous blood gas analysis, routine blood tests, and an electrocardiogram (ECG). Venous blood gas revealed a mixed alkalosis picture, along with hyponatremia, hypochloremia, hypokalemia, and elevated lactate levels. Routine blood tests, including renal and liver profiles, were largely unremarkable except for an elevated C-reactive protein (CRP) level. Notably, the patient exhibited low serum magnesium levels. The ECG showed incomplete left bundle branch block (LBBB) and prolonged QTc interval. However, the prolonged QTc was not initially noted on ECG interpretation. Urine ketone levels were elevated, but blood ketone levels were not assessed.
The patient received intravenous fluid resuscitation with 0.9% NaCl solution and potassium and magnesium supplementation to correct electrolyte imbalances. He was also administered intravenous ondansetron for nausea and vomiting, along with thiamine and chlordiazepoxide for alcohol withdrawal management. Despite these interventions, the patient experienced a cardiac arrest four hours after presentation, with successful return of spontaneous circulation (ROSC) achieved after 20 minutes of resuscitation.
Upon reflection, the cause of cardiac arrest was attributed to unrecognized and untreated AKA, compounded by the administration of ondansetron and electrolyte imbalances. Corrective measures such as appropriate intravenous fluid selection and vigilant monitoring of electrolyte status could have averted this complication.
Conclusion:
This case underscores several key lessons. Suspecting and evaluating for AKA is imperative in alcohol-dependent patients presenting with symptoms suggestive of metabolic disturbances. Prompt assessment with venous blood gas analysis, ECG, and ketone measurement aids in timely diagnosis. Treatment of AKA should prioritize correction of electrolyte imbalances with appropriate intravenous fluids to prevent life-threatening complications like cardiac arrest.
AKA often eludes recognition due to its subtle presentation, with patients appearing alert and clinically well. However, the presence of an increased anion gap serves as a crucial diagnostic clue. Failure to diagnose and treat AKA promptly can lead to catastrophic outcomes, emphasizing the importance of vigilance and a systematic approach in managing alcohol-related metabolic derangements.
N/A
Mahmuda CHADNI, Sergio B SAWH (London, )
00:00 - 00:00
#41425 - A case of atypical presentation for aortic dissection.
A case of atypical presentation for aortic dissection.
A case of atypical presentation for aortic dissection.
Patient has given consent to have details submitted.
A 55-year-old lady with a known history of hypertension and hyperlipidaemia presented to the Emergency Department (ED) with symptoms of left sided numbness and weakness for a duration of 2 days. She also reported left calf pain on exertion that started 2 days ago. There were no complaints of chest, abdomen, back pain or syncope.
On arrival in the ED, she was noted to have a blood pressure of 193/81, pulse rate of 60/min and saturating well on room air. Clinical examination was significant for decreased sensation and mild weakness over the left side of her body sparing the face. The left dorsalis pedis and posterior tibial pulses were slightly weaker compared to the contralateral limb. Capillary refill time was less than 2 seconds.
Non-contrasted computer tomography of her brain noted age indeterminate infarcts at the right corona radiata and left hemipons. Other laboratory tests performed were otherwise unremarkable. The clinical impression at this time was that of stroke with left sided mixed sensorimotor syndrome as well as left lower limb claudication. The patient was admitted to the general ward under the Neurology stroke unit.
During the admission, a transthoracic echocardiogram was performed to work up for a possible cardioembolic cause for her stroke and a dissection flap was incidentally seen in the abdominal aorta. An urgent computed tomography of her aorta was performed and revealed a Stanford A aortic dissection spanning the aortic arch down to the iliac arteries.
Patient was urgently seen by the cardiothoracic surgeons and underwent emergent surgical repair. She was eventually discharged from hospital well.
Learning point
Acute aortic dissection (AAD) classically presents with a sudden severe ‘tearing’ chest or abdominal pain that radiates to the back and may be associated with acute neurological deficits (from cerebral or spinal ischaemia) or limb ischaemia. Despite this, up to 20% of patients with Stamford A AAD do not have any chest pain and around 6% of patients with ADD may in fact be completely pain free. Over the years multiple other presentations have been reported, including syncope, heart failure, gastrointestinal bleeding etc.
In hindsight, the simultaneous development of stroke-like symptoms along with vascular claudication could have pointed to a possible unifying diagnosis of AAD. A bedside ultrasound could be performed in the Emergency setting to detect a dissection flap in the abdominal aorta, which could lead to an earlier diagnosis of AAD.
ADD, especially the Stamford A type, is a condition that carries high mortality rate and yet, diagnosis is often delayed or even missed. Treatment of ADD can be quite different from its atypical presentations e.g. stroke and peripheral vascular disease which requires antiplatelet therapy that some consider contraindicated in AAD. As such, it is essential for emergency physicians to maintain a high index of suspicion especially in patients who present with simultaneous complaints across multiple vascular systems even in the absence of typical symptoms like chest or abdominal pain.
Zhe Wei Leon TAN (Singapore, Singapore)
00:00 - 00:00
#41459 - A case of delayed onset jellyfish-induced vasospasm.
A case of delayed onset jellyfish-induced vasospasm.
Singapore rarely sees cases of jellyfish sting due to the lesser frequency of toxic jellyfish in our waters. As such there is unfamiliarity in the management of such cases. We present one such case managed at our paediatric tertiary hospital in Singapore. We seek to describe a case of jellyfish sting with delayed presentation and to share the experience of successful treatment via the usage of prostaglandin and supportive management. His father gave consent to have details submitted and we ensured anonymity. We describe a previously well 15 year old boy who was stung in chest-high water in Langkawi, during the monsoon period of December 2023. He was informed by a local guide that it was a jellyfish. Immediately after being stung, he noticed a rash over bilateral wrists, hands and fingers. There were no other associated symptoms, and the rash did not progress.
He presented to our hospital 7 days after being stung, with complaints of the left fourth finger turning purple, and numbness in the left hand more than the right. There was a vasculitic rash over both wrists (palmar and dorsal aspect). Left thumb, index and ring finger were cyanosed. There was decreased sensation over the left index, middle, ring and little finger approximately 80% of normal. Left fingers had a prolonged capillary refill time, and left radial pulse not well felt. Pin prick showed delayed capillary blood ooze from left thumb, middle, ring and little finger. Simple analgesia was given. His left hand was placed in a warm water bath whilst in ED. Vascular Surgery, Orthopaedic Surgery and Hematology were consulted. Radiant warmers were used in the ICU. He underwent a diagnostic and therapeutic regional block of the wrist with 10ml 1% lignocaine and 10ml of 0.5% bupivicaine. He was treated with an IV prostaglandin infusion (IV alprostadil 60mcg/dose over 3 hours once daily as per adult dose for Raynaud phenomenon for digital ischemia, then 0.05mcg/kg/min for 24h), IV glyceryltrinitrate infusion (titrated to blood pressure limits) for 24 hours, and IV heparin infusion (IV Heparin bolus 50U/kg, then infusion to target APTT 60-80s) for 24 hours. Blood cultures did not yield any growth after 5 days. He was empirically covered with IV co-amoxiclav and IV ciprofloxacin whilst hospitalised, on discharge completed 1 week total of oral antibiotic therapy. He stayed inpatient for a total of 3 days.
29 days after sting, hypoaesthesia was noted over the left middle finger radial and ulnar distribution 90% of normal, left ring finger ulnar distribution 90% of normal. All digits were pink. Healed scabs were noted in place of the rash. 16 weeks after the sting, light touch sensation was intact, with full range of motion of all digits. Without other complications of the sting (e.g compartment syndrome, bacterial infection) general observation that the use of prostaglandin analogues or intra-arterial infusion of thrombolytics averted the need for surgery in majority of jellyfish envenomation cases. Our case similarly showed good response to IV prostaglandin infusion.
Anand Kumar RAMALINGAM, Julia JAFFAR (Singapore, Singapore), Zi Yang WONG
00:00 - 00:00
#41469 - A case of fever induced fascicular ventricular tachycardia.
A case of fever induced fascicular ventricular tachycardia.
Patient has given consent to have details admitted.
A 30-year-old gentleman who was previously well was brought to the Emergency Department (ED) with a few days of fever, lethargy and symptoms of acute respiratory illness. He denied other localizing symptoms of infection.
Upon arrival in the ED, he was noted to be febrile at 40 degrees Celsius, heart rate 160/min, blood pressure 120/64mmHg and saturating well on room air. Clinical examination revealed a lethargic patient with no appreciable cardiac murmurs, no adventitious lung sounds and no lower limb edema.
Initial electrocardiogram revealed a regular wide complex tachycardia with rate of 147/min in a right bundle branch block (RBBB) pattern with left axis deviation. There were no p waves seen. A fusion beat was present.
His cardiac enzymes were mildly elevated. An initial diagnosis of ventricular tachycardia (VT) secondary to myocarditis was made.
The patient remained to be in VT despite multiple doses of intravenous (IV) amiodarone, magnesium sulfate and diltiazem. Electrical cardioversion also failed to terminate the VT. Notably, patient remained fiercely febrile during this time despite anti-pyretic medications.
This patient was admitted to the intensive care unit (ICU), where further investigations revealed that patient had disseminated Klebsiella pneumoniae bacteremia with liver abscesses and bilateral pneumonia. After receiving culture directed antibiotics, further doses of verapamil and aggressive cooling measures, patient’s VT terminated, coinciding with resolution of fever. Cardiac Magnetic Resonance Imaging was normal. He was eventually discharged after 2 weeks of hospitalization.
Learning points
VT is a life-threatening arrhythmia that must be addressed immediately. When standard advanced cardiac life support (ACLS) treatment for VT fails, one needs to consider the underlying cause of the arrhythmia in order to direct treatment appropriately. We often consider common causes such as myocardial ischemia and electrolyte abnormalities, but we need to be more cognizant of less common causes, including congenital diseases and in this case, fever.
Fever has been reported to be a precipitant of ventricular arrhythmias in patients with Brugada Syndrome, Type 2 Long QT Syndrome and also in healthy individuals. Postulated mechanism include the dysfunction of cardiac sodium channels at higher temperatures, resulting in shortening of action potential in myocytes and shortening of QT interval.
Fever can be treated with pharmacological agents such as non-steroidal anti-inflammatory drugs (NSAID) or acetaminophen. Non-pharmacological methods include use of cooling blankets and tepid water sponging. Evaporative and convective cooling can also be performed by spraying the patient with a mist of water while fans are used to blow over the moist skin. All of the above-mentioned methods carry low risk of adverse effects hence should be carried out as soon as possible once fever is identified as a possible trigger for VT. The cause of fever should also be addressed promptly, such as administration of antibiotics.
Geng Yu LIN (Singapore, Singapore), Wei Ling TAY
00:00 - 00:00
#41962 - A case of internal jugular vein thrombosis.
A case of internal jugular vein thrombosis.
A 66 year old male who is normally fit and well attended the emergency department with a painful swelling to the left side of the neck for two weeks duration. swelling and pain was gradually getting worst.
On examination he was apyrexial, was in mild to moderate pain, pulse rate was 76, blood pressure was 140/80, respiratory rate was 20 and saturations was 96%.
The swelling was moderate in size and was on the left side of the neck and was over the sternomastoid muscle towards the lateral aspect of his neck. It was firm, tender and small palpable nodules.
The differential diagnosis for a similar history will be cervical lymphadenopathy and swelling to the sternomastoid muscle.
The routine bloods were done, Haemoglobin was 126, WBC was 15 and CRP was 6.
CXR showed bi lateral hilar lymphadenopathy.
A contrast CT scan of the neck was done in the ED. It demonstrated left sided cervical lymphadenopathy and the left internal jugular vein thrombosis. He was treated with Enoxaparin and referred to ENT for further investigations.
Internal jugular vein thrombosis is a subtle vascular disease that is rarely seen, with potentially dangerous complications such as sepsis and pulmonary embolism.
Venous thrombosis usually results from impaired blood flow locally or systemically that leads to activation of coagulation. ED physicians should have a high degree of suspicion in patients who present with undiagnosed swelling of the neck.
Dr Janath WIJESINGHE (KETTERING, ), Tataji NANDIPA, Salman KHAN, Salma MOHAMED
00:00 - 00:00
#41740 - a case of ischemic ileitis with hepatic portal venous gas, treated conservatively.
a case of ischemic ileitis with hepatic portal venous gas, treated conservatively.
Hepatic portal venous gas (HPVG) is the abnormal presence of gas in the portal vein, most of which indicates severe intra-abdominal diseases, such as intestinal necrosis. HPVG is a rare condition, but it can be life-threatening, with a mortality rate of 75-90% with intestinal ischemia, and immediate surgical intervention is required. We report the case of an elderly woman with acute abdominal pain who received the diagnosis of HPVG secondary to ischemic ileitis, and was treated conservatively, not surgically.
A 97-year-old Japanese woman with an acute abdomen was brought to our hospital by an ambulance. She was in her usual state of health until the morning. When she defecated hard stools two hours after lunch, she experienced acute-onset abdominal pain in the periumbilical area with nausea, vomiting, and cold sweats. Therefore, the patient was transported to our hospital. She had a medical history of lacunar infarction occurring 13 years previously, which had left her right-sided paralyzed, and right inguinal hernia that had been operated 7 years previously. She did not have a history of antibiotics use.
On arrival, she was alert, and appeared in acute distress. Blood pressure was 154/71 mmHg, pulse rate was 58 beats per minute with irregularly irregular rhythm, respiratory rate was 22 breaths per minute, and body temperature was 35.4°C. Abdominal examination revealed a distended periumbilical area, normal bowel sounds, and moderate tenderness in the periumbilical region without guarding or rebound tenderness. Rectal examination was performed with bright red feces. Laboratory data showed a white blood cell count of 7.7×109 cells/L (neutrophils 80.0%) and a C-reactive protein level of 0.11 mg/dL. Arterial blood gas (ABG) analysis indicated an elevated lactic acid level of 20.0 mg/dL without acidosis. Intestinal ischemia, such as a superior mesenteric artery embolism or ischemic enteritis, was suspected, and contrast-enhanced computed tomography was performed. This revealed thickening of the terminal ileal wall with a decreased contrast effect, and increased pericolic fatty tissue density. The superior mesenteric artery was patent and hepatic portal venous gas was detected. Ischemic ileitis with hepatic portal venous gas was diagnosed and the patient was referred to the general surgery department. As her vital signs were stable and intestinal necrosis was not suspected, the surgeon decided on conservative treatment. The patient received antibiotics and anticoagulation therapy to prevent sepsis and thrombosis, with careful and frequent blood examination, ABG, and CT imaging. The patient’s condition was relieved, and contrast in the ileal wall on the CT scan was confirmed on hospital day six. She was transferred from the hospital to a rehabilitation institution 13 days after admission.
HPVG is a critical condition associated with bowel necrosis, ulcerative colitis, intra-abdominal abscess, small bowel obstruction, gastric ulcer, and bowel ischemia, which require immediate surgical intervention. Meanwhile, it is also reported HPVG can be treated conservatively in cases without intestinal necrosis, ischemia, perforation, peritonitis, or intra-abdominal abscess. It is important for patients with HPVG to accurately assess both the cause and the patient’s condition through close follow-up, using CT imaging and laboratory data.
Tomomi TOYOFUKU (Aizuwakamatsu, Japan), Motoyuki MUNAKATA, Kazuhiro KAMATA
00:00 - 00:00
#41238 - A case of missed acute myocardial infarction (AMI) in preexisting Right Bundle Branch Block (RBBB).
A case of missed acute myocardial infarction (AMI) in preexisting Right Bundle Branch Block (RBBB).
Right Bundle Branch Block (RBBB) can be a rare but benign electrocardiogram (ECG) finding which presents in approximately 0.2–1.3% of the general population without associated disease. Meanwhile, it presents more commonly in some patients with underlying pulmonary or heart disease. In acute settings, the prevalence of RBBB is about 8% in patients with acute myocardial infarction (AMI) and its presence is associated with a statistically significant increase of in hospital mortality. However, RBBB may cause repolarization abnormalities that can mask or mimic ischemic changes. Hence, diagnosis of anterior AMI may be missed, especially RBBB with very wide QRS, sinus tachycardia and short repolarization. This article presents a case of a 75-year-old lady with background history of aortic stenosis who presented to ED with intermittent mild chest discomfort. Unfortunately, the subtle ECG’s ST segment changes (suggestive of anterior AMI) with preexisting RBBB was missed in Emergency Department (ED). The emergent coronary angiography was only activated after the cardiologist review (three hours since ED presentation). The patient suffered from congestive heart failure after the procedure. The main learning point identified in this case is that anterior leads with RSR’ should have discordant ST/T segment changes and even subtle concordant elevation can be an abnormal sign of AMI. Unwary physician may miss the diagnosis and a reperfusion opportunity. Thus, appropriate interpretation of the ECG and recognition of associated cardiovascular risk are vital features in the early ED evaluation of patients with RBBB and ischemic symptoms.
Hong Khai LAU (Singapore, Singapore)
00:00 - 00:00
#41773 - A Case of Non-sustained Polymorphic Ventricular Tachycardia After Modified Valsalva Maneuver to Terminate Supraventricular Tachycardia.
A Case of Non-sustained Polymorphic Ventricular Tachycardia After Modified Valsalva Maneuver to Terminate Supraventricular Tachycardia.
Written consent from the patient for publication has been obtained.
Brief clinical history:
A 23 year old female presented to the Emergency Department (ED) with supraventricular tachycardia (SVT). She had consumed 2 glasses of champagne and was jumping rigorously at a beach party when she felt palpitations with dizziness. Physical examination was unremarkable. Electrocardiogram (ECG) showed regular narrow complex tachycardia at a rate of 219 beats per minute. She was hemodynamically stable .
Modified valsalva maneuver was attempted. While the patient’s legs were raised, SVT converted into non-sustained polymorphic ventricular tachycardia (NSVT) for 6 seconds before converting to sinus rhythm. During the NSVT, she remained conscious and alert. Post conversion ECG did not reveal any pre-excitation rhythm or prolonged QT intervals. There were no further arrhythmias in the ED.
Misleading elements:
She described a similar episode 6 months prior that self resolved, but did not seek medical attention. She had been having 5 days of nasal congestion prior to this episode for which she had consumed medications (name unknown). She denied illicit drug use but was vaping during the party. There was no known personal or family history of cardiac arrhythmias.
Further helpful details
The first serum troponin T was less than 13NG/L and rest of lab investigations including a full blood count, renal panel and serum calcium, magnesium and thyroid function test were within acceptable range. A chest x-ray did not show any abnormality. Serial troponin levels showed an upward trend to 57NG/L and then 51NG/L likely due to the tachycardia. Urine pregnancy test was negative. A point of care ultrasound (POCUS) of the cardiovascular system showed good cardiac contractility with no regional wall motion abnormalities and no pericardial effusion.
The patient was discharged with a followup to the Cardiology Department however there is no record of her attending the followup.
Differentials
The initial impression was that of atrioventricular nodal reentrant tachycardia (AVNRT). Vagal maneuvers have been recommended as the first line treatment of hemodynamically AVNRT and the Modified Valsalva maneuver has been known as a simple and safe method for termination of SVT. As this patient did not attend further followup, underlying cardiac abnormalities cannot be entirely excluded. It is also possible that the substance she was vaping could have induced cardiac arrhythmias.
What is the educational and or clinical relevance of this case?
SVT is a common presentation to the ED, and Modified Valsalva maneuver is frequently employed to terminate SVT but there is a paucity of reported adverse events related to this maneuver. Malignant arrhythmias have been postulated to be due to overstimulation of the vagus nerve or a physiological response to alternating sympathetic and parasympathetic activity. This underscores the importance of monitoring these patients with SVT cautiously, and have resuscitative equipment readily available.
Francesca LIM (Singapore, Singapore), Evelyn WONG
00:00 - 00:00
#41306 - A case of pancreatic tail tumor presenting with left flank pain.
A case of pancreatic tail tumor presenting with left flank pain.
Consent to submission/Anonymity: yes
Brief clinical history:
A 54-year-old man without systemic disease visited our emergency department following three days of progressive left flank dull pain. Initially, the discomfort localized to the left lower abdomen and gradually radiated to the back. He denied recent trauma and there was no fever, nausea or dysuria.
Upon examination, the patient exhibited a non-tender abdomen, but tenderness at the left flank was discovered by percussion. Except for a high glucose level of 299 mg/dL, other basic laboratory data, including lipase levels, were within normal limits. The urinalysis showed no signs of hematuria or urinary tract infection. A bedside ultrasound revealed no aortic abnormalities or hydronephrosis. Otherwise, a radiopaque nodule was noted in the right pelvic cavity on an abdomen plain film.
Due to intractable pain, the patient underwent a contrast-enhanced abdominal computed tomography scan. The scan disclosed a 2.7 cm multicystic mass at the distal end of the pancreas. The radiopaque nodule was a calcified lymph node, which was not relevant to the discomfort. Although the patient was referred to a specialist, he decided to seek medical advice at another hospital.
Misleading elements
1. Flank pain:
Flank pain often indicates renal or musculoskeletal conditions.
2. Abdominal radiography:
A radiopacity might be considered as a ureteral stone or fecalith, misleading to renal or gastrointestinal disorders.
3. Normal lab data:
Normal lipase levels reduce suspicion of pancreatic diseases.
Helpful details
1. Persistent pain:
Intractable pain indicates a more serious condition that requires further imaging.
2. Urinalysis and ultrasound:
Lack of hematuria and hydronephrosis suggest that there may be other causes than renal conditions.
3. Blood glucose levels:
Hyperglycemia can be associated with pancreatic disorders.
4. Computed tomography scan:
Computed tomography scans have a higher sensitivity in detecting abdominal masses compared to ultrasonography or plain radiography.
Differential and actual diagnosis
1. Renal conditions: urolithiasis, pyelonephritis, renal mass
2. Pancreatic conditions: pancreatitis, pancreatic mass
3. Gastrointestinal conditions: diverticulitis, colon mass
4. Abdominal aortic aneurysm
5. Musculoskeletal pain
Actual diagnosis: Pancreatic tail mass
Educational and/or clinical relevance
Flank pain was one of the frequent presenting symptoms in the emergency department. Stones or hydronephrosis on imaging and hematuria typically support the diagnosis of urolithiasis. The absence of these signs does not completely rule out the disease, but it rather suggests possibilities of alternative causes.
Pancreatic cancer, especially when located in the pancreatic tail, often presents with vague manifestation, causing late diagnosis and poor prognosis. Flank pain, although an uncommon symptom, can mislead physicians into considering renal or musculoskeletal disorders. Therefore, the diagnosis of our case is challenging. Nevertheless, the lack of hematuria and hydronephrosis decreased the likelihood of urolithiasis, whereas the new-onset hyperglycemia provided a subtle hint toward pancreatic disorders.
This case highlights that physicians should explore other diseases when typical signs of a more common etiology are not present. A thorough evaluation may improve the accuracy of diagnosis and the patient’s outcome.
Tzu Cheng WANG (Taipei, Taiwan, Taiwan), Chien Chieh HSIEH
00:00 - 00:00
#41260 - A case of severe lactic acidosis.
A case of severe lactic acidosis.
Introduction
Catastrophic conditions such as ischaemic bowel and aortic dissection are often first thought of as causes in patients presenting with severe abdominal pain radiating to the chest and back. Rarely, an underlying metabolic aberrancy occurring from a toxicological cause such as metformin overdose may result in a similar presentation. The managing clinician needs to consider this under the list of differential diagnoses.
Case Report
We present a patient with such symptoms secondary to metformin overdose.
A 54-year-old Indian lady presented to our Emergency department (ED) with severe abdominal pain radiating to the chest and back for the last two hours. She had no significant past medical history except for diabetes mellitus type 2, hypertension, and a uterine fibroid myomectomy 12 years prior. The patient complained of severe pain throughout the consult, making history-taking challenging. She denied ingestion of any medications.
She was tachycardic at 105/mim and tachypnoeic at 26/min. Her blood pressure was 150/80. On physical examination, the patient was writhing around in pain. Her abdomen was soft, non-tender, and not distended. Her lung and heart sounds were normal. Her peripheries were generally cool and clammy. There was no radial-radial or radial-femoral delay. No neurological deficits were appreciated.
Due to concerns of possible aortic dissection, she underwent an urgent CT aortogram, which did not show any aortic dissection, overt signs of bowel ischaemia or any other structural abnormality. Lab tests revealed a lactate of 23.6mmol/L, urea 12.2 mmol/L, creatinine 141 umol/L, potassium 5.7 mmol/L and bicarbonate 3.9 mmol/L. Her liver function tests were also deranged.
Shortly after the scan, the patient had a witnessed cardiac arrest in ED. Return of spontaneous circulation (ROSC) was obtained after resuscitation and bicarbonate infusion. Further history from her family members revealed that she had overdosed on 29 tablets of metformin 4 hours prior.
She was diagnosed with Metformin Associated Lactic Acidosis (MALA). She was subsequently admitted to the intensive care unit (ICU) for urgent dialysis. Unfortunately, her condition worsened and she demised the following day due to multi-organ failure.
Discussion
Though uncommon, MALA is a cause of severe lactic acidosis. It is primarily type B and due to inhibition of mitochondrial respiration in tissues (i.e. liver and muscle) responsible for lactate removal. This results in both accelerated lactate production and reduced lactate metabolism.1 In an overdose, the lactic acidosis can also be compounded by type A lactic acidosis when the drug’s lactic acid accumulation leads to cardiovascular collapse, tissue hypoperfusion and hepatic dysfunction, eventually resulting in death.2
References
1. Ralph DeFronzo, G. Alexander Fleming, Kim Chen, Thomas A. Bicsak. Metformin-associated lactic acidosis: Current perspectives on causes and risk, Metabolism, Volume 65, Issue 2, 2016, Pages 20-29, ISSN 0026-0495. https://doi.org/10.1016/j.metabol.2015.10.014.
2. Blough B, Moreland A, Mora A Jr. Metformin-induced lactic acidosis with emphasis on the anion gap. Proc (Bayl Univ Med Cent). 2015 Jan;28(1):31-3. doi: 10.1080/08998280.2015.11929178.
Serena WANG (Singapore, Singapore), Shao Hui KOH
00:00 - 00:00
#41790 - A case report of a patient with wide complex tachycardia due to Wolff–Parkinson–White syndrome.
A case report of a patient with wide complex tachycardia due to Wolff–Parkinson–White syndrome.
Introduction:
Wide complex tachycardia (WCT) is defined by a heart rate of more than 100 beats per
minute along with a wide QRS complex. It causes palpitations and syncope among young
patients that may hide an underlying life-threatening arrhythmia.
We report the case of a young patient with WCT of unknown etiology who was diagnosed
with Wolff–Parkinson–White (WPW) syndrome.
Case :
We report a case of a 44 year-old Patient who arrived at the emergency department with
sudden onset of palpitation. He had no chest pain and did not lose consciousness.
He had no medical history. The patient reports similar previous episodes during his teenage years while practising high intensity sports.
Initial vital signs included tachycardia of 250 beats per minute, blood pressure of 14/9 mm Hg, eupneic 18 cpm, normal lung sounds and oxygen saturation of 97% on room air.
The patient was afebrile.
The ECG showed a preexcited sinus rhythm of 194 bpm in sequence by wide complex tachycardia, supraventricular tachycardia, atrial fibrillation with rapid ventricular response, and degeneration to ventricular fibrillation.
The decision was to perform an External electrical cardioversion (EEC) under anaesthetic cover which resulted in a dramatic improvement of symptoms. The patient no longer complained of palpitations, his heart rate decreased to 116 beats per minute.
The Electrocardiogram following cardioversion showing sinus rhythm with narrow QRS
complexes followed by P waves and longer PR interval, delta wave was positive ; typical to
WPW Syndrome. And the patient remains non-algic with blood pressure of 12/07 .
He was subsequently referred to the cardiology intensive care unit for radiofrequency catheter ablation.
Conclusion:
WPW syndrome is a rare congenital heart defect due to an accessory pathway between the
atrium and the ventricle. It is not a common presentation and basically diagnosed by ECG.
It may lead to hazardous ventricular arrhythmias and sudden death. That’s why it’s often
discovered by its complications .
Hadhami KAROUIA, Imen KETATA, Sarra SOUA, Chaima MANAI, Khouloud KHEMILI (Tunisia, Tunisia), Bouhamed CHAFIAA
00:00 - 00:00
#42054 - A case report of pulmonary thromboembolism and inferior vena cava thrombosis in a patient with heterozygous coagulation factor II mutation, undergoing pre-IVF hormonal treatment.
A case report of pulmonary thromboembolism and inferior vena cava thrombosis in a patient with heterozygous coagulation factor II mutation, undergoing pre-IVF hormonal treatment.
A 44-year-old woman was admitted to the Emergency Department of the Polyclinic of Modena for left-sided and epigastric discomfort associated with dyspnea and asthenia appeared in the previous ten days.
In her medical history there was: heterozygous G20210A mutation of Factor II, hypothyroidism under therapy with levo-thyroxine, previous endouterine fetal death in primigravida at 33+4 weeks of gestation, recent completion of progestogen hormone therapy for assisted fertilization.
At presentation the patient was haemodynamically stable, with excellent SpO2 on room air and normal cardio-pulmonary objectivity. The blood tests showed a slight increase in the inflammatory indices, d-Dimer 5368 with a normal arterial blood gas (ABG). The ultrasound examination identified a slight left pleural effusion and at longitudinal IVC scan a fusiform image was floating into the vein.
For further diagnostic purposes, contrast-enhanced CT (CECT) was requested.
- The CECT Abdomen Scan confirmed the presence of a filling defect of thromboembolic nature measuring 12x10x39 mm in the endoluminal area of the IVC in its infra-retrohepatic section and which caudally involved the right renal vein at the confluence site, which was patent and well opacified upstream. It was associated with the presence of occlusive thrombosis involving the left internal iliac and obturator vein, extending for a short distance into the ipsilateral common iliac vein.
- The CECT Chest Scan revealed bilateral pulmonary embolism, greater on the left lung, where it involved the main pulmonary artery and its branches, in particular the pulmonary arterial branches for the lower lobe where occlusive filling defects were detected, determining the area of pulmonary consolidation at the dorsal-basal segment compatible with the infarct nature. On the right lung, these filling defects appeared limited to the pulmonary artery and some branches of the lower lobe. The presence of a thin layer of pleural effusion on the left side with dorsal-basal distribution and maximum thickness of 8 mm was confirmed.
The patient was admitted to the Department of Critical Care Medicine where anticoagulant therapy was started, initially with enoxaparin at the therapeutic dosage and, after a series of diagnostic tests, therapy with direct oral anticoagulant (DOAC) was started, opting for Rivaroxaban initially at the dosage of 15 mg 1 tablet bid.
In consideration of the low mortality risk of the patient's pulmonary embolism, the clinical conditions and the negativity of laboratory and instrumental markers, having also excluded forms of autoimmune thromboembolism, early discharge was planned with a strict outpatient follow-up program.
Giuseppe IARIA (Modena, Italy), Ennio LICHERI, Federica GRANDI, Dimitriy ARIOLI, Natale VAZZANA, Luca RONCUCCI, Lucio BRUGIONI
00:00 - 00:00
#41521 - A case report on esophageal penetration caused by ingested chicken bone and surgical intervention.
A case report on esophageal penetration caused by ingested chicken bone and surgical intervention.
Foreign body ingestion, though common, can lead to rare but serious complications such as esophageal penetration. This report highlights a case of esophageal penetration caused by the ingestion of a chicken bone in a 41-year-old female patient. Despite initially negative findings from nasopharyngoscopy, escalating symptoms prompted further evaluation, revealing a foreign body through contrast-enhanced computed tomography. Prompt surgical intervention led to successful extraction of the 2.2 x 0.5 x 0.3 cm chicken bone, mitigating potential severe complications. Esophageal foreign body disease predominantly affects men and often involves fish or chicken bones, with the upper esophageal sphincter commonly implicated. Timely removal within 24 hours is crucial to prevent complications, as prolonged retention increases the risk of adverse events. Computed tomography is preferred for suspected complications due to its superior sensitivity compared to conventional radiography. Severe complications, including aortoesophageal fistula, underscore the importance of prompt diagnosis and intervention. Consultation with a thoracic surgeon is recommended when aortoesophageal fistula is suspected, and unsuccessful endoscopic retrieval may necessitate tailored surgical intervention based on clinical presentation. This case underscores the significance of considering esophageal penetration in patients with a history of foreign body ingestion and escalating symptoms. Early recognition and appropriate management are essential in reducing morbidity and mortality associated with esophageal foreign body diseases.
Wei-Lun CHEN (Taipei, Taiwan), Tzu-Yao HUNG
00:00 - 00:00
#41296 - A Cautionary Serve: Vertebral Artery Dissection from a Tennis Ball Impact.
A Cautionary Serve: Vertebral Artery Dissection from a Tennis Ball Impact.
Brief Clinical History:
A 26-year-old male, with no significant medical history, presented to the emergency department complaining of a severe headache and neck pain, which had persisted for two days. He also reported a new onset of left-sided weakness. The patient noted that his symptoms started a day after he was accidentally struck on the neck by a tennis ball during a recreational tennis match.
Misleading Elements:
The seemingly trivial nature of the trauma initially misled the clinical team. Given the common occurrences of sports-related injuries, initial assessments leaned towards muscle strain or a mild concussion. The patient's initial presentation with non-specific symptoms such as headache and neck pain, which are common in less severe injuries, contributed to the initial diagnostic uncertainty.
Helpful Details:
The progression of the patient's symptoms, particularly the development of unilateral weakness, was a critical clue that prompted a re-evaluation of the case. Detailed neurological examination revealed mild left-sided hemiparesis and hypoesthesia, which were inconsistent with a simple concussion or muscle strain. These findings raised the suspicion of a more serious underlying condition, leading to further targeted investigations.
Differential and Actual Diagnosis:
The differential diagnosis included concussion, cervical spine injury, muscular injury, and early signs of a stroke. Given the traumatic event followed by neurological deficits, imaging studies were prioritized, which included a Doppler ultrasound and computed tomography angiography (CTA). These imaging modalities confirmed the presence of a vertebral artery dissection (VAD). This diagnosis explained the neurological symptoms as a result of compromised blood flow to the brain due to the arterial injury.
Educational and/or Clinical Relevance:
This case underscores the importance of considering vascular injuries such as vertebral artery dissection in young patients presenting with neurological symptoms following even minor neck trauma. VAD is a rare but serious condition that can lead to ischemic stroke if not promptly diagnosed and managed. This case highlights the need for emergency medicine practitioners to maintain a high index of suspicion for significant vascular injuries when patients present with atypical symptoms after head or neck trauma.
Furthermore, the case illustrates the pivotal role of appropriate imaging in the diagnosis of VAD. Doppler ultrasound and CTA are crucial in confirming the diagnosis, facilitating timely and appropriate management that can prevent severe outcomes like stroke. This report contributes to the broader knowledge base in emergency medicine, emphasizing the potential severity of seemingly minor injuries and the importance of a thorough assessment and consideration of less obvious diagnoses in acute presentations.
Dr Firas ABOU-AUDA (London, )
00:00 - 00:00
#41138 - A challenging case: Non-invasive ventilation in a patient with hypercapneic respiratory acidosis with septicaemic and cardiogenic shock.
A challenging case: Non-invasive ventilation in a patient with hypercapneic respiratory acidosis with septicaemic and cardiogenic shock.
BACKGROUND: Non-invasive ventilation (NIV) is an effective and safe alternative to intubation and mechanical ventilation in patients with acute hypercapneic respiratory failure. The use of NIV in patients with concomitant hypotension and low Glasgow Coma Scale (GCS) score is less studied but has shown promising results.
CASE REPORT: The present case report is about an elderly woman who had an altered mental state and acidotic respiratory failure with concomitant septic and cardiogenic shock. Her past medical history included obstructive sleep apnoea, hypertension, hyperlipidemia, diabetes mellitus, ischaemic heart disease, mild aortic stenosis, and aortic regurgitation with an ejection fraction of 48%, and end-stage renal failure on peritoneal dialysis. The patient was successfully managed with inotropic support and non-invasive ventilation, avoiding endotracheal intubation and invasive ventilation.
CONCLUSIONS: NIV can be a valuable tool in the management of patients with acute respiratory failure, but it should be used with caution in patients with hypotension and altered consciousness. Although precarious, a trial of non-invasive ventilation can be considered in such patients by keeping a close watch on the clinical status of the patient with close monitoring and adjustment to Non-invasive ventilation settings along with circulatory support may be necessary to prevent complications and ensure the best possible outcome for the patient.
Dr Irfan Abdulrahman SHETH (Singapore, Singapore), Evelyn WONG
00:00 - 00:00
#42360 - a chronic tetany due to alcohol use disorder in a Japanese young adult.
a chronic tetany due to alcohol use disorder in a Japanese young adult.
Alcohol consumption, particularly heavy drinking, is an important risk factor for a number of health problemsa . We report the case of a young woman with a chronic tetany, who eventually received a diagnosis of hypomagnesaemia due to alcohol use disorder. Hypomagnesemia causes tetany and convulsions, hypokalemia, hypocalcemia, and long QT syndrome. Therefore, early diagnosis to initiate correction of hypomagnesemia and intervention in drinking habits to prevent recurrence are important.
A 26-year-old Japanese woman visited our hospital because of 1-year facial and upper-limb stiffness of unknown etiology. She was reported to have visited another hospital fourteen days before admission, and blood tests were performed for upper limb stiffness; however, there were no significant findings with normal blood calcium levels. She had a daily intake–40-80 g of pure alcohol daily. She had no history of diarrhea, diuretic use, or medication, including proton pump inhibitors.
On arrival, the patient was alert and had no acute distress. Blood pressure was 92/68 mmHg, pulse rate was 112 beats per minute with irregular, respiratory rate was 20 breaths per minute, and body temperature was 36.9°C. Neurological examination revealed positive Trousseau’s and Chvostek’s signs and tetany on bilateral upper limb. On Manual Muscle Testing, the right hand grip was fair, and the right biceps brachii was good but not normal. Tendon reflexs were symmetry, neither enhanced nor diminished. Laboratory data showed calcium 9.3 mg/dL, magnesium 1.8 mg/dL. Electrocardiographic abnormalities were not observed. Chronic tetany due to hypomagnesemia due to alcohol use disorder was diagnosed, and the patient was started on oral magnesium oxide supplementation.
Tetany decreased in frequency and decreased to magnesium 2.5 mg/dL at an outpatient visit two weeks later. The patient was instructed to abstain from alcohol consumption.
Alcohol consumption is reported to be increasing in many countries, and there is concern that alcohol-related health problems are on the rise1. Women in particular are more likely than men to have elevated blood concentrations of alcohol and are at higher risk for cirrhosis and alcoholism. Therefore, intervention for alcohol intake is important in patients with alcohol-induced hypomagnesemia to prevent recurrence. Hypomagnesemia is implicated in chronic alcohol-related disorders.
Daichi HARA, Kazuhiro KAMATA (TOKYO, Japan)
00:00 - 00:00
#41314 - A Comparative Study of trauma information registry systems in the world and Iran: a literature review.
A Comparative Study of trauma information registry systems in the world and Iran: a literature review.
Abstract
Introductions: The first trauma data registry started in 1969 in a hospital in Chicago, which gradually expanded to 37 US states with trauma centers within 20 years. Gradually, developed countries such as Canada, England, and Germany and developing countries such as Singapore, Thailand, India, and Malaysia also began implementing regional trauma registration plans. In Iran, trauma registration was first started in 2000 in a limited way. The purpose of this study was to review the status of trauma registration systems in the world and Iran and to examine the main characteristics of these systems.
Methods: This review study searched PubMed and Google Scholar databases for English articles. Magiran and SID searched for Farsi articles using an advanced search strategy and appropriate operators for each scientific database, first based on the title and then keywords. The study data was collected using the English keywords injury, injuries, trauma, registry, registries, and Iran and the Persian keywords injury, injuries, trauma, register, and Iran without time limit.
Results: In the review of 620 studies, 16 were selected as final articles. One case was related to Iran, and the other to other countries. Paper forms were first used to collect patient data in all countries with a trauma registration system. In countries with more history, computer systems have been gradually designed so that data entry can be done electronically. Of course, despite the advancement of technology and the launch of new systems in some countries, including Iran, data collection still needs to be done using a paper form. After that, it has been tried to transfer the data into specialized software. Findings show that the trauma registration system in developing countries such as Brazil, South Africa, Saudi Arabia, and Uganda is still implemented locally.
Conclusions: In the last 20 years, Iran has tried to establish a comprehensive national trauma registration system. So far, appropriate local or hospital systems have been created to register trauma cases, but the necessary integration to create a national system has not been formed. Like the leading countries in this field, the design of comprehensive trauma registration software should be considered as the first step.
Tayeb RAMIM (Tehran, Islamic Republic of Iran)
00:00 - 00:00
#40851 - A Conscious Cardiac Arrest Patient: A case report of of 74 years old female with cardiopulmonary resuscitation induced consciousness.
A Conscious Cardiac Arrest Patient: A case report of of 74 years old female with cardiopulmonary resuscitation induced consciousness.
Background
While cardiac arrest is a frequent occurrence within emergency departments, the increasing effectiveness of cardiopulmonary resuscitation (CPR) techniques has led to a rise in cases of patients regaining consciousness following CPR intervention. However, despite this progress, a significant lack of published research exists about this specific phenomenon. In this case report, we present the experience of a 74-year-old woman who regained consciousness following CPR administration within the emergency department setting.
Case Report
A 74-year-old Malay female presented to the emergency department (ED) with chronic left lower abdominal pain and admitted for further workup. While awaiting a room assignment in the ED, staff nurses saw episodes of eye rolling. Subsequently, she became pulseless, prompting immediate initiation of cardiopulmonary resuscitation (CPR). Advanced Cardiac Life Support (ACLS) protocols were followed throughout the resuscitation. The patient exhibited periods of consciousness during CPR, even attempting to resist chest compressions. When CPR was briefly interrupted for pulse checks, she would lose consciousness and lapse into asystole. Restarting CPR would restore consciousness. The patient was then sedated with IV ketamine, paralysed with succinylcholine, and then intubated. She experienced ventricular fibrillation on four separate occasions, requiring electrical cardioversion. She regained consciousness again when succinylcholine wore off. As resuscitation efforts continued, her level of consciousness progressively declined. After a prolonged resuscitation attempt exceeding one-hour, medical futility was declared, and resuscitation was discontinued.
Discussion
In the past, cardiac arrest and consciousness (including breathing, movement, and awareness) were believed to be incompatible. However, recent evidence, though mostly anecdotal, suggests that a phenomenon called CPR-induced consciousness (CPRIC) might exist, albeit rarely.
According to Parnia et. Al, individuals may experience consciousness, awareness, and cognitive function during cardiac arrest. In his prospective 25-site in-hospital study of 567 in hospital cardiac arrest (IHCA), 53(9.3%) survived, they interviewed 28 of the survivors, and 11 (39.3%) reported memories or sensations suggesting they were aware during the cardiac arrest or shortly after. The reported experiences fell into four main categories: regaining consciousness during CPR (7.1%), having conscious experiences soon after resuscitation (7.1%), dream-like experiences (10.7%), and feelings of transcendence associated with near-death (21.4%).
A 2017 review by Haydon et al. re-evaluated the quality of life and well-being of cardiac arrest survivors. While the majority of survivors reported an acceptable quality of life, the review also highlighted the prevalence of mental health challenges such as anxiety, depression, and post-traumatic stress disorder, alongside cognitive impairments experienced by some survivors .
Due to the potential for psychological distress associated with CPRIC, some guidelines recommend sedation upon encountering this phenomenon. The Dutch protocol suggests fentanyl and midazolam, while Nebraska recommends a bolus followed by a continuous infusion of ketamine and midazolam(4). IV ketamine and IV succinylcholine were used in our case.
Conclusion
This case report details the characteristics of CPRIC as well as the difficulties it presents during resuscitation efforts. Further research is crucial to establish the true prevalence of CPR-induced consciousness and develop treatment protocols that ensure optimal safety for both patients and HCW.
Mian Jie LIM (Singapore, Singapore)
00:00 - 00:00
#41218 - A Culinary Conundrum leading to Methaemoglobinemia.
A Culinary Conundrum leading to Methaemoglobinemia.
We describe a case of a middle aged lady with dietary induced methaemoglobinemia, which is uncommon and reported mainly in infants. This case highlights how everyday dietary selections can trigger methemoglobinemia and it can serve as a valuable reference for managing dietary-induced methaemoglobinemia.
Clinical History
A 68-years-old Chinese lady with a history of type 2 diabetes mellitus and hypertension presented with chest discomfort, shortness of breath and cyanosis. Apart from chronic dry cough, she had no other infective symptoms.
Helpful Details
Her oxygen saturations were 90% on room air and worsened to 85% despite oxygen supplementation through non-rebreather mask. She had central cyanosis over her mouth and hands with a slate-gray discoloration of the skin. Her jugular venous pressure was not elevated, auscultation of lungs were clear and there was no peripheral oedema. Arterial blood gas was dark colored and showed pH 7.408 (7.35-7.45), pCO2 38mmHg (35-45mmHg), pO2 343mmHg (70-100mmHg). Electrocardiography showed sinus tachycardia at a rate of 108 beats per min with no ischemic changes. Chest X-ray did not reveal any consolidation or pneumothorax.
Differentials
The presence of central cyanosis and saturation gap led to suspicion of methaemoglobinemia, confirmed by elevated methaemoglobin levels at 41.0 % (0-2%). Differentials were pneumonia and acute myocardial infarction, which were less likely given the lack of infective symptoms and reduced saturations. Dietary history revealed exposure to nitrate or nitrite from duck or chinese cabbage, as these compounds are used as preservatives(1) or found in vegetables(2). Within the 1st hour, she was treated with intravenous methylene blue 1% 100mg (1.6mg/kg) over 15 minutes and central cyanosis rapidly resolved (Fig 1B). Oxygen saturations picked up to 95% on room air 40 minutes after. She was admitted to the Emergency Department (ED) Short Stay Ward and methaemoglobin levels checked 11 hours after normalized to 1.2%. She was discharged 22 hours from time of presentation to ED.
Discussion
Methaemoglobinaemia is characterized by oxidized hemoglobin compromising oxygen-carrying capacity(3). Congenital causes include enzyme deficiencies and acquired causes include exposure to agents like dapsone, sulfonamides and quinolones. Clinical clues include cyanosis-saturation gap, chocolate colored blood and refractory hypoxia(4). Methemoglobinemia in this case was dietary induced from exposure to nitrate or nitrite. Nitrates are reduced to nitrites by enzymes in the gastrointestinal tract and nitrites are oxidative stressors, inducing methaemoglobinemia in a dose dependent fashion(5). Dietary induced methaemoglobinemia is more commonly reported in infants with higher levels of fetal haemoglobin and are more susceptible to oxidation(6).
The patient’s prompt recovery highlights the effectiveness of methylene blue, acting as an electron acceptor, reducing iron back to ferrous state(7). In patients with G6PD deficiency, methylene blue may precipitate hemolysis and ascorbic acid may be used for treatment instead.
Learning Points
This case underscores potential for everyday dietary choices to induce methaemoglobinemia. Swift recognition and removal of the inciting cause, coupled with the administration of appropriate treatment like methylene blue, leads to a rapid and positive response. This allows for the safe discharge of patients without further complications.
Lee KAI YI (Singapore, Singapore), Waruni DE SILVA, Hoon Chin LIM, Kelvin Kb KUAN
00:00 - 00:00
#42282 - A diabetic foot hiding an Infective Endocarditis.
A diabetic foot hiding an Infective Endocarditis.
Introduction:
Infective endocarditis is a serious infectious disease that can be life-threatening. Its clinical presentation can vary, leading to occasional delays in optimal management.
when should physician evoke this disease?
We report the case of a patient initially treated in our emergency department for cutaneous-onset septic shock, which proved finally to be secondary to infective endocarditis. We declare that the patient has given consent to have details submitted, and that we ensure anonymity.
Case presentation:
We present a 61-year-old man who was admitted to emergency with septic shock after his usual haemodialysis session, with a history of fever and impaired general condition for 3 days.
He was a diabetic on insulin at the stage of degenerative complications, with arterial disease and chronic renal failure at the stage of haemodialysis.
In first assessment, the patient was polypneic, with free lungs auscultation, he was in acute circulatory failure and no heart failure signs. He was confused and febrile and had a left diabetic foot infection.
Biological findings have shown an inflammatory syndrome with White count cells about 13 mg/dl and C-Reactive protein at 40 mg/dl. Lactate were about 4.8 mg/dl with 54 mg/dl of Creatinine, 1.2 g/l of urea and 4.7Eq/l of potassium level.
Cytobacteriological examination of urine and Chest x-ray were negatives.
He was treated as a septic shock with a primary cutaneous infection, but the evolution was marked by an improvement in the foot's local condition and a worsening of the hemodynamic situation with increased norepinephrine doses, leading to further investigations. Abdominal CT showed a mesenteric infarction, and transesophageal echocardiography revealed vegetation in the right atrium and an image suggestive of an abscess in the mitro-aortic junction. The definitive diagnosis in this patient was infective endocarditis. The clinical outcome was favorable with antiobiotics.
Conclusion
Our aim in presenting this case is to raise awareness among doctors of the possibility of infective endocarditis when dealing with high-risk situations, particularly in patients suffering from chronic renal failure.
Sarra AKKARI, Saloua HOUIMLI (la Marsa, Tunisia), Mohamed ASSADI, Wiem DERBALA, Fatma HEBAIEB
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#41763 - A Fast Track zone in an Emergency Department – a descriptive analysis of population and flow.
A Fast Track zone in an Emergency Department – a descriptive analysis of population and flow.
Introduction:
Emergency departments (EDs) around the world are reporting increased incidence of crowding. To improve throughput in EDs, a Fast Track (FT) solution for selected patient groups, including optimization of working processes can be implemented. The literature indicate that implementing a FT solution for patients with less acute conditions leads to reduced waiting time and shorter length of stay. However, FT can appear differently across hospitals and countries in terms of physical framework and patient intake.
The aim of this study was to investigate the population and flow in a newly established Fast Track zone in an ED in Denmark. Furthermore, to investigate differences in patient- and admission-related characteristics among patients with medical conditions or abdominal symptoms.
A prospective observational cohort study was designed. All patients 16 years or older and with medical or abdominal symptoms entering the FT zone from Sept 1st, 2022, to April 30th, 2023, were included. Every weekday, a dedicated secretary recorded data, including age, sex, date, time of arrival and discharge, specialty, referral reasons and discharge course.
General practitioners, ambulance personnel or doctors in outpatient clinics will via the visitation centre refer patients, who have become acutely unwell and who need medical attendance fairly quickly. The visitation centre, staffed by qualified ED nurses, triages the referred patients and based on pre-defined criteria determines whether the patient is suitable for assessment in the FT. One Emergency Medicine consultant, one foundation-year doctor from the Department of Gastroenterology surgery (with a possibility of supervision by a senior colleague) and an emergency nurse every weekday from 08 to 16, staffs the T.
When assessing numeric patient and admission-related characteristics, we used medians (quartiles) and Kruskal-Wallis test as data were not normally distributed. When assessing categorical variables, we used proportions and the chi-squared test.
Results
In total, 2045 patients entered the FT zone during the study period; 1301 and 744 patients with medical or abdominal symptoms, respectively. Patients with medical symptoms was significantly older than patients with abdominal symptoms (median age: 62 vs. 49 years, respectively), and more often men (55 % men vs. 47% men). Furthermore, length of stay (LOS) was significantly shorter for patients with medical symptoms (median LOS: 101 vs 168 minutes); however, within the study period they tended to return to the FTzone more often than patients with abdominal symptoms (50% vs. 20%). The reasons for entering the ED were heterogeneous with stomachache (14%), abdominal infection (8%), infection/infection related treatment (21%) and deep vein thrombosis (10%) being the main courses.
Of the entire population, 6% of the patients with medical conditions and 9% of the patients with abdominal symptoms needed admission in the ED or in a specialized department at the hospital. Most patients (79%) were treated and discharged to home directly from the FT zone or after being treated in a short-term surgical or medical unit (7%). In total, 7% received a follow-up by telephone.
Conclusion
A Fast Track solution may contribute to shorter hospital stays and few admissions for patients with less acute conditions.
Funding
This study received no funding.
Trial registration, ethical approval and informed consent
The study was approved by the Hospital Management and registered with the record of data process of the Registry of Southern Denmark (Journal no. 22/46734). Informed consent was not required. Data was stored in a secure server only available to the data collectors and researchers.
Charlotte ABRAHAMSEN, Charlotte ABRAHAMSEN (Kolding, Denmark), Ditte ORBESEN, Mohamad EL-FARAMAWI, Peter HERTZ, Gitte SPARKE, Anne Friesgaard CHRISTENSEN
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#41561 - A five-year review of research recruitment in the Emergency Department at Oxford University Hospital – A descriptive comparative study.
A five-year review of research recruitment in the Emergency Department at Oxford University Hospital – A descriptive comparative study.
Title:
A five-year review of research recruitment in the Emergency Department at Oxford University Hospital – A descriptive comparative study.
Introduction and background:
According to the 2022/23 Clinical Research Network annual statistics, research participation levels have significantly increased compared to pre-pandemic levels. The number of people participating in life-changing research has reached almost one million.
Over the past five years, the Emergency Medicine Research team (EMROx) based at Oxford University Hospital’s (OUH) Emergency Department, has served as a dynamic arena for clinical research, necessitating effective recruitment strategies to address the high paced and diverse clinical environment.
This study aims to analyse the evolution of research recruitment over the past five years by identifying key shifts, trends and advancements. Through a descriptive comparative study, we seek to shed light on changes in research priorities, methodologies and outcomes which contributes to a deeper understanding of patients’ involvement within research.
Question:
What are the key differences observed in emergency medicine research between 2017 and 2023?
Methods:
A descriptive comparative study was conducted to compare emergency medicine research activities at OUH in 2017 and 2023. Data was collected from the EMROx team’s research portfolio. This includes the number and types of research studies (observational versus interventional) conducted, patient screening and recruitment data. The distribution of study types, and the recruitment rates were compared between the two time periods.
Results and discussion:
In 2017, the EMROx team was comprised of 5 equivalent full time hours Research Nurses (RN) and conducted 12 research studies, while in 2023 there were 6 equivalent full time hours RN and the number of studies increased to 26.
The distribution of study types in 2017 consisted of 6 observational studies and 6 interventional studies. However, in 2023, there was a notable shift towards interventional studies, with 18 interventional and 8 observational studies.
In 2017, a total of 2,225 patients were screened for participation in research studies, with 59% (1,321 patients) recruited. In contrast, in 2023, following the COVID-19 pandemic, the number of patients screened increased to 3,745. However, the recruitment rate decreased to 23%, with 862 patients recruited.
The decrease in the recruitment rate in 2023, despite the increase in the number of patients screened, is noteworthy. This decrease may be primarily attributed to the higher complexity of interventional studies conducted in 2023 compared to 2017. Complex interventional studies often require stricter inclusion and exclusion criteria, leading to a more selective recruitment process. Additionally, the impact of the COVID-19 pandemic on patient willingness to participate in research studies cannot be overlooked.
Conclusion:
In summary, the significant increase in emergency medicine research activities at OUH in 2017 and 2023 reflects a growing emphasis on research within the department. The doubling of research studies, particularly the increase in interventional studies, suggests a broader and more comprehensive approach to research. These findings underscore the need for innovative recruitment strategies, for example increasing the number of research staff, in future research endeavours.
No funding received for the study.
Martina IORIO (Carteton, ), Rufino Roger MAGALLANO, Alexis ESPINOSA, Tinelly SAMBO, Dominique GEORGIOU
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#41970 - A Frequently Used Antiepileptic in Children and Its Frightening Side Effect: Ataxia.
A Frequently Used Antiepileptic in Children and Its Frightening Side Effect: Ataxia.
BACKGROUND
Ataxia is usually the result of cerebellar dysfunction. Although causes of acute ataxia include life-threatening conditions such as mass lesions and central nervous system infections, the majority of children have a benign, self-limited process. The most common causes of acute ataxia in children are acute infections, post-infectious inflammatory conditions, toxins, tumors, and trauma. Exposures commonly associated with ataxia include anticonvulsants (phenytoin, carbamazepine, phenobarbital, and primidone), lead, carbon monoxide, inhalants (such as toluene), alcohol, benzodiazepines, and other drugs of abuse. In this case report, we wanted to present a pediatric patient who had seizures, a history of trauma, and developed ataxia after phenytoin treatment.
CASE
A 4.5-year-old boy was admitted to the emergency department with head trauma after falling from a chair. While he was sitting in the chair, he suddenly fell and hit his head. He was conscious at the time and answered questions. Half an hour later, the patient started vomiting and had tremors in his hands and feet that lasted 3 minutes. He becomes somnolent for 5 minutes. At that time, the temperature was measured at 37.5 degrees. During one week, he had a cough without phlegm and a runny nose. When he applied to the emergency room, his fever was 38.8 degrees. The child was conscious, alert, and oriented, with no abnormalities in examining cranial nerves, neuromotor, and sensory systems. An ecchymotic area with a diameter of 1.5 cm in the right frontotemporal area was noted. Tonsils and oropharynx were hyperemic, and postnasal serous discharge was present. In laboratory examinations, blood gas (venous); ph:7.29 pco2:43.5 hco3:18.9 lactate:2.1, hemogram; hemoglobin: 13.7 g/dl, leukocyte: 37000/mm3, platelet: 196,000/mm3, C-reactive protein:6.9 mg/L. Liver and kidney function tests, electrolytes, and electrocardiograms were normal. The rapid influenza diagnostic test was negative. Brain computed tomography showed no pathologic findings. There was a history of febrile convulsions at 2.5 and 3 years of age. Electroencephalography (EEG) was performed before and showed no epileptic activity and no history of taking any antiepileptic medication. The patient was evaluated for a complicated febrile seizure and consulted with the pediatric neurology department. The neurologist recommended 20 mg/kg phenytoin intravenous infusion as a loading dose at 1 hour (0.34 mg/kg/min infusion rate). Fifteen minutes after the end of the phenytoin loading treatment, the patient developed signs of ataxia. The patient was admitted to the neurology ward and monitored closely. Serum phenytoin level resulted in 19 mcg/mL (therapeutic range of 10–20 mcg/mL). He showed significant improvement in symptoms during hospitalization in 16 hours of time. Ataxia and drowsiness symptoms improved in the follow-up. The patient showed no other seizures or abnormal neurological examination findings. He was discharged after two days of follow-up.
CONCLUSION
This case emphasizes the importance of follow-up examination and monitoring pediatric patients who receive anticonvulsant drug therapy before discharge, even if the dosage or infusion rate is not high. Neurological symptoms at young ages may be difficult to recognize and should be observed closely.
Emine UGUZ KIZILAY, Huriye CETIN, Ayla AKCA CAGLAR (ANKARA, Turkey), Ebru ARHAN, Oksan DERINOZ GULERYUZ
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#42196 - A girl in a coma: a case of drug intoxication induced by a pharmacobezoar.
A girl in a coma: a case of drug intoxication induced by a pharmacobezoar.
A 33 years old woman was brought to our ED for a drowsy state and suspected incongruous drugs assumption. She had a history of bipolar and borderline disorder with previous multiple access to the ED for depression. On that date she was on Lamotrigine, Quetiapine and Alprazolam. Her mother reported that she didn’t take any medications since the morning but the night before she took her therapy twice. Paramedics on the scene reported they found only empty blisters of Alprazolam.
On admission her conditions were extremely critical, she didn’t respond to verbal and painful stimulation, GCS was 9/15. Blood pressure, heart rate, peripheral oxygen saturation, respiratory rate and body temperature were 105/70 mmHg, 120 bpm regular, 99% while breathing in room ambient air, RR 22 breaths/minutes, TC 37°C respectively.
The electrocardiogram (ECG) demonstrated no abnormality.
Blood gas showed normal pH with lac 1.4 mg/dL, BE -2.1 . Laboratory data showed a normal blood cells count, normal coagulation markers, C-Reactive protein was 3.1 mg/dL, myoglobin was 50 ug/L and CPK was 56 U/L.
A toxicology screening resulted positive for BZD and cannabinoids.
At first, the Pavia’s poison control center was contacted and the toxicologist suggested performing decontamination with 50mg of activated charcoal and SELG and Flumazenil infusion in case of desaturation. A cerebral CT scan performed as screening resulted negative.
As no improvement was seen after 24 hours, other options were considered. Cerebral CT scan and angio were performed and the results were negative. Brain MRI was obtained as well, resulted negative.
The patient had a minimal rise of WBC and body temperature, in the suspicion of cerebral inflammatory disease she was seen by the neurologist who performed a LP.
Cerebrospinal fluid was clear, no abnormalities were found on microscopic analysis.
Patient was admitted to the Emergency Medicine ward for further evaluation in the suspect of anticholinergic syndrome or quetiapine and benzodiazepine intoxication, since the new finding of tachycardia, mydriasis and hyperthermia.
After 36 hours peripheral saturation and blood pressure were persistently normal but the patient appeared to be unresponsive on the AVPU evaluation of the consciousness levels. Minimum variation was observed on Flumazenil boluses.
An episode of desaturation occurred during the night and a chest XR was performed that revealed pleural effusion on the left side. An angio pulmonary CT scan was obtained and evinced bilateral mucus plugs, mainly in the left main bronchus consisting in complete atelectasia of the lung.
After 48 hours patient’s neurological status was unchanged. POCUS of the abdomen showed gastrectasia with abundant gastric materials, therefore an EGDS was requested on the suspicion of pharmacobezoar. Nearly after 56 hours from the ingestion, multiple pharmacobezoars induced by Quetiapine were present in the stomach so they were endoscopically removed. Succeding 24 hours the neurological status was fully recovered and the patient was transferred to the Psychiatric ward for specific management.
Lorenzo DEMITRY, Michela CASCIO, Giuseppe ROMANO, Michela CASCIO (ROME, Italy)
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#42379 - A man with left eye pain for 3 days.
A man with left eye pain for 3 days.
A 45-year-old male presented with a three-day history of left eye pain and blurred vision, without associated fever or recent trauma. Physical examination revealed conjunctival injection and chemosis, along with left-sided ophthalmoplegia upon neurological assessment. Bedside point-of-care ultrasound exhibited engorgement of the left eye vessel with a pulsatile waveform in pulse wave mode (Figure A and B). Subsequent computed tomography and angiography (Figure C and D) confirmed the presence of a carotid cavernous fistula, resulting in dilation of the left ophthalmic vein. Following embolization of the fistula using seven platinum coils, the patient experienced complete resolution of the exophthalmos with a return to normal visual acuity. In addition to clinical findings, ultrasound emerges as a valuable and accessible diagnostic tool for carotid cavernous fistula in the armamentarium of emergency physicians.
Chun Yen HUANG (New Taipei City, Taiwan)
00:00 - 00:00
#41154 - A man with left thigh pain.
A man with left thigh pain.
An 85-year-old man presented to the emergency department with a history of difficulty walking for 3 weeks. He had hypertension and denied any recent trauma. Physical examination revealed left thigh swelling and one painful pulsatile mass over the left groin. Point-of-care ultrasound performed by the emergency physician demonstrated swirling flow within the pouching cavity in the left thigh. A hyperechoic thrombus was also seen in the right thigh. Computed tomography angiography confirmed the diagnosis of ruptured pseudoaneurysms in the right external iliac artery and left superficial femoral artery. The patient underwent emergent open surgical repair.
Pseudoaneurysms typically result from a tear in the vessel after arterial puncture or trauma. Spontaneous pseudoaneurysms of iliac artery, femoral artery, and their branches are rare. Atherosclerosis and connective tissue disease had been proposed to be the etiologies. Pseudoaneurysms can be asymptomatic or present with pulsatile masses, thrills, bruits, pain, skin necrosis, or rupture. Sonography is a useful diagnostic tool due to its high sensitivity and specificity. Pseudoaneurysms appear as hypoechoic masses with a neck communicating to the feeding vessel. “Yin-yang sign” and “to-and-fro signal” represent turbulent and bidirectional flow respectively. Observation alone is reasonable for small pseudoaneurysms, whereas ultrasound-guided compression, ultrasound-guided thrombin injection, or surgery may be indicated for pseudoaneurysms larger than 3cm, those with rapid expansion or infection, and symptomatic ones.
Peng-Yu LEE (Taipei, Taiwan), Jen-Tang SUN
00:00 - 00:00
#41697 - A man with spontaneous movements during endovascular balloon occlusion of the aorta-assisted resuscitation.
A man with spontaneous movements during endovascular balloon occlusion of the aorta-assisted resuscitation.
A 65-year-old man with no significant medical history collapsed suddenly after experiencing chest tightness. Family-initiated cardiopulmonary resuscitation (CPR) was followed by emergency medical services intervention. Despite achieving return of spontaneous circulation after two defibrillations, he re-arrested en route to the emergency department (ED). With all extracorporeal membrane oxygenation devices in use, the team employed the experimental resuscitative strategy, the endovascular balloon occlusion of the aorta (REBOA).
Fifty-one minutes after the initial out-of-hospital cardiac arrest (OHCA), which is fifteen minutes following ED admission, the REBOA balloon was successfully inflated in zone 1 of the aorta. The patient subsequently exhibited spontaneous movements of the upper limbs during ongoing CPR. However, once compressions ceased, he had no palpable pulses and became unresponsive. Eventually, sustained ROSC was not achieved, despite the potential preservation of neurological function.
This case illustrates CPR-induced consciousness after REBOA use, implying REBOA's potential for preserving neurological integrity, that has been confirmed in animal studies but not yet proven in humans. Our ongoing multinational randomized controlled trial seeks to confirm REBOA’s efficacy in non-traumatic cardiac arrest, potentially improving resuscitation strategies and patient outcomes.
Tzu Cheng WANG (Taipei, Taiwan, Taiwan), Sheng-En CHU
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#42080 - A mixed-method study, to assess the acceptability and applicability of using virtual reality for training mass casualty incidents.
A mixed-method study, to assess the acceptability and applicability of using virtual reality for training mass casualty incidents.
Background: Professionals working in ambulance services traditionally train and learn how to handle a mass casualty incident based on reading, and/or training through computer-based scenarios, or sometimes through live simulations with actors. Professionals should practice in realistic environments to narrow the theory-practice gap, and the possibility of repeating the training is important for learning. High-fidelity virtual reality is a promising tool to use for realistic and repeatable simulation training but needs to be further evaluated. The aim of this ongoing study is to assess the acceptability and applicability of using virtual reality for training mass casualty incidents.
Methods: A high-fidelity virtual reality simulation with mass casualty incident scenarios, named GoSaveThem (www.crash.nu), is used. In the virtual reality simulation, the participants are directed to perform primary triage, which is a system to initially sort out whom to help first in a mass casualty incident, with the intention to save as many injured as possible. To assess the acceptability, the participants will fill in a questionnaire with four open-ended questions after doing the virtual reality simulation. The applicability will be assessed by how the participants rate the technical aspects (usability), learning experiences, and improvement of preparedness. Furthermore, how long it takes for the participants to triage the first 10 patients, to what extent the triage for the first 10 patients is correct, and if there are any differences between age, sex and/or educational background, and previous experiences that affect the outcome of triaging will also be analyzed. This mixed methods study will integrate qualitative and quantitative findings in the discussion.
Preliminary results: Training with virtual reality enables repeatable and realistic simulation training of mass casualty incidents. Training with virtual reality is exciting and the participants express motivation to repeat the training and experience expanded virtual reality scenarios. Virtual reality offers a cost-effective and safe learning environment. The acceptability and applicability of virtual reality training in mass casualty incidents
Sophiahemmet University, AISAB (an ambulance serices company in Stockholm, Sweden), and Laerdal foundation, funded this PhD student project.
Sara HELDRING (Stockholm, Sweden), Jirwe MARIA, Jonas WIHLBORG, Veronica LINDSTROM
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#42408 - A national survey on current state and development needs of clinical and academic emergency medicine in China.
A national survey on current state and development needs of clinical and academic emergency medicine in China.
Background To characterize the current state of emergency medicine (EM) and the requirements for advancing EM
clinical practice, education and research in China.
Methods An anonymous electronic survey was conducted by Chinese Society of Emergency Medicine during
September to October 2021. The survey contained 30 questions divided into 2 sections: the current state of EM
development and the requirements for EM growth.
Results 722 hospitals were included, of 487 were Level III and 235 were Level II hospitals. We found that after 40
years of development, EM had established a mature disciplinary system and refined sub-specialties including critical
care, cardiopulmonary resuscitation, toxicology, disaster and emergency rescue. In Level III hospitals, 70.8% of EDs
were standardized training centers for EM residents, but master’s degree program, Doctor Degree program and
post-doctoral degree program was approved in only 37.8%, 8.4% and 2.9% of EDs respectively and postgraduate
curriculum was available in 1/4 of EDs. Only 8% have national or provincial key laboratories. In addition to advance
clinical practice, there was also a high demand to improve teaching and research capacities, mainly focusing on
literature review, research design and delivery, paper writing, residency training.
Conclusions EM has built a mature discipline system and refined sub-specialties in China. Teaching and research
developed parallel with clinical practice. However, there was still a lack of EM master’s and doctoral programs and
research capacities need to be improved. More outstanding clinical and academic training should be provided to
promote the rapid growth of EM in China.
Foundation of Construction of remote multi-point training course of
emergency skills based on 5G and AR technology (2022bysyjxkt11).
The special fund of the National Clinical Key Specialty Construction Program,
P. R. China (2022).
Lanfang DU (Beijing, China), Yan LI, Zhenjie WANG, Guoqiang ZHANG, Xiaohui CHEN, Yingping TIAN, Changju ZHU, Jinsong ZHANG, Lidong WU, Peiwu LI, Yuguo CHEN, Bing JI, Shuming PAN, Jun ZENG, Yanfen CHAI, Yesai MU, Mao ZHANG, Yu MA, Chuanzhu LV, Qingbian MA
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#40868 - A new Acute Palliation Concept: An observational study of dying patients without specialized needs.
A new Acute Palliation Concept: An observational study of dying patients without specialized needs.
Background: Of all dying Danish patients, 80% rely on non-specialized palliative care, an area lacking national and international guidelines. In this pilot study we developed and tested an Acute Basic Palliation Concept (ABPC), a structured End-of-Life (EOL) care plan for patients being discharged from the Emergency Department to die at home.
Methods: This study compared symptom scores and EOL care statement scores during a standard care period compared to an ABPC period using unvalidated questionnaires. Each period included 25 patients. The study was conducted across two emergency departments in Denmark and included patients aged ≥18 and nearing end-of-life. Further we asked if healthcare professionals would use the ABPC again.
Results: Relatives reported better symptom scores for three of four symptoms during the ABPC period. Doctors and municipal caregivers reported better scores for most EOL care statements during the ABPC period, while hospital nurses reported unchanged scores between periods. All 100% (n=67) healthcare professionals would use the ABPC again, with 96% who wrote positive free text comments.
conclusion: Relatives’ and healthcare professionals reported better symptom and EOL care scores during the ABPC period with all healthcare professionals stating they would use the ABPC again. Future studies with larger sample sizes and validated questionnaires are needed to verify our findings.
Funding was provided by Beta.Health, Region Nordjylland's Health Innovation Fund, and Health Hub by Spar Nord Fund.
Mike ASTORP (Aalborg, Denmark), Dorte MELGAARD, Johannes RIIS, Anne Lund KRARUP
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#41865 - A novel approach for aerosol therapy education in emergency care settings: simulation-based program.
A novel approach for aerosol therapy education in emergency care settings: simulation-based program.
Introduction: Aerosol delivery is a vital therapeutic strategy for both adult and paediatric patients presenting to the emergency department with respiratory distress. There is a considerable body of evidence supporting the use of Aerogen vibrating mesh nebuliser technology. Following the recently published studies on aerosol therapy in emergency care settings, the objective of this pilot course was to educate physicians on aerosol therapy, gain insights in current clinical practice, understand gaps in the published literature and educational needs and improve relationships with physicians.
Methods: This meeting was held in the AQAI Simulation Centre in Germany and comprised of three elements. Previously published in vitro studies were replicated using an advanced patient simulation across various modes of respiratory support through the escalation of care, from when the patient is admitted to the emergency department through to use during high flow nasal cannula therapy, non-invasive ventilation and mechanical ventilation in the intensive care unit. Imaging studies examining aerosol deposition were visualised through a 3D lung model. Clinical studies were presented by physicians who are experts in aerosol drug delivery. 20 participants from across Europe were in attendance and subsequently answered a questionnaire.
Results: At the end of the program, 70% of attendees acknowledged the course's efficacy in enhancing their competence in aerosol drug delivery across modes of respiratory support. 50-60% of attendees said they need to establish local protocols and educational courses to integrate this technology as their practice's standard of care. Attendees also suggested extending this educational approach to both physicians and nurses involved in the same emergency care units, to achieve better interdisciplinary alignment. Patient simulation enabled the demonstration of a wide range of incidents and complications through interactive sessions.
Conclusions: This peer-to-peer approach provides a platform to educate and train health care professionals on the complexities of respiratory drug delivery in the emergency department as well as in the emergency medical services environment.
N/A
Arash TAKI (Galway, Ireland), Gavin BENNETT, Amy TATHAM, Charalambos TSAGOGIORGAS
00:00 - 00:00
#41410 - A Novel Simulation Program to Enhance Inter-Speciality Referral Skills Among Emergency Medicine Trainees in Northern Ireland.
A Novel Simulation Program to Enhance Inter-Speciality Referral Skills Among Emergency Medicine Trainees in Northern Ireland.
Introduction: In the UK, where no established curriculum or specialized course is dedicated to emergency medicine (EM) referral skills, there is a pressing need for a comprehensive training program.
A 2022 survey of 148 EM doctors and 279 doctors from in-hospital specialities in Northern Ireland found that 73% of EM doctors struggled with referrals, while 79% of in-hospital doctors felt EM referrals were of low quality. A novel simulation-based referral skills pilot course was developed, offering education, practice opportunities, feedback, and assessment.
Methods: A specifically designed simulation-based education (SBE) was delivered on the 8th of November, 2023, in Craigavon Area Hospital. The simulation was delivered by four faculty members and attended by fifteen EM ACCS trainees. The objectives were to teach the EM Drs to Stop, think, and prepare before referral, use the SBAR referral tool, show assertiveness, and stop deflection. Four challenging referral scenarios were delivered, mirroring a real-life situation that EM doctors often encounter (Argumentative, bossy, dismissive, and challenging clinical referrals). The Scottish Centre debriefing model was used, and the following microteaching topics were delivered (reactions to difficult situations, assertiveness, stopping deflection, redirecting behaviour, conflict management styles, and emotional intelligence).
Results: The impact of the simulation program was significant. Of the 15 attendees, 60% had never received any training on referral skills. However, post-simulation, their confidence in making referrals improved from 13% to 80%. 87% rated the simulation high quality and 13% very high quality. 100% felt that the simulation would change their future practice and would recommend it to other EM Doctors. A follow-up questionnaire conducted five months post-simulation received ten responses, with 87% reporting a significant improvement in their referral skills.
Discussion: While simulation programs in EM traditionally focus on resuscitation, trauma and procedural skills, there is a lack of emphasis on referral skills. Some EM specialists argue that referral skills are acquired through experience rather than formal training. Consequently, junior doctors rarely receive guidance on how to conduct referrals. Inadequate handovers have been associated with events and clinical errors in emergency medicine due to communication and missing information (1). SBE expands medical education, recreating clinical settings for teaching, practising, and assessing. Trainees learn from mistakes and receive feedback. It is effective for teaching ED-specific skills. (2) The results of this pilot SBE on EM referral skills were promising and encouraging to expand its delivery at a broader scale.
References:
1. Moslehi S, Masoumi G, Barghi-Shirazi F. Benefits of simulation-based education in hospital emergency departments: a systematic review. Journal of education and health promotion. 2022 Jan 1;11(1):40. lww.com
2. Hock SM, Cassara M, Aghera A, Saloum D, Bentley SK. Attending physicians as simulation learners: summary of current practices and barriers in emergency medicine. Clinical and Experimental Emergency Medicine. 2024 Jan 29. ceemjournal.org
The simulation program was funded by the Northern Ireland Medical Dental Training Agency.
Mohamed SHIRAZY (Belfast, ), Julie-Anna RANKIN
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#42014 - A novel use of venous access in Serratus Anterior Plane block for thoracic blunt trauma.
A novel use of venous access in Serratus Anterior Plane block for thoracic blunt trauma.
INTRODUCTION:
Thoracic blunt trauma is often associated with multiple rib fractures (MRF) and pulmonary contusions, and it is challenging to manage the consequence due to the severe pain generated. Several studies suggest that high-flow nasal cannula (HFNC) is comparable with other methods of non-invasive ventilation and may be beneficial for patients with thoracic injury. HFNC could reduce the need for mechanical ventilation (MV) and to decrease hospital and intensive care unit days for patients with severe respiratory compromise. The pain can compromise the capacity to expand the thorax and to expel the secretions, and as consequence the risk of pneumonia increases. There are numerous strategies for pain management and its choice depends on the operator skill (such as continuous epidural infusion, paravertebral block, intrapleural infusion) and on the side effect of drugs (e.g. in the case of opioids administration, respiratory depression, and suppression of cough reflex). Current guidelines for thoracic blunt trauma recommended the use of thoracic epidural analgesia for patients who do not have any contraindications (level I recommendations), but its implementation is not easy to plan in the context of emergency department. Nowadays, a new technique for the pain management has been introduced and its purpose is to block the lateral branches of the intercostal nerves providing a thoracic wall analgesia: ultrasound-guided Serratus Anterior Plane (SAP) block. This procedure is relatively simple to perform without important side effect and for these reasons is catching on. In literature, numerous studies are testing the use of SAP block with the positioning of an epidural catheter to guarantee a continuous infusion of anaesthetic for the management of MRF. Nevertheless, this procedure is often complicated by a progressive reduction of beneficial effect probably due to its displacement caused by patient movement or infusion pressure.
METHODS:
To overcome the obstacle, we have hypothesized a “periodic” bolus administration of anaesthetic via placement of an ultrasound-guided venous access on serratus muscle and we tested the duration of beneficial effect of drugs.
RESULTS:
We enrolled three patients with thoracic blunt trauma and MRF associated to a persistent numerical rating scale (NRS) > 7 after acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) administration. All of them presented an abnormal alveolar-arterial gradient (Delta A-a) due to the concomitant presence of pulmonary contusions that exacerbate the gas exchange treated with HFNC. After the placing of venous access to practice SAP block, we administrated 20 ml of Ropivacaine 0.5% twice daily (every 12 hours). We observed a reduction of request of painkiller supplementation with a persistent NRS < 2. The improvement of the pain perception has guaranteed a faster normalization of Delta A-a and discharge of patients.
CONCLUSION:
The persistence of anaesthetic effect is probably due to the minor risk of displacement of venous access from serratus site and his major inflexibility. Our purpose is to increase the population, analysing pain perception over the time and its effect on gas exchange via Delta A-a evaluation.
Claudia CARELLI (Naples, Italy), Riccardo CANDIDO, Flavio CESARO, Claudia Sara CIMMINO, Angela Smeralda GIUNTA, Natja VALENTI, Danila GALLUCCIO, Mario GUARINO, Cosimo COSIMATO
00:00 - 00:00
#42236 - A Pediatric Emergency Medicine Medical Education collaboration focused on knowledge translation.
A Pediatric Emergency Medicine Medical Education collaboration focused on knowledge translation.
A Pediatric Emergency Medicine Medical Education collaboration focused on knowledge translation.
Spyridon Karageorgos, Owen Hibberd, Andrew Tagg, Tessa Davis, Becky Platt, Dani Hall
Faculty of Medicine and Dentistry, Blizard Institute, Queen Mary University of London, London E1 2AT, UK
Don’t Forget the Bubbles
Background
Pediatric Emergency Medicine (PEM) is a rapidly evolving field combining pediatrics, anesthesia, emergency medicine and pediatric intensive care. PEM training varies worldwide, whereas free open-access medical education (FOAMed) projects assist in PEM knowledge translation and dissemination.
Methods
In 2021, the combined Queen Mary University London (QMUL), in collaboration with the PEM online education platform Don’t Forget the Bubbles (DFTB), established the PEM MSc. The goal was to provide high-quality interactive online education on PEM practices.
A total of 52 students are enrolled forming a multidisciplinary team consisting of pediatric and emergency medicine trainees and fellows, paramedics, nurses and nurse practitioners. Via innovative assignments that include infographic creation, writing blog spots and creating a video presentation, students enhance their knowledge translation and critical appraisal skills. Students get feedback on their work and some blog posts are chosen for publication on DFTB.
Article metrics were used to quantitively measure the accessibility and dissemination of published articles.
Results
As of April 2024, 15 students’ blog posts were published on DFTB, and two DFTB Bubble Wraps critically appraising 5 interesting PEM papers. Published article metrics showed a total of 446 tweets and an upper bound of 1,309,548 followers. Two students participated as guest speakers in the renowned Skeptic Guide to Emergency Medicine (SGEM) podcast. Also, 3 peer-reviewed articles have been published through student and faculty collaboration.
Conclusion
The online QMUL DFTB PEM MSc provides an innovative medical education platform that enhances students’ knowledge translation skills while also providing opportunities to participate in research projects and peer-reviewed articles.
Spyridon KARAGEORGOS (Athens, Greece), Owen HIBBERD, Andrew TAGG, Tessa DAVIS, Becky PLATT, Dani HALL
00:00 - 00:00
#41096 - A Pilot Study in the Use of the Delphi Method to Document Conference Proceedings: Comparison of the Rate of Consensus Among Attending and Non-attending Participants.
A Pilot Study in the Use of the Delphi Method to Document Conference Proceedings: Comparison of the Rate of Consensus Among Attending and Non-attending Participants.
OBJECTIVE: While many medical practitioners value the interactive nature of in-person conferences, results of these interactions are often poorly documented. The objective of this study was to pilot the Delphi method for developing consensus following a national conference and to compare the results between experts who did and did not attend.
METHODS: A three-round Delphi included experts attending the 2023 Society of Disaster Medicine and Health Preparedness Annual Meeting and experts who were members of the society but did not attend. Each conference speaker provided statements related to their presentations. Experts rated the statements on a 1-7 scale for agreement using STAT59 software. Consensus was defined as a standard deviation of <= 1.0.
RESULTS: Seventy-five statements were rated by 27 experts who attended and ten who did not: 2634 ratings in total. There was no difference in the number of statements reaching consensus in the attending group (26/75) versus the non-attending group (27/75) (p=0.89). However, which statements reached consensus differed between the groups.
CONCLUSION: The Delphi method is a viable method to document consensus from a conference. Advantages include the ability to involve large groups of experts, statistical measurement of the degree of consensus, and prioritization of the results.
None
Dr Jeffrey FRANC (Edmonton, Italy), Eric WEINSTEIN, Manuela VERDE
00:00 - 00:00
#41787 - A possible role of incident reporting in evaluating non technical skills and their effect on patient safety in pre-hospital emergency services.
A possible role of incident reporting in evaluating non technical skills and their effect on patient safety in pre-hospital emergency services.
Background: Despite the critical role of non-technical skills (NTS) in coping with emergencies, these have hardly been researched in the pre-hospital setting. Aim of this study was to assess the perception by pre-hospital emergency personnel of how NTS affect patient safety, using incident reporting.
Methods: Since 2017, Trentino Emergenza (TE), the emergency medical service of Trento Province, Italy, established an anonymous incident reporting system. To assess the perception by TE personnel on how NTS affect patient safety, a multidisciplinary peer-reviewing group of six (one physician, three nurses and two healthcare technicians) analyzed incidents related to issues regarding NTS which were reported in 2023. Each report was examined by reviewers for: leadership, situational awareness, decision making, communication, teamwork, assertiveness, education and cooperation. For each incident report regarding NTS, reviewers highlighted every NTS issue noted awarding it a point. For each incident, we identified the severity level of risk experienced by the patient, as recorded on the report and thus perceived by the compiler.
Results: In 2023, 356 incident reports were recorded, of which 52 (14,6%) reported NTS issues. Among these, reviewers awarded an overall 18 points to issues concerning leadership; 59 points to teamwork; 53 points to assertiveness; 35 points to cooperation; 124 points to situational awareness; 32 points to decision making; 117 points to communication; 55 points to education.
On a scale ranging from 1 (dangerous situation) to 8 (severe outcome), a level of risk of 1 was reported 3 times (5,8%); a level of risk of 2 (intercepted event) was reported 9 times (17,3%); a level of risk of 3 (event occurred with no damage) was the most represented, being reported in 35 reports (67%); a level of risk of 4 (event occurred with minor damage) was reported 3 times (5,8%); a level of risk of 6 (event occurred with a moderate-significant outcome) and 7 (significant outcome) were each reported in one occasion (1,9% for each); no event with a level of risk of 5 (event occurred with a moderate outcome) or 8 was reported.
Discussion & Conclusions: The number of reports regarding the effects of NTS on patient safety show that this is a heartfelt problem by pre-hospital emergency personnel. Issues most perceived concern situational awareness (recognition and comprehension of changes in the environment/threats to self or others in the immediate or near future that require an immediate response) and communication (collaborative, productive, accurate communication among team members). Although in most cases issues concerning NTS resulted in no damage for the patient, it is notable how in one occasion these were responsible for a significant outcome. Increased emphasis on NTS recognition must lead to specific training on currently underrecognized skill sets that have the potential to transform emergency medical patient care.
Trial Registration: non-clinical work
Funding: This study did not receive any specific funding
Elena VERDINI (Trento, Italy), Sonia GIULIANI, Elena PEDROTTI, Caterina COMPOSTELLA, Alessandro VITALI, Luca CONTE, Roberta LEVATO, Andrea VENTURA
00:00 - 00:00
#40722 - A Prehospital Case of Severe Malaria.
A Prehospital Case of Severe Malaria.
It is a with great pleasure that I present to you a comprehensive analysis of imported malaria in Europe, intertwined with a compelling clinical case that sheds light on the challenges and triumphs in managing this complex condition. Malaria, once deemed a disease of distant lands, now poses a significant threat to global health security, with increasing instances of imported cases in Europe. Our journey today delves into the intricacies of imported malaria, exploring diagnostic dilemmas, therapeutic strategies, and public health implications through the lens of a compelling clinical scenario.
Clinical Case Presentation:
Picture worker coming to Europe to work from his tropical native country, assailant within – Plasmodium falciparum, the most virulent strain of malaria. Our patient, a 41-year-old famworker, black race, who has been living in Spain for years, andpresents with fever, deorientation, decreased GCS and jaundice, symptoms reminiscent of countlles other tropical illnesses. However, amidst the diagnostic uncertainty, meticulous history-taking unveils a recent journey to malaria-endemic regions, igniting suspicion and urgency in our clinical approach. In this case, as he had a late onset and because of his living conditions (a house without light and windows) the jaundice was not detected until we went out of the house, this late onset difficulted the diagnose in the beginging. On his arrival to the hospital he is haemodynamically stable, his CBC shows haemoglobin of 12, lactate 5, CPR 247, bilirubin 9.06.
Through a collaborative effort between clinicians, (24% plasmodium detected in erythrocytes), our team embarks on a diagnostic odyssey, employing rapid diagnostic tests, microscopy, and molecular techniques to confirm the diagnosis swiftly and accurately. The race against time ensues as we navigate the complexities of antimalarial therapy, weighing efficacy, safety, and regional resistance patterns to tailor treatment regimens that ensure our patient's swift recovery.
Review of Imported Malaria in Europe:
Delving beyond the confines of our clinical vignette, let us cast a broader gaze upon the landscape of imported malaria in Europe. With globalization fueling increased travel to malaria-endemic regions, Europe stands as a gateway for imported cases, posing formidable challenges to healthcare systems across the continent. From the shores of the Mediterranean to the urban centers of Northern Europe, imported malaria knows no bounds, demanding vigilant surveillance, robust diagnostics, and evidence-based management protocols.
Exploring epidemiological trends, we unravel the dynamic interplay between travel patterns, migrant populations, and regional variations in malaria endemicity, underscoring the need for tailored public health interventions that transcend borders. Moreover, in an era fraught with emerging antimalarial resistance, we confront the sobering reality of therapeutic limitations and the imperative for continued research and innovation in drug development.
Conclusion:
As we draw the curtains on our exploration of imported malaria in Europe, let us embrace the lessons gleaned from our clinical case and review, recognizing the collective responsibility to safeguard the health and well-being of travelers, migrants, and indigenous populations alike. Through interdisciplinary collaboration, rigorous surveillance, and unwavering commitment, we stand poised to confront the challenges of imported malaria with resilience, compassion, and scientific rigor.
Izaskun TELLITU (Tarragona, Spain), Roca Burgueño JUDITH
00:00 - 00:00
#41552 - A Rare Case ; Post Traumatic Dissection of the Internal Carotid Artery.
A Rare Case ; Post Traumatic Dissection of the Internal Carotid Artery.
Abstract:
Introduction: Traumatic neck injuries are a major cause of morbidity and mortality in patients presenting to emergency departments. Neck injuries resulting from inertial loading of the head and neck (whiplash) can affect the internal carotid artery. This case report highlights the importance of early diagnosis and appropriate management of traumatic internal carotid dissection.
Case presentation:
A 38-year-old woman was admitted to the emergency department (ED) for a motorcycle accident with no abnormal findings other than multiple fractures . However, after admission, she developed symptoms of numbness in the right arm, dysarthria, and obliteration of the nasolabial sulcus on the left side. A contrast computed tomography scan of the brain and neck was performed. The images showed a dissection of the left internal carotid artery at the C3 segment of the left carotid artery.
Conclusion:
Emergency physicians and other first responders to trauma patients should be aware that a passenger in a mildly damaged vehicle may be severely injured. Post-traumatic ICA dissection, which is rare, is one of the emergencies that should be considered in the differential diagnosis of cases such as whiplash injury.
Cengizhan KESKI, Mustafa Tolga ÖZDAL (Bursa, Turkey), Sümeyra GÜRSOY, Melih YÜKSEL
00:00 - 00:00
#41311 - A rare case of abdominal pain - A case report on Celiac artery dissection.
A rare case of abdominal pain - A case report on Celiac artery dissection.
Background:
Isolated celiac artery dissection is a rare condition whereby the superior mesenteric artery is most commonly affected1. Though often asymptomatic2 and picked up incidentally, it can present as a rare cause of abdominal pain with potentially devastating complications.
Case presentation:
We describe the case of a 55-year-old male who presented with left sided abdominal pain secondary to spontaneous celiac artery dissection.
A 55-year-old male with background history of hypertension and hyperlipidaemia presented to the Emergency Department for left sided abdominal pain of 1-day duration. He described a crampy, colicky sensation over the epigastrium and left abdominal region, associated with nausea. There were no other associated symptoms.
On examination, he was hypertensive with a blood pressure of 211/93mmHg. Tenderness was elicited over the left iliac fossa, left hypochondriac and epigastric regions, without rebound tenderness or guarding. There were no inguinal hernias, no renal angle tenderness bilaterally and no motor or sensory neurological deficits.
Initial laboratory investigations were unremarkable. X-ray KUB (Kidneys Ureter Bladder) showed faecal loading in the ascending and descending colon but there were no obvious renal calculi.
A Computed Tomography (CT) scan of the Abdomen and Pelvis was performed in view of persistent pain despite analgesia, which revealed periarterial wall thickening of the celiac artery extending into the splenic artery and proximal segment of the common hepatic artery. These findings suggested celiac artery dissection with distal extension, without evidence of end-organ ischaemia.
He was admitted to the Department of General Surgery’s High Dependency Unit and started on intravenous antihypertensives to keep his blood pressure controlled to target, and planned for a repeat CT Mesenteric angiogram to monitor progression of the dissection. However, he was discharged against medical advice before his blood pressure could be adequately controlled.
Discussion:
Asymptomatic cases of celiac artery dissection are often incidentally picked up on advanced imaging techniques – of which CT angiography is the imaging technique of choice3.
Symptomatic cases are usually due to intestinal angina or bleeding, most typically presenting with acute onset epigastric or hypochondriac pain. Atypical presentations may be due to involvement of the surrounding arteries, such as, malabsorption with superior mesenteric artery dissection, jaundice with hepatic artery dissection or pancreatitis with pancreatic artery involvement4. Complications of isolated celiac artery dissection include visceral organ ischaemia (splenic infarcts or intestinal ischaemia) and aneurysm rupture.
The causes of arterial dissection are usually atherosclerosis, trauma, iatrogenic, pregnancy, syphilis, polyarteritis nodosa and congenital disorders of the vascular wall4,5. Precipitating events include microtrauma caused by exertion or sudden increases in abdominal pressure such as sneezing or heavy lifting.
Due to the rarity of this condition, large prospective studies have not been conducted and there are no consensus guidelines for the mainstay of treatment of isolated celiac artery dissection6. Treatment options include conservative medical therapy (anticoagulation medication and blood pressure control), endovascular stenting, and open surgery.
In conclusion, celiac artery dissection is a rare cause of abdominal pain but should be considered as a differential in view of its potentially disastrous complications.
Nicole CHENG (Singapore, Singapore), Gwendolyn SEAH, Huiling HUANG
00:00 - 00:00
#41100 - A rare case of Fahr’s Syndrome presenting as syncope and hypocalcaemia.
A rare case of Fahr’s Syndrome presenting as syncope and hypocalcaemia.
Introduction:
Fahr's disease is a rare genetic neurodegenerative disorder, also known as “bilateral striopallidodentate calcinosis”. It is characterized by calcium deposition crossing the blood-brain barrier and calcifying different brain areas, including basal ganglia, dentate nuclei, cerebral cortex, and other brain structures. We report a case of Fahr’s disease presenting with syncope and hypocalcemia secondary to hypoparathyroidism.
Case Report:
A 47-year-old woman presented to the Emergency Department (ED) with a fall in the toilet sustaining head injury and loss of consciousness. She had a past medical history of Graves’ disease with subtotal thyroidectomy. Her vital signs in ED were stable and there was no postural hypotension. Her neurological examination was normal. Blood glucose was normal and ECG showed normal sinus rhythm with prolonged QTc interval. Blood tests were normal except calcium which was 1.11mmol/L (normal 2.2 – 2.7 mmol/L). Computed tomography (CT) scan of the head did not show intracranial haemorrhage but there was symmetrical confluent calcification, predominantly in the basal ganglia bilaterally, suggestive of FAHR syndrome. She was admitted to intensive care and the calcium was replaced. She was discharged well with oral calcium supplements and outpatient follow-up with endocrinology.
Discussion:
Fahr’s disease is classified into two forms, the primary form "Fahr's disease" is familial, autosomal dominant, and sporadic. The secondary form "Fahr's syndrome" occurs in association with the presence of other underlying conditions. Hypoparathyroidism is the most common secondary cause, with other causes being toxoplasmosis, brucellosis and HIV resulting in encephalitis.
Fahr's disease has variable symptoms at presentation, including seizures, cognitive impairment, parkinsonism, tremor, dystonia, ataxia, chorea, dysarthria, headache, and other neuropsychiatric symptoms. The modality of choice in diagnosing Fahr's syndrome is a non-contrast CT scan. It was suggested that progressive inflammatory or metabolic processes within the brain lead could lead to intra-cranial calcification, which results in neurological defects. It is often detected incidentally during radiological investigations, with a reported range of 0.3% to 1.2%. The basal ganglia and cerebellum are the most common sites of calcifications. Neurological and psychiatric symptoms depend on the calcification area in the brain.
Management of Fahr's syndrome includes treatment of the underlying conditions. Our patient who presented with syncope was diagnosed to have Fahr’s syndrome secondary to hypoparathyroidism leading to hypocalcaemia. She was treated with intavenous calcium and discharged on oral calcium replacement (calcium carbonate) and vitamin D for hypoparathyroidism.
Conclusion:
Our case emphasizes the importance of neuroimaging and metabolic workup when investigating a case of syncope, which could be secondary to Fahr’s syndrome. If the diagnosis is made early and the underlying condition treated, the process of calcification could be slowed down with improvement in the patient’s condition.
Dr Amar SATYAM (Singapore, Singapore), Sohil POTHIAWALA
00:00 - 00:00
#41514 - A rare case of iliopsoas abscess associated with drug-induced hepatitis.
A rare case of iliopsoas abscess associated with drug-induced hepatitis.
Background:
A Psoas abscess is a collection of pus in the iliopsoas muscle compartment. While it is rare, the frequency of diagnosing this condition has risen due to computed tomography. Previously, most cases were only identified during postmortem examinations.
Case report:
A 49-year-old female patient, known to have high blood pressure, presents to the Emergency Department for pain in the right hypochondrium and the lower abdominal floor with maximum intensity in the left iliac fossa and at the level of the lumbar spine. The symptomatology appeared 14 days ago and progressively intensified. At the time of emergency admission, the patient had jaundiced skin and sclera, which she related for 24 hours. Until the computer tomograph of the abdomen and pelvis with contrast substance was performed, the blood tests arrived, which were drastic.
Initially, the patient received antipyretics and analgesics in the Emergency Department. From the patient's reports, it appears that due to the high intensity of the pain, she repeatedly self-administered different types of painkillers at home, including Aspirin, Paracetamol, Ibuprofen, and Diclofenac. Thus, the patient reaches the stage of developing post-drug hepatitis, evidenced by elevated liver samples.
A CT examination of the abdomen and pelvis is performed with a contrast substance that detects fused abscess-type collections at the interfibrillar level at the level of the left iliopsoas muscle.
She received intravenous (IV) fluid resuscitation, paracetamol, and empiric ceftriaxone.
A chest X-ray and blood tests were performed to rule out tuberculosis. I resorted to this gesture because of Pott's disease, tuberculous spondylitis, which can give psoas muscle abscess. Following the CT result, it was decided that the patient should be transferred to the surgery department. After the preoperative preparation, surgical intervention is performed, and the Dos Santos incision is practiced. After dissection of the anatomical planes, a voluminous abscess is drained from the level of the left psoas muscle, taking cultures from this level simultaneously. It continues with the debridement and washing of the operative area, placing drain tubes at this level.
The culture results from the abscess were positive for Staphylococcus aureus. According to the antibiogram, the strain of Staphylococcus aureus identified at the abscess level was sensitive to Linezolid. Thus, it has been decided that treatment should be started with Linezolid 600 mg twice a day for seven days.
The patient shows a favorable postoperative evolution. She is in good general condition, appetizing, and afebrile, and he was discharged home after 12 days of hospitalization.
Conclusion
Patients afflicted with a psoas abscess often experience nonspecific symptoms that may gradually manifest. Common indications include elevated body temperature, discomfort in the lower back or hip that may extend to the groin, a lump, and a general feeling of unease. The utilization of percutaneous drainage is crucial for the primary treatment of the abscess (to control the source) and for identifying the microorganism(s) responsible for the infection.
Daian-Ionel POPA (Timișoara, Romania), Carmen WILLIAMS, Florina BULEU, Dumitru ȘUTOI, Cosmin TREBUIAN, Ovidiu Alexandru MEDERLE, Raluca RADBEA
00:00 - 00:00
#41549 - A rare cause of abdominal pain.
A rare cause of abdominal pain.
A 79-year-old man with a history of DM2, biological aortic prosthesis, atrial fibrillation and cholecystectomy 7 years earlier who came to the emergency department for abdominal pain of 3 days' evolution in the left iliac fossa associated with nausea. The patient had been admitted until the week prior to consultation for acute cholangitis associated with choledocholithiasis. During admission, two ERCP procedures were performed for two-stage extraction of the choledocholithiasis with placement of a biliary prosthesis in the first of them.
He presented with pain on palpation in the left iliac fossa, neutrophilia and increased CRP. An abdominal CT scan showed pneumoperitoneum bubbles in relation to perforation of the hollow viscera. In the lumen of the sigma, a 7 cm radiodense linear image was observed, corresponding to the migrated ERCP plastic prosthesis penetrating through the anterior wall of the sigma. The patient underwent surgery and a resection of the sigma with unloading colostomy was performed.
Migration of biliary stents is a rare complication of the procedure (3%-6%). Most often they are asymptomatic and eliminated in the faeces. Intestinal perforation is an exceptional complication occurring mainly in the duodenum or ileum. Only about 20 sigmoid perforations due to migration of biliary prostheses have been described in the literature.
Ana Belén CARLAVILLA MARTINEZ, Isabel FERNÁNDEZ-MARÍN, Cuadrado Fernandez MARÍA, Vazquez Rodriguez TAMARA, Ana Belén CARLAVILLA MARTÍNEZ (MADRID, Spain)
00:00 - 00:00
#41388 - A rare cause of hoarse voice and wheezing.
A rare cause of hoarse voice and wheezing.
Question:
What is an emergency physician’s approach to voice hoarseness?
Brief clinical history:
A 62-year old Malay male presented with a 5-day history of hoarse voice, cough, sore throat and wheezing. He was a smoker of 10 pack years, and was a teetotaller. He has hyperlipidaemia, hypertension, transient ischaemic attack, oesophageal cystic lesion and possible underlying obstructive airway disease. Further history revealed no globus sensation, odynophagia, dysphagia, haemoptysis, fever, chest pain, rhinorrhoea or constitutional symptoms. He has not had any significant travel history. His vital signs were within limits. A physical examination revealed a well-looking patient with biphasic wheezing and hoarse voice. He was able to speak in full sentences and did not have a stridor.
Misleading elements:
ENT was consulted in the Emergency Department - a laryngoscopy did not reveal any obstructions or vocal cord/upper airway abnormalities. His full blood count, urea and electrolytes and C reactive protein levels were normal. Radiographs of the chest did not reveal any consolidation or pleural effusion or radio-opaque foreign bodies. Lateral neck radiograph did not reveal any pre-vertebral soft tissue swelling, gas lucencies, radio-opaque foreign bodies or abnormalities of the epiglottis. The initial impression was that of exacerbation of obstructive airway disease (COPD and/or asthma). The patient was started on oral steroids, antibiotics and regular nebulisers.
Helpful details:
The patient had already been started on prednisolone and co-amoxiclav by his primary care physician and reported minimal improvement of his symptoms. He continued to be become more breathless with transient desaturation after admission to the ward.
Actual diagnosis:
He suffered a cardiac arrest the following morning with a rhythm of pulseless electrical rhythm. CT thorax with contrast showed that the cystic oesophageal structure had enlarged over a period of 5 years, and that there was increased tracheal deviation with narrowing of the trachea. He developed hypoxic ischaemic encephalopathy as result of the cardiac arrest. The coroner ruled the cause of death as hypoxic ischaemic encephalopathy following acute tracheal obstruction from oesophageal cyst.
Educational points:
Oesophageal cysts are rare - and can be asymptomatic or present with a variety of symptoms depending on the location. Patients with cysts that are located in the lower third of the oesophagus may have dysphagia and cardiac arrhythmias. Patients with cysts that are located in the middle or upper third of the oesophagus can present with chest pain, stridor, hoarse voice and wheezing. Surgical removal is required for most symptomatic cases.
It is important to consider a wide range of differential diagnoses for patients presenting with hoarse voice and wheezing. It would be prudent to do an assessment of the oral cavity, ears, respiratory and neurological system.
Timothy WONG (Singapore, Singapore), Ser Hon PUAH
00:00 - 00:00
#42154 - A retrospective analysis of the clinical profile and outcome of patients, presenting with tricyclic antidepressant overdose, to the emergency department of a tertiary care centre in india.
A retrospective analysis of the clinical profile and outcome of patients, presenting with tricyclic antidepressant overdose, to the emergency department of a tertiary care centre in india.
Introduction: There is a dearth of evidence and information about the presentation and treatment of patients who present with overdose of tricyclic antidepressants in India.
Aim: The aim was to elaborate the clinical profile and outcome of patients with Tricyclic Antidepressant overdose, presenting to the Emergency Department.
Materials and methods : This was a single center, retrospective, observational study. Ethical clearance was obtained and all patients that presented to the Emergency Department with history of overdose of Tricyclic Antidepressant between January 2017 to December 2022 were included.
Results: Data was collected from the electronic database of the hospital. Among the 3191 patients that presented with history of deliberate self harm during this period, 75 had consumed Tricyclic Antidepressants. Of the 75, 18.6% were very sick, requiring ICU care. A higher heart rate and respiratory rate, low blood pressure, low glasgow coma score and a wide QRS on ECG at presentation were associated with a worse outcome. 45% of our patients needed Inj Sodium Bicarbonate infusion for alkalinization and 12% needed intubation and ICU care. We had 3% mortality among these patients, secondary to aspiration pneumonia.
Conclusion: There is scarce data on Tricyclic antidepressant overdose presentation and management in India. There is a need for a large multicentric study to really understand outcome in relationship to treatment. This is a small single center experience, trying to elaborate what we have seen.
Conclusion: Information
No funding required
Gina CHANDY (Vellore, India)
00:00 - 00:00
#42096 - A service evaluation into factors affecting pre-hospital emergency anaesthesia outcomes at the North West Air Ambulance service.
A service evaluation into factors affecting pre-hospital emergency anaesthesia outcomes at the North West Air Ambulance service.
Background: Pre-Hospital Emergency Anaesthesia (PHEA) is a core skill in the emergency management of critically ill and unwell patients in the prehospital environment. Each year, at least 1,700 patients in the UK undergo PHEA. When compared with in-hospital intubation, this pre-hospital patient cohort present as a challenging, unstarved and unprepared group who are often in some degree of shock and respiratory failure. Many past studies measure first pass success (FPS) as a proxy marker for a successful procedure, but the physiological challenges post-PHEA such as hypotension, hypoxia, or cardiac arrest are more common in the prehospital setting and arguably more important to patient outcome. The objective of this study is to identify the factors associated with post-PHEA complications and develop a predictive model to mitigate these outcomes in future practice.
Methods: Using data recorded by the North West Air Ambulance (NWAA) service, we are conducting a retrospective service evaluation exploring both patient and procedural factors affecting adverse events post-PHEA. The adverse effects are defined as failed FPS, hypotension (systolic blood pressure (SBP) <120mmHg) and/or hypoxia (SpO2<96%) within the first five minutes or cardiac arrest post-induction. Anonymised data of patients who received PHEA between 18th March 2022 and 1st May 2024 will be exported from HEMSbase and collated into a password-protected data sheet. The following data items will be retrieved for analysis: patient demographics (age, estimated-weight, gender), mechanism of injury, indication for PHEA and details regarding intubation (number of attempts, blade used, presence of a soiled airway). A manual review of each case will then be conducted to extract relevant physiological data recorded immediately prior to PHEA (heart rate (HR), systolic blood pressure (SBP) and respiratory rate (RR)), together with environmental and clinician data. A logistic regression model has been developed using the SPSS software to identify pre-PHEA variables associated with hypotension, hypoxia <5 minutes post-induction or cardiac arrest.
Anticipated Results: During the study period, 3120 patients were attended, 641 underwent intubation and, of these, 341 underwent PHEA. On preliminary analysis, 48.8% of patients experienced at least one of the defined adverse outcomes post-intubation, with the most common being hypoxia. Comprehensive results that delineate the relative association between these factors and physiological complications post-induction will be available to be presented at the conference once the regression analysis has been performed.
Conclusion: Our data from a large data set of UK PHEA will provide a better understanding of factors associated with adverse outcomes post-PHEA. This project will create a predictive model for PHEA that can be used to risk stratify PHEA outcomes for future audit, research, and service evaluation.
Abigail LAYCOCK (Manchester, United Kingdom), Simon CARLEY, Robert EVANS
00:00 - 00:00
#41718 - A Stroke mimic in the elderly: myasthenia gravis.
A Stroke mimic in the elderly: myasthenia gravis.
An 80-year patient presented to the Emergency Department with a 3-week history of diplopia, left-sided ptosis, and left-sided weakness. On examination, there was a left-sided ptosis, but no other acute neurology was identified. A CT head showed a left cerebellar hemisphere. FBC showed a mild microcytic anaemia, LFTs, CRP, and the renal profile were normal.
The initial diagnosis was of a left cerebellar stroke. The patient was given 300mg aspirin and transferred to the local stroke emergency assessment centre. However, after a stroke consultant review, he was diagnosed with Myasthenia Gravis (MG).
MG is an autoimmune disorder where the immune system develops antibodies against acetylcholine receptors or other molecules in the postsynaptic membrane of the neuromuscular junction, causing fatigable muscle weakness. MG can be difficult to diagnose in the elderly for several reasons: Sagging of eyelids makes ptosis harder to identify; diplopia can be masked by eye diseases, e.g. macular degeneration, or cataracts. Misdiagnosis of MG could lead to inappropriate stroke treatment. This case highlights the danger of false positive imaging, especially in the elderly population where the rate of silent infarct is high. Therefore, imaging should not be a substitute for good history taking and examination. Despite the increased co-morbidities of elderly patients, treatment outcomes are comparable to that of younger patients, and as such MG is a diagnosis not to be missed in the elderly.
William MARTIN (Liverpool, ), Balakrishna VALLURU
00:00 - 00:00
#41289 - A subset of PRES: isolated brainstem encephalopathy.
A subset of PRES: isolated brainstem encephalopathy.
Posterior reversible encephalopathy syndrome (PRES) is a condition that usually presents with headaches, altered mental status, visual disturbances, and seizures. Neuroimaging of such patients would highlight reversible vasogenic oedema in the white matter of bilateral cerebral hemispheres, especially at the parieto-occiptal regions. Isolated brainstem involvement without the typical parieto-occipital regions is not commonly reported, with mainly case reports noted in the current literature search.
Clinical case report:
A 37 year old male with a background of hypertension and chronic kidney disease presented post seizure activity to the Emergency Department. Upon arrival, he was in the post ictal phase, with his GCS subsequently improving 15 with a normal neurological examination within a few minutes. His vitals were BP 224/168, HR 130, SpO2 99% RA. A CT brain was completed revealing diffuse hypodense/oedematous changes of the brainstem, suggestive of hypertensive brainstem encephalopathy, with hypodense white matter changes of bilateral thamali likely due to hypertensive insults. His blood pressure was subsequently controlled with IV labetalol, and was admitted to ICU for further management and titration of his anti-hypertensive medications. A MRI brain was completed, showing a slightly swollen brainstem with diffuse FLAIR high signal and absence of restricted diffusion, further confirming the diagnosis of hypertensive brainstem encephalopathy. He was subsequently discharged after good control of his blood pressure with the decision to follow up back in his home country.
Clinical relevance + differentials
PRES is thought to occur when the acute rise in blood pressure (BP) breaks through the upper limit of the cerebral autoregulation, resulting in passive overdistension of the blood vessels, breakdown of the blood-brain barrier and the shift of fluids and proteins into the brain interstitium. It is postulated that the posterior circulation has lesser sympathetic innervation, leading to an increased inclination for the posterior regions to be involved.
Risk factors for isolated brainstem encephalopathy include hypertension and end stage renal disease, with the latter resulting in an inability to maintain constant blood perfusion due to the uraemic state, as well as ongoing electrolyte imbalances and urinary protein loss contributing to vasogenic oedema formation. Case studies have also showed chemotherapy agents to be a risk factor resulting in PRES as well.
Neuroimaging, with MRI being the gold standard, is critical in identifying PRES with isolated brainstem involvement, with increased signal in T2/FLAIR sequences, consistent with vasogenic oedema. This differentiates it from another important differential of brainstem infarction. This is especially significant as the management for both conditions differ greatly in terms of BP control. Other differentials include demyelinating diseases, central pontine myelinolysis, and brain stem glioma, lymphoma, and infectious diseases.
The treatment priority is to control the BP, with case studies using IV labetalol as an agent. The prognosis is usually good with adequate control of the BP and reducing the risk factors involved.
Natalie TANG (Singapore, Singapore)
00:00 - 00:00
#41217 - A SURPRISING HIATAL HERNIA.
A SURPRISING HIATAL HERNIA.
Hiatal hernia (HH) type IV is a rare pathology. It results in herniation of the stomach and other adjacent organs. The most frequent organs are colon, small intestine, omentum and spleen. Herniation of the pancreas is very rare with few cases described in the literature.
Approved by the hospital’s Ethics and Research Unit.
• CASE REPORT
A 89-year-old female patient with no vascular risk factors, who lives alone, is self-sufficient and does not take regular medical treatment. Surgical history of appendectomy and right inguinal herniorrhaphy. Diagnosed 14 years ago with cholelithiasis and a small sliding HH that has not caused any symptoms. She came to the Emergency Department (ED) with 10 hours of abdominal pain in the epigastrium with nausea and bilious vomiting. Stools were normal and she had no fever. Blood pressure: 113/70, heart rate: 75. Physical examination was normal, except for the abdomen. It was painful on palpation in the epigastrium with normal bowel sounds without peritonism. Laboratory tests with complete biochemical blood count, coagulation, urine were normal. The chest x-ray revealed cardiomegaly. Computerized Axial Tomography (CT) showed a voluminous HH containing the stomach, body and tail of the pancreas, and a segment of splenic vein. With the diagnosis of giant HH type IV with intrathoracic pancreas, she was admitted with analgesia to complete the study and consider the indication for surgical intervention.
• DISCUSSION
HH can be congenital or acquired. It is caused by migration of the stomach and other organs through the diaphragm. HH is more common in women and increases with age. Depending on the position of the gastroesophageal junction and the extent of herniation, HH are classified as follows:
1. Type I: Sliding hernia, the most frequent (95%).
2. Type II: Herniation of the gastric fundus in the mediastinum adjacent to the esophagus with the gastroesophageal junction in the correct position.
3. Type III: At least 30 % of the stomach is herniated with the gastroesophageal junction.
4. Type IV: Herniation of the stomach and other adjacent organs occurs. Represents 0.3% of acquired HH.
The clinical manifestations of HH are heterogeneous and vary according to the degree and size of the hernia and the herniated structures. Symptoms include abdominal pain, nausea, vomiting, gastroesophageal reflux symptoms, rarely presenting as subocclusive symptoms. HH with pancreatic herniation may present with acute pancreatitis. HH may present with cardiorespiratory symptoms such as persistent cough, chest pain and dyspnea.
CT is the test of choice for the diagnosis of HH, as it defines the degree and the herniated structures. The diagnosis is completed with the gastroesophageal study with barium, which provides anatomical information of great use for surgical treatment.
Treatment can be conservative in patients with oligosymptomatic low-grade hernias or surgical in high-grade or symptomatic hernias that cannot be controlled with conservative treatment.
• CONCLUSION
HH with intrathoracic pancreas is a very rare cause of abdominal pain. These are giant type IV HH that require surgical treatment to avoid other serious complications. For this reason, early diagnosis is important.
Patricia MARTÍNEZ-OLAIZOLA (GETXO, Spain), Erika.y CÉSPEDES-SUZUKI, Federico MORAN-CUESTA, Maria Isabel SIERRA-TORRIJOS, Ana Maria ANGULO-SAIZ, Carlos LOUREIRO-GONZÁLEZ, Mercedes VARONA-PEINADOR
00:00 - 00:00
#41462 - A Systematic Review on The Effectiveness and Safety of Half-Dose Thrombolytic Therapy in the Treatment of Acute Pulmonary Embolism.
A Systematic Review on The Effectiveness and Safety of Half-Dose Thrombolytic Therapy in the Treatment of Acute Pulmonary Embolism.
Introduction: Acute pulmonary embolism (PE) is a significant cause of morbidity and mortality. The standard approach to its management has traditionally relied on full-dose thrombolytic therapy. While this treatment modality has been instrumental in saving lives, its association with severe bleeding complications, notably intracranial hemorrhage, has necessitated a reevaluation of therapeutic strategies. Emerging evidence suggests that half-dose thrombolytic therapy might offer a viable alternative, promising comparable efficacy with a potentially reduced risk profile. This systematic review delves into this proposition, aiming to give healthcare practitioners and policymakers a nuanced understanding of the effectiveness and safety of half-dose thrombolytic therapy in treating acute PE.
Objective: This systematic review evaluates the effectiveness and safety of half-dose thrombolytic therapy in the treatment of acute PE.
Methods: We conducted a comprehensive literature search following PRISMA guidelines across multiple databases, including PubMed, EMBASE, and the Cochrane Database of Systematic Reviews. The review included studies from 1990 to the present that compared half-dose with standard-dose thrombolytic therapy in adult patients with acute PE. Both randomized controlled trials (RCTs) and cohort studies were analyzed.
Results: The evidence suggests that half-dose thrombolytic therapy achieves similar outcomes in reducing mortality and recurrence of PE compared to the standard dose. Importantly, half-dose therapy is associated with a significantly lower incidence of major bleeding events, particularly intracranial hemorrhages. These findings are consistent across various studies, highlighting the potential of half-dose therapy to balance efficacy and safety effectively.
Efficacy and Safety of Half-Dose Thrombolytic Therapy:
The synthesis of the collected evidence paints a compelling picture of the potential of half-dose thrombolytic therapy. The findings uniformly suggest that this approach is associated with similar efficacy in reducing mortality rates and the recurrence of PE when compared to the standard dose regimen. This parity in therapeutic outcomes is significant, indicating that a reduced dosage does not compromise the primary objectives of thrombolytic therapy. However, the most striking revelation pertains to the safety profile of half-dose therapy. The data indicates a lower incidence of major bleeding events, including intracranial hemorrhage, which stands as a considerable advantage over full-dose therapy.
Implications for Clinical Practice and Policy Formulation
The findings have profound implications for clinical practice, suggesting that half-dose thrombolytic therapy could be preferentially considered for patients at heightened risk of bleeding complications. This assertion is supported by the evidence suggesting its favorable safety profile without a trade-off in efficacy. For policymakers, this review underscores the need for updated guidelines that reflect the emerging evidence on half-dose thrombolytic therapy. It calls for a shift towards more flexible, patient-centered treatment protocols that account for individual risk profiles and preferences.
Conclusion: Half-dose thrombolytic therapy is a viable alternative to standard-dose therapy for acute PE, offering comparable efficacy and a better safety profile. This review supports the consideration of half-dose therapy, especially for patients at an increased risk of bleeding complications. Future research should focus on larger, multicenter RCTs and longitudinal studies to validate these findings and explore personalized thrombolytic therapy approaches.
Trial Not registered. Funding is not required.
Shumaila Muhammad HANIF (Doha, Qatar), Russell KABIR
00:00 - 00:00
#42123 - A training programme based on high-fidelity simulations may improve the non-technical skills of trauma team providers.
A training programme based on high-fidelity simulations may improve the non-technical skills of trauma team providers.
Background: Simulation-based training (SBT) is a pivotal learning methodology in emergency medicine, enabling healthcare providers to practice real-life scenarios in a safe environment and thus to improve not only technical competences but also their non-technical skills (NTS) without risks for the patients. NTS are a set of cognitive and interpersonal skills essential for the effective and efficient functioning of a team in critical and time-dependent situations, such as the management of trauma patients. This study aimed to investigate whether a programme of high-fidelity simulations (HFS) may improve the knowledge and implementation of NTS in trauma team providers.
Methods: We performed a prospective study to evaluate the impact of an HFS-based training programme involving trauma teams working in Level III Trauma Units of the Area Vasta Toscana Centro, Italy. Each edition included a brief lecture on NTS and four scenarios involving the management of major trauma patients, comprising both prehospital and in hospital care. Each simulation was followed by a debriefing based on the Plus-Delta model focusing on the implementation of the NTS. Trauma teams were evaluated during each simulation with the Team Emergency Assessment Measure (TEAM) scale, assessing leadership, team-work and task management items on a zero-four Likert scale. At the beginning and end of each edition, all participants also completed the Emergency Team Competency (ETC) questionnaire to investigate on a zero-ten numeric rating scale their subjective knowledge and implementation of the following domains: communication, decision-making, clinical competency, leadership, task management, team-work and situation-awareness. The Friedmann test was used to investigate the variation in trauma team performance according to the TEAM and ETC scales.
Results: A total of eight editions of this HFS training programme have been performed between March and April 2024 and included in this analysis. These involved 40 physicians, 32 nurses and 8 radiology technicians. A signal for an improvement in the trauma team performance, as measured by the average score of the eleven TEAM items, was present (p=0.069). In particular, continuous situation reassessment (p=0.045) and task prioritisation (p=0.035) showed a significant improvement over time. Across the whole study population and within the physician subgroup, the score for both subjective knowledge and implementation of the seven ETC domains significantly improved at the end of the training programme (all p<0.01). Nurses, instead, did not show a consistent improvement as regard to knowledge, with only significant results for communication and decision making (p<0.05), but primarily a significant amelioration in terms of implementation (all p<0.05).
Conclusions: HFS-based simulation programmes may determine an improvement in the team performance in managing patients with major trauma. The subjective perception of such improvement was relevant both in terms of knowledge and implementation of the NTS investigated, with some differences between trauma team providers.
Andrea ROSSETTO (Firenze, Italy), Martina DE MARCO, Francesco PEPE, Selena GASPARRO, Puccio MARIANI, Francesca SCOLARO, Alessandro LOTTI, Eugenia LOMBARDI
00:00 - 00:00
#40772 - A woman battling a persistent fever and enduring days of stomach agony.
A woman battling a persistent fever and enduring days of stomach agony.
A 78-year-old woman with a medical history of hypertension, diabetes mellitus, and pancreatic cancer presented to the emergency department with a fever persisting for several days and abdominal pain. Physical examination revealed diffuse abdominal tenderness without rebound tenderness. Laboratory investigations showed a white blood cell count of 4.6×103/µL with 11% band forms, a total bilirubin level of 1.97 mg/dL, serum alanine aminotransferase level of 34 U/L, and serum lipase level of < 4 U/L. Point-of-care ultrasonography (POCUS) of the abdomen detected a large, regular border, hypoechoic lesion in the liver (Figure 1).
Subsequent contrast-enhanced computed tomography (CT) confirmed the presence of a large lesion in the liver with peripheral enhancement and central hypoattenuation, accompanied by air-fluid levels, consistent with the diagnosis of a liver abscess(Figure 2).
Under ultrasonographic guidance, an interventional radiologist inserted a pigtail catheter to drain a total of 200 mL of purulent fluid. The patient was subsequently admitted to the ward and commenced on broad-spectrum intravenous antibiotics. Culture of the purulent fluid revealed the growth of Lactobacillus gasseri and Lactobacillus fermentum. Following treatment, the patient's condition improved.
Lactobacilli are commonly regarded as non-pathogenic bacteria in humans and are widely recognized as probiotics. Liver abscesses caused by Lactobacillus are rare, with only a few cases reported in the literature. Risk factors for Lactobacillus infections include diabetes mellitus, cancer, hepatopancreaticobiliary diseases, and intracolonic conditions[1,2]. Symptoms typically include fever, abdominal pain, or discomfort. Point-of-care ultrasonography plays a crucial role as a bedside tool for physicians in assessing abdominal emergencies. It can detect hypoechoic collections within the liver parenchyma consistent with liver abscesses, thereby aiding in prompt diagnosis and management, particularly in patients with sepsis[3].
Hon Pheng TAM (TAINAN, Taiwan), Lih-Wen JANG, Yu-Chang LIU
00:00 - 00:00
#41610 - Abdominal pain and eosinophilia.
Abdominal pain and eosinophilia.
A 67-year-old woman came to the emergency department for ten days of continuous abdominal pain in the right upper quadrant, radiating to the back, with fever of up to 38.3ºC.
On physical examination, she was in good general condition, febrile, hemodynamically stable, and eupneic.
Abdominal examination revealed pain on superficial and deep palpation in the right hypochondrium, mesogastrium and right flank without defence or peritonism.
The rest of the examination showed no findings of interest.
In the laboratory tests performed in the emergency department, elevated acute phase reactants, mild alteration of the liver profile and moderate peripheral eosinophilia were observed.
In the presence of fever, abdominal pain and the laboratory tests described above, a computerised axial tomography (CT) was requested to complete the assessment, which showed multiple microabscesses in both hepatic lobes, with pseudobranched morphology, with a discrete amount of perihepatic liquid without dilation of the biliary tract.
The patient was admitted to the hospital to rule out a parasitic infection due to the presence of moderate peripheral eosinophilia in blood tests.
During admission, the patient’s anamnesis was completed with a history of her diet, mentioning that she had eaten raw watercress collected from spring water in a village two months before consulting the emergency department.
Therefore, taking into account the epidemiological history, the patient's clinical presentation, the peripheral eosinophilia, as well as the radiological findings, acute Fasciola hepatica infection was suspected.
An exhaustive study was performed with positive results of parasite serology for Fasciola hepatica. All other parasite studies were negative.
Treatment with triclabendazole was started with resolution of the symptoms.
FINAL DIAGNOSIS: Acute phase of Fasciola hepatica infection.
CONCLUSIONS
Fascioliasis is a parasitic infection caused by trematodes of the genus Fasciola spp. The most common species is Fasciola hepatica.
Sheep and cattle are the most important definitive hosts, snails are intermediate hosts and humans are an incidental host, becoming infected after ingesting raw watercress and other freshwater plants.
In any patient with fever, abdominal pain in the right upper quadrant and peripheral eosinophilia, the possibility of fascioliasis should be considered. Even more so in areas where this disease is endemic.
In the acute phase of the disease there is liver involvement, the patient will present fever, abdominal pain in the right upper quadrant and peripheral eosinophilia. The diagnosis in this phase is made by serology.
In the chronic or biliary phase, the patient may be asymptomatic or present with symptoms related to bile duct obstruction. We will find eggs in feces, duodenal aspirate or bile, as well as adult flukes in the bile duct.
The serological test of choice is immunoelectrophoresis and enzyme-linked immunosorbent assay (ELISA) using specific antigens.
Imaging studies can contribute to the diagnosis, the most useful and currently the most widely used is CT.
Treatment of choice is oral triclabendazole, with two doses of 10/mg/kg given twelve hours apart.
Isabel FERNÁNDEZ-MARÍN, Beatriz ANGÓS SÁEZ DE GUINOA (Madrid, Spain), María CUADRADO FERNÁNDEZ, Ana Belén CARLAVILLA MARTINEZ, Juan VILA SANTOS, Luis PÉREZ ORDOÑO, Susana BORRUEL NACENTA
00:00 - 00:00
#41577 - abdominal xray indication as per irefer guideline.
abdominal xray indication as per irefer guideline.
ABDOMINAL X-RAY INDICATION AS PER iREFER GUIDELINES
Audit Abstract:
Dr. Farah Mustafa (Consultant Emergency Medicine)
Dr. Syed Muhammad Saqib (Senior House Officer Emergency Medicine)
Our Lady Of Lourdes Hospital Drogheda
Introduction:
Abdominal X-ray is very frequently ordered in Irish Emergency Departments for all the patients. The dose of radiation of one Abdominal X-ray is equivalent to the dose of radiation of 35 Chest X-rays. Numerous studies have shown that abdominal X-rays have low sensitivity in several conditions such as acute abdominal pain. Therefore, It is prudent to restrict the use of abdominal X-ray to the appropriate indication.
iRefer is a set of guidelines produced by the Royal College of Radiologist(RCR) that provide guidance for clinical referrals to radiology. iRefer has set out the guidelines for indication of Abdominal X-rays.
The Standard:
iRefer Guidelines for indication of Abdominal X-rays
Clinical suspicious of obstruction
Acute exacerbations of inflammatory bowel disease
Palpable mass (specific circumstances)
Constipation (specific circumstances)
Acute or chronic pancreatitis (specific circumstances)
Sharp/poisonous foreign body
Smooth and small foreign body e.g. battery, coin(specific circumstances)
Blunt of stab abdominal injury (specific circumstances)
Post gastrografin follow through study
This audit was conducted by the Emergency Medicine team in the Emergency Department at Our Lady of Lourdes Hospital Drogheda to evaluate the compliance of practice of prescribing Abdominal X-rays with the iRefer guidelines.
The clinical audit included the X-ray requests of 33 patients from the Emergency Department during the period of 10/Nov/2023 to 16/Nov/2023
Target:
100% compliance of prescribing Abdominal X-rays according to iRefer Guidelines.
Results of first cycle:
Out of 33 requests 24 were in compliance with the iRefer Guidelines ,with a compliance rate of 72.7%.
Interventions:
Circulate the indications of Abdominal X-rays according to the iRefer Guidelines to the Emergency Medicine clinicians for rational use of Abdominal radiographs.
Re-audit for evaluation of compliance with the standards in 8 weeks time.
RE-AUDIT:
Re audit conducted between 16 January 2024 to 21 January 2024 using the same methodology and it shows massive improvement in compliance of of irefer guideline.
Result of Second Cycle:
Out of 37 requests 34 were in compliance with the iRefer Gudielines, with a compliance rate of 91.89%
Future Recommendations:
Re audit in few months to get 100% compliance with irefer guideline.
Prevent exposing patients to unnecessary radiations by complying with iRefer guidelines.
HSE
Syed Muhammad SAQIB, Farah MUSTAFA (Drogheda, Ireland)
00:00 - 00:00
#40798 - Acceptability of telephone-cardiopulmonary resuscitation (T-CPR) practice in a resource-limited country- a cross-sectional study.
Acceptability of telephone-cardiopulmonary resuscitation (T-CPR) practice in a resource-limited country- a cross-sectional study.
Background: T-CPR has been shown to increase bystander CPR rates dramatically and is associated with improved patient survival.
Objective: To evaluate the acceptability of T-CPR by the bystanders and identify baseline quality measures of T-CPR in Karachi, Pakistan.
Methods: A cross-sectional study was conducted from January to December 2018 at the Aman foundation command and control center. Data was collected from audiotaped phone calls of patients who required assistance from the Aman ambulance and on whom the EMS telecommunicator recognized the need for CPR and provided instructions. Information was recorded using a structured questionnaire on demographics, the status of the patient, and different time variables involved in CPR performance. A One-way ANOVA was used to compare different time variables with recommended AHA guidelines. P-value ≤ 0.05 was considered significant.
Results: There were 481 audiotaped calls in which CPR instruction was given, listened to, and recorded data. Out of which in 459(95.4%) of cases CPR was attempted Majority of the patients were males (n = 278; 57.8%) and most had witnessed cardiac arrest (n = 470; 97.7%) at home (n = 430; 89.3%). The mean time to recognize the need for CPR by an EMS telecommunicator was 4:59 ± 1:59(min), while the mean time to start CPR instruction by a bystander was 5:28 ± 2:24(min). The mean time to start chest compression was 6:04 ± 1:52(min.).
Conclusion: Our results show the high acceptability of T-CPR by bystanders. We also found considerable delays in recognizing cardiac arrest and initiation of CPR by telecommunicators. Further training of telecommunicators could reduce these delays.
None
Fareed AHMED (Karachi, Pakistan)
00:00 - 00:00
#41950 - Accidental mydriasis in an otherwise healthy person: a case report of ocular instillation from Angel trumpet (Brugmansia) plant.
Accidental mydriasis in an otherwise healthy person: a case report of ocular instillation from Angel trumpet (Brugmansia) plant.
Aim:
The aim of this study is to report clinical observations following accidental ocular exposure to Angel's trumpet (Brugmansia) sap and to outline a systematic approach for managing isolated unilateral mydriasis resulting from this exposure.
Methods:
We present findings from a case involving a patient who experienced abrupt onset of unilateral mydriasis and mild visual disturbances subsequent to handling cuttings from a Brugmansia plant in their garden. We describe the methodical approach employed in managing such a patient.
Results:
The observed symptoms manifested following ocular contact with the sap of Angel's trumpet, a plant known to contain natural alkaloids with parasympatholytic properties. Initially, the patient was unaware of the etiology of their symptoms. However, a thorough patient history revealed recent contact with Angel's trumpet. Utilizing a systematic approach involving history-taking, clinical examination, and basic investigations, we clinically diagnosed pharmacologically-induced pupil dilation due to Brugmansia sap and ruled out other pathological etiologies.
Conclusion:
Accidental ocular exposure to Angel's trumpet sap should be considered as a potential cause of sudden-onset mydriasis in individuals with an otherwise unremarkable medical history. A suggestive patient history, coupled with meticulous examination and appropriate investigations to exclude central or biochemical pathologies, is crucial in arriving at an accurate diagnosis and guiding appropriate management strategies.
N/A
Mahmuda CHADNI, Sergio B SAWH (London, )
00:00 - 00:00
#40819 - ACE – inhibitors induced angioedema.
ACE – inhibitors induced angioedema.
Brief clinical history: In early morning hours, EMS brings in a crashing patient directly to Santaros Clinics ED resus bay. A suspected angioedema after a pill of Ramipril. Patient’s vitals were: unmeasurable BP, severe bradycardia, tachypnea and SpO2 of 37 %. On arrival severely edematous neck and lips were noticed. ENT physician was called. 4 min later – cardiac arrest and an EMD resuscitation protocol was initiated. Successful intubation on the first try using direct laryngoscope. ROSC achieved after few cycles (4min.). Afterwards lines were placed and vasopressors started – NE infusion 0.5 mcg/kg/min. Patient’s vitals were: BP – 107/76 mmHg; HR – 192 beats/min; SpO2 98 % (on mechanical ventilation). To treat severe laryngeal edema patient received Hydrocortisone bolus of 100 mg i/v followed by infusion of 100 mg via pump. Afterwards the patient was moved to the ICU. In the ICU angioedema specific treatment consisted of: hydrocortisone infusion, 1g of TXA i/v and 2 units of FFP. 6 days later angioedema regressed, the patient was extubated and moved to internal medicine. Where treatment lasted for 15 days. Released to the nursing home in fair general condition.
This clinical case about a rare condition of ACE – inhibitors induced angioedema is a great reminder on how to act and what specific treatment can be given then faced with a patient like that. The main focus is the airway. Immediate evaluation and frequent monitoring is the key. Prompt intubation and initiation of the mechanical ventilation needs to be performed quickly if the patient is breathing with extreme difficulty. On the pharmacological aspect of ACE – inhibitors induced angioedema’s treatment, it is based on studies of hereditary angioedema (HAE). While some of the drugs as C1 inhibitor concentrate, ecallantide and icatibant are definitely unavailable in all the ED’s. TXA and FFP might be helpful and should be easily reachable for many. TXA of 1 g is sufficient for most presenting with ACE – inhibitors induced angioedema and 2 units of FFP is the recommended dose for the adults.
Having all this knowledge, facing a patient with a condition of ACE – inhibitors induced angioedema will not look that scary anymore.
Martynas JUDICKAS (Vilnius, Lithuania)
00:00 - 00:00
#41282 - Acute confusional syndrome: a diagnostic challenge in emergency care.
Acute confusional syndrome: a diagnostic challenge in emergency care.
On arrival at our department, the patient stands out with altered level of consciousness, initially tending to sleep and during her stay in our office, she begins with psychomotor agitation presenting an acute confusional picture.
During the anamnesis through her daughter, she refers us a picture of otalgia of only 24 hours of evolution, onset of intense headache for about 4 hours accompanied by vomiting that she describes as “shotgun”. No thermometric fever at home, although on admission to the emergency room she presented a fever peak of up to 38.5ºc.
EXPLORATION: BP 131/73 mmHg, HR 78, SatO2 96 % basal, Temperature: 38.5ºc. Poor general condition, vigil, disoriented in time and space, psychomotor agitation in consultation requiring containment. Neurologically Glasgow Eating Scale 14/15. Normoreactive isochoric pupils, eye movements preserved, mobilzia four extremities without strength deficit. No initial assessment of gait or dysmetria due to poor collaboration. Cardiorespiratory auscultation and abdominal examination without findings.
COMPLEMENTARY TESTS: Initially, a complete blood test with determination of acute phase reactants, urinalysis, electrocardiogram and chest X-ray was performed. In order to rule out possible respiratory or urinary infectious origin and given the normality of the initial tests, it was decided to complete the study. Cranial CT scan with no acute brain lesions or other lesions. Later a lumbar puncture was performed in the emergency room, highlighting polymorphonuclear leukocytosis with decreased glucose concentration and increased protein concentration, all suggestive of bacterial meningitis. During admission, acute phase reactants were elevated, and finally a positive CSF culture of Pneumococcus was isolated. PLAN: Antibiotic therapy was started empirically and early before knowing the results of the Gram stain and CSF cultures. Taking into account the microorganisms that most frequently produce out-of-hospital meningitis, treatment was started including dexamethasone, ceftriaxone, vancomycin and acyclovir. In addition, given the history of otalgia with doubtful otitis, it was decided to add metronidazole to the treatment. The patient was admitted to Internal Medicine with good and favorable evolution, being discharged from hospital after 12 days, with good level of consciousness and no further deterioration or sequelae.
CLINICAL JUDGMENT AT DISCHARGE: PNEUMOCOCCAL MENINGITIS
Meningitis may present as an acute fulminant illness that progresses rapidly in a few hours. The classic clinical triad includes fever, headache and neck stiffness, but sometimes this triad is absent. It should be noted that in more than 75% of patients the level of consciousness decreases.
The main objective of this presentation is the earliest possible diagnostic approach and treatment in the Emergency Department. The request and evaluation of complementary studies requires good clinical judgment.
Vanesa YAÑEZ BERMEJO, Álvaro MARTÍN PÉREZ (Badajoz, Spain), Rafael ROLDÁN JIMÉNEZ
00:00 - 00:00
#42031 - Acute heart failure in prehospital care: the diagnostic performance of concorde scale.
Acute heart failure in prehospital care: the diagnostic performance of concorde scale.
Background:
Clinical probability scores for acute heart failure (AHF) have demonstrated their value in emergency departments and cardiology and few studies have validated them in the Emergency Medical Services (EMS).
The aim of our study was to evaluate the diagnostic performance of Concorde scale during the management of AHF in prehospital care.
Methods:
A retrospective and observational study was conducted over a period of six months including patients whose clinical symptomatology was acute dyspnea in EMS. Comparison of two groups: patients with AHF (AHF+) versus patients without AHF (AHF-). The diagnosis of AHF was confirmed, during hospitalization following transport by EMS, by clinical, biological and ultrasound arguments. CONCORDE score was calculated. It’s variables: Cardiac medicine≥3, Orthopnea, No pulmonary disease, Chronic heart disease, Oedema (lower limbs), Rales (crackling), Date of Birth ≥ 65ans, Elevation of Right Heart Pressure (jugular). Statistical analyses included: evaluation of the discriminative power of the score and characteristics of the ROC curve, calculation of Youden’s index and likelihood ratios (LR).
Results:
Inclusion of 85 patients. The average age was 66±17 years. The gender ratio was 1.4. The diagnosis of AHF was confirmed in 33 patients (39%). The comparison of two groups showed that patients with AHF were older (p=0.04) and had more history of hypertension (p<0.001) and diabetes (p=0.002). The mean value of CONCORDE score was 4±3. The analysis of the ROC curve showed a good diagnostic performance (AUC; p): (0.89; 0.03). The characteristics were: sensitivity (58%), specificity (92%), positive predictive value (83%), negative predictive value (77%), Youden index (0.5). The LR of CONCORDE score: Positive LR (7,5) and negative LR (0.46).
Conclusion:
The CONCORDE score had high specificity in predicting AHF in EMS. However, our results need to be validated by studies on a larger scale.
Raja FADHEL (Ain Zaghouan, Tunisia), Ahlem HENDILI, Mohamed ZOUARI, Syrine KESKES, Hela BEN TURKIA, Amira BAKIR, Hanene GHAZALI, Sami SOUISSI, Ines CHERMITI
00:00 - 00:00
#41901 - Acute Myocarditis - Dengue Virus - Case Report- Ribeirão Preto – Brazil.
Acute Myocarditis - Dengue Virus - Case Report- Ribeirão Preto – Brazil.
Myocarditis can be defined as an inflammatory disease of the myocardium. It is caused by a wide variety of infectious agents, including viruses, protozoa, bacteria, chlamydia, rickettsia, fungi and spirochetes.
Dengue virus infection (DENV) is an arboviral disease that affects millions of people in many countries throughout the world every year. The disease is caused by the bite of a mosquito (Aedes aegypti and/or Aedes albopictus).
Case Description:
Woman, 17 years old, without comorbidities, complaining of chest pain for 9 days, accompanied by diffuse abdominal pain and dyspnea that worsened in the last 12 hours. No other complaints. He sought care at an emergency department on two occasions. During the second consultation, she experienced a short-term syncope. Laboratory tests collected that day diagnosed leukopenia and thrombocytopenia. The patient's clinical condition rapidly worsened, with a decrease in the level of consciousness and respiratory distress. Physical examination- BP- 80 x 60 mmHg, Cardiovascular device- RCR 2T, hypophonetic heart sounds, no murmurs. Pulmonary system- vesicular murmur present, without adventitious sounds, Glasgow- 7, isochoric and photoreactive pupils. ECG- elevation in all leads. Management: volume replacement, rapid sequence for orotracheal intubation, administration of vasoactive drug - noradrenaline at 30 ml/h. Evolution - no answer. Partial stabilization of the condition with noradrenaline at 50 ml/h. Transfer to the Intensive Care Center. He developed a pericardial effusion and died within 24 hours. Final diagnosis: Acute Viral Myocarditis – Dengue – Arboviruses.
Discussion and Conclusion-
The most common clinical manifestations of Dengue include: fever, headache, arthralgia, retro-orbital pain, rash and myalgia. A more severe clinical form is seen in dengue hemorrhagic fever (DHF) and dengue shock syndrome (SSD). DHF and SSD are characterized by increased vascular permeability, thrombocytopenia and bleeding
Cardiovascular involvement is often the result of myocardial inflammation due to direct invasion by viruses and the production of inflammatory cytokines and free oxygen rootlets. Myocarditis, pericardial effusion, heart block and arrhythmias are manifestations of cardiovascular involvement that generally follow a benign and self-limited course, but can rarely be fatal.
In cases of Dengue, with progression to SSD, the diagnostic hypothesis of Dengue Myocarditis must be considered and researched.
Ethical approval and informed consent: Brazil Plataform- CAAE: 53339116.2.0000.5498
Rosemary F DANIEL, Ana Luiza Normanha ALMEIDA (RIBEIRÃO PRETO, Brazil), Francine FULQUINI, Tufik GELEILETE, Priscila RONCATO, Silvia SILVA, Edilson CARITA, Nyara CONTIERO, Reinaldo BESTETTI
00:00 - 00:00
#41948 - Acute Osteomyelitis in Children: Clinical Characteristics and Therapeutic Strategies.
Acute Osteomyelitis in Children: Clinical Characteristics and Therapeutic Strategies.
Introduction: Osteoarticular infections are common in children, such as acute hematogenous osteomyelitis and acute septic arthritis, requiring consideration in the diagnosis of limb pain. Mainly caused by bacteria introduced hematogenously, Staphylococcus aureus and Kingella kingae are the predominant pathogens. Rapid intervention by an orthopedic surgeon is crucial for prompt evaluation and early treatment.
Objective: To describe the clinical and therapeutic characteristics of acute osteomyelitis (AOM) in children treated at the Fattouma Bourguiba Orthopedic Department in Monastir.
Patients and Methods: This is a retrospective study including all patient records hospitalized in the orthopedic department of Monastir for AOM over an 8-year period (January 1, 2015 - December 31, 2022). All patients underwent clinical examination, laboratory tests, and diagnostic radiological assessment. All data were recorded on a pre-established form.
Results: 50 patients were included in our study. The average age of patients was 8 years and 4 months, with a male-to-female ratio of 2.12. The main reason for consultation was bone pain, often accompanied by fever in 84% of cases. The preferred infectious site was the lower limbs in 82% of situations. The most frequent symptomatology was functional impairment in 74% of cases. A portal of entry was identified in only 30% of patients, with cutaneous lesions in 33.3% and hematogenous route, especially septicemia, in 33.3%. Pathogens were identified in half of the cases (n=25), mainly through intraoperative sampling (n=14). Staphylococci represented 92% of isolated pathogens (n=23). The average duration of antibiotic therapy was 48 days, ranging from 2 to 183 days. Oral antibiotic therapy was chosen in 46 cases (92%): monotherapy (n=38; 82.6%) and combination therapy (n=17.4%). Complications noted were mainly progression to chronicity in 10% of cases.
Conclusion: Acute osteomyelitis (AOM) is a bone infection caused by a germ that reaches the bone hematogenously, predominantly affecting the metaphyses of long bones. Diagnosis relies on clinical, laboratory, and imaging findings, with MRI being the preferred examination in the early stage. The medical-surgical management depends on the evolutionary stage of the disease.
This study did not involve a trial registration. No external funding was received for this study.
Firas CHAOUECH, Jacem SAADANA, Khouloud KHEMILI (Tunisia, Tunisia), Kais KHARROUBI, Amine SIOUD, Bilel FAIZI, Said ABID, Ahmed MDAOUKHI, Habib HADJ TAIEB, Iheb NTICHA, Hatem BELGACEM, Aymen FEKIH, Abderrazek ABID
00:00 - 00:00
#41121 - Acute Pain Management in Trauma Patients: Is the Emergency Department at Mater Dei Hospital following EUSEM Guidelines?
Acute Pain Management in Trauma Patients: Is the Emergency Department at Mater Dei Hospital following EUSEM Guidelines?
Introduction & Background
Effective pain management is a core component of emergency care. In March 2020, the European Society of Emergency Medicine (EUSEM) published guidelines on the management of severe acute pain, recommending morphine, fentanyl, or sufentanil as first-line agents, paracetamol and weak opiates as second line, and ketamine as third-line analgesic. The goal of this audit is to examine whether patients attending the Emergency Department of Mater Dei Hospital in Malta (MDH ED) in severe pain secondary to trauma are managed according to these guidelines.
Methods
Performance of a computed-tomography trauma series (CT polytrauma) was considered indicative that patients had sustained significant trauma and required management of severe pain. Patients were identified retrospectively over two, three-month periods. Electronic records were accessed and analgesia use extracted.
Results
Between 1st June and 31st August 2022, 139 CT polytraumas were performed with eighty cases suitable for analysis. Paracetamol was used in 85% of cases, opiate analgesia in 56%, ketamine in 14%, and NSAIDs in 1%. When opiates were selected, morphine was used in 80% of cases, with fentanyl and codeine administered in 13% and 4% of cases, respectively. Diclofenac was the only NSAID used.
From 1st June to 31st August 2023, 124 CT Polytraumas were performed and eighty-three cases included in the analysis. Paracetamol was used in 89% of cases, opiates in 48%, ketamine in 11%, and NSAIDs in 7%. A breakdown of opiate selection revealed morphine was given in 93% of cases, and fentanyl and codeine in 5% and 3%, respectively. NSAID use comprised of ibuprofen and diclofenac. There was no statistical difference (p=0.24) between years.
Discussion & Conclusion
Broadly speaking, MDH ED management follows EUSEM guidelines. However, the increased frequency of paracetamol over opiates suggests that paracetamol is used as a first-line agent followed by morphine, which is the reverse to guidelines. The negligible use of sufentanil, fentanyl, and ketamine is conspicuous and, given their advantages such as rapid onset, potency, and haemodynamic stability, they should be more frequently considered in select cases. NSAID administration was low and is inappropriate in the context of trauma.
N/A
Sean KELLEY (Malta, Malta)
00:00 - 00:00
#42222 - Acute pancreatitis complicated by thrombosis of the inferior vena cava extending to the portal trunk and right renal vein.
Acute pancreatitis complicated by thrombosis of the inferior vena cava extending to the portal trunk and right renal vein.
Acute pancreatitis complicated by thrombosis of the inferior vena cava extending to the portal trunk and right renal vein
A .ALAOUI, MA. FEHDI, A. DAFIR, B. AGGOUG, M. MOUSSAOUI, M. MOUHAOUI .
Emergency departement , Ibn Rochd University Hospital , Casablanca , Morocco
INTRODUCTION : Acute pancreatitis (AP) is a common condition in adults often associated with hypercoagulability, which can result in venous thrombosis, typically affecting the portal vein, splenic vein, and superior mesenteric vein. Thrombosis of the inferior vena cava (IVC) is uncommon. Here, we present a medical case of AP complicated by IVC thrombosis extending to the portal trunk and right renal vein.
OBSERVATION: Patient SO, 43 years old, with a 5-year history of HIV managed with antiretroviral therapy ( under tritherapy), and currently undergoing one-month treatment for pulmonary tuberculosis under antibacillary treatment, presented to the emergency department for severe epigastric pain persisting for 48 hours. Initial evaluation demonstrated a conscious patient with a Glasgow Coma Scale score of 15/15, stable hemodynamics, respiratory function, and neurological status. Physical examination disclosed epigastric tenderness and a dehydration fold. The initial electrocardiogram (ECG) showed no abnormalities. Subsequent laboratory investigations indicated elevated lipase levels (2248 IU/L), renal insufficiency evidenced by urea levels of 2.60 g/L, creatinine levels of 105.98 mg/L, and a glomerular filtration rate (GFR) of 86 ml/min, C-reactive protein (CRP) levels of 170 mg/L, hyperleukocytosis with a white blood cell count of 32640/mm^3, and thrombocytopenia with a platelet count of 77000/mm^3. Abdominal computed tomography (CT) revealed stage C acute pancreatitis (AP) accompanied by thrombosis of the inferior vena cava (IVC) extending to the portal trunk and right renal vein. Symptomatic management of the AP commenced, and surgical intervention for the thrombosis was recommended. However, it was not feasible due to the patient's deteriorating overall health. The patient was initiated on unfractionated heparin (UFH) as part of palliative care. Unfortunately, the patient succumbed to the condition on day 15 post-diagnosis.
DISCUSSION : Vascular complications associated with acute pancreatitis (AP) encompass venous thrombosis, hemorrhage, and pseudoaneurysm formation. Among these, venous thrombosis, particularly affecting the splenic vein, is the most commonly observed. Thrombosis of the inferior vena cava (IVC) in the context of AP is exceedingly rare, with only seven reported cases documented in literature. The pathogenesis primarily revolves around blood stasis, spasm, and the mass effect exerted by the inflamed pancreas, coupled with vessel wall damage caused by the release of pancreatic enzymes. Interestingly, there appears to be no direct correlation between the severity of acute pancreatitis (AP) and the occurrence of venous thrombosis. Various therapeutic modalities can complement symptomatic management of venous thrombosis associated with acute pancreatitis (AP), spanning from thrombolysis and heparin therapy to surgical intervention. Despite the absence of a definitive consensus, heparin therapy followed by transition to vitamin K antagonists (VKAs) stands as the most commonly employed treatment approach.
Anas ALAOUI (, Morocco), Mohamed Anass FEHDI, Asmae DAFIR, Badria AGGOUG, Mohammed MOUSSAOUI, Mohammed MOUHAOUI
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#42370 - Acute Paraquat poisoning A study of clinical profile and predictors of outcome from a tertiary care center in South India.
Acute Paraquat poisoning A study of clinical profile and predictors of outcome from a tertiary care center in South India.
INTRODUCTION: Paraquat dichloride is widely used as a herbicide in view of its low cost, easy availability and excellent herbicidal properties. It is also used by people for suicide. It leads to multiple organ dysfunction and has extremely high mortality. Here we describe the clinical profile of patients with paraquat poisoning and their outcomes.
AIM: To study the profile and outcome of Paraquat poisoning
METHODOLOGY: This is a retrospective study conducted over a period of 6 years from September 2015 to August 2021. Data was extracted from the inpatient electronic medical records. Patients with a diagnosis of paraquat poisoning were enrolled into the study.
Statistical analysis: The analysis was done using Statistical Package for Social Sciences for Windows (SPSS Inc., released 2015, version 23.0. Armonk, New York, USA). Descriptive statistics were employed for all variables in the study. Further analysis of predictors of mortality was done using bivariate analysis and logistic regression. p Vale of <0.05 was considered statistically significant.
RESULT: The study comprised of 36 patients with a median ( IQR) age of 26 (17 – 70) years. Majority of our patients were males, 78%. Most presented to our center after referral from a primary center. Point of first medical contact was around 2.5 hours. The most common symptoms seen at admission were that of vomiting (72.8%), dysphagia (30.6%) and breathlessness (30.6%). Most common clinical toxidromes that patients developed were that of acute kidney injury (88.9%), acute hepatitis (69.4%) and acute respiratory distress syndrome (61%). None of the treatment modalities offered any survival benefit. The overall mortality from our study was 80.6% and pooled mortality with 5 other Indian studies revealed a mortality of 76.4% (95% Confidence Intervals 59.6 to 90.2 %). From our study the predictors of mortality obtained were a low baseline APPACHE-2 score and amount of paraquat ingested <25ml had 11 times higher odds for survival than with higher amounts consumed.
CONCLUSION: Paraquat poisoning presents with multi organ involvement and has extremely high mortality. Hence strict policy reforms regarding paraquat use is necessary.
Ethical considerations: This was a retrospective observational study and ethical committee approval was obtained prior to commencement of the study
Funding: As this was a retrospective study, funding was not required.
Paul KUNDAVARAM (Vellore, India), Gunasekaran KARTHIK
00:00 - 00:00
#41947 - Acute poisoning in emergency room.
Acute poisoning in emergency room.
Acute poisoning represents a frequent reason of admission in emergency rooms and intensive care units (ICU). Evaluation of intoxication severity should rely on a rigorous approach based on analysis of prognostic factors. Existing prognostic scores are not efficient enough to predict ICU admission in daily practice. We purpose to identify ICU transfer risk factors in acute poisoning.
Methods :
Retrospective and monocentric study from January 2016 to December 2022. All patients admitted to emergency department (ED) with a diagnosis of accidental or voluntary intoxication were included. Clinical and toxicological data were first analyzed with univariate tests. Factors significantly associated with ICU admission were then introduced in a logistic regression model.
Results :
During study period, 946 patients were included, 71% were women. Mean age was 26 +/- 12 years. Toxic ingestion was voluntary in 89 % of cases. The median delay of consultation was 2 hours after ingestion. 10% had psychiatric history: hospitalization in a psychiatric department (n=21), suicide attempt (n=54) and history of previous ICU admission for poisoning (n=14). The offending toxic was a drug in 47% of cases (dominated by psychotropic drug: n=130 and cardiotropic drug: n= 117) and a pesticide in 34% of cases. The initial examination had showed: consciousness disorders (n=227) with coma in 95 cases, digestive disorders (n=340), hypotension (<90mmHg) n=123 and fasciculation in 55 cases. The toxidrome were identified in 230 cases. 52% of patients were admitted in ICU. The initial management in ED: digestive decontamination in 63% of cases, antidotes n=141, intubation n=168 and vasoactive drugs n=49. The mortality was estimated at 8,45%. In multivariate analysis, history of previous ICU admission for poisoning (OR 4,94 ; IC 95% 1,04- 15,28 ; p=0,03), chloralose ingestion ( OR 3,35 ; IC 95% 1,28 - 5,43; p=0,03), anticholinergic toxidrome (OR 2,78 ; IC 95% 1,14 – 4,59 ; p=0,04) and Glasgow Coma Scale (GCS) less than 13 (OR 4,48 ; IC 95% 3,7 – 8,36 ; p<0,001) were identified as risk factor for intensive care admission.
Conclusion :
Anamnestic content (history of previous ICU admission for poisoning, type of toxic = chloralose) and clinical criteria at admission (GCS <13 and the presence of an anticholinergic toxidrome) are easily identified prognostic factors for early and appropriate orientation patients admitted to the ED for acute poisoning
Neila MAAROUFI, Rahma LTIFI (sousse médina, Tunisia), Firas KESSENTINI, Houcem ZAMIT, Leila KACHROUDI
00:00 - 00:00
#40859 - Acute traumatic infrarenal abdominal aortic dissection associated with acute vertebral lumbar fractures due to trauma from fall: A case report and literature review.
Acute traumatic infrarenal abdominal aortic dissection associated with acute vertebral lumbar fractures due to trauma from fall: A case report and literature review.
Aortic dissection resulting from blunt trauma is a rare occurrence, with 1.79% of patients with blunt trauma experiencing a traumatic aortic dissection (TAD).TAD due to fall from height is notably less common than RTAs, with few case reports publishing this potentially life-threatening pathology.
We present a thirty-year-old man brought in by ambulance to our emergency department (ED) following a fall from a first-floor window of a building (three metres high). He landed onto his feet and subsequently hit his head and chest on the ground. On primary survey patient had normal observations and with no life-threatening injuries identified. He was complaining of back pain and pain in his feet. A trauma CT was done due to the mechanism of injury which showed non-displaced fractures of the superior endplates of L1,L2 and L3. An intimal flap in the infra-renal abdominal aorta was seen, demonstrating an acute traumatic aortic dissection. There was no evidence of retroperitoneal haematoma and no active contrast extravasation. X-ray imaging of the left knee and both feet showed a right medially displaced comminuted extra-articular fracture of the medial process of the right calcaneal tuberosity. The patient was transferred to a tertiary centre specialising in vascular surgery where he received conservative medical management for the traumatic intimal flap in the infra-renal abdominal aorta. Observations were monitored with a target systolic blood pressure of <110 mmHg. The patient was monitored for signs of mal-perfusion with regular checks of peripheral pulses, abdominal examination and blood tests particularly for lactate and renal function monitoring. Fluid input and output was closely monitored. Conservative management of the extra-articular calcaneal tuberosity fracture was performed with elevation, application of a walking boot and crutches. The patient was advised to weight bear as pain allowed. L1, L2 and L3 superior endplate fractures were managed conservatively.
From a literature search, only four cases of TAD associated with vertebral fractures due to falling were identified, with the lowest height of fall being from five metres. The majority of cases resulted from RTAs. We theorise that the deceleration from the fall from three metres caused a large energy transfer through
this gentleman’s body. Hitting the ground caused L1, L2 and L3 superior endplate fractures and injury to the nearby aorta. Our case builds on the evidence of association between blunt traumatic aortic dissection and vertebral fractures, even in the case of low impact falls. Low velocity trauma does not exclude TAD. Additionally, this case demonstrates the rare entity of aortic dissection occurring without displacement of the vertebral fracture.
Salman NAEEM (Maidstone, ), Luke PEACOCK
00:00 - 00:00
#42049 - Acute unilateral visual loss as a first presentation of mixed phenotype acute leukaemia.
Acute unilateral visual loss as a first presentation of mixed phenotype acute leukaemia.
Central retinal artery occlusion (CRAO) is a rare phenomenon that presents with sudden vision loss over seconds. It is typically due to thromboembolic phenomenon and is associated with atherosclerosis, with the mean age of presentation in the early 60s. We present a rare case of CRAO in a young male due to hyperviscosity as a first presentation of leukaemia.
A 33 year-old male with a past history of follicular thyroid cancer in remission presented to the Emergency Department with sudden onset atraumatic unilateral painless loss of vision. The left eye was noted to have no light perception in all areas save for a small spot on the temporal side, through which the visual acuity was 6/6. The extraocular range of movements were intact. Slit lamp examination showed a normal anterior segment, but fundal examination revealed a flat retina with the exception of the cilioretinal artery area being spared. Systemic examination did not reveal organomegaly or bleeding diathesis. Initial blood tests showed a leukocytosis with white blood cell count of 120.55 x 10^9/L, predominantly myelocytes and neutrophils with associated bicytopenia.
The patient was admitted and urgent leucopheresis, hydroxyurea, and allopurinol were initiated. Anterior chamber paracentesis was performed. Further investigations including a Magnetic Resonance Imaging (MRI) of the brain showed mild diffusion restriction in the left retrobulbar optic nerve consistent with ischaemia. A bone marrow aspiration showed myeloid hyperplasia with dysgranulopoiesis, however the flow cytometry showed 20% cytoplasmic CD3+ blasts. A diagnosis of CRAO secondary to hyperviscosity due to T lymphoid and myeloid mixed phenotype acute leukaemia (MPAL) was confirmed. The patient was started on FLAG-Ida (fludarabine, cytarabine, granulocyte colony stimulating factor, idarubicin) by the haematologist and observed. During his inpatient stay he developed bleeding from vascular access sites and aspirate sites, requiring platelet transfusion. On further follow up, the patient reported slight improvement in the central area of vision and the best visual acuity was 6/9.5 in the affected eye.
MPAL represents a diverse group with myeloid and lymphoid origin and makes up 1-3% of acute adult leukaemias. Therapy for this group of malignancies is not well established in view of its rarity and is associated with poor outcomes. A literature search across Embase and Pubmed revealed 15 relevant articles for CRAO and leukaemia. The majority of patients presented with CRAO secondary to optic nerve infiltration, optic neuropathy, and vasculitis; most cases were also reported in the younger age group below 56 years old. Only 2 articles reported CRAO due to hyperviscosity in conditions including Essential Thrombocytosis and Hairy Cell Leukaemia. Leukaemia classically presents with fatigue, fevers, and bleeding, with ocular manifestations reported in 20-90% of patients. On the other hand, CRAO tends to be associated with thromboembolic causes. It is imperative that the emergency physician keeps a wide differential when reviewing younger patients with acute visual loss and includes a systemic evaluation and haematological work up to facilitate an early diagnosis, allowing for timely vision sparing intervention and treatment to prevent further thrombotic events.
Chelsea ONG (Singapore, Singapore), Jeremy WEE, Huiling HUANG
00:00 - 00:00
#41915 - Addressability and management of acute coronary syndrome in the Republic of Moldova: a comprehensive study.
Addressability and management of acute coronary syndrome in the Republic of Moldova: a comprehensive study.
Objectives
Acute coronary syndrome (ACS) is one of the leading causes of morbidity and mortality worldwide. It has a high incidence rate, varying among European countries, with the highest rates in Central and Eastern Europe ranging from 3/1000 to 5.9/1000, affecting males more than females, with incidence increasing with age. The aim of the study was to evaluate the addressability of patients with acute coronary syndrome to Emergency Medical Services in the Republic of Moldova.
Materials and Methods
Over the course of one year, 5743 calls from patients with ACS were analyzed (1.01.23 – 31.12.23). The structure of acute coronary syndrome, daytime and seasonal addressability, and diagnoses mimicking acute coronary syndrome were evaluated.
Results
Throughout the year 2023, 170,110 cardiovascular emergencies were recorded, with ACS diagnosed in 5743 (3.37%) patients. ACS with ST-segment elevation constituted 2235 (38.9%); 1794 (80.2%) cases without complications; 182 (8.15%) with cardiogenic shock; 120 (5.36%) with ventricular failure, and 139 (6.12%) developed ventricular arrhythmias. ACS without ST-segment elevation constituted 3508 (61.1%), of which 169 cases (4.8%) were accompanied by cardiogenic shock; 213 (6.1%) with ventricular failure, 256 (7.3%) ventricular arrhythmias, and 2870 (81.8%) cases progressed without complications.
Of the total number of ACS cases, the hospitalization rate for cases with ST-segment elevation was 90.4%, and for those without ST-segment elevation, 92.1%. Of these, 2525 (47%) patients were transferred to regional medical centers and 2847 (53%) were transported to specialized cardiology centers equipped with percutaneous coronary angiography.
The analysis of collected data showed a higher incidence of acute coronary syndrome in males, but with a higher addressability in females. The evaluation of risk factors showed the presence of hypertension, dyslipidemia, diabetes, atrial fibrillation, smoking, and obesity.
Conclusions
Acute coronary syndrome remains one of the main causes of death in the Republic of Moldova. Although it represents a small percentage of the cardiovascular emergencies structure, it maintains a high rate of complications and hospitalization, with only about half of patients having the opportunity to receive specialized coronary treatment.
Victoria MELNICOV (Chisinau, Moldova), Tatiana MALACINSCHI-CODREANU
00:00 - 00:00
#42228 - Addressing Gaps in Pre-hospital Research: A Critical Analysis of Resuscitation Guidelines.
Addressing Gaps in Pre-hospital Research: A Critical Analysis of Resuscitation Guidelines.
Background
The resuscitation guidelines outlined by the European Resuscitation Council (ERC) are predominantly derived from the Consensus on Science and Treatment Recommendations (CoSTR) established by the International Liaison Committee on Resuscitation (ILCOR), which undergoes updates every five years. While these guidelines are rooted in evidence-based practices with robust research methodologies, they primarily reflect insights gleaned from hospital-based studies. Consequently, there exists a need to ascertain areas within these guidelines where the pre-hospital perspective is underrepresented.
Methods
This study entails an evidence analysis of the 2021 ERC guidelines and the ILCOR CoSTR, with a specific focus on identifying knowledge gaps pertinent to adult pre-hospital emergency care.
Results
Through our analysis, we have identified numerous topics within the adult advanced life support guidelines that rely solely on research conducted in hospital and simulation settings (e. g. advanced life support provided in two-member ambulance crew). Furthermore, disparities between pre-hospital and hospital care have been uncovered (such as the limited exploration of the utilization of capnography in early post-resuscitation care in the pre-hospital setting).
Discussion
Our findings underscore the necessity of bolstering pre-hospital research efforts and advocating for recommendations supported by evidence derived from the pre-hospital setting. Recognizing this imperative, the ERC Science and Education Committee for Advanced Life Support (ALS) has initiated a task force dedicated to generating evidence for 2-rescuer ALS. However, it is imperative to address the broader spectrum of identified knowledge gaps.
Conclusion
In conclusion, our analysis highlights a deficiency in pre-hospital research within the current resuscitation guidelines. There is an urgent need to prioritize the accumulation of robust evidence to inform pre-hospital emergency care guidelines effectively. This imperative underscores the importance of cultivating a comprehensive understanding of resuscitation practices across diverse clinical settings to optimize patient outcomes.
David PERAN (Karlovy Vary, Czech Republic), Miroslav KESELICA, Roman SYKORA
00:00 - 00:00
#41220 - Adequacy of Primary survey of trauma patients referred to a tertiary Hospital - A Prospective Observational Study.
Adequacy of Primary survey of trauma patients referred to a tertiary Hospital - A Prospective Observational Study.
Title: Adequacy of Primary survey of trauma patients referred to a tertiary Hospital - A Prospective Observational
Study
Authors: Mayank Badkur, Sreenivasa Reddy, Dr.Naveen Sharma
Introduction: A thorough primary survey is vital for trauma patient care, providing crucial information and prioritizing
treatment for life-threatening injuries. Patients who have received care based on a thorough primary survey have better
outcomes and reduced morbidity. Despite its significance, many hospitals fail to conduct primary surveys adequately,
resulting in suboptimal care. This study aimed to assess the adequacy of primary surveys conducted in hospitals and identify
common areas of improvement.
Method: We conducted a prospective observational study at a tertiary hospital, involving consenting adults (age≥18 years)
admitted for various traumas. We conducted a detailed interview and extracted objective patient data from medical records
using a predetermined form. We observed and analysed the quality of primary surveys received by each patient, focusing on
key components including airway management, breathing assessment, circulation evaluation, disability assessment, and
exposure. We also analysed the adherence to guidelines and identified any areas of deviation.
Results: The results of the study showed that out of the 42 patients included, most (40.5%, n = 17) received primary
treatment from general Surgeons. half of the patients (n = 21) were referred within 24 hours of trauma. Most common
deficiencies: airway/breathing assessment - lack of ICD insertion (n = 13, 30%), circulatory management - absence of large
bore cannula (n = 34, 81%), disability/exposure assessment - no cervical spine stabilization (n = 19, 45.2%).
Conclusion: Primary surveys in trauma patients is suboptimal with significant deficiencies in key interventions like ICD
insertion, Intravascular access and cervical spine stabilisation.
The registration number for this trial is CTRI/2024/03/064623.
Mayank BADKUR (JODHPUR INDIA, India)
00:00 - 00:00
#41851 - Adherence & outcomes of fluid management in pancreatitis presentations to the emergency department: a retrospective chart review.
Adherence & outcomes of fluid management in pancreatitis presentations to the emergency department: a retrospective chart review.
Background: Despite widespread implementation of aggressive fluid resuscitation for acute pancreatitis, recent literature has revealed significantly poorer safety outcomes in patients receiving aggressive fluid resuscitation for pancreatitis, compared with moderate fluid resuscitation. Current management guidelines for pancreatitis at Canberra Hospital, suggesting fluid resuscitation for all patients at a rate of 5-10mL/kg/hr, are poorly aligned with literature. The study aimed to evaluate adherence to current fluid management guidelines and examine the relation with patient outcomes, given that aggressive fluid resuscitation is potentially associated with poorer outcomes.
Methods: A retrospective chart review of acute pancreatitis presentations to Canberra Hospital Emergency Department from 2021-2022. Adult patients with a clinical diagnosis of acute pancreatitis and elevated lipase with a length of stay of at least 48 hours were included. Only the first presentation was included for recurrent presenters. Fluid administration from time of admission over 24 and 48 hours was used to divide patients into moderate (<1.5mL/kg/hr), intermediate (1.5-3mL/kg/hr) or aggressive (>3mL/kg/hr) fluid resuscitation. Primary outcome variable was complications (pleural effusion, ascites, and fluid overload, defined as new development of either) developing during admission and up to 1 week after discharge were identified. Development of organ failure, requirement for ICU transfer and death were also recorded. Results were analysed using Chi square tests.
Results: A total of 248 (123 females, 124 males, 1 indeterminate) patients presented were included, with a median age 55 years. Adherence to current management guidelines was poor, with all patients prescribed less fluid than suggested over 24 and 48 hours. Based on fluid administration over 24 hours, moderate fluid patients (44) had a 20% rate of pleural effusions and 25% fluid overload, whereas intermediate patients (184) had 43% and 47% respectively, and aggressive (20) had 60% and 65%. Significantly increased rates were observed for both pleural effusion (p=0.005, Chi-square test) and fluid overload (p=0.008) based on 24 hour fluid administration.
Based on fluid administration over 48 hours, moderate fluid patients (123) had a 29% rate of pleural effusions and 34% fluid overload, whereas intermediate patients (123) had 51% and 54% respectively. Only 2 patients received aggressive fluid resuscitation over 48 hours. These results were consistent for 48 hour fluid administration for pleural effusion (p = 0.0004) and fluid overload (p=0.001). There was no significant difference in development of organ failure, requirement for ICU or death.
Discussion & Conclusions: Current fluid management guidelines for pancreatitis at Canberra Hospital are poorly aligned with literature and do not reflect current practice. The study revealed that increasing fluid administration is associated with significantly increased rates of fluid overload and pleural effusion, which is consistent with recent randomised control trials showing higher incidence of fluid overload with aggressive fluids. Ultimately, this study supports the utilisation of moderate fluid resuscitation for pancreatitis to minimise development of pleural effusion or fluid overload. The findings contribute to improved understanding of how fluid management impacts outcomes for pancreatitis and may inform future updates to best practice guidelines.
Trial Registration: Not registered, non-clinical work.
Funding: This study did not receive any specific funding.
Ethical approval & informed consent: This project has been approved by the ACT Health Human Research Ethics Committee (2023/ 00099).
Anastasia HATZIS (Canberra, Australia), Drew RICHARDSON, Timothy FROMMER
00:00 - 00:00
#42150 - Adult Intestinal Intussusception: A rare case of bowel obstruction.
Adult Intestinal Intussusception: A rare case of bowel obstruction.
Introduction:
Intestinal intussusception is a rare but potentially serious condition, especially in adults. This case report highlights the diagnostic challenges and clinical presentation of adult intestinal intussusception, emphasizing the importance of considering this uncommon entity in the differential diagnosis of acute abdominal pain.
Case Presentation:
A 35-year-old woman presented to the Emergency Department with a 2-hour history of severe abdominal pain. She described the pain as sudden and excruciating, comparing it to the sensation of a chainsaw, and had two episodes of vomiting prior to seeking medical attention. Her medical history was notable for appendicitis and a gastric polyp, though she had no risk factors for pregnancy.
Upon examination, the patient appeared distressed due to the intensity of her pain, yet her vital signs remained stable with no abnormalities. Ten milligrams of morphine were administered prior to the abdominal examination. On palpation, the abdomen was globally tender, particularly in the epigastric and right upper quadrant regions; there was no evidence of Murphy’s sign. Urinalysis revealed no abnormalities, blood tests showed no signs of inflammation, the BHCG test returned negative, and levels of lipase and liver enzymes were within the normal range.
Given the clinical presentation and inconclusive laboratory findings, a point-of-care ultrasound was performed revealing evidence suggestive of intestinal intussusception on the right upper quadrant (fig 1), there were no fluid effusion, no argument for acute cholecystitis or kidney stone.
An abdominal CT scan was performed confirming the diagnosis of adult intestinal intussusception.
During the surgical management, the intussusception was successfully reduced, a grelic mass was palpated and resected. The patient recovered uneventfully and was discharged.
Discussion and conclusion
Adult intestinal intussusception is a rare condition often associated with underlying pathologies such as tumors, adhesions, or inflammatory bowel disease. Prompt recognition and surgical intervention are crucial for preventing complications and ensuring favorable outcomes. This case underscores the importance of maintaining a high index of suspicion for uncommon etiologies of acute abdominal pain, particularly in patients with unexplained intense pain and nonspecific clinical presentation. Point-of care ultrasound is a tool in the diagnosis arsenal.
Christelle HERMAND (Paris), Marie CALVEZ, Youri YORDANOV
00:00 - 00:00
#42030 - Adverse cardiovascular events in adults with acute intoxications in the emergency department in two high complexity hospitals.
Adverse cardiovascular events in adults with acute intoxications in the emergency department in two high complexity hospitals.
Background:
Drug use and abuse, along with drug overdose or poisoning, pose a global public health issue. During 2020, 284 million people aged 15–64 worldwide had used illicit drugs in the past 12 months, an increase of 26% from 2010. In Colombia 17,332 patients entered emergency room admissions during 2020, aged 15 to 29.
Methods:
A retrospective cohort study was conducted during the years 2015 to 2021. A multicenter investigation took place at two hospitals in Colombia. A convenience sampling method was implemented. Patients admitted were those who entered the emergency room and were diagnosed with acute intoxication.
Inclusion criteria:
a) suspicion of intoxication (exposure to any drug, substance, or toxin in an estimated dose sufficient to evoke symptoms and/or consumption of a therapeutic agent in a known supratherapeutic dose), or overdose (utilization of a therapeutic agent or recreational drug in a dosage exceeding the normative range); b) age above 18 years; and c) presentation within 24 hours of exposure.
The primary outcome was the occurrence of one of four cardiovascular adverse events. Data collection was carried out through the review of medical records and recording in a database using Microsoft Excel. Including demographic characteristics, cardiovascular medical history, information on mode of exposure and substances involved, clinical and laboratory variables, electrocardiographic findings, and the presence of outcomes of interest (primarily CVAs), as well as mortality and length of stay in the emergency department. After completing the data collection and organization phase, all corresponding statistical analyses were performed using the statistical software STATA. For demographic variables, a normality test was conducted using the Shapiro-Wilk test, and a univariate analysis was performed for their description. Measures of central tendency and dispersion were calculated for quantitative variables, while qualitative variables were expressed as frequencies and percentages.
Results:
This study included 243 patients with a median age of 29 years [IQR: 22-39]; 62.14% were females. During the study period, 30 adverse cardiovascular events (ACVEs) were recorded, accounting for 12.34% of the population. Among these, 18 patients experienced shock (60.0%), 6 had cardiac arrest (20%), 3 cases involved ventricular arrhythmias (10.0%), and 3 showed evidence of myocardial injury (10%). Of all patients, 164 (67.49%) were hospitalized on the ward, 53 were discharged from the emergency department (21.81%), and 17 were transferred to the ICU (7.0%). The overall mortality rate was 1.23%, with 3 recorded deaths.
Discussion & Conclusions:
Acute intoxications lead to significant emergency department admissions, with associated cardiovascular adverse events contributing substantially to morbidity and mortality. In this study, a 12.34% incidence of cardiovascular adverse events and an overall mortality rate of 1.23% were observed. Demographically, the affected population resembles findings from similar studies, predominantly affecting young individuals, mostly women, with suicidal intent being the primary cause of intoxication. However, causal factors and electrocardiographic abnormalities differ from those reported in other clinical contexts and geographic locations. Associations with clinical outcomes relate to the number of substances involved and the combination of pharmacological groups, exacerbating cardiovascular physiological effects.
Sebastian CRUZ, Camilo MOLINA, Valentina VILLARREAL (, Colombia), Miguel Angel SAAVEDRA, Gabriela GUERRON
00:00 - 00:00
#41735 - Age influences the prognostic value of serum albumin and venous lactate in the emergency department.
Age influences the prognostic value of serum albumin and venous lactate in the emergency department.
Background:
High lactate levels and low serum albumin levels are associated with increased mortality and morbidity. Older age has also been observed to be associated with poor outcomes. Our study aimed to investigate the prognostic value of venous lactate and serum albumin in ED patients and to determine if age has an impact on its prognostic value.
Methods:
This prospective single-centre study was conducted in the ED of a Hong Kong university hospital, Prince of Wales Hospital, between July 2016 and June 2017. We recruited 1253 ED patients who were triaged as category 2 (Emergency) and 3 (Urgent). Venous lactate (VL) and serum albumin (Alb) levels were measured. The primary outcome was 7-day mortality. Their prognostic values for 7-day mortality were calculated. Receiver Operating Characteristic analyses were performed to determine the Areas Under the Curve (AUC) of two age groups, <65 years and ≥65 years old, which were then compared pairwise.
Results:
Of the 1253 recruited patients, 50.9% were male and the median age was 72 years old. Data were available for serum albumin levels for 1203/1253 (96.0%) patients. 42.9% of patients had low albumin. The overall 7-day mortality was 2.6%. The 7-day mortality rate in the subgroups of <65 years and ≥65 years old were 1.2% and 3.2%, respectively. Higher lactate levels and lower albumin levels were found in patients who died compared to survivors (p<0.001). The prognostic value for 7-day mortality, with AUCs for Alb for all patients, patients aged <65 years and ≥65 years old were 0.84 (95%CI 0.82 to 0.86), 0.92 (95%CI 0.89 to 0.95) and 0.80 (95%CI 0.77 to 0.83), respectively. The prognostic values of lactate for prediction of 7-day mortality, with AUCs for overall patients, aged <65 years old and aged ≥65 years old were 0.69 (95%CI 0.67 to 0.72), 0.89 (95%CI 0.86 to 0.92) and 0.66 (95%CI 0.62 to 0.69), respectively. Using pairwise comparison of ROC curves, the prognostic value of Alb and VL performed better in predicting 7-day mortality in ED patients in patients aged <65 years old compared to patients aged ≥65 years old (p<0.02).
Discussion and Conclusions:
Among emergency and urgent ED patients, the prognostic values of Alb and VL were influenced by age, and performed better in patients aged <65 years old compared to patients aged ≥65 years old.
Trial Registration: No intervention
Funding: This study did not receive any specific funding
Ly LEUNG, Kkc HUNG, C CHO, Sy MAN, Ca GRAHAM (Hong Kong, Hong Kong)
00:00 - 00:00
#40844 - Air-fluid level in the mediastinum.
Air-fluid level in the mediastinum.
A 19-year-old man presented to the emergency department with weakness, loss of appetite and a weight loss of at least 13 kg in 5 months. He also complained of exertional dyspnea, dry cough, day and night sweats, and abdominal plus lower back pain. The physical examination revealed a temperature of 39.3°C and nothing else abnormal. The chest X-ray (Figure 1) revealed a mass that appeared to be located in the posterior mediastinum.
Diagnosis : Pott's disease with extended double peri-spinal collection
A CT scan (Figure 2) was performed in the emergency room to assess the extent of the disease, which showed pulmonary tuberculosis and spinal osteomyelitis associated with a peri-spinal collection from T1 to T12 and from L5 to S2, suggesting Pott's disease (1). The diagnosis of disseminated tuberculosis was confirmed by the presence of Mycobacterium tuberculosis in culture (2). A quadri-therapy for tuberculosis was initiated with Isoniazid, Rifampicin, Pyrazinamide and Ethambutol, then downgraded to a tri-therapy due to the absence of resistance at the antibiogram (3). Magnetic resonance imaging (Figure 3) performed later during the hospitalization revealed a staged spondylodiscitis associated with collections with the beginning of extension to the central nervous system. Echocardiography confirmed the presence of associated chronic pericarditis. Finally, the indication for radio-controlled drainage of the posterior mediastinal collection was decided due to the important risk of fistulization (4).
Tuberculosis is caused by slow growing aerobic bacilli, mycobacterium tuberculosis complex. This disease, affecting mainly the lungs, also takes osteoarticular forms, the most frequent of which is spondylodiscitis. Spinal involvement is always secondary to hematogenous dissemination of bacilli from the primary site (5). Pott's disease results from an infection of the vertebrae (spondylitis) and intervertebral discs (discitis) with M. tuberculosis. Intervertebral disc is a relatively avascular structure, and is spared until late stage of the disease. Bone destruction in spinal tuberculosis can be fragmentary, osteolytic, subperiosteal, or localized destruction with sclerosed margins. Cold abscesses are pus collections that lack surrounding inflammatory response, and are seen in nearly 70% of patients with spinal tuberculosis. This is a severe form of the disease, located near nerve structures, which may be significantly and permanently affected, and may be life-threatening.
Alexis FREMERY (Cayenne, French Guyana), Magaly ZAPPA, Jean PUJO, Loïc EPELBOIN
00:00 - 00:00
#41107 - Airway Obstruction due to FB.
Airway Obstruction due to FB.
Abstract:
Airway obstruction is a critical condition often encountered in emergency departments. We present a case of a young IVDU who experienced respiratory arrest following excess heroin use. Prompt intervention with naloxone reversed the respiratory depression, but the patient presented with dysarthria and an inability to speak. Subsequent evaluation revealed a unique aetiology of airway obstruction: his denture was found lodged in his vocal cords. This case highlights the importance of a thorough airway assessment in patients presenting with altered mental status, especially in high-risk populations such as IVDUs.
Introduction:
Airway obstruction is a potentially life-threatening emergency requiring immediate intervention. In the emergency department (ED), patients presenting with respiratory arrest often necessitate rapid assessment and management to prevent adverse outcomes. We report a case of airway obstruction in an IVDU who experienced respiratory arrest following heroin use, with subsequent discovery of denture dislodgment causing obstruction of the vocal cords.
Case Presentation:
A 32-year-old male, a known intravenous drug user, was brought to the ED by paramedics following a respiratory arrest. On arrival, the patient was unconscious, and his friend reported a heavy dose of heroin ingestion prior to the arrest. Cardiopulmonary resuscitation (CPR) was initiated by the friend until the arrival of paramedics. Naloxone was administered, leading to the successful reversal of respiratory depression. However, upon regaining consciousness, the patient was unable to speak and exhibited signs of dysarthria. He attempted to communicate but only produced incoherent noises.
Physical examination revealed bilateral decreased breath sounds with accessory muscle use. The patient appeared agitated and restless. Given the concern for potential brain damage or cerebrovascular accident (CVA) secondary to the respiratory arrest, a CT scan of the head was scheduled. However, due to the patient's agitation and compromised airway, he was prepared for endotracheal intubation for the CT procedure.
During the intubation process, direct visualization of the airway revealed a foreign body obstructing the vocal cords. Further examination revealed the foreign body to be the patient's denture, which had become dislodged and lodged in the larynx. Removal of the denture immediately restored the patient's airway, and he began vocalizing loudly, expressing anger and confusion.
Discussion:
Airway obstruction can result from various aetiologies, including anatomical, mechanical, or pathological factors. In this case, the unusual presentation of dysarthria and inability to speak prompted further investigation, leading to the discovery of denture dislodgment obstructing the vocal cords. Intravenous drug use can predispose individuals to airway compromise due to depressed respiratory drive, aspiration, or foreign body inhalation. Prompt recognition and management are essential to prevent adverse outcomes.
Conclusion:
This case emphasizes the importance of considering diverse aetiologies of airway obstruction in patients presenting to the ED, particularly in high-risk populations such as intravenous drug users. A thorough airway assessment, including direct visualization, if necessary, is crucial for timely diagnosis and intervention.
This has been taught in the Advanced Life Support (ALS) Course but is not seen to be strictly adherent while the airway is assessed initially.
Nadeem Ahmed KHAN (Manchester, )
00:00 - 00:00
#42198 - Alternative dispatch pathways: how to handle increasing number of emergency calls?
Alternative dispatch pathways: how to handle increasing number of emergency calls?
Introduction:
Emergency medical services (EMS) are currently facing new challenges: the number of calls has been rising sharply for several years, while the number of doctors in EMS has been falling steadily. This dual challenge calls for new solutions in dispatch centers. In a doctor-managed dispatch center, the current trend is to empower emergency medical dispatchers (EMDs).
A limited number of selected protocols enables EMDs to make fully autonomous decisions for selected calls (PACTE), while retaining medical supervision where necessary.
The aim of this study was to measure the evaluation of these protocols PACTE by EMDs seven months after their implementation.
Material and methods:
This was a prospective study carried out between 01/09/23 and 31/10/23. The collected data concerned: seniority in the department, frequency of use and comfort with PACTE, and reasons for not using them, PACTE considered the most difficult, other syndromes that could be adapted in PACTE, feeling of being sufficiently trained, and feelings about PACTE use in daily practice and suggestions for improvement.
Results:
Out of 60 EMDs, 40 (67%) completed the questionnaire.
Forty-three percent of EMDs used regularly PACTE. Half of them felt comfortable with PACTE, (score ≥7 on a scale from 0 to 10). They said they felt more valued in their work (34%), and felt they had more autonomy (29%) and skills (13%). A third of them felt they were not sufficiently trained and in 48% of cases, EMDs preferred to pass the call on to the doctor to avoid making a mistake. Sufficient training was associated with feeling comfortable with PACTE (p<0.06) and sense of comfort was significantly associated with their more frequent use (p<10-3). On the other hand, a more experienced EMD did not necessarily use more often PACTE than a less experienced one (p=0.57).
Conclusion:
Implementation of PACTE for EMD is an effective solution. As part of an evolution of the EMS, new PACTEs could be set up, with reinforced operator training.
Gaelle LE BAIL (Garches), Clarence FISCHER, Margot CASSUTO, Anna OZGULER, Michel BAER, Thomas LOEB
00:00 - 00:00
#42166 - AMAX4 – Algorithm for Anaphylaxis and Asthma Resuscitation.
AMAX4 – Algorithm for Anaphylaxis and Asthma Resuscitation.
Introduction: Anaphylaxis is a severe and potentially life-threatening hypersensitivity reaction that requires immediate management. The AMAX4 algorithm highlights the standard of critical care when treating hypoxic anaphylaxis and asthma in order to prevent unnecessary deaths. The initiative was launched in 2022, following the death of dr. Ben McKenzie’s son, Max, who died at the age of 15, from hypoxic brain injury sustained during food anaphylaxis related bronchospasm/asthma. This abstract provides an overview of the key components discussed in the AMAX4 guidelines.
Discussion: AMAX4 algorithm is providing guidelines for anaphylaxis/asthma patient who is unconscious and requiring bag valve mask support. The time to hypoxic brain injury is extremely short and cannot be extended by CPR in hypoxic arrest. AMAX4 is a mnemonic for structured approach to ER room anaphylaxis management. Intravenously applied adrenalin in push doses ensures immediate effect compared to delay from 5-8 minutes in intramuscular administration. In severe bronchospasm there is high risk of CICO (can’t ventilate, can’t oxygenate) so early intubation is recommended with administration of muscle relaxants if needed, because our first attempt at laryngoscopy must be the best attempt. Definitive airway and ventilation management (endotracheal intubation or surgical airway) needs to be done in the first 4 minutes before hypoxic brain injury starts to develop in respiratory arrest. To ensuring adequate oxygenation and ventilation in high airway pressures present in bronchospasm we need to apply higher PIP while simultaneously applying supportive therapy (bronchodilators, volume therapy and vasopressors as required).
Conclusion: The AMAX4 guidelines provide evidence-based, comprehensive approach to the management of anaphylaxis. Adherence to these guidelines within emergency department will improve overall management, reduce the risk of complications, and enhance patient safety.
Matea BINGULA (Zagreb, Croatia), Bojana RADULOVIĆ
00:00 - 00:00
#42117 - An artificial neural network-based model for predicting the risk of ventilator-associated pneumonia.
An artificial neural network-based model for predicting the risk of ventilator-associated pneumonia.
Objective The occurrence status of ventilator-associated pneumonia (VAP) was collected through literature analysis and investigation method, and its related influencing factors were explored and analyzed, which provided objective data support for the construction of VAP risk prediction model. Then, a risk prediction model of VAP based on artificial neural network algorithm (ANN) is constructed, and compared with the logistic regression prediction model, the model with better prediction effect is selected, in order to provide a convenient and scientific evaluation tool for VAP prediction. Methods Patients who met the inclusion criteria in a tertiary care hospital from January 2021 to November 2022 were used as the study population using convenience sampling method. The study tools were a self-administered general information questionnaire and VAP scoring criteria to investigate the current status of VAP. Using IBM SPSS Statistics 26.0 statistical software, whether the patient had VAP as the dependent variable and the influencing factors as the independent variables, the χ2 test, Fisher's exact probability method and t-test were applied to the independent variables that might affect VAP for univariate analysis, and the variables with statistical significance in the univariate analysis were gradually included in the multi-factor logistic regression overall analysis was performed to screen out the independent influencing factors of VAP. Thirdly, the patient data were randomly divided into model construction group and validation group in the ratio of 7:3, and two methods of ANN and logistic regression were used to establish the VAP risk prediction model, and the efficacy of the two prediction models were compared and analyzed according to the data of the model validation group, respectively, and the evaluation indexes included the area under the working characteristic curve of the subjects, Gini coefficient, sensitivity, specificity, and accuracy. Results A total of 132 valid questionnaires were collected in this study, and the total VAP score was (27.33±4.45). All samples were randomly divided into 93 cases in the model construction group and 39 cases in the model validation group. There were 49 patients with VAP in the model construction group and 16 patients with VAP in the validation group. There was no statistically significant difference between the baseline data of the two groups (P > 0.05). In the model construction group, the AUC of ANN was 0.712, Gini coefficient was 0.774, sensitivity was 78.23%, specificity was 72.26%, and overall accuracy was 71.24%; the AUC of logistic regression model was 0.756, Gini coefficient was 0.672, sensitivity was 71.121%, specificity was 70.12%, and overall accuracy was 76.45%. The overall accuracy was 76.45%; the prediction effect of ANN was significantly better than that of the logistic regression model. Conclusion The high incidence of VAP needs to be of great concern to society, families, and clinical caregivers. The risk prediction model of VAP developed by ANN has better predictive efficacy than the traditional logistic regression method and can be used as an assessment and prediction tool to assist medical personnel to identify the high-risk group of VAP as early as possible.
Mingxin HE, Li YANYAN (shenzhen, China), Yang YALOU
00:00 - 00:00
#41236 - An Atypical Presentation Of Infective Endocarditis.
An Atypical Presentation Of Infective Endocarditis.
Patient was consented for publication/ presentation.
Brief clinical history: 37 years old male with no prior medical history presented to the Emergency Department (ED) with fever, diarrhoea and abdominal pain for one week. He had travelled to Malaysia a week ago and denied recreational drug usage. On arrival, he was febrile and tachycardic with right iliac fossa tenderness. Computed Tomography scan of the Abdomen and Pelvis (CTAP) revealed splenic and left kidney infarcts with bilateral iliac artery thrombi. Bedside point of care ultrasound (POCUS) showed a large mitral valve vegetation.
Misleading elements: The patient’s presenting complaint of fever, diarrhoea and abdominal pain initially seemed like a typical case of gastroenteritis. However, as he subsequently looked more unwell with tachypnoea and had abdominal pain, a CTAP was performed. He had leucocytosis, C-reactive protein of 253mg/L and procalcitonin of 36.9μg/L. Liver enzymes were slightly elevated, Troponin T was 359ng/L, and dengue was negative. Electrocardiogram showed sinus tachycardia of 116 beats per minute.
Helpful details: The patient was given intravenous antibiotics, crystalloids and antipyretics. Chest X-ray was normal. CTAP showed splenic and left kidney infarcts with bilateral iliac artery thrombi. Bedside POCUS showed mitral valve vegetation which clinched the diagnosis of infective endocarditis with septic emboli. He was thus referred to the cardiology team and the cardiothoracic surgeons, and intubated due to hypoxia and worsening shortness of breath. The same night, he underwent emergency mitral valve replacement and embolectomy of bilateral iliac arteries. Blood culture grew Group B streptococcus. During his stay, he developed multiple mycotic pseudoaneurysms and a left insular cortex infarct as complications from the septic emboli. He was discharged two months later.
Differential and actual diagnosis: This patient presented with fever and abdominal pain; possible differential diagnoses included gastroenteritis, intra-abdominal sepsis, appendicitis, and the possibility of myocarditis was also entertained in view of the raised troponin. Dengue fever or malaria were also possibilities in view of travel history. Final diagnosis of infective endocarditis with septic emboli was made with the help of the CTAP as well as in particular the bedside POCUS performed in the ED.
What is the educational and/or clinical relevance of the case? IE is a life threatening disease which is relatively rare (3–11 cases per 100 000 per year). Diagnosis of IE is via the Duke’s criteria which includes both major and minor criteria. This patient had 1 major criteria and 3 of the minor criteria (including blood culture results). As seen in this case, patients with IE can rapidly deteriorate due to valve insufficiency. This patient had an atypical presentation and indeed infective endocarditis is difficult to pick up in the emergency department. Although it is rare, emergency physicians should be aware of the diagnosis and its potential complications, and consider IE in prolonged fever without a clear source.Bedside ultrasound was also key to the diagnosis in this particular case as the vegetation was large.
Yee Kent LIEW (Singapore, Singapore), Ming Jing Elizabeth TAN, Yuan Helen ZHANG, Si Yong Ivan CHUA
00:00 - 00:00
#41937 - An audit of Consultant Sign-Off (CSO) standards at the Emergency Department at University College London Hospital.
An audit of Consultant Sign-Off (CSO) standards at the Emergency Department at University College London Hospital.
Background: The Quality in Emergency Care Committee Standard, established in June 2016, delineates criteria for ensuring excellence in emergency medical (EM) services across UK hospitals. This standard addresses a spectrum of critical conditions necessitating specialized care within emergency settings and serves as a benchmark for evaluating the quality of EM services. It encompasses protocols for patient assessment, treatment, resource management, communication, and quality improvement initiatives. Consultants and senior trainees are pivotal in upholding these standards, ensuring the delivery of competent and professional emergency care.
Specific patient groups identified by this standard include adults aged 30 years and above presenting with atraumatic chest pain, infants under 1 year with fever, individuals aged 70 years and older with abdominal pain, and patients returning to the Emergency Department (ED) within 72 hours with the same condition. At University College London Hospital (UCLH), pediatric patients with fever are managed directly by pediatricians.
Methods: Data analysis conducted at UCLH from January to March 2024 focused on three patient categories: those with atraumatic chest pain, unscheduled return visits within 72 hours, and elderly patients with abdominal pain. The analysis included patients seen in the Urgent Treatment Centre (UTC), Major care units, and those admitted to the Same-Day Emergency Care (SDEC) facility.
Results: Atraumatic chest pain: Among 62 patients, 24 were seen in UTC, 24 in Major care, 1 admitted to SDEC, and 13 self-discharged. Of the 24 seen in Major care, 17 underwent senior review, with 6 directly assessed by EM senior trainees or consultants.
Abdominal pain in patients aged 70 years and over: Among 59 patients, 7 were seen in UTC, 44 in Major care, 3 admitted to SDEC, and 5 self-discharged. Of the 44 in Major care, 12 lacked senior review, while 32 received senior evaluation, with 2 directly assessed by ED senior trainees.
Unscheduled return to the ED within 72 hours: Among 50 patients, 29 were seen in UTC, 9 in Major care, 3 admitted to SDEC, and 2 self-discharged. Among the 9 in Major care, 3 were assessed by senior trainees, 5 received senior review, and 1 had no review. Among 7 pediatric patients, 2 lacked review, 2 were assessed by Pediatric senior trainees, 1 by a Pediatric Emergency consultant, and 2 received senior review with additional documentation.
Conclusion:
Optimally, all four cohorts of patients should undergo senior review. Our analysis revealed that 71% of patients with atraumatic chest pain, 73% with abdominal pain, 89% with unscheduled returns, and 71% of pediatric patients received senior reviews. Efforts are underway to enhance performance across these domains. This entails intensive training for senior clinicians to ensure complete documentation, aiming for 100% compliance with established standards.
N/A
Yuri KAWASHIMA, Ahmad EL-MAHMOUD, Sergio B SAWH (London, )
00:00 - 00:00
#41772 - An audit of ultrasound governance in emergency departments in West & South Yorkshire, United Kingdom.
An audit of ultrasound governance in emergency departments in West & South Yorkshire, United Kingdom.
Introduction
The Royal College of Emergency Medicine (RCEM) updated their curriculum1 in 2021 to improve the provision of Point-of-Care Ultrasound (PoCUS). It focuses on the importance of ongoing education and training during specialty training years 1-5, and highlights the need for robust governance in every department. The Royal College of Radiologists (RCR) and British Medical Ultrasound Society (BMUS) have jointly produced guidance2 for specialists practising ultrasound independently of radiology departments in the UK, including recommendations regarding the governance of the use of ultrasound. Appropriate governance is important for both patient and staff safety. Our audit focused on emergency departments (ED) in West and South Yorkshire and their current governance practice and aimed to highlight areas of potential improvement.
Methods
We created and distributed an online survey to the ED ultrasound lead at each of the trusts with an emergency department, or a named contact if the trust did not have a dedicated ultrasound lead. The questions focused on their department’s current governance practice, and also on the ultrasound equipment. We had 13 responses in total, which was a return rate of 100%.
Results
The responses came from a mix of teaching hospitals and district general hospitals with and without trauma centre status. The machines largely had similar capabilities, and were most often used for FAST scanning, echo in life support, and vascular access. All but one trust had a dedicated ultrasound lead, a recommendation set in the guidance. The majority of images (69.2%) are stored on the machine hard drive itself, with some having the facility to upload to PACS (53.8%). Only one trust (7.7%) had standardised documentation for ultrasound reporting using a template, and the majority (76.9%) put their reports directly onto patient notes. In most cases, any clinician is allowed to use the ultrasound machine without restriction. None of the trusts have an audit process in place in their department and 84.6% have no built in safety net for when junior members are using the ultrasound or reporting scans. Only 23.1% (or 3 out of 13) of departments have a written policy or guideline on ultrasound governance.
Conclusion and Recommendations
The most salient point of this audit is the current lack of formal governance and audit process when it comes to the use of ultrasound independent of radiology departments. It would be important to implement a regular audit within each department in order to maintain appropriate standards. There also does not seem to be a universally accepted way of reporting ultrasound scans performed in the emergency department, and it would be one of our recommendations that a template is developed for this. To aid with these recommendations, it is vital that there is an ultrasound lead in each department to help oversee the governance. Whilst we acknowledge that this audit was conducted on a relatively small subset of emergency departments in the UK, it has the potential to expand and take place UK-wide across other departments, to best inform current and future practice.
Amy FEATHER (Bradford, ), Asoka WEERASINGHE, Suneel GALIPOTHU
00:00 - 00:00
#42103 - An epidemiological study of the drug withdrawal syndrome.
An epidemiological study of the drug withdrawal syndrome.
Background:
Drug withdrawal syndrome (DWS) is one major complication of drugs consumption. The most described syndrome is Cannabis withdrawal syndrome and DWS can complicate other substances use such as illicit drugs, cocaine, benzodoazepines and cafeine. DWS is imperative to prevent and diagnose in order to better manage it and to reduce its high rate of morbidity, mortality and economic costs.
The aim of the of our study was to describe the epidemiological profile of DWS and to characterize its management strategy.
Methods: We conducted a study at the emergency department of the center of urgent medical care Mahmoud Yaakoub in Tunis, Tunisia from January 2021 to January 2023, including all patients who presented for drug withdrawal syndrome according to the DSM-V definition criteria.
Results:
Our study included 117 patients. Their mean age was 34 ± 9.6 years. There was a masculine predominance with a sex ratio of 10.7. Only 5 patients (4.3%) had a medical history. Four of them (3.4%) had depression and one patient had hypertension. The most common symptoms on admission were : a generalized pain in 62 patients (53%), insomnia in 39 patients (33.3%), a headache in 33 patients (28.2%), diarrhea in 29 patients (24.8%), anxiety in 21 patients (17.9%) and vomiting in 16 patients(13.7%). The physical examination of the patients found: a mean heart rate of 83 bpm (std variation=14.14). Eighteen patients (15,38%) were tachycardic (100-120bpm). Systolic blood pressure (SBP) varied from 68 to 180 mmHg with a mean value of 127 and a standard variation of 15.69. Diastolic blood pressure (DBP) varied from 40 to 113 mmHg with a mean value of 75 (std variation=10.98). All patients were eupneic with a mean respiratory rate of 15.5 cpm (std variation=2.1) and they all had a normal subcutaneous oxygen pressure (95-100%). They were conscious with a GCS of 15 with no neurological signs of localization. All pupils were intermediate and reflective. The most observed substances were: Heroin was the most frequent used drug in 69 patients (59%), followed by cannabis in 28 patients (23.93%), then buprenorphine (BUPE) in 22 users (18.8%) and cocaine in 20 patients (17.1%). Nineteen patients (16.2%) had benzodiazepine toxicomania. All patients received symptomatic treatment. It included hydration and analgesics. Twenty-nine patients received a prescription of an antidiarrheal treatment. The median length of stay varied from 20 minutes to 9 hours with a mean value of 1.75 hours. Most of the patients (64.1%) were oriented to addiction consultation. 25 patients (21.4%) returned home. Eight patients (6.8%) were transferred to another emergency department. Three patients (2.6) were oriented to the psychiatry consultation and the rest of the patients (5 patients representing 5.1%) evaded or left against medical advice.
Conclusion : The DWS is a major complication of substance consumption. It mostly touches young men. It includes various symptoms. Many substances could be incriminated, especially opioids, cannabis, cocaine and benzodiazepine. DWS is usually mild and not life-threatening, but vital distresses should be detected and managed.
Boutheina FRADJ (Mahdia, Tunisia), Mohamed KILANI, Hafedh THABET, Kamilia JEDDI
00:00 - 00:00
#41084 - An Interesting Case Of Rhabdomyolysis From Pregabalin Use.
An Interesting Case Of Rhabdomyolysis From Pregabalin Use.
This case demonstrates a rare case of rhabdomyolysis caused by excessive pregabalin use, resulting in anuric acute kidney injury requiring the initiation of continuous renal replacement therapy.
A 37-year-old Malay gentleman presented with acute onset of bilateral lower limb weakness (right > left) and was noted to have a preceding history of significant ingestion of pregabalin. He had taken five tablets of pregabalin (150mg tablet) in close succession on a single day for chronic lower back pain and had been taking one tablet a day five days prior. The patient had prolonged immobility after experiencing bilateral lower limb weakness, and was anuric for three days before his presentation.
In the emergency department, the patient was initially noted to be hypotensive, which was fluid-responsive. The most significant finding on examination was that of reduced power distally in the patient's bilateral lower limbs, but the sensation was otherwise intact. Power in his upper limbs were preserved, and the patient did not display symptoms of urinary or bowel incontinence. Glasgow Coma Score (GCS) was preserved at 15. A bedside point of care ultrasound showed good cardiac contractility. There was no pericardial effusion. The bladder was not distended and there was no hydronephrosis in bilateral kidneys as well.
Laboratory investigations showed new onset acute kidney injury, with a serum creatinine 957umol/L, urea 27.5 mmol/L, eGFR <15ml/min/1.73m2. The patient also had a potassium level of 6.9mmol/L, with refractory hyperkalemia which did not respond to initial medical therapy, such as fluid replacement and repeated doses of insulin and dextrose 50%. This was accompanied by electrocardiogram (ECG) changes of tall, tented T waves. Furthermore, the creatinine kinase level was 315,000 U/L.
The diagnosis for this patient was that of Kidney Disease Improving Global Outcomes (KDIGO) Stage 3 anuric acute kidney injury, likely caused by rhabdomyolysis from pregabalin use. Other differentials that were considered include possible underlying myositis, pre-renal from dehydration and poor oral intake, or underlying undiagnosed chronic kidney disease, though less likely.
The patient was admitted to the intensive care unit (ICU) and was newly initiated on continuous renal replacement therapy in view of severe acute kidney injury and refractory hyperkalemia. Subsequently, his creatinine and potassium levels and urine output improved after days of intravenous fluid infusion and renal replacement therapy. His creatinine kinase levels eventually normalised as well.
The case emphasises the need to understand the various causes of rhabdomyolysis, including that from the use of uncommon medications such as pregabalin in this case.
Xin Yi Hannah LIM (Singapore, Singapore), Than Zaw OO
00:00 - 00:00
#41889 - An international systematical review of the management of out-of-hospital cardiac arrest.
An international systematical review of the management of out-of-hospital cardiac arrest.
Background: Out-of-hospital cardiopulmonary arrest (OHCA) has an overall survival rate of 8% and major differences exist between survival rates by country. Despite the international consensus recommendations’, each country has its practices, especially about the application of the chain of survival. No study has explored these heterogeneities in the world. The primary outcome is to describe the management of an OHCA until the arrival of emergency services. The secondary outcome is to compare the management in France to the other countries.
Methods: This systematical review analyzes data from signatory countries of the International Liaison Committee on Resuscitation (ILCOR). It is based on the analysis of articles according to the Prisma Statement 2020 with to observational studies from the Embase, MEDLINE, and Web of Sciences databases published in English or French, between January 2018 and September 2023. The aim was to describe the epidemiology of OHCA, the initiation of cardiopulmonary resuscitation (CPR), the dispatch-assisted CPR (DA-CPR), the continuation of CPR by the placement of the defibrillator (AED), the engagement of institutional rescue, sometimes preceded by the mobilization of a citizen rescuer.
Results: Of 6437 studies identified, seventeen met the including criteria and representing fourty countries out of fifty-one. OHCA occurs more frequently in men, at home, and due to a cardiogenic etiology. Global survival at 30 days is 11% [0%; 19%]; CPR was performed in 49% [6%; 100%]; an AED was applied in 1.8% of cases [0,8% à 9%]. DA-CPR and citizen rescuers seem to be worldwide present. No study discusses the rate of people trained in first aid and the type of skills learned by the population. Emergency medical services skills are different in each country, most countries are based on paramedics trained to apply Advanced Life Support. France is no exception to these observations except regarding the paramedical response and survival rates (global survival rate is 5%).
Discussion & Conclusion: The statistics on the onset of OHCA are homogenous, but the review shows that each country has its practices and data with non-harmonized adjustments, preventing any reliable comparison between countries. It seems to be impossible to compare the “performance” of each country without a periodical publication and harmonization of data from local registers. A unique international register could help to compare the data. In our review, the practices of 40 countries were explored but some important countries were excluded as China or Ireland (no ILCOR signatory) and this could be a sample bias; and a bias of interpretation exists by the presence of continental study-based on surveys. Despite a worldwide consensus on the management of OHCA, future researches will need to focus on the harmonization of the data, to compare practices between countries to improve survival in OHCA.
Ethical approval and informed consent: not needed.
Trial registration: no registration was made.
Funding: This study did not receive any specific funding.
Kevin HEURTAUX (Amiens), Daniel Aiham GHAZALI, Raphaël VIGOT, Florian CANU, Michel SLAMA, Emilie LESIEUR
00:00 - 00:00
#40833 - An observational study of sexual assaults in French Guiana during 2019-2020.
An observational study of sexual assaults in French Guiana during 2019-2020.
Introduction: Sexual violence is a major public health issue, including in French Guiana. The feeling of insecurity is significant in this part of France. Sexual violence is an important reason for consultation in forensic and emergency medicine. The challenge is to provide care within the first 72 hours, particularly in medicolegal terms and for infectious diseases management. The objectives of our study were, firstly, to establish the epidemiology of sexual assaults at Cayenne General Hospital (CGH), and secondly, to evaluate the management of these victims.
Materials and methods: From January 1st, 2019, to December 31st, 2020, we conducted a single-center retrospective descriptive study including patients who were consulted for sexual assaults in the Forensic medicine and the Emergency departments of CGH.
Results: Over this period, 400 sexual assault victims were consulted. Most of them, were women (87%) with a median age of 13 years-old [8; 17.5]. The aggressor was mostly male (99%) frequently known by the victim (87%) and from her family (39%). Suspected assaults represented 19% of consultations. The most frequent assault on women was penile-vaginal penetration (82%) and penile-anal penetration (77%) on men. The delay of consultation was superior to 72 hours in 60% of the cases. A psychological follow-up was recommended for 62% of these victims.
Conclusion: This work allowed to identify a young and female population at risk, most often assaulted by a male known to her. Most of the patients consulted more than 72 hours after the assault. Our study highlights the need for prevention actions in French Guiana focusing on this population at risk.
None
Victoire MENSEAU, Jeanne CHARBONNIER, Angélique FRANCHI, Jean PUJO, Mathieu NACHER, Alexis FREMERY (Cayenne, French Guyana)
00:00 - 00:00
#41714 - An unusual foreign body in a middle-aged male.
An unusual foreign body in a middle-aged male.
The patient has given consent to have details submitted.
Brief clinical history:
A 48-year-old male presented to the Emergency Department (ED) by ambulance due to being found inebriated on the street with active gluteal bleeding. Owing to severe alcohol intoxication, a comprehensive medical history could not be obtained. The patient exhibited a Glasgow Coma Scale score of 12 (E2, V4, M6), with an oxygen saturation of 96% on 10 L/min supplementary oxygen. Initial blood pressure was recorded at 75/40 mmHg, with a heart rate of 109 BPM. A laceration was observed on the left gluteal region, prompting consultation with a trauma surgeon for wound closure.
After a physical examination, laboratory investigations and diagnostic imaging were undertaken. Pelvic ultrasound did not reveal evidence of internal bleeding. Arterial blood gas analysis disclosed acidosis with a pH of 6.99, while complete blood count indicated mild anemia at 109 g/L, other laboratory tests were within normal limits. Given the constellation of severe alcohol intoxication, hypotension, and acidosis, the patient was admitted to the Intensive Care Unit (ICU) for close monitoring and management. Following a brief ICU stay, the patient was transferred to the Toxicology department for treatment of alcohol intoxication.
A week later the patient was discharged to a nursing facility due to the presence of severe alcoholic neuropathy necessitating ongoing care. Nineteen days post-discharge, the patient presented to the ED once again, because arterial bleeding from the gluteal wound site has resumed. The patient was conscious and hemodynamically stable upon initial examination, but impaired motor and sensory function in the left leg, indicating damage to the sciatic nerve, was noticed. A pelvic CT scan revealed a 40 mL intramuscular hematoma involving the m. piriformis and m. gluteus, likely stemming from damage to the left internal iliac artery caused by a foreign body identified as a 60x10 mm piece of glass located medially to the obturator foramen. Urgent angiography with embolization of the injured vessel, wound revision, and foreign body removal were performed successfully. Following a 5-day hospitalization, the patient opted for discharge home, declining further care at a nursing facility.
Misleading elements:
severe alcohol intoxication may have initially obscured other underlying medical conditions or injuries, potentially leading to a delayed/inaccurate diagnosis;
normal pelvic ultrasound – no CT scan was performed during the first hospitalization;
the presence of a foreign body causing significant internal damage was not initially evident and highlights the possibility of unexpected findings.
Helpful details:
loss of sensory and motor function of the left leg – damaged sciatic nerve;
CT scan findings – hematoma and foreign body near the wound site;
involvement of various specialties including trauma surgery, interventional radiology, and toxicology facilitated comprehensive care and successful management of the patient's complex condition.
What is the educational/clinical relevance of the case?
the importance of clinical acumen and utilizing available diagnostic tools in intoxicated patients;
the importance of a multidisciplinary approach in diagnosing and treating patients with multiple comorbidities;
the important role of interventional radiology techniques in managing vascular injuries.
Asta KOLOMENSKYTE (Vilnius, Lithuania), Iveta VEGELYTE
00:00 - 00:00
#42321 - Analgesics in severe trauma patients admitted to the emergency room: Predictive factors for prescription.
Analgesics in severe trauma patients admitted to the emergency room: Predictive factors for prescription.
Traumas are frequent reasons for consultation in the emergency room, the mechanisms and
clinical manifestations are multiple, the treatment consists on the one hand of treating the
lesions and on the other hand of relieving the pain which presents itself in the majority of
cases. as an almost present symptom.
Objective:
Determine the predictive factors for prescribing analgesics in severe trauma patients admitted
to the emergency room
Materials and methods:
This is a prospective, descriptive, comparative, single-center study that took place over six
months in the emergency department.
Inclusion criteria: Age over 18 years, both genders, patients admitted for multiple trauma
Non-inclusion criteria: pregnant woman, patient in cardio-respiratory arrest
We defined two groups according to the presence or absence of analgesic treatment: analgesic
group – and an analgesic group+.
the analgesic treatment received by our patients: analgesic treatment level 1 and/or level 3
Results:
Two hundred patients were collected, analgesic group – (n=83) versus an analgesic group +
(n=117); mean age (43.7±17.3 years VS 39.7±13.7 years; p=0.068); gender-ratio (4.5 VS 3.2;
p=0.320); AVP (67 VS 103; p=0.154); work accident (4 VS 3; p=0.452); HTA (15VS 8;
p=0.014); diabetes (15 vs 12; p=0.111) the mechanisms were: collision (15 vs 14; p=0.227);
slippage (9 vs 17; p=0.445); in barrels (5 vs 8; p=0.818); fall greater than 3 meters (5 vs 10;
p=0.593); thoracic deformity (2 vs 14; p=0.016); open fracture (3 vs 8; p=0.529); limb
dislocation (2 vs 3; p=1); clavicle fracture (4 vs 6; p=1); pelvic fracture (29 vs 40; p=0.505);
spinal fracture (40 vs 35; p=0.001); vertebral fracture (4 vs 11; p=0.410); unstable fracture (3
vs 4; p=0.941); multiple fractures (9 vs 27; p=0.032); brain injury (28 vs 18; p=0.002);
subarachnoid hemorrhage (18 vs 10; p=0.009); acute HED (4 vs 4; p=0.722); Acute HSD (13
vs 8; p=0.048); brain contusion (19 vs 10; p=0.006); maxillofacial lesions (16 vs 17;
p=0.373); ISS score (24.36 VS 19.39; p=0.257); RTS score (24.7 VS 8.4; p=0.087); TRJSS
score (24.9 VS 16.7; p=0.320).
Conclusion :
The prescription of analgesics in severe trauma patients is significantly associated with the
presence of hypertension, thoracic deformity, spinal fracture, multiple fractures, brain injury,
subarachnoid hemorrhage, acute SDH, brain contusion.
Khaireddine JEMAI (Tunis, Tunisia), Dhekra HOSNI, Hana HEDHLI, Chaima TLAIES, Ghada MARZOUGUI, Safia OTHMANI, Mariem TLEMCENI, Sarra JOUINI
00:00 - 00:00
#41655 - ANALYSIS AND RISK FACTORS OF THE PATIENTS WITH SEVERE HYPERKALEMIA.
ANALYSIS AND RISK FACTORS OF THE PATIENTS WITH SEVERE HYPERKALEMIA.
Background:
Hyperkalemia is a disease known for its high mortality, and its relationship with some pathologies and medications frequently used among the population, especially the elderly. It is interesting to know and discuss the risk factors that are associated with mortality in an episode of hyperkalemia treated in the emergency department (ED), in order to establish more adjusted prevention and action protocols.
Aim:
To know the factors that are associated with in-hospital mortality in patients with severe hyperkalemia (>6.5 mEq/L).
Methods:
Retrospective descriptive study. Inclusion criteria: Patients over 18 years of age who present in the first analysis upon arrival at the ED a serum potassium level above 6.5 mEq/ between January 2022 and December 2022. Exclusion criteria: Pregnant patients, patients with pseudohyperkalemia, and patients with insufficient or unavailable data. Independent variables: demographics, personal background, parameters obtained in the analysis. Main dependent variable: hospital mortality (HM). Continuous quantitative variables: median and interquartile range (IQR). Qualitative variables: relative frequencies (%). Comparison of quantitative and qualitative variables: Man-Whitney U and Chi-square respectively. Multivariate analysis for HM. Statistical significance: p<0.05. 95% confidence interval (95% CI). Software: SPSS 24.00.
Results:
Results.
N: 93. Median age: 85 (73-90) years; male: 69.9%; median age male: 81 (70-50), female: 87 (73-92) years; Exitus: 32.3%. Median age survivors: 82 (71-89) years, HM: (74-93) years (p<0.05). HM male: 28.6%, female: 37.8% (p>0.05); HM: institutionalized: 43.6% (p<0.05), hypertension: 28.16% (p>0.05), dyslipidemia: 21.6 (p>0.05), heart failure: 33.3 % (p>0.05), diabetes: 30.8% (p>0.05), tumor: 29.0% (p>0.05), chronic renal failure: 27.9% (p>0.05). Analytical parameters (HM vs. survivor): Potassium: 7.05 (6.8-7.6) vs. 7.1 (6.7-7.6) (p>0.05); Leukocytes: 13.75 (9.42-17.50) vs 9.8 (8-13) (p<0.05); Glucose: 133 (105-197) vs 120 (94-149) (p>0.05), Urea: 218 (174-390) vs 173 (132-210) (p>0.05), creatinine: 3.97 (2.43-6.00) vs 3.87 (1.91-7.92) (p>0.05), PCR: 99 (60-164) vs 58 (6-134) (p<0, 05), lactic acid: 3.7 (1.8-7.8) vs 1.7 (1.2-2.4) (p<0.0001); Bicarbonate: 13.8 (9.8-16.8) vs 19.2 (14.7-21.8) (p<0.05). Multivariate study: Age, institutionalized, leukocytosis, CRP, bicarbonate (p>0.05); lactic acid: OR: 1.679 (95% CI 1.060-2.660) (p<0.05).
Discussion:
Hyperkalemia is a disease accompanied by high mortality that occurs relatively frequently in hospital emergency departments. Increased lactic acid is the only factor independently associated with mortality. It would be important to determine this parameter in this group of patients.
Dr Raul LOPEZ IZQUIERDO, Estefania CAUADRADO ABAJO, Susana SANCHEZ RAMÓN, Francisco MARTÍN RODRIGUEZ, Carlos DEL POZO VEGAS (Valladolor, Spain), Jesus ALVAREZ MANZANARES, Ramos Rodriguez ANA, Ingelmo Astorga ELISA, Ruben PEREZ GARCIA, Raquel TALEGON MARTIN, Antonio DEL REY VIEIRA, Inmaculada GARCIA RUPEREZ, Irene CEBRIAN RUIZ, Rut ANEL CUADRILLERO, Henandez Gajate MARIO
00:00 - 00:00
#41807 - Analysis of a clinical simulation program using the SWOT matrix.
Analysis of a clinical simulation program using the SWOT matrix.
INTRODUCTION AND JUSTIFICATION
The training of emergency situations is essential for emergency professionals. A participatory training with simulations would train the team for the benefit of the patient and the satisfaction of the professional. The Emergency Department of General Hospital of Villalba has developed a clinical simulation program for the past 3 years, which was presented at EUSEM 2023.
Using the SWOT matrix (Strengths, Weaknesses, Opportunities, and Threats), we have analyzed our clinical simulation program, asking whether it can be useful to improve it.
MATERIALS AND METHODS
The coordinating group developed an analysis to evaluate the potential Strengths, Weaknesses, Opportunities, and Threats, intensifying and assessing both internal and external factors of our Emergency Department that negatively affect (weaknesses and threats) and positively impact (strengths and opportunities) patient safety improvement. This analysis includes the evaluation of daily clinical practice as well as the clinical simulation program.
RESULTS
According to the SWOT analysis, among the Weaknesses of our service we find dependence on other services such as ICU for managing unstable patients or internal medicine for patient admission. Another weakness identified is the absence of an annual schedule to conduct clinical simulation exercises. Regarding Strengths, we have a multidisciplinary team with ambition and a willingness to learn, as well as adaptability. As for the external analysis, the main Threats include the need to confront infrequent but complex situations or techniques that require extensive safety and training, as well as the difficulty in coordinating clinical simulation exercises within such a large team of professionals. Finally, external Opportunities include enhancing patient safety through coordinated clinical simulation with different services (such as gynecology or ICU).
CONCLUSIONS
Based on the SWOT analysis, the following improvement actions are proposed for the clinical simulation program:
- Generate an annual schedule of clinical simulation exercises allowing joint programming with collaborating services such as ICU.
- Schedule multidisciplinary training sessions where participants and spectators propose improvement actions, with the involvement of different services.
- Consolidate the program as a strategic reference in patient safety at the General University Hospital of Villalba.
- Present the program in a general session of the hospital along with the other medical services.
- Participation in an area of interest such as critical patient care through simulations promotes learning, engagement, and teamwork among all professionals. This translates into safety for the patient and satisfaction for all roles in the emergency department. We will use satisfaction surveys to measure the perceived quality by the emergency service staff.
Alfredo PIRIS VILLAESPESA (MADRID, Spain), Juan ANDUJAR TAVERAS, Teresa NUÑEZ GOMEZ ALVAREZ, Borja SANTOS CAMACHO, Maria Teresa CERDAN CARBONERO, Borja HERNANDEZ MORENO
00:00 - 00:00
#42334 - Analysis of Emergency Department Visits According to Incidence of Covid-19. A multicentric retrospective study.
Analysis of Emergency Department Visits According to Incidence of Covid-19. A multicentric retrospective study.
Introduction: In 2020, the emergence of Covid-19, rapidly evolves into a global pandemic. The government has put in place measures and recommendations to limit the spread of the virus. Some studies have focused on the effects of lockdown and social distancing on the number of Emergency Department (ED) visits. As with lockdown, our hypothesis is that the number of covid and non-covid ED visits vary with the incidence.
Methods: We designed a multicentric, observational, retrospective study between May 13, 2020 and May 3, 2021. All patients over 18 years old from 8 ED were included, excluding inter-hospital transfers. Demographic variables, reasons for use, discharge diagnosis and final orientation were extracted from electronic files. A visit was considered covid-like (CL) if one of the reasons for use was fever, cough or dyspnea. Reasons for use and discharge diagnosis were grouped by specialty for subgroup analysis. We compared the number of weekly entries according to the Covid incidence rate at the local level using the Pearson Correlation test adjusted to the government measures in force.
Results : 237,888 ED visits of patients of 49 on average with 50.7% women were enrolled, or 4,664 ± 393 per week. The 3 largest centers have accumulated 40% more visits than the 5 others. The correlation between weekly ED visits and the Covid-19 incidence rate adjusted for government measures is 0.22 (p=0.131). The correlation between weekly visits and the incidence rate was 0.24 (p=0.454) during lockdown, 0.157 (p=0.467) during unlockdown, and 0.832 (p<0.0001) during the curfew. The correlation between weekly attendance and the Covid-19 incidence rate was 0.83 (p<0.0001) for CL reasons compared to 0.02 (p=0.880) for non-Covid-like (NCL) reasons. Only respiratory and miscellaneous reasons, where CL reasons are classified (dyspnea, cough and fever), have a significant to moderate correlation (respectively r=0,86, p<0,0001 and r=0,53, p<0,0001). Only diagnoses of infectious and respiratory pathologies have a moderate to significant correlation in relation to the incidence rate of Covid-19 (respectively r=0,68, p<0,0001 and r=0,91, p<0,0001) with an increase in hospitalizations in ward units (r=0,69, p<0,0001). There are any correlation between tne Covid-19 incidence rate and intensive care units admission. The analysis according to the size of the centers finds a correlation between weekly emergency room attendance and the Covid-19 incidence rate of 0.28 (p=0.052) for centers with more than 80 visits per day and 0.15 (p=0.289) for centers with fewer than 80 visits per day.
Conclusion: Our study does not highlight a link between the incidence of Covid-19 and global ER visits or for NCL use. Our results show that the incidence does not influence ER visits during confinement. As other studies show, we observe fatigue among the population regarding compliance with instructions to limit the overcrowding of ER and the fear of virus. The incidence rate does not seem to be a good indicator for predicting ER visits unrelated to Covid.
Number Clinical Trial : NCT05126641
Rémy DIESNIS (Roubaix), Jeremy WALLART, Vincent PEGORARO, Vidji CLAEYSSEN, Grégory BERTOLOTTI, Jerome MIZON, Lucile VIENNE, Jean-Baptiste LEZY, Bérengère VOGEL, Eric WIEL
00:00 - 00:00
#41897 - Analysis of long-term mortality from brain trauma in ederly patients treated in the emergency department.
Analysis of long-term mortality from brain trauma in ederly patients treated in the emergency department.
Background:
Brain trauma (BT) that occur in the elderly population have higher mortality and worse functional prognosis. Physiological aging, suffering from chronic diseases, together with polypharmacy may be associated with increased morbidity and mortality in this age group.
Aim:
To study the accumulated mortality in one year and its associated factors in elderly patients who suffer a BT.
Methods.
Retrospective descriptive study of patients 75 years of age or older who have been treated in an emergency department for BT during the year 2022. Exclusion criteria: those under 75 years of age. Variables analyzed: age, age group (EG): 75-90, >90 years; sex, hypertension, dyslipidemia, diabetes mellitus, ischemic coronary, heart failure (HF), stroke, dementia, nephropathy, solid tumor, antiplatelet therapy, anticoagulation therapy, cerebral hemorrhage (CH). Dependent variable: 365-day mortality (M365). Descriptive analysis. Continuous quantitative variables are described as median and interquartile range (IQR), qualitative variables are explained by relative frequencies (%). To compare the means of quantitative variables, the Mann-Whitney test was used and the Chi-square test was used for qualitative variables. To determine the predictors of mortality, a univariate and multivariate analysis was performed using Cox regression with the calculation of the hazard ratio (HR). Those variables with a p value < 0.05 in the univariate analysis were included in the multivariate analysis. In the tests carried out, a confidence level of 95% was considered significant (p < 0.05). SPSS 29.0.
Results.
N: 620. Median age: 86.3 (IQR: 81.5-90.7). GE: 75-90: 76.8%, >90: 23.2%. Women: 65.0%. M365: 99 patients 16.0 (%). M365 Female: 11.9%, male: 23.5% (HR: 2.117 95% CI: 1.427-3.140, p<0.001); M365 in GE 75-90: 12%, M365 in GE >90: 29.2%. HR: 2.642 95% CI: 1.773-3.937, p<0.001). M365: hypertension: 16.2% (HR: 1.085, 95% CI 0.675-1.742, p>0.05); dyslipidemia: 17.0% (HR: 0.418, 95% CI 0.792-1.751, p>0.05); dabetes: 12.1% (HR: 0.147, 95% CI: 0.403-1.146, p>0.05); ischemic coronary: 16.9% (HR: 1.086, 95% CI: 0.594-1.985, p>0.05); heart failure: 32.1% (HR: 2.751, 95% CI 1.758-4.306, p<0.001); stroke: 12.8% (HR: 0.774, 95% CI: 0.339-1.767, p>0.05 ), dementia: 19.1% (HR: 1.126, 95% CI: 0.795-1.860, p>0.05), nephropathy: 19.2% (HR: 2.812 95% CI 1.705-4.638, p<0.001), solid tumor: 26.2% (HR: 1.887, 95% CI: 1.105-3.222, p<0.05) antiplatelet: 12.9%, (HR: 1.751, 95% CI: 0.445-1.1266, p>0.05); anticoagulant: 24.2% (HR: 1.989, 95% CI 1.331-2.972, p<0.001), CH: 33.3% (HR: 2.894 95% CI 1.802-4.650, p<0.001).
Multivariate study: Age >90 years: HR: 2.955 (95% CI: 1.917-4.554, p<0.0001), male sex: HR: 2.201 (95% CI 1.464-3.309, p<0.0001), heart failure: HR: 1.917 (95% CI: 1.176-3.126, p<0.05), anticoagulant: HR: 2.012 (95% CI: 1.137-3.073, pz0.001), HC: HR: 2.976 (95% CI: 1.830-4.839, p<0.001). Nephropathy and solid tumor p>0.05
Conclusions:
Almost 2 visits a day are observed with a relatively high cumulative mortality. This is associated with the age group over 90 years, being male, having a history of Heart failure in addition to being anticoagulated, and some type of CH associated with trauma. It is important to observe care in this group of patients.
Dr Raul LOPEZ IZQUIERDO, Higinia Karolina MENDOZA DE FREITAS, Maria Fernanda GUZMAN LEDESMA, Ivan GONZALEZ CAMPOS, Ignacio PEREZ DOMINGUEZ, Carlos DEL POZO VEGAS (Valladolor, Spain), Raquel TALEGON MARTIN, Maria Jesus GIRALDO PEREZ, Angela Maria AREVALO PARDAL, Hilda FERNANDEZ OVALLE, Juan Carlos SANCHEZ RODRIGUEZ, Jorge GUTIERREZ MIGUEL, Marco PÉREZ GÓMEZ, Ruiz Merino ROCIO, Francisco MARTÍN RODRIGUEZ
00:00 - 00:00
#41606 - Anterior cutaneous nerve entrapment syndrome: a 5-years case-control study in Fukushima, Japan.
Anterior cutaneous nerve entrapment syndrome: a 5-years case-control study in Fukushima, Japan.
Anterior cutaneous nerve entrapment syndrome (ACNES) is a rare cause of abdominal pain, accounting for approximately 2% of patients presenting to the emergency department. However, the number of reports on ACNES has recently increased in Western countries and Japan, it has attracted much attention, in fact derivatives of ACNES have been described as lateral cutaneous nerve entrapment syndrome (LACNES) and posterior cutaneous nerve entrapment syndrome (POCNES). ACNES and its derivatives present a diagnostic challenge; they are finally diagnosed by the exclusion of other differential diagnoses. This study aimed to investigate the characteristics of patients diagnosed with ACNES, LACNES, or POCNES.
We conducted a case-control study for five years, using data from two hospitals in Fukushima prefecture, Japan: an academic hospital and a regional hospital. We reviewed the medical records of all patients with the following key terms: ‘anterior cutaneous nerve entrapment syndrome,’ ‘entrapment neuropathy,’ and ‘abdominal trigger point injection.’ We collected data on presentation, symptoms, physical findings, examinations, treatments, and outcomes from each case. We also assessed patients with a misdiagnosed ACNESs.
Of the 12 patients who were suspected to have ACNES, LACNES, or POCNES, eight patients (five women, median age 53 years [interquartile range (IQR); 46.5-68.5 years]) were finally compatible with those diseases. They presented with various chief complaints such as unilateral abdominal pain (62% [5/8]), epigastric pain (25% [2/8]), and back pain (25% [2/8]). On physical examination, all patients showed localized tenderness without signs of peritoneal irritation, and 88% [7/8] showed a positive Carnett’s sign. Before diagnosis, all patients underwent imaging tests including abdominal ultrasonography, computed tomography, and magnetic resonance imaging. All patients were treated with trigger point injections, and most reported improvement in abdominal pain during regular follow-up.
Four patients (4/12) received a misdiagnosis of ACNES and its derivatives; three patients had abdominal cancer and one patient had retroperitoneal abscess. All four misdiagnosed patients (two women; median age, 67 years [IQR; 63-71.5years]) also showed localized tenderness, and 50% [2/4] showed a positive Carnett’s sign. Two patients did not undergo any diagnostic inspection, while the other two underwent only blood tests and abdominal ultrasonography. 75% patients [3/4] had an unscheduled revisit within five days due to the low efficacy of trigger point injection.
ACNES, LACNES, and POCNES are underdiagnosed causes of abdominal pain, and disseminating the disease concept of ACNESs can lead to better management of patients. Localized tenderness or positive Carnett’s sign are useful findings, while the specificity of Carnett’s sign was 67% in a previous study and 50% in our study; Carnett’s sign is not sufficient to rule out intra-abdominal diseases that can coexist with musculoskeletal pain syndromes. Therefore, imaging tests, such as computed tomography, are necessary to rule out intra-abdominal diseases, especially cancer, in elderly patients. Our study showed that abdominal pain from ACNESs could be relatively well-controlled with trigger point injection. If a patient has an early unscheduled revisit with difficulty in pain control, further investigations should be considered.
none
Junya KURIMURA (Aizuwakamatsu, Japan), Masahiro ONO, Kazuhiro KAMATA
00:00 - 00:00
#41951 - Antibiotic Treatments in the Elderly: Navigating Vulnerability and Septic Challenges.
Antibiotic Treatments in the Elderly: Navigating Vulnerability and Septic Challenges.
Introduction:
In 2017, individuals aged over 65 represented 8% of the Tunisian population. Today, this percentage has exceeded 10%. Indeed, infectious diseases are more common and often more severe in the elderly. Therefore, it is imperative to conduct a specific analysis of the increased risks associated with antibiotics.
Objective:
To descriptively analyze the side effects associated with antibiotic administration in patients aged over 65.
Materials and Methods:
This was a retrospective, descriptive, analytical, and monocentric study conducted in the orthopedic and trauma department of the Fattouma Bourguiba University Hospital (CHU) in Monastir, including all hospitalized patients treated with antibiotics over a period of 6 years and one month from January 1, 2018, to January 31, 2024.
Results:
Our study included 26 patients, with a male predominance characterized by a male-to-female ratio of 1.36. The mean age was 73 years and 5 months. Regarding lifestyle habits, 34% of patients were smokers, and only 3.8% were alcohol consumers.
All patients had at least one medical history, with hypertension being the most common (53.8%), followed by diabetes (27%). Two cases of drug allergy were recorded, involving ciprofloxacin and Tienam. The ASA score was greater than or equal to 2 for 84.7% of patients. Fourteen patients were admitted for sepsis due to medical devices, accounting for 53.8% of the sample. Among them, ten were initially operated on for a prosthesis following trauma. Just over one-fifth of patients (23%) were on broad-spectrum antibiotic therapy. The average duration of antibiotic therapy was 2 months and 2 weeks.
Sixty-nine percent of patients were on combination therapy. The main molecules used in the first line were imipenem (38.5%), ciprofloxacin (23%), and vancomycin (15.5%). Antibiotic-related side effects were observed in 13 patients, accounting for 50% of the sample. Among these effects, skin rash was the most common (in 5 patients), followed by renal insufficiency (3 patients), vomiting upon the first administration (4 patients), and one case of DRESS syndrome. Vancomycin was the most frequently implicated antibiotic (30.76%), followed by amoxicillin-clavulanic acid (23%).
Conclusion:
The criteria for selecting antibiotic therapy in the elderly present specific nuances. Drug interactions, frailty of the terrain, and comorbidities complicate management and justify an adaptation of medical practices. Our study provides an in-depth insight into the characteristics of antibiotic use in the elderly, focusing particularly on joint infections, which often require prolonged broad-spectrum antibiotic therapy.
This study did not involve a trial registration.
No external funding was received for this study.
Jacem SAADANA, Khouloud KHEMILI (Tunisia, Tunisia), Firas CHAOUECH, Bilel FAIZI, Ahmed MDAOUKHI, Hatem BELGACEM, Insaf BEN MESSAOUD, Amine SIOUD, Kais KHARROUBI, Iheb NTICHA, Aymen FEKIH, Abderrazek ABID
00:00 - 00:00
#41767 - Aortic dissection presenting as obstructive lung disease. (Not all that wheezes is OLD – obstructive lung disease).
Aortic dissection presenting as obstructive lung disease. (Not all that wheezes is OLD – obstructive lung disease).
Clinical History
81-year-old gentleman presented with acute onset of exertional dyspnoea, possible orthopnoea, and a long-standing cough. He denied fever, chest pain, nor diaphoresis. He was seen in the resuscitation area due to active wheeze and hypoxia. After giving him multiple cycles of nebulizers, his dyspnoea and wheeze temporarily improved but persisted with requiring non-rebreather mask to maintain oxygen saturations above 94%. The patient’s laboratory values including cardiac enzymes, inflammatory markers, and electrolytes were unremarkable except for an elevated NT-proBNP.
Misleading events
Despite the initial treatment, the patient’s respiratory failure and drowsiness worsened hence the decision was made to intubate him. After intubation, the patient persisted in a hypotensive state requiring noradrenaline to support his blood pressure. He was also started on IV meropenem for a presumed severe community acquired pneumonia. His ventilator settings were targeted for lung protective ventilation. Regular venting of the chest with disconnection from the ventilator and external compression was also done. Regular doses of salbutamol were given through the ETT. The patient’s wheeze had also improved, peak airway pressures were less than 40cmH2O, and lung compliance assessed by manual ventilation was good.
The patient subsequently deteriorated into a PEA cardiac arrest and was resuscitated according to ACLS principles. Post ROSC ECG showed a known RBBB and tachycardia which was attributed to the effects of adrenaline. Once haemodynamically stabilized, the patient was expediently transferred to the ICU.
Helpful details
After admission to ICU, the patient underwent a CT pulmonary angiogram to evaluate for pulmonary embolism. This showed a large proximal descending thoracic aorta aneurysm abutting a retro-oesophageal superior mediastinal haematoma. The study did not opacify the aorta, but the findings were suspicious for aneurysmal rupture. There was also left lower lobe focal consolidation and right lung ground glass opacities. Cardiothoracic surgery was consulted and in view of the prohibitive risk for surgical intervention, conservative management decided. The patient unfortunately demised a few days later.
Differential and actual diagnosis
This patient was initially treated as a undifferentiated dyspnoea likely secondary to inflammatory airway disease, or acute pulmonary oedema presenting with cardiac wheeze. He was treated for concomitant severe community acquired pneumonia. After CT imaging, it was determined with retrospect that the wheezing was likely secondary to extra-luminal compression of the airways by the aortic haematoma and hence improved after intubation due to the “stenting” mechanism of the ETT. This also accounted for the lack of difficult ventilator management post intubation in a patient with presumed primary lung pathology.
Further clinical images show size of the aorta and haematoma abutting the trachea which is kept patent by the ETT.
Educational Relevance
This case highlights the difficulties of making a diagnosis of a thoracic aortic dissection in the absence of “typical symptoms” of tearing chest pain and profound hypotension or syncope. Furthermore, this case reminds us of the need to consider extraluminal obstruction as a cause for persistent wheezing other than just intraluminal obstruction (anaphylaxis, foreign body). Especially with improvement after intubation and lacking expected ventilatory challenges.
Yao Qun YEONG (Singapore, Singapore), Daniel TAN
00:00 - 00:00
#41491 - Aortic mural thrombosis: a rare cause of emboli.
Aortic mural thrombosis: a rare cause of emboli.
Brief clinical history
A 45-year-old man with a history of deep vein thrombosis presented to our emergency department with right hemiparesis and speech difficulties. The patient was last seen well 3 days before presentation. Further examination revealed a cold, pulseless left foot. Blood results showed leucocytosis and elevated C-reactive protein of 81.1 mg/L. Initial non-contrast head CT showed a thrombus in the left middle cerebral artery. CT-angiography of the lower limbs was obtained but showed no signs of arterial occlusion. The presence of the cold leg was explained by cold exposure and immobility. The patient was diagnosed with ischaemic stroke and admitted to the stroke unit. No thrombolysis or thrombectomy was indicated because of the delayed presentation, treatment with dual antiplatelet therapy was initiated. During admission a CT scan of the thorax and abdomen was obtained and revealed a mural thrombus in the ascending aorta and emboli in both kidneys. After multidisciplinary assessment, heparinisation was initiated and the patient was admitted to the intensive care unit. The clot resolved after 3 days of heparinisation. Further diagnostic tests were performed, including a full auto-antibody-screening, a viral screening, lipid profile and coagulation tests, which were all negative.
Discussion
Although no occlusion was seen on CT-angiography of the lower limbs, probably an embolism had been present and resolved spontaneously as an explanation for the cold limb at admission. The clinical presentation of acute ischemic stroke in addition to a peripheral embolism should have raised further suspicion to look for thrombo-embolic events in the upper part of the aorta.
The patient’s history of deep vein thrombosis (DVT) prompted investigation into underlying prothrombotic conditions. Although aortic mural thrombosis is exceptionally rare, there is an established association with antiphospholipid syndrome. In this case, screening for underlying prothrombotic conditions was negative.
In the case of an ischemic stroke occurring in a young patient with elevated inflammatory markers; endocarditis, aortitis and large vessel vasculitis were considered. However, aortic dissection was deemed unlikely, due to the absence of predisposing high-risk conditions, high-risk pain features or high-risk examination findings. Consequently, the decision was made not to obtain aortic imaging at the emergency department.
While most emboli originate from the heart, it’s crucial to broaden our perspective beyond the “cardiac box.” In patients without classical atherosclerotic risk factors, we should consider the aorta as a potential source of emboli, even beyond dissection scenarios. Therefore, we recommend that when investigating emboli in patients with central and peripheral emboli, expanding the protocol to include cardiac CT alongside cerebral CT angiography would be prudent. This approach ensures a comprehensive evaluation and helps identify potential sources of embolism beyond the heart.
This case highlights the importance of looking at the clinical picture, rather than relying on imaging methods to guide further diagnosis and treatment.
Manon VERVENNE, Manon VERVENNE (Brussels, Belgium), Katleen DEVUE, Elien DE SCHAMPHELAERE, Rinaldo LAUWERS, Ives HUBLOUE
00:00 - 00:00
#41430 - Aorto-Enteric Fistula with Gastric Ulcer Resulting in Gastrointestinal Bleeding in a Patient with a History of Aortic Dissection Repair: A Case Report.
Aorto-Enteric Fistula with Gastric Ulcer Resulting in Gastrointestinal Bleeding in a Patient with a History of Aortic Dissection Repair: A Case Report.
Abstract:
This case report describes a rare instance of an aorto-enteric fistula (AEF) with a concurrent gastric ulcer in a 78-year-old female with a history of aortic dissection and surgical repair, presenting as significant gastrointestinal bleeding. AEF is an uncommon but severe complication often associated with aortic prosthetic grafts. This report emphasizes the importance of a multidisciplinary approach for prompt diagnosis and treatment, highlighting the necessity for heightened surveillance in patients with similar surgical histories.
Introduction:
Aorto-enteric fistulas (AEF) are rare but potentially fatal complications that can occur following aortic aneurysm repair, primarily due to the proximity of the aorta to the gastrointestinal (GI) tract. These fistulas are most associated with aortic prosthetic grafts and can present with severe gastrointestinal bleeding. This condition often represents a diagnostic and therapeutic challenge due to its nonspecific presentation and the complexity of the involved anatomy. Despite being most linked to the small intestine, particularly the third part of the duodenum, this case presents a rare instance of AEF involving the stomach, compounded by the presence of a gastric ulcer, which is an uncommon site for AEF.
Case Presentation:
A 78-year-old woman, with a past medical history notable for aortic dissection and subsequent surgical repair via an aortic graft in 2016, presented as a transit passenger with hematemesis. Initial assessment revealed melena, with subsequent diagnostic procedures confirming active gastrointestinal bleeding. An endoscopic examination identified a gastric ulcer in close proximity to the previously placed aortic graft, suggesting a possible aorto-gastric fistula.
Discussion:
The development of an AEF post-aortic graft surgery is a rare but known complication, primarily due to graft infection or chronic erosion against the intestinal wall. In this case, the location of the fistula in the gastric region is particularly noteworthy, given the typical predilection for involvement of the small intestine or colon. The presence of a gastric ulcer near the graft site may have facilitated the erosion process leading to fistula formation.
This patient's presentation with gastrointestinal bleeding necessitated urgent and coordinated efforts across multiple specialties. The rapid identification of the source of bleeding through endoscopy was critical in guiding subsequent management strategies. In managing AEF, surgical intervention remains the gold standard, particularly in stable patients, and involves removal of the infected graft, repair of the aortic and intestinal walls, and revascularization procedures. Endovascular approaches, such as stent grafting, provide an alternative in patients who are poor surgical candidates due to their less invasive nature.
Learning Points:
• Recognition of gastrointestinal bleeding as a potential complication of AEF in patients with aortic grafts.
• Importance of considering gastric involvement in AEF, despite its rarity.
• The critical role of a multidisciplinary team in managing complex vascular and gastrointestinal pathologies.
Conclusion:
This case report delineates the rare occurrence of an aorto-enteric fistula involving the gastric region, leading to significant gastrointestinal bleeding. The management of this condition requires a high index of suspicion, especially in patients with previous aortic repairs, and a rapid, coordinated multidisciplinary response to prevent fatal outcomes.
Shumaila Muhammad HANIF (Doha, Qatar), Thirumoorthy Samy KUMAR
00:00 - 00:00
#40850 - Aortoenteric fistula with gastric ulcer and upper gastrointestinal bleeding.
Aortoenteric fistula with gastric ulcer and upper gastrointestinal bleeding.
An elderly female, a transit passenger traveling to the US from Japan, presented to the emergency department with hematemesis. She has been a known case of aortic dissection since 2016, managed conservatively with medicines in the US. Her hemoglobin is 6 gm/dl, and she is drowsy and tachycardic. There was a high suspicion of an aortoenteric fistula. CT revealed abnormal false vascular connections between the aorta, stomach, and duodenum. However, vascular surgery requested a gastroenterology review upon getting further information from her family on the phone back home, who told her about a history of gastric ulcers and the procedure a few years ago. The Intensivist requested an upper gastrointestinal endoscopy. Endoscopy showed pre-pyloric gastric Forest 1B ulcer, which underwent clipping. She stabilized and was discharged safely after two days of observation from the intensive care unit. It signifies the co-existence of critical diagnoses and confusing overlapping clinical presentations, which warrant consideration of all possible life threatening and alternative pathologies. Travelers with limited medical background information challenge emergency physicians and might mislead initial management.
Shumaila MUHAMMAD HANIF, Tahir SHAHZAD (Toledo, USA)
00:00 - 00:00
#42297 - 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.
Mona TITEY (tunis, Tunisia), Saloua HOUIMLI
00:00 - 00:00
#40800 - Appendicitis after Appendectomy: A Rare Presentation of Acute Appendicitis as Stump Appendicitis.
Appendicitis after Appendectomy: A Rare Presentation of Acute Appendicitis as Stump Appendicitis.
Appendicitis is one of the frequent complaints for which patients visit the Emergency Department. Appendectomy is one of the most commonly performed procedures. Stump appendicitis is a rare but severe complication of appendectomy due to the inflammation of the remaining part of the appendix. Because it is rare and partly due to physicians’ lack of understanding of this entity, the diagnosis is highly delayed, leading to severe complications including perforation or peritonitis. This article aims to raise the importance and awareness and shed light on how possibly it could be avoided.
A 66 years old man known case of rheumatoid arthritis, cerebrovascular accident, mitral valve replacement presented to the Emergency Room with complaints of fever for 4 days, high-grade continuous, without chills and rigors, which was relieved after taking paracetamol, diarrhea for 2 days, 3–4 episodes per day, watery in consistency, no blood or mucous, not foul-smelling, and lower abdominal pain since morning. Initially, the pain was diffuse but later became sharp and localized to the right iliac fossa. It was moderate to severe in intensity, with a subjective pain score of 7 out of 10. It had a sudden onset without any radiation. There were no aggravating factors, but associated with fever and diarrheal episodes.
In the emergency room patient was initially resuscitated with adequate analgesia and hydration. Initial lab workup was unremarkable then CT abdomen was done, and the general surgery team was taken on board.
The CT scan showed findings suggestive of appendicitis. It demonstrated small inflamed appendicular stumps, thickening walls, and intraluminal free air. Based on this, a diagnosis of SA was made (Fig. 1a, b). The patient was admitted in special care under the general surgery team. Similar management was continued with appropriate antibiotics, analgesics, hydration, anti-emetics, and the patient kept nothing per oral. The patient improved clinically within few days and tolerate diet orally henced planned for discharged with further follow up in clinics.
A few differential diagnosis also mimics clinically with SA including Crohn's disease, residual surgical drain tract and epiploic appendicitis. Therefore, emergency physicians’ familiarity with SA may lead to earlier diagnosis and treatment, preventing unnecessary complications. SA is a rare and dangerous complication post-appendectomy. Being unfamiliar with this entity, it can be tough to diagnose it. Our case report aims to raise awareness for it as a differential for right lower quadrant abdominal pain in any patient despite prior history of appendectomy.
Fareed AHMED (Karachi, Pakistan)
00:00 - 00:00
#41529 - Application of anti-barotrauma system in hyperbaric oxygen therapy for emergency patients.
Application of anti-barotrauma system in hyperbaric oxygen therapy for emergency patients.
1. Objective
Barotrauma is the most common complication during hyperbaric oxygen therapy(HBOT), and to prevent barotrauma during HBOT, authors developed a barotrauma early detection system (AntiBaroTrauma: ABT) by connecting a headset type tympanometry-based device with a hyperbaric oxygen chamber. The purpose of this study is to check whether early detection of barotrauma is possible when applying the ABT system to hyperbaric oxygen therapy.
2. Background
Hyperbaric oxygen therapy is required in many emergency situations such as fires, chemical accidents, and dysbarism. In Korea, there are many patients who visit emergency medical centers with suicidal attempts, and many of the method for suicidal attempts is to burn a briquette in a closed space, such as inside a car or in a room, and in this case, emergency hyperbaric oxygen therapy is required. During hyperbaric oxygen therapy, patients are usually required to perform pressure control efforts such as the Valsalva maneuver periodically, and medical staff communicate with patients to check their condition, such as occurrence of ear pain to prevent barotrauma. However, if barotrauma causes ear pain, barotrauma has already progressed to a certain extent, so researchers have been looking for ways to detect barotrauma before symptoms occur. We developed a headset-type barotrauma early detection system and applied it to patients receiving hyperbaric oxygen therapy to identify its effectiveness, advantages and disadvantages.
3. Method
The study was conducted in the form of a single-blinded prospective parallel randomized controlled study for two years from January 2021 to December 2022 in patients aged 18-65 years visiting one government-affiliated regional emergency center and receiving hyperbaric oxygen therapy. Pregnant women, pneumothorax, respiratory symptoms and diseases, high fever, history of thoracic/ear surgery, claustrophobia and other academic and clinical contraindications were excluded. Both test and control groups were pressurized to >2.4 atm during hyperbaric treatment, with ABT applied in the test group and regular questioning of patients by medical staff during pressurization in the control group to determine discomfort. Number of treatment interruptions/completions due to pressure damage, otoscopic findings (Edmond's Score Grade 0~5), ear pain scale, and satisfaction of patient based on questionnaire were evaluated
4. Results
The test group utilizing ABT had a longer pressurization time than the control group. In video otoscopic findings, Edmond's Score Grade increased less in the test group, but there was no statistical difference between the two groups. The test group took more pressurization time and total treatment time than the control group.
5. Conclusion
ABT allows for early detection of barotrauma compared to traditional periodic patient checks, but may add to pressurization time and total treatment time, and can reduce provider effort to check on patients during pressurization.
[Acknowledgement]
1. This work was supported by the National Research Foundation of Korea(NRF) grant funded by the Korea government(MSIT) (No. NRF-2023R1A2C1002938).
2. This work was supported by the Korea Medical Device Development Fund grant funded by the Korea government (Project Number: KMDF_PR_20200901_0000 ) (NTIS, KMDF-RnD 202014X24)
Soon-Joo WANG (Hwaseong city, Republic of Korea), Minsub HAN, Eunae AHN
00:00 - 00:00
#41707 - Are prehospital measured shock, modified shock, age shock indexes and some scoring systems effective in predicting the prognosis of high energy trauma patients?
Are prehospital measured shock, modified shock, age shock indexes and some scoring systems effective in predicting the prognosis of high energy trauma patients?
Introduction:
The aim of this study is to investigate the effectiveness of shock index (SI), modified shock index (MSI), age shock index (ASI), Injury Severity Score (ISS), Rapid Emergency Medicine Score (REMS), and Triage in Emergency Department Early Warning Score (TREWS), derived from prehospital vital signs, in predicting emergency department blood transfusion, emergency surgical intervention, and 24-hour and 28-day mortalities of patients with high-energy trauma.
Materials and Methods:
Patients transported by ambulance due to high-energy trauma to a tertiary emergency department were prospectively examined between August 1, 2023, and January 31, 2024. The predictive performance of patients' measured SI, MSI, ASI, ISS, REMS and TREWS scores for emergency department blood transfusion, emergency surgical intervention, and mortality at 24 hours and 28 days was evaluated.
Results:
A total of 209 patients meeting the inclusion criteria were included in the study. For the prediction of emergency department blood transfusion, the area under the curve (AUC) of MSI was 0.789 [95% CI 0.668-0.911, (p<0.001)], SI was 0.783 [95% CI 0.663-0.903, (p<0.001)], ASI was 0.688 [95% CI 0.542-0.834, (p=0.016)], and ISS was 0.883 [95% CI 0.808-0.957, (p<0.001)]. For the prediction of emergency surgical intervention, the AUC of SI was 0.784 [95% CI 0.664-0.904, (p<0.001)], MSI was 0.760 [95% CI 0.628-0.891, (p<0.001)], ISS was 0.664 [95% CI 0.557-0.771, (p=0.018)], and TREWS was 0.641 [95% CI 0.516-0.765, (p=0.043)]. For the prediction of 24-hour mortality, the AUC of ASI was 0.872 [95% CI 0.787-0.957, (p<0.001)], MSI was 0.768 [95% CI 0.600-0.935, (p=0.007)], TREWS was 0.980 [95% CI 0.961-0.998, (p<0.001)], ISS was 0.959 [95% CI 0.919-1.000, (p<0.001)], and REMS was 0.831 [95% CI 0.666-0.996, (p=0.001)]. For the prediction of 28-day mortality, the AUC of ASI was 0.759 [95% CI 0.605-0.913, (p=0.001)], TREWS was 0.942 [95% CI 0.900-0.984, (p<0.001)], ISS was 0.896 [95% CI 0.812-0.980, (p<0.001)], and REMS was 0.826 [95% CI 0.687-0.965, (p<0.001)].
Conclusion:
In patients with high-energy trauma, the prehospital TREWS score demonstrates the best performance in predicting mortality at both 24 hours and 28 days. It was found that the performance of ASI in predicting mortality at both 24 hours and 28 days was more successful compared to other shock indices. The best performance for predicting emergency department blood transfusion was observed with ISS, while the best performance for predicting emergency surgical intervention was observed with SI.
None
Melih YÜKSEL, Mehmet Oğuzhan AY, Fatma Betül ÇALIŞKAN, Musatafa Tolga ÖZDAL (Bursa, Turkey), Ayşe KILIÇ, Atakan AYDOĞAN, Yeşim İŞLER, Halil KAYA
00:00 - 00:00
#41573 - Are women with a cardiac arrest less likely to be treated with an automated external defibrillator?
Are women with a cardiac arrest less likely to be treated with an automated external defibrillator?
Introduction
Out-of-hospital cardiac arrest (OHCA) patients receiving bystander cardiopulmonary resuscitation (BCPR) or treated with an automated external defibrillator (AED) have better outcomes than their counterparts. Women are less likely to receive BCPR than men, but it is unknown if they are also less likely to be treated with an AED. Therefore, we explored the association between gender and rates of AED usage amongst OHCA patients.
Methods
Using a North American OHCA registry, we included adult patients with nontraumatic bystander witnessed OHCA in a public location who received BCPR. We excluded OHCA events witnessed by emergency medical services personnel or with missing critical data. The primary outcome was the installation of an AED by a bysander. We performed a multivariable logistic regression and adjusted for relevant covariates (age, Cardiac Epistry version) using an enter method.
Results
Of the 229,637 OHCAs in the registry, we included 6,086 patients (installation of an AED: 23%; women: 15%; mean age: 62 years [SD 14]; initial shockable rhythm: 66%; survival to discharge: 38%). Patients for whom an AED was installed were more likely to survive to hospital discharge than their counterparts (adjusted odds ratio [AOR]=1.92 [95%CI 1.70-2.17]). Women were less likely than men to have an AED installed (AOR: 0.84 [95%CI 0.71-0.99], p=0.043).
Conclusion
Our results suggest that women are less likely to be treated with an AED when they experience an OHCA. Given the strong association observed between the installation of an AED and survival for OHCA patients, that difference probably leads to unnecessary deaths amongst women. Future studies should explore the mechanisms and barriers to bystanders using an AED on women, even after they initiated BCPR.
This program has received financial support from the ‘Département de médecine familiale et de médecine d’urgence de l’Université de Montréal’ in the form of salarial support.
This program has received in-kind support from the ‘Fonds des urgentistes de l’Hôpital du Sacré-Coeur’ in the form of logistical support.
This manuscript was prepared using the data from the ROC Cardiac Epistry 1, 2 and 3 from the NHLBI Biologic Specimen and Data Repository Information Coordinating Centre and does not necessarily reflect the opinions or views of the ROC Cardiac Epistry 1, 2 and 3, ROC-PRIMED, ROC-CCC and ROC-ALPS or the NHLBI.
Dr Alexis COURNOYER (Montréal, Canada), Zoé GARCEAU-TREMBLAY, Samuel BLAIS, Justine LESSARD, Rodrigo FLORES-SOTO, Sylvie COSSETTE, Yiorgos Alexandros CAVAYAS, Jean PAQUET, Martin MARQUIS, Judy MORRIS, Véronique CASTONGUAY, Raoul DAOUST
00:00 - 00:00
#41073 - Are you sure it's just anxiety?
Are you sure it's just anxiety?
The patient is a 55-year-old woman,with a history of dermal lupus,hypothyroidism and hysterectomy on chronic treatment with levothyroxine,hydroxyl.
She reports that 1-2months earlier,suddenly,she presented a dizziness with a fall to the ground and doubtful loss of consciousness.Denies post-critical state or sphincter relaxation.Assessed by her regular doctor,he was prescribed sulpiride.
Weeks later,she had an accident with the vehicle indicating that she thought she had been distracted,but since then the feeling of dizziness became continuous.Days later,she had an anxiety attack while back in the vehicle.She was transferred to another hospital,where she underwent laboratory tests and a CTscan,with no alterations reported.Since then,in addition to dizziness,episodes of bradypsychia,drowsiness,clumsiness and poor stress management begin,so she comes to our center and is admitted.
During admission,brain MRI was performed,which ruled out structural pathology.Blood tests showed TSH 34.99 and antimicrosomal antibodies>1300,so the condition was related to hypothyroidism and the dose of levothyroxine was increased.After hospital discharge,she was evaluated on an outpatient basis and diagnosed with acute stress(sister's malignant illness,work-related stress)was treated with escitalopram.
Despite treatment,the patient presented progressive motor worsening,with gait alteration and cognitive difficulties,affecting the semantic content and daytime sleepiness,so she consulted neurology again.
On examination,mild bradypsychia with ataxic gait and fluctuating mnesic deficit stood out,admission was made to rule out autoimmune encephalopathy.
In lumbar puncture:clear liquid,increased protein,leukocytes and mononucleates.Ac anti-receptor NMDA y Ac anti-receptor GABA-A negative;AC anti-AMPA receptor:Positive.Multiplex CPR:Negative.Steroid treatment was initiated(250mg/day).EEG:No alterations.Cervical dorsal MRI:No alterations.Brain MRI:Mild hyperintensity of signal in IR of bilateral and symmetrical temporal cortical location with subinsular and medial temporal involvement,not present in previous study.Metabolic and autoimmune etiology to be assessed as a first possibility.
Cranial-thoracic-abdominal CTscan with contrast:no alterations.
During admission,there was a progressive deterioration in the level of consciousness with occasional stiffness and fever.She was transferred to the ICU. Treatment with acyclovir and meropenem was initiated,in addition to steroid treatment(500 mg/day)and gamma globulins,combining quetiapine and clonazepam.Clinical judgment of probable autoimmune/paraneoplastic limbic encephalitis is performed.EEG was repeated,with moderate diffuse cortico-subcortical involvement.
She presented neurological deterioration with rigidity,hypertonia and coma,requiring airway support.Anti-NMDA and AMPA receptor acs are repeated in CSF,with POSITIVE result.EEG is repeated,with no changes.She presents episodes of apnea and atelectasis,which show bulbar involvement,treatment with Rituximab was started.Complementary tests were performed to rule out occult neoplasia.The patient's condition did not improve as she remained in a vigil coma with brainstem involvement,disappearance of oculocephalic reflexes and deterioration of respiratory stimulation.Given the lack of response to all treatments,including plasmapheresis,and respecting the patient's last wishes,the situation is discussed with the family members and the therapeutic effort is adapted.
Anti-NMDA receptor antibody encephalitis is an acute and severe entity.It affects the middle-aged population,80%in women.The clinical picture usually progresses in 3stages.It is the second stage where the first psychiatric changes appear(anxiety,psychomotor agitation,emotional lability).In the third stage,first psychiatric changes are usually followed by decreased responsiveness that sometimes progresses to a catatonic state.All this, associated with hypoventilation and autonomic instability. There are authors who propose performing lumbar puncture for the study of cerebrospinal fluid in all early acute psychotic episodes to make a differential diagnosis with autoimmune encephalitis.
Cristina BARREIRO MARTÍNEZ, Blanca GUERRERO MOÑUS, Noemi SOTO TOSTADO, Marta HUEDO JIMÉNEZ, María REDONDO LOZANO, Pilar VARELA GARCÍA, Miriam UZURIAGA MARTÍN (Madrid, Spain), Vanesa Natalia ISAAC
00:00 - 00:00
#41139 - Artificial Intelligence-Based Evaluation of Carotid Artery Compressibility via Point-of-Care Ultrasound in Determining the Return of Spontaneous Circulation During Cardiopulmonary Resuscitation.
Artificial Intelligence-Based Evaluation of Carotid Artery Compressibility via Point-of-Care Ultrasound in Determining the Return of Spontaneous Circulation During Cardiopulmonary Resuscitation.
Aim: This study introduces RealCAC-Net, an artificial intelligence (AI) system, to quantify carotid artery compressibility (CAC) and determine the return of spontaneous circulation (ROSC) during cardiopulmonary resuscitation.
Methods: A prospective study based on data from a South Korean emergency department from 2022 to 2023 investigated carotid artery compressibility in adult patients with cardiac arrest using a novel AI model, RealCAC-Net. The data comprised 11,958 training images from 161 cases and 15,080 test images from 134 cases. RealCAC-Net processes images in three steps: TransUNet-based segmentation, the carotid artery compressibility measurement algorithm for improved segmentation and CAC calculation, and CAC-based classification from 0 (indicating a circular shape) to 1 (indicating high compression). The accuracy of the ROSC classification model was tested using metrics such as the dice similarity coefficient, intersection-over-union, precision, recall, and F1 score.
Results: RealCAC-Net, which applied the carotid artery compressibility measurement algorithm, performed better than the baseline model in cross-validation, with an average dice similarity coefficient of 0.90, an intersection-over-union of 0.84, and a classification accuracy of 0.96. The test set achieved a classification accuracy of 0.96 and an F1 score of 0.97, demonstrating its efficacy in accurately identifying ROSC in cardiac arrest situations.
Conclusions: RealCAC-Net enabled precise CAC quantification for ROSC determination during cardiopulmonary resuscitation. Future research should integrate this AI-enhanced ultrasound approach to revolutionize emergency care.
Funding
This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Ministry of Science and ICT (MSIT) (NRF-2022R1C1C1011864), and the Future Medicine 20*30 Project of the Samsung Medical Center (SMX1240781).
Hee YOON, Subin PARK (seoul, Republic of Korea), Soo Yeon KANG, Seung Jin MAENG
00:00 - 00:00
#41501 - ASD Repair Unveiling Unusual Conduction Conundrum – Type 1 Mobitz Wenckebach.
ASD Repair Unveiling Unusual Conduction Conundrum – Type 1 Mobitz Wenckebach.
Compulsory question: What arrhythmia is a common complication of ASD Repair?
- Mobitz Type 2 AV Block is a more common arrhythmia with ASD repair; however, Mobitz Type 1 (Wenckebach) can be seen as well.
Case Presentation:
Brief Clinical History: A 42-year-old female with a congenital atrial septal defect (ASD) presented with palpitations of recent onset. Previously diagnosed with right heart increased pressures and pulmonary hypertension secondary to Eisenmenger syndrome, she exhibited Mobitz Type 1 (Wenckebach) atrioventricular block on electrocardiogram (ECG). She has no history of syncope, chest pain, shortness of breath or family history of cardiac arrhythmias.
Misleading Elements: The absence of syncope, chest pain or shortness of breath, may initially lead one to underestimate the severity of the arrhythmia.
Helpful Details: History of ASD and pulmonary hypertension provides context for the cardiovascular pathology. Recent onset palpitations prompt investigation into potential arrhythmias. Diagnosis of Mobitz Type 1 atrioventricular block on ECG aids in understanding the underlying conduction abnormality.
Differential Diagnosis:
Mobitz Type 1 (Wenckebach) atrioventricular block.
Other forms of atrioventricular block (e.g., Mobitz Type 2, Third-degree AV block).
Paroxysmal supraventricular tachycardia (PSVT) due to atrial septal defect.
Pulmonary hypertension-related arrhythmias.
Actual Diagnosis: Mobitz Type 1 (Wenckebach) atrioventricular block in the context of congenital atrial septal defect (ASD) and pulmonary hypertension secondary to Eisenmenger syndrome.
Despite the potential risks associated with her condition, the patient chose to defer intervention, opting for observation due to the anticipated self-resolution of arrhythmia within three months.
Educational and Clinical Relevance:
This case highlights the rare occurrence of Mobitz Type 1 atrioventricular block in the context of ASD, emphasizing the crucial role of ECG in timely identification. The discussion explores the prevalence of ASD, ranking as the third most common congenital heart defect, and underscores the importance of ASD closure beyond age four to prevent arrhythmias and complications. Understanding the reversible nature of Mobitz Type 1 and its contributing factors, including medications and procedural interventions, is pivotal for effective management. Post-ASD closure, research findings reveal arrhythmia occurrences, with antiarrhythmic medications often resolving most cases. The intricate nature of congenital heart defect management is emphasized, advocating for timely closure and a nuanced approach to associated rhythms and complications.
Questions:
Why is this case interesting & Does it describe a unique/rare condition or a typical presentation? The occurrence of Mobitz Type 1 atrioventricular block in the context of atrial septal defect (ASD) is relatively rare, making this case notable. It sheds light on an uncommon manifestation of a congenital heart defect. The combination of ASD and Mobitz Type 1 atrioventricular block presents an unusual conduction conundrum.
Does it provide good learning points? The case offers valuable learning points, such as the importance of timely identification of arrhythmias through electrocardiography (ECG) and the significance of ASD closure beyond a certain age to prevent complications. It also underscores the reversible nature of Mobitz Type 1 atrioventricular block and the potential role of medications and procedural interventions in management.
Does it include informative results? Abnormal, interesting ECG.
Wayne MARTINI (Scottsdale, USA), Matthew VAN LIGTEN, Shari BRAND, Marcie TORRES, Andrej URUMOV
00:00 - 00:00
#41595 - Aslanger’s sign in electrocardiogram.
Aslanger’s sign in electrocardiogram.
A 68-year-old man with no prior medical history and no known cardiovascular risk factors presents to the emergency department of a district hospital with atypical and paroxysmal chest pain (tingling) for 48 hours. His physical examination revealed no abnormalities, with the following vital signs: systolic blood pressure 120 mmhg; diastolic blood pressure 50 mmhg; heart rate 99 beats per minute ; respiratory rate 20/min; and oxygen saturation 96% on air. The patient's oxygen saturation was 96% on air, his temperature was 37°C, and his finger blood sugar was 0.9 g/l. His initial electrocardiogram is depicted in Figure 1. The 12-lead ECG of the patient demonstrated a normal sinus rhythm with a heart rate of 80 beats per minute and a normal axis. The 12-lead ECG also demonstrated aberrant T waves with peculiar morphology in leads I, II, aVL, aVR, aVF, and from V1 to V6 in precordial leads. This anomaly was observed in the 11-lead ECG, with the exception of lead III, which was normal. The emergency department physician interpreted these unusual "T waves" as "ischemic hyperacute T waves." The patient was transferred to the emergency department at the university hospital with a suspected acute coronary syndrome. However, the ED ECG was completely normal. The high-sensitivity cardiac troponin (hs-cTn) tests were twice negative. Consequently, the pre-hospital ECGs were recognized as artifacts, and the patient was discharged home.
In our case, the electrocardiogram revealed anomalous T waves with unusual morphology in leads I, II, aVL, aVR, aVF, and V1 to V6. This distinctive pattern was noticeable in the 11-lead ECG, excluding lead III. The synchronous occurrence of this abnormality with the cardiac cycle indicated the presence of an arterial pulse-tapping artifact, also recognized as electromechanical association or Aslanger's sign, as initially described by Aslanger and referred to by some authors as Aslanger’s sign .
The EMA artifact arises from the transmission of arterial pulsations, typically from the radial artery, onto the lead clips, generating aberrations in the ECG waveform. While contemporary electrocardiogram machines record only lead I and lead II, deriving the waveforms for other leads from these two, the majority of limb leads and augmented leads are susceptible to the artifact. However, a consistent feature of EMA artifacts is the sparing of one lead, contingent on the limb generating the artifact. This serves as a crucial diagnostic clue, as outlined by Aslanger . In our patient, lead III remained unaffected, as it represents an ECG recording between the left arm and left leg. This led us to conclude that the source of the artifact was the right arm. During a repeat ECG in the emergency department, when the clip was placed proximally, the 12-lead ECG exhibited no artifacts. The relatively recent description of Aslanger's sign is underscored by the limited number of reported cases in the literature. It is imperative to highlight the potential dangers associated with this condition, which can imitate symptoms of acute coronary syndrome, potentially triggering unnecessary invasive investigations if not promptly recognized.
Sondes LAAJIMI, Chebbi NABIL (Tunisie-Sousse, Tunisia), Haifa BRADAI, Dorra LOGHMARI, Rabeb MBAREK, Mounir NAIJA, Naoufel CHEBILI
00:00 - 00:00
#41664 - Assessing the role of families in emergency departments.
Assessing the role of families in emergency departments.
Introduction: The presence of the families in emergency departments (EDs) is not clearly defined at national level in France, with each department establishing its own rules even though it can bring certain benefits. The aim of this study was to evaluate the place of families in EDs.
Method: We carried out an observational study of healthcare managers in EDs in the Rhône Alpes region of France who were members of the Emergency Department Collegial (Organisational Network). An anonymous questionnaire was sent to them.
Results: We received 28 responses, giving a response rate of 100%. The responses came from university hospital (75%), peripheral hospital (14%), private healthcare establishments of collective interest (7%) and private clinics (4%). In 57% of departments, families were present: 32% authorised them without restriction, 21% in the event of end of life and for vulnerable people, 12% if there was a language barrier and 6% in the event of a life-threatening emergency or at the patient's request. In 69% of cases, families are present throughout the care process, 37% during reception by the nurse, 31% at the end of the care process, 25% in the waiting area and 19% during the care process. One accompanying person was authorised for 62.5% and two for 37.5%. Visiting time was limited to less than 30 minutes for 19% and without restriction for 81%. The presence of families was protocolised in 37.5% of emergency departments. Among EDs, that did not allow families to visit (43%), the reasons given were: the wishes of the medical and paramedical team (92%), overcrowding (75%), lack of space (50%) and an institutional decision (25%).
Obstacles to the presence of families include overcrowding (75%), unsuitable premises (57%), family’s aggression (46%), and reluctance on the part of the paramedical (39%) and medical (25%) teams. The benefits identified were that patients were calmed (82%), better understood (61%) and less aggressive (46%). Some EDs (68%) have a room dedicated to communication with families, and for 79% of them the COVID-19 pandemic has led to more restrictions.
Conclusion: The presence of families is not systematic in EDs despite the benefits identified by healthcare workers. The obstacles seem to be more structural, but also on the part of healthcare workers. The impact of the presence of families remains to be assessed.
Serieys LAETITIA (Lyon), Sabine PERRET, Cindy HERNANDEZ, Goeffrey SAGNOL, Sebastien BEROUD, Sophie VESCO, Julien DURAND, Marion DOUPLAT
00:00 - 00:00
#41335 - Assessment of Basic Life Support Competence among Nursing Staff in Patras, Greece: Implications for Training and Preparedness.
Assessment of Basic Life Support Competence among Nursing Staff in Patras, Greece: Implications for Training and Preparedness.
Background: Nurses are in the front line of providing first aid to patients in emergency departments as well as to inpatients. Therefore, their training in Basic Life Support (BLS) is of outmost importance. This study aimed to assess the competence of nursing staff in BLS within hospitals and health centers in Patras, Greece.
Methods: A cross-sectional study was conducted from March to July 2023. A questionnaire was distributed to 552 nurses to evaluate their BLS training, self-assessment of skills, cardiopulmonary resuscitation (CPR) proficiency, automated external defibrillator (AED) usage, and readiness to apply CPR.
Results: Only 45.6% of nurses had attended a BLS seminar, with higher education (MSc, PhD) having a statistically significant influence (p<.001). In addition, 34% considered their BLS skills “excellent” or “adequate”, with a significantly stronger association with higher level of education (p<.001), working in departments where CPR-AED skills were mandatory (p<.001) and being male nurse (p=.031). Education displayed a statistically significant effect in relation to CPR skills, with participants with MSc/PhD giving significantly more (p≤.013) correct answers in most questions. Nurses in mandatory CPR-AED departments demonstrated greater proficiency in AED usage (p<.05) compared to nurses working in other settings. Overall, 47.2% of participants considered themselves ready to provide CPR when needed.
Conclusions: Approximately half of the nursing staff had undergone BLS training, with higher education and departmental requirements influencing competence levels. Targeted training programs and departmental policies may enhance BLS preparedness among nurses.
Vangeli EVANGELIA, Chasiakou STAMATIA, Bakola MARIA, Charalambous GEORGE (ATHENS, Greece), Jelastopulu ELENI
00:00 - 00:00
#41674 - Assessment of health literacy in a French emergency department.
Assessment of health literacy in a French emergency department.
Background
Health literacy (HL) has become a subject of major interest in public health worldwide. It is known to be linked to self-efficacy in care use and to global health status, and a non-negligible frequency of problematic or inadequate levels of HL in populations worldwide is reported. As this has yet to be evaluated in France, the present study aimed to evaluate the HL level of patients in a French emergency department (ED).
Methods
We conducted a descriptive, cross-sectional observational, single center study in the ED of the Lyon Sud hospital (Hospices civils de Lyon, Lyon, France). The primary endpoint was the HL level of the patients determined according to the score obtained using the 16-item European Health Literacy Survey Questionnaire. The secondary endpoint was the identification of sociodemographic factors associated with the HL level.
Results
A total of 189 patients were included for analysis. 10% (95% CI [3%; 17%]) of the patients had an inadequate HL, 38% (95% CI [31%; 45%]) had a problematic HL, and 53% (95% CI [46%; 61%] had an adequate HL. In multivariate analysis, age and perceived health status were independent predictors of the HL level; OR =0.82 (95% CI [0.69; 0.97]; p=0.026) for a 10-year increase in age, and OR =1.84 (95% CI [1.22; 2.82]; p=0.004]).
Conclusions
The HL level of the patients in the ED studied herein was similar to that found in the population of France and other European countries and was influenced by age and perceived health status, which are both associated with care needs. It may be therefore interesting to explore in future studies how taking into consideration HL in the general population may lead to a better self-efficacy in care and optimize the use of the healthcare system.
Pauline MARIE (Lyon), Véronique POTINET, Anne-Marie SCHOTT, Nicolas ROMAIN- SCELLE, Sophie VESCO, Marion DOUPLAT
00:00 - 00:00
#41699 - Assessment of Heat Stroke-Induced Brain Injury: A Preclinical Study with a Rat Model Using 18F-FDG Brain PET.
Assessment of Heat Stroke-Induced Brain Injury: A Preclinical Study with a Rat Model Using 18F-FDG Brain PET.
Purpose: Heat stroke is the most serious heat-related illness and is recognized as a worldwide public concern as global temperatures continue to rise. Although the clinical neurological complications of heat stroke are relatively well described, a limited number of studies exist that document imaging findings. Therefore, in this preclinical study, we aimed to identify the imaging findings of 18F-FDG brain PET following heat stroke and elucidate the utility of FDG PET in the evaluation of heat stroke-induced brain injury.
Methods: Heat stroke was induced in Sprague Dawley rats by placing them in a hot and humid chamber maintained without food and water until they exhibited the heat stroke onset diagnostic criterion. Three hours after the induction ended, 18 F-FDG brain PET images were acquired in 7 controls and 14 rats with heat stroke. Between groups, region-based (standardized uptake values were normalized to the whole brain and SUV of the whole brain (SUVWB), and voxel-based analyses were performed.
Results: Of the 14 rats with heat stroke, 8 survived, whereas 6 did not. In the region-based and voxel-base analyses, the rats that did not survive showed significantly higher SUVRHB in the hypothalamus and significantly lower SUVRHB in several cortical regions than the controls. In the region-based analysis, the survival rats showed a significant increase or decrease in SUVRHB compared to the controls in a few cortical regions. However, no difference was observed in the voxel-based analysis.
Conclusions: The 3-hour post-injury PET scan showed a distinctly different regional distribution of 18F-FDG in the brains of lethally injured heat stroke rats compared to the controls. The 18F-FDG brain PET may have the potential to provide early indicators of catastrophic injury and reflect the early neurological pathophysiology of heat stroke.
Sang Yun KIM (Republic of korea, Republic of Korea)
00:00 - 00:00
#42294 - Assessment of knowledge about the manangment of pediatric mild traumatic brain injury among family medicine and emergency medicine residents.
Assessment of knowledge about the manangment of pediatric mild traumatic brain injury among family medicine and emergency medicine residents.
Introduction : Pediatric mild traumatic brain injury is a public health problem , it is commonly encountered as a complaint in emergency departments. Its management involves brain imaging in some cases particularly head computed tomography scans to detect craniocerebral injuries. However studies indicates that one quarter of these CT scan was not indicated and was by radiation exposure potantially leading to malignancies such as leukemia and brain tumors in children. Therefore, guidelines such as PECARN CHALICE and CATCH have been established to determine the appropriate use of CT scans in pediatrics mild traumatic brain injuries, aiming to reduce their use and associated risks.
Objective: To assess the knowledge about the PECARN guidelines(Figure 1) among emergency medicine and family medicine residents.
Methods : we conducted a cross-sectional study among residents in emergency medicine and family medicine . We excluded residents with less than 6 months of training in an emergency department. Then we elaborated a questionnaire of 14 items on google forms to assess the knowledge of participants regarding the indications for Head CT scans in paediatrics mild traumatic brain injuries and when observations alone was indicated. We contacted all participants via social network and data were analysed using SPSS.25.
Results : sixty seven residents participated in the study with 51 (76.1%) family medicine residents and 16(23,9%) emergency medicine residents . twenty seven residents (40,3%) did not know the existence of a pediatric Glasgow coma scale and 28 participants(41.8%) did not recognize the potential cancer risk associated with head CT scans in children. One of the most common reasons for not indicating head CT scans included : A single and isolated history of vomiting and frontal scalp hematomas.(Tab 1) On the other hand the definition a violent mechanism- by its length - indicating a head CT scan was underestimated in falling situations by more than two quarter of participants 47(70.1%).
Conclusion: There is a need for greater integration of guidelines such as PECARN, CHALICE, and CATCH into the training curriculum of emergency medicine and family medicine residents to improve their understanding of when observation alone is sufficient for managing pediatric mTBI cases and when a Head CT scan is indicated.
Achraf KOOLI, Houda BEN SALAH (sousse, Tunisia), Hajer YAAKOUBI, Rahma JABALLAH, El Bechir DEDDE, Nada BOUJELBENE, Jalloul ESSID, Imen TRABELSI, Rym YOUSSEF, Asma ZORGATI, Lotfi BOUKADIDA, Riadh BOUKEF
00:00 - 00:00
#42281 - Assessment of serious trauma patients in the emergency department recovery room.
Assessment of serious trauma patients in the emergency department recovery room.
Introduction : A serious trauma patient is classically defined by the presence of two or more injuries, at least one of which is life-threatening; but this definition assumes that the injury assessment has already been restored and therefore it has no practical interest in emergency medicine, hence the importance of taking into consideration the injury mechanism and the violence of the trauma to qualify the patient. severely traumatized. We conducted this study in the emergency department of a university hospital center in order to evaluate the initial management of multiple trauma patients in the emergency discharge room and study the epidemiological profile; clinical; paraclinical, therapeutic and progressive for polytrauma patients.
Patients and Methods : This is a prospective, cross-sectional descriptive analytical study. It was carried out from August 1 until November 31, 2023. We included all serious trauma patients admitted to the recovery room presenting at least one of the Vittel score criteria.
Results :
we collected 50 patients. The average age of our series was 44.26 years with extremes of age ranging from 1 year to 90 years. The age group of 21 to 40 was the most represented with 34% of our series. In our study we noted a predominance of males, i.e. 76%, with a sex ratio of 3.16. The majority of our patients were brought back to the emergency room by civil protection, i.e. 46%, followed by SAMU in 22%. In our series, 14% had an SGW lower than 8 on arrival at the emergency room. Whole body scan: was requested in 32 patients or 64%, among them 4 patients or 8% of body scans returned without abnormalities.
in our series 90% of brain scans were done, 38% of which came back without abnormalities. Among these scans, 64% were done as part of a body scan and 26% were an isolated brain scan.
Conclusion: Multiple trauma constitutes a significant scourge and a major public health problem; treatment must be comprehensive and rapid by a well-established and experienced multidisciplinary team.
Khaoula HLIMI, Rym YOUSSEF, Houda BEN SALAH, Salihou FALL, Farah MANSOUR (Sousse, Tunisia), Ons HMISSI, Arij BAKIR, Imen TRABELSI, Rahma JABALLAH, Hajer YAAKOUBI, Asma ZORGATI, Lotfi BOUKADIDA, Riadh BOUKEF
00:00 - 00:00
#41875 - Assessment the frequency of use of complementary medicine in patients referred to the emergency department of a university hospital.
Assessment the frequency of use of complementary medicine in patients referred to the emergency department of a university hospital.
Introduction: The goal of medical science is to treat and raise the health level of people, and the way to achieve this goal requires different and appropriate performance and attention according to the specific conditions of each patient. Alternative medicine or complementary medicine or Complementary and alternative medicine (CAM) refers to all treatment methods that are not included in the scope of modern medicine or their effectiveness is sometimes not proven. Specialists and supporters of this type of therapy, while rejecting modern medical treatment methods, use traditional and alternative treatment methods to improve and cure diseases. On the other hand, conventional medical experts consider traditional and alternative treatment methods unscientific and a form of pseudoscience.
Methods: In the present study, which was conducted in an observational-cross-sectional manner, the research population consists of 425 patients who referred to the university emergency department in the winter of 2022. The prepared questionnaire consisted of several parts: the first part included the personal and demographic information of the patients. The second part includes the underlying disease, the patient's previous drug regimen, the use and non-use of complementary medicine and, if used, the type of complementary medicine that the patients used. In this section, the number of times, the reason for using it and not using it on the day of visiting the emergency room, the method of finding out about complementary medicine, the effects of complementary medicine, the opinion of the patient's doctor regarding complementary medicine, and the level of patient satisfaction with the methods that have been used so far It has been registered.
Results:Finally, 425 patients referred to the emergency department were included in the study. Out of 425 people under study, 270 (63.5%) people had not used any type of complementary medicine in the last 3 months, and 36.5% (155 people) had used one of the types of complementary medicine at least once in the last three months. They were. 138 people (32.5%) used complementary medicine treatments less than 4 times and 17 people (4%) more than 4 times. According to the patients, the most common reason for using supplements was "fewer side effects" (48%) and then "responding to these methods in the past" (27%). Also, there was a relationship between the level of education and the amount of using complementary medicine in such a way that it was more common in people with education lower than diploma. (P < 0.001)
Conclusion: According to the results of success and the positive opinion of patients in the treatment of some diseases and improvement of their general condition, it is suggested to scientifically examine these cases and the possibility of using complementary medicine in specific cases and recommend or prohibit it to patients and inform the public. Also, considering the possibility of disorders of complementary medicine treatments with modern medicine, it is recommended that doctors pay attention to this issue when taking a history of patients.
Neda ASHAYERI, Dr Mahdi REZAI (Tehran, Islamic Republic of Iran), Ebrahim KAZEMI
00:00 - 00:00
#41799 - Association between medication related Missed Nursing Care and nurse work experience: a national cross-sectional study in Danish Emergency Departments.
Association between medication related Missed Nursing Care and nurse work experience: a national cross-sectional study in Danish Emergency Departments.
Background:
Missed Nursing Care (MNC) poses a threat against patient safety and quality of care. Multiple factors, such as staff shortage, competencies, and work experience, influence the prevalence of MNC. Nurses in ED’s often prioritize acute care needs, potentially leading to the omission of other essential tasks, notably medication. This omission increases the risk of errors and adverse events, impacting patient safety and imposing economic burdens on healthcare systems. According to studies, less years of work experience as a nurse increases the risk of medication errors. The aim of this study was to examine the association between medication related MNC and nurse work experience.
Methods:
A cross-sectional study (Missed Nursing Care in Danish Hospitals - a National Survey) with anonymous self-reported data using The Danish validated version of the MISSCARE Survey instrument. The study was conducted in 19 Danish hospital clusters from August 2022 to October 2023. All clinical registered nurses were invited to participate. The survey consisted of three parts: Participant demographic information (25 items); nursing activities (24 items); and possible reasons for MNC (17 items). Responses from nurses employed in the ED's short stay units were selected for analyses. Years of work experience as a nurse was considered the exposure, divided into ≤2 years of experience and >2 years of experience (reference group). Three medication related questions (“Medications administered within 60 min before or after scheduled time”, “PRN medication requests acted on within 15 min” and “Assess effectiveness of medications”) reported as missed were considered the outcome. A multiple logistic regression model was used to estimate the association.
Results:
319 authorized nurses were included. 82% had more than 2 years of work experience as a nurse. Overall, 63.0% of the nurses perceived scheduled medication administration as missed in their department, 63.3% perceived PRN-medication administration as missed and 73.0% of the nurses perceived assessing effectiveness of medications as missed. Nurses with ≤2 years of experience had OR 0.37 (0.17;0.80) of reporting medication administration within 60 min as missed compared their colleagues. OR of reporting PRN-medication as missed was 1.17 (0.53;2.59) and OR for assessing effectiveness of medication was 0.84 (0.37;1.91) compared to nurses with >2 years of experience. Regardless of years of experience as a nurse, “unexpected rise in patient volume and/or acuity on the unit” and “inadequate number of staff” were the most common reasons for MNC in Danish ED’s.
Discussion & Conclusions:
The study indicates an association between years of work experience as a nurse and medication related MNC in ED's. The prevalence of medication related MNC is higher in Danish ED’s when compared to results from medical/surgical departments in previous studies. This could indicate a threat against patient safety and quality of care in ED’s. A possible mediator in the association could be the level of knowledge and education regarding medication errors and MNC. Most common reasons for MNC are related to organizational factors, indicating a need of focusing on creating a better environment, task sharing and developing competencies to prevent MNC.
Funding:
This study did not receive any specific funding.
Ethical approval and informed consent:
Answering the questionnaire was considered informed consent to participate in the study.
According to Danish law, approval from The Danish National Committee on Health Research Ethics was not necessary as the study is based on data from an anonymous questionnaire survey (§14 stk. 2). The data extraction required for this study from the national survey was fully anonymized beforehand.
Louise NØRSKOV (Risskov, Denmark), Hanne MAINZ, Karen VESTERGAARD ANDERSEN, Marianne LISBY
00:00 - 00:00
#41495 - Association between single nucleotide polymorphisms in TLR4, LTA and RFP175 genes and susceptibility to invasive bacterial infections in infants under 3 months of age.
Association between single nucleotide polymorphisms in TLR4, LTA and RFP175 genes and susceptibility to invasive bacterial infections in infants under 3 months of age.
Purpose: Invasive bacterial infections (IBIs) are globally significant, with high mortality rates, particularly within the critical 0-3 month age bracket. This study investigates the association of TLR4 rs2149356, LTA rs2229094, and RFP175 rs1585110 gene polymorphisms with IBIs in neonates and young infants.
Methods: We conducted a prospective, observational study on 200 infants aged 0-3 months, comprising 100 IBI-diagnosed patients and 100 controls with non-IBI complaints. Next-generation sequencing was performed to analyze the TLR4, LTA, and RFP175 genes, with a focus on specific single nucleotide polymorphisms (SNPs).
Results: The patient cohort primarily suffered from urinary tract infections (n=84), with a minority presenting with gastroenteritis (n=6), bacteremia (n=5), pneumonia (n=3), and meningitis (n=2). Six patients necessitated intensive care. Comparing both groups revealed no significant differences in basic characteristics or in the incidence of the SNPs under study.
Conclusion: Contrasting with studies in diverse demographics, our findings within a Turkish infant cohort indicate no correlation between the targeted gene polymorphisms and IBI susceptibility in the first three months of life.
Dr Ali YURTSEVEN (İzmir, Turkey), Tahir ATIK, Enise AVCI DURMUSALIOGLU, Caner TURAN, Halit IŞIK, Benay TURAN, Eylem Ulas SAZ
00:00 - 00:00
#41206 - Association of frailty and sarcopenia with short-term mortality in older critically ill patients.
Association of frailty and sarcopenia with short-term mortality in older critically ill patients.
Background:
There is still no study on the use of the SARC-CalF questionnaire for older critically ill patients. Moreover, there is limited evidence on whether a combination of sarcopenia and frailty can provide incremental improvements in risk stratification for older critically ill patients.
Methods:
A total of 653 patients older than 60 years were recruited. We used the clinical frailty scale (CFS) and SARC-CalF questionnaire to assess the frailty status and sarcopenia risk, respectively, of older patients shortly after admission to the ICU. The effect of frailty and sarcopenia risk on ICU mortality and 30-day mortality was evaluated.
Results:
A total of 147 (22.5%) patients died in the ICU, and 187 (28.6%) patients died within 30 days after ICU admission. The CFS score was associated with increased ICU mortality [per 1-score increase: odds ratio (OR) = 1.222, 95% confidential interval (CI): 1.003–1.489] and 30-day mortality (per 1-score increase: OR = 1.307, 95% CI: 1.079–1.583). The SARC-CalF score was also associated with increased ICU mortality (per 1-score increase: OR = 1.204, 95% CI: 1.120–1.294) and 30-day mortality (per 1-score increase: OR = 1.247, 95% CI: 1.163–1.337). The addition of the CFS+SARC-CalF score to Acute Physiology and Chronic Health Evaluation (APACHE) II improved discrimination and reclassified ICU and 30-day mortality risk.
Conclusion:
Sarcopenia risk assessed by the SARC-CalF questionnaire provided independent prognostic information for older critically ill patients. A combination of sarcopenia and frailty improved the prediction of mortality for older critically ill patients and thus might be useful in the clinical decision-making process.
Weimin BAI (zhengzhou, China), Qin LIJIE
00:00 - 00:00
#41753 - Associations Between Readmission and Length of Stay in the Acute Admission Unit for Patients with Alcohol-Related Diagnoses–A Cohort Study.
Associations Between Readmission and Length of Stay in the Acute Admission Unit for Patients with Alcohol-Related Diagnoses–A Cohort Study.
Objective: Patients with alcohol-related diagnosis in emergency departments (ED) are at high risk of readmission. Evidence shows an association between alcohol related admissions and a wide range of diseases and disorders. Understanding the risk factors for readmission and the association with length of stay in the ED may help identify those who would benefit from targeted interventions. Thus, the hypothesis of this study is that patients with alcohol-related diagnoses and a short length of stay in the ED have a higher risk for readmission. Therefore, this study aimed to investigate the association between length of stay in the ED and 30-day readmission for patients with alcohol-related acute admissions as well as to uncover possible risk factors for 30-day readmission.
Methods: The study used a multicenter retrospective cohort design and was carried out from March 1, 2019, to January 31, 2020. The inclusion criteria were > 18 years, admitted to an ED, and having an alcohol-related primary or secondary diagnosis (based on ICD-10 codes). Patients from five acute hospitals in Central Denmark Region were included. Patients were followed for 30 days after discharge from initial hospitalization to identify associations between length of stay at the hospital and 30-day readmission. Cox proportional hazards were used to estimate the risk of 30-day readmission in relation to Length of Stay.
Results: We included 1,174 patients and found that 17% (95% CI: 15–20) of the patients admitted with an alcohol-related primary or secondary diagnosis were readmitted within 30 days. The hazard ratio (HR) for readmission increased with length of stay when compared to admission < 24 hr; admission > 24–48 hr HR 1.50 (95% CI: 1.08–2.08), admission > 48 hr HR 2.08 (95% CI: 1.23–3.52).
Conclusion: The study revealed that patients with alcohol-related diagnoses were at a higher risk of ED readmission the longer they stayed in the ED. Furthermore, the risk of readmission increased if patients had a medical or psychiatric diagnosis prior to admission or lived alone.
Ethics: The Central Denmark Region Research Register approved the study (1-45-70-40-21) as did the Danish Data Protection Agency (case no: 1-16-02-396-21). According to Danish law, approval from the Regional Ethics Committee was not required.
Funding: This study did not receive any specific funding.
Nanna Fauerholdt SKOV (Aarhus, Denmark), Tygesen GITTE, Marianne LISBY
00:00 - 00:00
#41604 - Atrial Infarction: A Unique and Often Unrecognized Clinical Entity.
Atrial Infarction: A Unique and Often Unrecognized Clinical Entity.
Atrial infarction is a poorly studied condition, as evidenced by the lack of published reports in the literature. In contrast with ventricular infarction, it represents a unique clinical entity that, when diagnosed, requires significant changes in therapy. This report describes a patient presenting with heart failure and acute atrial fibrillation who received a final diagnosis of atrial infarction associated with ventricular infarction.
Mr. M.D, aged 76, is a type 2 diabetic and hypertensive patient on medication. He presented to the emergency department with epigastric pain of paroxysmal nature for the past two days.
On examination, the patient was tachypneic with crepitant crackles heard bilaterally in the lung fields and oxygen saturation of 95% on high-concentration mask at 8L/min.
The patient's hemodynamic status was unstable, exhibiting signs of shock, cold extremities, and prolonged capillary refill time. The electrocardiogram (ECG) demonstrated inferior ST-segment elevation with complete heart block and PR segment elevation, suggestive of inferior ST-elevation myocardial infarction (STEMI) with atrial infarction (PR elevation).
The patient was administered anti-thrombotic treatment, atropine, and initiated on a dobutamine infusion.
Eventually, the patient underwent angioplasty, but unfortunately, experienced cardiac arrest at the beginning of the procedure and despite resuscitation efforts, he passed away.
In conclusion, atrial infarction has been a relatively understudied entity. Clinical atrial infarction may present with supraventricular arrhythmias, atrial rupture, hemodynamic compromise from loss of atrial "kick," and thromboembolic phenomena. Currently, diagnosis is made in an appropriate clinical setting with characteristic PR interval changes. Other noninvasive techniques have shown only limited diagnostic utility, but esophageal echocardiography may prove to be a useful technique in this setting.
Haifa BRADAI, Rabeb MBAREK, Sondes LAAJIMI, Dorra LOGHMARI, Naoufel CHEBILI, Chebbi NABIL (Tunisie-Sousse, Tunisia)
00:00 - 00:00
#42335 - Attempted suicide by burns in children: Risk factors for mortality.
Attempted suicide by burns in children: Risk factors for mortality.
Introduction: Patients with self-inflected burns have extensive burns and worse prognosis than patients with accidental burns1.
The aim of our study was to determine the prevalence of self-immolation in children, their epidemiological and clinical features and to identify factors associated with mortality.
Methods: A case-control study was conducted in intensive burn care department in Tunisia over a 5-year period (January 2018-December2022). All children (age<18 years) admitted for burns following self-immolation were included.
After inclusion, epidemiological, clinical and evolutionary data of children were collected. Two groups of patients were individualized (deceased/live) and compared in order to highlight risk factors associated with mortality.
Results: During period study, 300 children were admitted, 20 of whom had attempted suicide by self-immolation (prevalence of 7%). Mean age was 16±1 years with a sex ratio of 2. Eleven patients (52.4%) had a low socio-economic status, and only 8 patients had attended school (38.1%). Mean TBSA was 47.8±17.6% and median UBS score 33.5[8;173]. The majority of burns were thermal (n=20; 95.2%). Mechanical ventilation (MV) was required in 16 cases. Median length of stay was 10 days [2;172]. Mortality was 52.4% (n=11).
In univariate analysis, TBSA, burn prognostic scores (ABSI, IB and UBS), hypovolemic shock, use of MV and escharotomy incisions were identified as risk factors for mortality with a p value <0,05.
ROC curve analysis identified 2 cuttoffs: TBSA greater than 29.5% (AUC=0.91; Se=89%; Sp=89%) and a UBS score greater than 31.25 (AUC=0.827; Se=78%; Sp=67%) as predictive factors for mortality.
Conclusions: Suicide attempts by self-immolation in children mainly affect adolescents (7%). Risk factors for mortality were extensive burns (TBSA > 29.5%), deep burns, hypovolemic shock, use of mechanical ventilation and escharotomy incisions.
Reference
Nisavic.M, Nejad.SH, Beach.SR. Intentional self-inflected Burn injuries: Review of the literature. Psychosomatics. nov 2017; 58(6):581-91.
Hana FREDJ (Ben Arous, Tunisia), Mariem CHEIKHROUHOU, Amal ALOUI, Souhaila BEN MASSOUD, Amenne ALOUINI, Lilha DEBBICHE, Bahija GASRI, Imen JAMI, Amel MOKLINE, Amen Allah MESSADI
00:00 - 00:00
#42304 - Audit of Point of Care Ultrasound Abdominal Aorta Documentation In the Emergency Department.
Audit of Point of Care Ultrasound Abdominal Aorta Documentation In the Emergency Department.
Point of care ultrasound (PoCUS) offers a safe and high quality method for diagnosing patients with abdominal aortic aneurysm (AAA). A anteropostero measurement of greater than 3 cm represents an aneurysm. Certificate of completion of training in Emergency Medicine requires competency in performing an ultrasound examination of the abdominal aorta to exclude aneurysm. However documentation of the results of these results is not currently standardised. The available literature demonstrates that accurate documentation of key results can be as low as 13%. We sought to analyse the documentation of PoCUS scans of the abdominal aorta performed in our Department and to compare it against the Royal College of Emergency Medicine (RCEM) recommended standards for documentation.
Data was collected from the symphony electronic system.
1st cycle data was collected April 1st to 30th 2024.
Patients who met either of the below criteria (based on RCEM indications for bedside US scan) were included
In patients over the age of 50 years presenting with abdominal/back pain AND hypotension;
• In patients with a known AAA and symptoms of either abdominal/back pain OR hypotension/collapse
Scanned notes from patient attendances during this timeframe were reviewed.
Data which included documented evidence of bedside ultrasound performed was compared against RCEM guidelines for documentation. RCEM guidelines suggest using the guidelines of the Royal College of Radiologists (RCR).
Documentation as per RCR guidelines should include:
• Patient details.
• Indications.
• Findings.
• Conclusion.
• Signed and dated.
Our intervention of choice prior to second cycle of auditing was departmental teaching. This teaching sessions aimed to instruct ED staff on when bedside aorta US scans should be performed, as well as the standards for documentation. In addition to this, a new section was added to the EPR to document POCUS findings to ensure that results could be documented at the same time as usual e-notes.
Results pending manual review of records.
Krishnaswamy MACAULEY (, Ireland), Victoria MEIGHAN
00:00 - 00:00
#41511 - Audit on adherence to Chest Pain Pathway in Midlands Regional Hospital Tullamore ED.
Audit on adherence to Chest Pain Pathway in Midlands Regional Hospital Tullamore ED.
Adherence to Chest Pain Pathway in Midland Regional Hospital Tullamore Emergency Department.
Authors: Dr Laura Mesa, Dr Durriya Kazi, Dr Subramaniam Dineshkumar, Dr Therslan Dharamalingum
BACKGROUND
Chest pain represents a common and potentially serious symptom encountered in the emergency department (ED). The HEART score is a risk stratification aid that may safely reduce chest pain admissions for ED patients; it helps to differentiate patients with chest pain into low, medium, and high-risk groups. Low risk patients have a 1.6% chance of experiencing a major adverse cardiac event (MACE) within 30 days and are safe discharges from the ED without further testing. However, differences in interpretation of subjective components potentially alters the performance of the score.
AIM
This audit aims to evaluate the assessment and management practices for patients presenting with chest pain to the ED at Midland Regional Hospital Tullamore to enhance patient care outcomes, more specifically looking at the adherence to the use of HEART score and appropriate referral to the Acute Medical Assessment Unit (AMAU) unit for a further work-up.
Due to resource limitations (only two slots are available to AMAU for acute cardiac work up i.e, ECHO, stress test etc) it is crucial to interpret the HEART score precisely in order ensure the most efficient resource use.
METHODS
We did a retrospective audit on the ED notes of patients who had presented with chest pain. Data were recorded on Microsoft Excel and the use of HEART score and appropriate referral to AMAU was analyzed and compared with the standard outlined in the ED chest pain pathway guidelines (patients with HEART score ≥4 require a referral to the Medical team on call; score 3 – referral to AMAU; score 0-2 – GP follow up). We also calculated the average time taken to do an ECG for a patient presenting with chest pain. The data for the first audit cycle were collected in February 2024. Following an educational session at the ED weekly teaching, we did our second audit cycle in April 2024.
RESULTS
During the first audit cycle 199 patients presented to the ED with chest pain, out of which 36 (18%) patients were referred to AMAU. From AMAU referrals, 12 (33%) were not in accordance with the chest pain pathway guidelines. The average time taken to do the first ECG was 37 min. During the second cycle, there were 18 patients referred to AMAU out of which 3 (17%) were found not to be in accordance with the chest pain pathway guidelines, and the average time taken to do the first ECG had improved to 30 min. We note an improvement in adherence to the chest pain pathway and referral system, however, we recommend further education of staff to continue improving the service and more efficient use of resources. Other potential intervention to consider are discussing the case with a senior medical personnel prior to referring to AMAU and adding prompts of the guidelines along with the HEART score calculator which is printed on the ED notes.
Not registered for trial and no funding used
Laura MESA, Subramaniam DINESHKUMAR (Portlaoise, Ireland), Durriya KASI, Therslan DHARAMALINGUM
00:00 - 00:00
#41902 - Autoimmune disease – is there a catch? The challenges of the emergency nurse.
Autoimmune disease – is there a catch? The challenges of the emergency nurse.
Medical triage is a complex mechanism that often requires the development of a sixth sense on behalf of the nurse. Used correctly, aided by tools such as National Early Warning Score (NEWS), it represents the first diagnostic and management step of emergency department (ED) patients, with an inclusive prognostic role in patients evolution.
We present the case of a 41-years-old female patient who was admitted to the ED for common symptoms of viral respiratory tract infection (dysphonia, barking cough), but who’se evolution and investigations required emergency hospitalization due to major acute renal failure, severe acid-base and electrolyte imbalance (requiring dialysis), in the context of an underlying disease - systemic lupus erythematosus (SLE ).
The patient, known to have SLE (therapeutically neglected for 10 years), presented to the ED at (12:10 PM), for persistence of ear-nose-throat (ENT) symptoms for approximately 2 weeks, secondary to a viral flu episode, for which she received specific antiviral treatment (oseltamivir). Additionally, for the last 2 days, the patient associates generally altered status , anxiety, low fever, palpebral edema and pale skin. At the time of triage, we documented tachycardia and subfebrililye , receiving 3rd level of triage(urgent – code green).The respiratory rate was regrettably not documented.
At 12:31 PM, the tachypneic, anxious and pale patient was observed by an ED doctor and taken immediately to the consultation/treatment area. The NEWS at takeover is 5 points (RR≥25, HR=112).
Given the patient's medical history and the recent viral intercurrence that required etiological treatment, it was decided to repeat the one day old paracliclincal tests, with the completion of the investigations. Thus, samples were collected for blood gas analysis, complete blood count, biochemistry and , urinary summary .
The diagnosis of acute laryngo-tracheitis was a clinical one, being confirmed the previous day by the ENT specialist consultation . In contrast, the investigations performed in the ED revealed severe metabolic acidosis, severe hyperkalemia and sepsis, in the context of acute renal failure, associated with the underlying systemic pathology (SLE). The patient's discharge code was level 1 (resuscitation- code red), requiring immediate admission to the nephrology department.
The presentation of this case emphasizes the relevance of integrating the entire clinical history, when dealing with patients with chronic pathologies with multisystemic involvement. In such situations, medical professionals must interpret the signs and symptoms from the perspective of the underlying disease, being observant of the smallest, even seemingly, alterations . For our patient, the presence of triage tachycardia and tachypnea were indicative of level 2 of triage (code yellow – immediate emergency) . Moreover, avoiding bias factors in triage (especially under -triage) and using ED risk scores such as (News/Early Warning Score) in the ED allows early identification of life-threatening situations.
Alexandru Costinel GANA (Cluj-Napoca, Romania), Alina GANA, Raluca Mihaela TAT, Eugenia – Maria LUPAN-MUREȘAN, Adela GOLEA
00:00 - 00:00
#41367 - BAL-LUS: Bronchoalveolar Lavage Plus Lung Ultrasound. Etiopathological Correlation of Pneumonia with Lung Ultrasonographic Semiotics.
BAL-LUS: Bronchoalveolar Lavage Plus Lung Ultrasound. Etiopathological Correlation of Pneumonia with Lung Ultrasonographic Semiotics.
Background: Pneumonia stands as the leading cause of death from infectious diseases globally. Thoracic ultrasound has now emerged as the second-most sensitive and specific imaging modality for chest infectious pathologies, following CT scans. However, it remains unclear if there's a clear correlation between sonographic appearance and the causative pathogen and its class. Standard methods for the etiological diagnosis of pneumonia (antigens, blood cultures, serology) identify the pathogen in 20-40% of cases, while new molecular techniques combined with respiratory sample cultures achieve an etiological diagnosis in 90-95% of cases. Thus, we aimed to correlate the sonographic appearance with the microbiological findings on BAL. To date, no similar studies exist.
Materials and Methods: BAL-LUS is a prospective observational non-profit study conducted in the Emergency Department, aiming to assess whether there is a correlation between the etiopathogenetic agent of pneumonia and the sonographic appearance, particularly examining differences in sonographic images between bacterial and viral pneumonia.
Results: Sixty-three patients were enrolled, with a mean age of 70.88 ± 14.2 and a male prevalence (60%). The Film Array Pneumonia on BAL yielded positive results in 90%, while BAL culture was positive in 63.8% of patients. Viral pneumonia is associated with involvement of more than 4 lung fields (90%) and predominantly interstitial syndrome (75% of pathological lung fields). Conversely, bacterial pneumonia is more frequently associated with involvement of 1 to 3 lung fields (69%) and the presence of a dynamic air bronchogram pattern (84%). Pleural effusion is typically associated with bacterial pneumonia (34% vs. 13%, p<0.05).
Discussion: Targeted BAL execution based on radiological findings and processing of these samples using syndromic molecular panels for pneumonia and BAL cultures allow for an etiological diagnosis in a high number of patients with a high sensitivity and specificity rate, currently representing the diagnostic gold standard. Traditional methods (blood cultures, serology, antigens), unlike molecular investigations, yield a diagnosis in a limited number of cases. Thanks to the correlation between BAL investigation outcomes and sonographic appearance, it was possible to establish typical sonographic signs of bacterial and viral pneumonia.
Conclusions: Viral pneumonia is usually associated with involvement of a greater number of lung fields and the presence of interstitial syndrome; on the other hand bacterial pneumonia is usually associated with involvement of a limited number of lung fields, dynamic air bronchogram, and pleural effusion.
funding none
Lorenzo PELAGATTI (Florence, Italy), Vannini IACOPO, Francesca MANGANI, Gian Maria ROSSOLINI, Simone VANNI, Peiman NAZERIAN, Stefano GRIFONI
00:00 - 00:00
#41670 - Beware foragers: a case series of Amanita phalloides, the death cap, as cause of acute liver failure.
Beware foragers: a case series of Amanita phalloides, the death cap, as cause of acute liver failure.
We introduce two cases of Amanita phalloides poisoning, also named ‘the death cap’. Two Chinese women aged 57 and 66, with no prior medical history arrived together at the emergency department with abdominal pain, repeated vomiting and diarrhea. The first patient was in hypovolemic shock and needed fluid resuscitation, whereas the second patient was hemodynamically stable. Physical examination revealed no other abnormalities, specifically none of the abdomen. Blood tests showed no inflammation, a normal blood count, and no elevated liver enzymes. Electrocardiograms were normal.
The gastrointestinal symptoms had reportedly started 10 hours after consumption of a soup made from self-foraged mushrooms, of which they presented a picture. We immediately consulted a mycologist attached to the national poison control centre who identified them as the highly toxic Amanita phalloides fungus. Our differential diagnosis at that point included ingestion of other mushrooms and forms of acute gastro-enteritis. However, due to the seriousness of an amatoxin-containing mushroom poisoning we promptly admitted the patients and started treatment with intravenous silibinin, intravenous acetylcysteine and multiple-dose activated carbon (MDAC).
The alanine transaminase level of both women increased by tenfold after 24 hours and rose to >1300IU/L just 48 hours after admission. They were transferred to a tertiary care centre. The first patient developed liver failure with signs of hepatic encephalopathy, coagulopathy, hypoglycemia and ascites, 96 hours after ingestion of the fungi. Infectious and auto-immune causes of liver failure were excluded. She was transferred to the intensive care unit and put on the liver transplantation list. Thankfully, after three weeks of continuous silibinin and acetylcysteine infusion the liver synthesis normalised and transplantation was no longer necessary. The second patient was discharged just 6 days after admission, as her liver enzyme levels normalised after continuous sibilin infusion and MDAC.
The liver enzymes of both patients were consistently normal after 6 months.
Relevance:
Amatoxin-containing mushrooms, such as Amanita phalloides, cause approximately 50 deaths in Europe and Asia each year due to their association with acute liver failure through amatoxins. The most common reason being misidentification due to their likeness to edible mushrooms such as paddy straw mushrooms (Volvariella volvacea) and white Caesar (Amanita princeps).
The toxins are absorbed in the intestine and transported through the portal circulation, where active transport into the hepatocytes causes a high intracellular toxin concentration. Amatoxins halt protein synthesis by binding to RNA polymerase type II, thereby resulting in apoptosis.
The most important strategy to reduce toxicity is preventing active uptake into hepatocytes by inhibiting the transport proteins on hepatocyte membranes. The strongest uptake inhibitor and therefore preferred compound is silibinin dihemisuccinate, extracted from Mediterranean milk thistle (Silybinum marianum). Concurrent and synergistic therapies include activated carbon (AC) and N-acetylcysteine (NAC). AC binds amatoxin and increases its elimination through the feces. NAC serves as antioxidative therapy.
In case of acute liver failure a liver transplantation may be the only viable therapy. If it is performed 4 or more days post-ingestion, no toxicity to the transplanted liver can be expected.
Informed consent ws received from both patients.
Wubbo DE BOER (Amsterdam, The Netherlands), Jan Willem UFFEN
00:00 - 00:00
#40880 - Beyond the walls of the Emergency Room; Emergency Physicians leading Hospital at Home,with potential to reduce bed blocks.
Beyond the walls of the Emergency Room; Emergency Physicians leading Hospital at Home,with potential to reduce bed blocks.
Background:
The Hospital-at-Home (H@H)model presents at innovative approach to patient care, offering a potential solution to the many challenges faced by traditional inpatient models. We aim to describe the outcomes of H@H programme, delivered by a tertiary hospital in Singapore.
Method:
A cohort of all patients enrolled under H@H service in our hospital over 5 months who required hospitalisation and accepted the 'recuperation at home' programme were studied.
Results:
A total of 81 patient enrolments were admitted during the initial 156 days period. 77% of the referrals for H@H were direct from the Emergency Department with the remaining 23% from inpatent wards. Average length of stay was 3.48days, contributing to 282 bed days saved. The top admission diagnoses was cellulitis (38.2%), exertional rhabdomyolysis(18.5%), dengue fever(8.6%), pyelonephritis(7.4%) and pneumonia(6.2%).
During the hospitalisation, 8.6% were readmitted back to inpatient wards due to deterioration in clinical condition. There was no mortality. There were 2 falls at home and no cases of hospital acquired infections.
Conclusion:
Judicious selection of patients for H@H and proper care delivery is able to reduce acute bed utilization in hospitals, which in turn leads to reduced bed wait times for patients with higher acuity illnesses awaiting inpatient beds in the Emergency Department.
Jean LEE (Singapore, Singapore), Chong Yau ONG
00:00 - 00:00
#41731 - Bilateral leg swelling and crackles – typical signs of heart failure or else? - A case report.
Bilateral leg swelling and crackles – typical signs of heart failure or else? - A case report.
Brief clinical history:
A 75-year-old patient presented to the emergency department due to painless swelling of both legs over the past 2 weeks, initially on the right, then on both legs. Denies trauma. Reports full regression of swelling when lying in bed. Reports progressive shortness of breath over the past 2 days with minimal exertion. Previously afebrile, dry cough present for several days. Denies chest pain, and no loss of consciousness. Denies palpitations or irregular heartbeat. The patient had a history of arterial hypertension, hyperlipidemia, type II diabetes, and nephrolithiasis. Hospitalized four years ago with a suspected ischemic stroke, which was later ruled out during hospital stay. Chronic medication therapy included acetylsalicylic acid, oral hypoglycemic agents, antihypertensives, statins, and beta-blockers. On arrival, the patient appeared well, eupnoeic at rest, but tachycardic, subfebrile (37.6°C). Heart rhythm on auscultation was tachyarrhythmic, no murmurs. On auscultation basal crackles on the right. Mild symmetrical pretibial edema bilaterally, with symmetrical pulses.
Misleading elements:
ECG showed atrial fibrillation of unknown duration with ventricular response of 140/min and right bundle branch block, without clear ischemic changes. No successful rate control by oral bisoprolol was achieved. Elevated body temperature, history of cough, laboratory findings of leukocytosis 15.9x10^9/L with left shift and CRP 148.8mg/L were indicative for inflammatory process in the background. ABG analysis revealed normal pCO2 and pO2 and SO2 94%. D-dimers came immeasurably high >4.4 which is a nonspecific finding. NT pro-BNP was not evaluated.
Helpful details:
Chest X-ray was unremarkable, without infiltrative changes or signs of heart failure. COVID-19 test negative. High-sensitivity troponin initially and in follow-up were normal. The echocardiogram showed normal left ventricular systolic function, no wall motion abnormalities, and no signs of right ventricular overload. Wells score was 2 - moderate clinical probability so lower extremity ultrasound was performed which revealed concurrent deep vein thrombosis in both legs (at the level of VFC and VFS). Additionally, CT pulmonary angiography showed a filling defect in the right pulmonary artery and its branches for the lower and middle lobes, and in segmental branches of the left pulmonary artery for the lower lobe with no pneumonic infiltrates.
The differential and actual diagnosis:
The differential diagnosis for this patient included pneumonia, heart failure with atrial fibrillation in the background, acute coronary syndrome, deep vein thrombosis and pulmonary embolism. Bilateral proximal deep vein thrombosis was verified by CD ultrasound of lower extremities. Symptoms supporting pulmonary embolism included shortness of breath on exertion, persistent tachycardia, high D-dimer, and proximal bilateral deep vein thrombosis and the diagnosis was eventually confirmed with CT pulmonary angiography (intermediate low risk according to PESI score).
Educational and clinical relevance:
This case underscores the importance of considering bilateral deep vein thrombosis even in patients on acetylsalicylic acid therapy. Our patient had neither provocative nor risk factors for thrombosis, emphasizing long-term daily therapy with acetylsalicylic acid. The successful diagnosis relied on the integration of clinical symptoms, diagnostic criteria such as the Wells score (2 -moderate clinical probability), and imaging modalities.
Adela MARINELLI, Maša SORIĆ (Zagreb, Croatia)
00:00 - 00:00
#42350 - Blood exposure accidents in a Tunisian university hospital: a 2-year study.
Blood exposure accidents in a Tunisian university hospital: a 2-year study.
Objective
To identify the prevalence of blood exposure accidents (BEAs) among healthcare workers at the FSI hospital in Tunisia and their risk factors, and to assess the quality of their management.
Materials and methods
Exhaustive retrospective study, spread over a period of 2 years, of reported BSEs Data collection was based on the BSE reporting and monitoring forms used in the department.
Results
A total of 58 cases of HAE were reported during the study period, representing an annual incidence of 28 cases/year. The sex ratio was 0.6, the average age was 33 ± 7.8 years and the average length of service was 6.2 ± 5 years. Paramedics accounted for 40.8% of victims, doctors for 38.4% and manual workers for 20.8%. The departments most affected were the emergency department and the intensive care unit. The AES was secondary to a needle stick in 87.3% of cases. Recapping of needles was the direct cause in 43.3% of cases. At the time of the accident, only 43% of healthcare workers were wearing gloves. In 35% of cases, the immediate course of action following an HAI complied with universal recommendations. The hepatitis B vaccination schedule was correctly followed in 68% of cases. In the analytical study, a number of occupational factors emerged as risk factors for HAEs, in particular the position of nurse, professional seniority of more than five years, as well as ongoing tasks and non-compliance with universal recommendations.
Conclusion
In our hospital, the prevalence of reported HAEs is considerable, and management remains unsatisfactory, particularly with incomplete post-accident serological monitoring and non-generalized immunization of staff against hepatitis B. Preventive measures were initiated and focused on training cycles, increased availability of personal protective equipment and the systematic and compulsory summoning of staff for biological surveillance.
Mona TITEY (tunis, Tunisia), Saloua HOUIMLI, Kalthoum DRIDI
00:00 - 00:00
#41532 - Blood on the Go: Prehospital Transfusion Experience for Trauma Patients at North Estonia Medical Centre Foundation.
Blood on the Go: Prehospital Transfusion Experience for Trauma Patients at North Estonia Medical Centre Foundation.
Background
In Estonia, injuries rank as the third leading cause of death, with bleeding-related deaths following head injuries as the second most common cause of mortality among trauma cases. Haemorrhage could be assessed clinically considering the mechanism of the trauma, injuries and shock index – all of which are applicable variables in a prehospital setting. Early diagnosis and management of bleeding, including the administration of blood products and tranexamic acid, are highly recommended in current guidelines. Nevertheless, the literature presents conflicting results regarding the benefits of prehospital transfusion.
The North Estonia Medical Centre Foundation is a major trauma center in Estonia, offering ambulance services to a region encompassing nearly 800,000 inhabitants, including rural areas and small islands. Ambulance service includes an intensive mobile support unit with emergency or intensive care physicians. National legislation permits prehospital transfusion, and since 2020, intensive mobile units have been equipped with O negative packed red blood cells (pRBCs).
The aims of this analysis are:
To describe the demographic and clinical characteristics of trauma patients who received prehospital pRBC.
To compare the on-scene time of ambulances between the pRBC+ and pRBC- groups.
Methods
This retrospective study received approval from the institutional research ethics committee. Patients who received prehospital pRBCs from February 2020 to April 2023 were identified from the hospital blood bank database. Non-trauma patients and patients with incomplete medical records were excluded from the analysis. For the control group, trauma patients requiring intensive mobile unit support and O negative pRBCs during emergency department (ED) stay were enrolled. These patients were identified through screening of all major trauma admissions during the respective time period prior to the introduction of prehospital pRBCs (January 2017–January 2020).
Results
During the study period, a total of 33 patients received prehospital pRBC, with 17 of them experiencing major trauma. Among these patients, three received prehospital pRBC during traumatic cardiac arrest and resuscitation, while four received it during interhospital transfer. Median age of patients receiving prehospitally pRBC was 41 (37–55) years. Patients’ data are depicted in Table 1 and Table 2. No significant differences were found in on-scene time between the prehospital pRBC+ and pRBC- groups (median on-scene time of 27 minutes (IQR 22–32 min) versus 28 minutes (IQR 26–35 min), respectively; p = 0.6. Additionally, no major transfusion reactions were identified.
Conclusions
The observed frequency of patients requiring prehospital pRBC transfusion was relatively low. The shock index appears to be a superior indicator for transfusion requirement compared to hypotension. Despite our limited experience with prehospital transfusions, no adverse effects were documented. Additionally, there was no significant difference in on-scene time between the prehospital pRBC+ and pRBC- groups.
Keskpaik TRIINU (Tartu, Estonia)
00:00 - 00:00
#41980 - Body-packing and cocaïne poisoning : a case report.
Body-packing and cocaïne poisoning : a case report.
Body-packing is an increasingly common mode of transporting illegal substances. It allows for the transport of significant amounts of drugs concealed in the digestive tract after ingestion in the form of capsulesn in this case : cocaïne. This method exposes the body packer not only to the risk of massive intoxication in case of capsule rupture but also to mechanical complications. Patients are often seen at the stage of complications, and the diagnosis is generally based on abdominal CT scan. Although there is no consensus on management, the therapeutic strategy depends on the patient's condition and includes conservative treatment, resuscitation measures, and even surgery. We report a case of acute cocaine poisoning due to the rupture of cocaïne capsules, which despite medical-surgical management led to the patient's death.
Younes HAMDI (Casablanca, Morocco), Fehdi MOHAMED ANASS, Asmae DAFIR, Badria AGGOUG, Mohamed MOUHAOUI, Mohamed MOUSSAOUI
00:00 - 00:00
#41232 - Brain abscess in an alcoholic male after dental procedures.
Brain abscess in an alcoholic male after dental procedures.
Brief clinical history:
A 40-year-old man presented to our emergency department due to drowsiness for two days. Prior to this admission, he had experienced a toothache for over a month. His dentist performed intraoral incision and drainage for odontogenic cellulitis a few days ago. He had no chronic diseases but had been drinking three bottles of beer every day for twenty years.
Misleading elements:
Fever with body temperature of 40℃ was detected a few days ago. Apart from facial swelling, he reported no other discomforts. Heart rate was 124 beats/min, respiratory rate 18 breaths/min, oxygen saturation 100% on room air, and blood pressure 205/122 mmHg.
Helpful details:
His Glasgow Coma Scale (GCS) was E3V4M6 with no focal weakness noted. Laboratory data showed leukocytosis and elevated C-reactive protein. Liver and renal function tests, as well as urine analysis, were normal. Brain computed tomography (CT) and magnetic resonance imaging (MRI) revealed a pyogenic mass in the left temporal region. There were increased enhancement and emphysematous changes along the left masseter, pterygoid, and temporalis muscles. Fluid accumulation in the left maxillary sinus, swelling tissue in the left masticator space, and free air in the middle cranial fossa all suggested local infection.
Differential and actual diagnosis:
Deep neck infection and central nervous system infection may be considered given the history of fever, facial swelling, and consciousness impairment. However, the diagnostic key for this case is neuroimaging, which disclosed a cerebral abscess. Abscesses are usually hyperintense on diffusion-weighted MRI and hypodense with enhancing rings on CT.
Educational and/or clinical relevance:
Brain abscess, with an estimated global incidence rate of 1 case per 100,000 individuals, poses a significant clinical challenge due to its high mortality rate, ranging from 10% to 40%. Risk factors include obesity, diabetes mellitus, alcoholism, immunosuppression, poor oral hygiene, head trauma, and recent neurosurgical and dental interventions. The most prevalent pathogens among immunocompetent patients are Streptococcus and Staphylococcus spp., followed by anaerobes. Pathogens can invade the brain via direct spread from adjacent sites such as ear, sinus, or oral cavity, or through hematogenous seeding. Patients may manifest with fever, headache, altered mental status, nausea, vomiting, focal neurological deficits, and seizures. MRI is the imaging modality of choice for its sensitivity, although CT can serve as an alternative if MRI is unavailable. Imaging findings vary according to the stage of infection. Successful treatment typically requires a combination of surgical drainage and antimicrobial therapy. Odontogenic cerebral abscess, as in our case, is rare (5%) and can result from untreated caries or periodontal diseases. Diagnosis of odontogenic brain abscess often relies on excluding other sources of infection. Our patient underwent multiple craniotomies. Blood and pus cultures yielded Fusobacterium nucleatum and Streptococcus constellatus, both commonly associated with oral flora. He was discharged in stable condition after a two-month hospitalization. This case highlights the potential for brain abscess development from dental origins and emphasizes the importance of comprehensive evaluation and management in such cases to prevent morbidity and mortality.
Peng-Yu LEE (Taipei, Taiwan)
00:00 - 00:00
#42067 - Bridging the gap: a comprehensive approach to implementing a child abuse & neglect readiness package in emergency departments - an exploratory study.
Bridging the gap: a comprehensive approach to implementing a child abuse & neglect readiness package in emergency departments - an exploratory study.
Background:
Introducing new strategies and protocols in bustling emergency department (ED) settings poses significant challenges. Ensuring their effectiveness relies on successful implementation and dissemination. This process requires careful consideration and scientific validation. We developed a comprehensive Child Abuse & Neglect Readiness Package (CAN-Ready) featuring a screening instrument called SCAN (Hoedeman et al. 2022), an educational program with two online courses for ED personnel, and a hospital policy framework. To assess both clinical impact and feasibility of our approach, we developed a Hybrid type 2 study that combines effectiveness and implementation evaluation. Furthermore, to ensure the applicability and relevance of the CAN-Ready in diverse contexts, we will conduct cross-cultural validation using three EDs situated in different European countries. This exploratory study aims to break down the comprehensive approach from validation to implementation of the CAN-Ready in EDs.
Methods:
A Hybrid type 2 study design was chosen to blend clinical effectiveness assessment with implementation research. The clinical effectiveness aspect aims to gauge whether the screening rate, and consequently the detection rate of child maltreatment, improves. Meanwhile, the implementation evaluation focuses on assessing the strategies employed to implement the CAN-Ready.
For clinical effectiveness, we will analyze screening results pertaining to child maltreatment at baseline and during implementation, including patient demographics and data on child maltreatment management in the ED.
Regarding implementation research, we have identified several strategies to formulate and evaluate implementation of the CAN-Ready. These encompass organizational, marketing, and healthcare professional-related strategies. This will involve administering questionnaires and semi-structured interviews during implementation support sessions to assess barriers and facilitators both at baseline and during implementation.
The entire process from validation to implementation of the CAN-Ready is anticipated to span 12 months, encompassing preparation, package implementation, evaluation, and analysis.
Results:
Successful implementation of the CAN-Ready is contingent upon achieving the following outcomes: a) Sustained high screening rates for child maltreatment using the SCAN tool defined as screening rate >80%; b) High participation rates over 80% in the educational program among ED personnel; c) Identification and mitigation of barriers to implementation, with enhancement of facilitators; d) Improvements in the competence and behavior of ED personnel regarding child maltreatment recognition, communication and management; e) Applicability and significance of the package in different cultural settings will be verified by comparison of results between EDs from this multi-site approach.
Discussion & Conclusions:
In ED settings where resources are limited and the effectiveness of new protocols is crucial, the Hybrid type 2 study design emerges as a desirable method for combining effectiveness and implementation research. Important lessons obtained from designing the CAN-Ready package implementation study underscore the importance of clearly defining all implementation strategies and measurements essential for successful clinical validation and implementation. For the CAN-Ready package, increased detection of possible child maltreatment not only validates the SCAN but also provides proof of concept for successful implementation. Moreover, results from this multicenter approach will demonstrate its cross-cultural value in different operational landscapes, thereby enhancing further implementation efforts and bridging the gap in addressing child maltreatment across European EDs.
Trial registration: study is not registered because no appropriate register is available.
Funding: this study is partially funded by Augeo Foundation from the Netherlands.
Ethical approval and informed consent: ethical approval will be obtained prior to the start of the implementation study.
Feline HOEDEMAN (Rotterdam, The Netherlands), Andrea SMITS, Ruth FARRUGIA, Amanda FENECH, Marta SIMÓ, Josefine CATTELL, Louise LAURELL, Mariëlle DEKKER, Rianne OOSTENBRINK, Erwin ISTA, Patrycja PUIMAN
00:00 - 00:00
#41696 - Broken heart syndrome presented in our ED [Takotsubo cardiomyopathy].
Broken heart syndrome presented in our ED [Takotsubo cardiomyopathy].
A 52-year-old female patient , who is diabetic and hypertensive, came to our ED for epigastric pain and chest discomfort after she got severe choking while she was eating since few hours back . She looked well. She said while she was eating she got sudden choking and a lot of coughing, then they got epigastric pain and chest discomfort not relief for 4 hours. She got supportive treatment for gastritis and painkiller . She did blood work up .The trop T was elevated about 205 . ECG showed inverted T in the lateral leads , it was old changes since 2 years back , last time she did trop T was one year back and it was 5. The ECG had old changes like sign of left ventricular hypertrophy, second to chronic hypertension. The trop T repeated was 385 . The patient got admission for further cardiology investigations: Echos showed multiple hypo-kinesia in the left ventricle and apex of the heart , reduced left ventricular function and apical ballooning. The coronary angioplasty showed : no significant stenosis in the coronary artery. The MRI showed: [Akinetic LV apex with moderate degree of ballooning in some views , Increased wall thickness at the septum.Normal right ventricular volumes and function.No myocardial oedema or significant myocardial fibrosis.The overall findings are consistent with Tako-tsubo cardiomyopathy]. The patient got supportive treatment then discharge after 5 days when trop T fall to normal level . she did echo , one month after that showed normal global systolic LV function. Broken heart syndrome or takotsubo cardiomyopathy is sudden and temporary cardiac event affected the left ventricle and apex of the heart that cause kinesia after emotional or physical stress. The patient got high trop T and acute coronary syndrome symptoms like chest pain. The coronary angioplasty result usually showed no stenosis.
This case showed rare and non-frequent presentation of emotional heart syndrome in ED , emotional heart syndrome and cardiac attack should be considered in any emotional or physical stress in the patient's history .
Dr Islam ELROBAA (Al wakra, Qatar), Ajay NAICKER, Ahmed KASSEM
00:00 - 00:00
#41127 - Brugada ECG pattern in a patient with abdominal colic.
Brugada ECG pattern in a patient with abdominal colic.
A 37–year–old male patient was brought to the emergency department due to vomiting and abdominal pain. Diabetic, admitted for the same complaints in October 2023 in the intensive care unit. He has chills, and nausea and has vomited on several occasions. Yesterday he consumed two bottles of beer in the afternoon. The last meal was yesterday and since yesterday afternoon he has had pain in the upper part of his abdomen. Previous illnesses: diabetes mellitus type I (since 15 years ago), chronic alcoholism (treated psychiatrically). In 2019, he was hospitalized because of GI bleeding and a toxic liver lesion. Functions and habits: appetite weak, urination decreased, last stool this morning with a regular consistency. Nonsmoker. Alcohol consumption almost every day. Medicines: short and long-acting insulin, benzodiazepine. Status: oxygen saturation 100 %, respiratory rate 20 breaths per minute, pulse 100 per minute, blood pressure 120/60 mmHg, GCS 15, Temp 36.0°C, conscious, rapid breathing (Kussmaul), tremor, poorly hydrated and perfused skin and mucous membranes. On the ECG, the elevation of the ST segment was visible in leads V1 and V2, similar to Brugada's syndrome (Figure 1), which was not described in the previous ECG findings. Laboratory: mild leukocytosis, hemoglobin 133 g/l, glucose 36.4 mmol/L, renal insufficiency, potassium 7.2 mmol/L, lipase 216 U/L and acid-base disorder: pH 7.129, pCO2 1.57 kPa, pO2 14.84 kPa, HCO3 8.7 mmol/L and base excess -22.8 mmol/L. The patient was admitted to the hospital after consulting cardiology. Treatment was started with intensified parenteral rehydration with plasma glucose and potassium correction, gastroprotection therapy, anticoagulant therapy in a preventive dose, and other chronic and supportive therapy. Abdominal ultrasound revealed milder hyperechoic liver parenchyma, other findings were unremarkable. In the continuation of hospitalization, an adequate response to the given therapy is monitored along with an improvement in the metabolic status with a gradual decrease in pancreatic enzymes, improvement in renal function, and clinical condition with the resolution of the Brugada pattern seen previously on the ECG trace. The patient was free of abdominal pain in the further hospital course. He was discharged from the hospital with normal ECG and clinical status, symptom-free. Electrolyte disturbances such as hyperkaliemia have been associated with transient Brugada pattern due to similar electrolyte dysfunction. The treatment is focused on resolving the underlying cause, in this case hyperkaliemia. The Brugada pattern in diabetic ketoacidosis is a diagnostic challenge because it can mislead physicians into making wrong decisions as it can be confused with acute coronary syndrome.
Boris DELIĆ, Adela MARINELLI, Maša SORIĆ (Zagreb, Croatia)
00:00 - 00:00
#42121 - CAMI-STEMI score: a predictive factor for fibrinolysis failure.
CAMI-STEMI score: a predictive factor for fibrinolysis failure.
Introduction :
ST-segment elevation myocardial infarction (STEMI) is a serious cardiovascular event that requires prompt reperfusion therapy to minimize myocardial damage. Fibrinolysis is a common reperfusion therapy for STEMI. However, fibrinolysis has a variable success rate, and identifying patients who are unlikely to benefit from fibrinolysis is crucial for optimizing treatment strategies.
Aim :
The aim of this study is to evaluate the performance of the CAMI-STEMI score in predicting fibrinolysis failure in ST-segment elevation myocardial infarction (STEMI).
Methods :
It's a prospective analytical and observational study made in emergency department from september 2022 to november 2023. We included all patients admitted to our department for STEMI management with recourse to fibrinolysis. The CAMI-STEMI score was calculated for all these patients.The predictive value of the CAMI-STEMI score for fibrinolysis failure was determined using the ROC curve.
Results:
We included 81 patients with mean age 60 ± 12 years. The sex ratio was 3.6.
The cardiovascular risk factors found in our study were essentially smoking, diabetes and hypertension, with percentages of 67.4%, 38.4% and 32.6% respectively. Among the studied patients, 97.7% consulted for chest pain.
The CAMI-STEMI score was calculated for all these patients with a mean of 2.41 ± 2.32 (minimum: 0; maximum: 9). Lysis failure was observed in 43.6% of patients. Four patients presented with cardiogenic shock.
The study of predictive factor of fibrinolysis failure was studied by the ROC curve with (AUC 0.69; p: 0.002; IC [0.58-0.8]). The threshold value was 0.5 with a sensitivity of 88% and a specificity of 68%.
Conclusion :
The CAMI-STEMI score is a valuable tool for risk stratification in STEMI patients. Our study showed that this new score can be used to identify patients who are at high risk of failing fibrinolysis and who may benefit from alternative reperfusion strategies which can help optimize treatment strategies and improve patient outcomes.
Kheireddine JEMAI, Yessmine WALHA, Wided BAHRIA, Intissar BOUSSAID, Dhekra HAMDI, Nourelhouda NOUIRA, Kheireddine JEMAI (Tunis, Tunisia)
00:00 - 00:00
#40905 - Can prehospital point-of-care troponin-myoglobin-CK MB provide support in the screening of chest pain?
Can prehospital point-of-care troponin-myoglobin-CK MB provide support in the screening of chest pain?
Background: Technological advances have made possible the availability of reliable point-of-care testing (POCT) bedsides that are reduced in size, easy to maintain, simple to clean and user friendly. In certain pathologies such as chest pain, it is essential to have reliable diagnostic tests that help in the decision-making process. In this regard, the use of ultrasensitive troponin has proven to be the gold standard for this pathology, detecting acute coronary syndromes in which the electrocardiogram or the characteristics of the pain are non-specific.
The objective of this study was to determine the usefulness of three cardiac biomarkers, i.e., ultrasensitive troponin, myoglobin, and creatinine kinase MB (CK-MB) in chest pain patients to detect acute coronary syndrome cases.
Methods: Prospective, multicentric, EMS-delivery, ambulance-based, pragmatic cohort study of patients with chest pain, referred to three hospitals (Spain), between January 2022, and February 2024. Patient treated consecutively by EMS with prehospital diagnosis of chest pain and transferred with high priority by ambulance to the ED was included in the study. Patients under 18 years of age, pregnant women, traumatic patients, acute coronary syndrome with ST elevation or new or suspected new right or left bundle branch block were excluded. Demographic data (age and sex) and venous sampling were collected during the first contact with the patient in prehospital care.
The prehospital troponin, myoglobin and CK-MB test was measured with the Affias-6 (© Boditech Med Inc, Gang-won-do, Korea). Data were obtained by reviewing the patient's electronic history. The primary dependent outcome was acute coronary syndromes hospital diagnosis. The area under the curve (AUC) of the receiver operating characteristic (ROC) of the three biomarkers were calculated, and then the Delong test was used to test the statistical significance between both biomarkers.
Results: A total of 168 patients with chest pain were included in our study. The median age was 69 years (IQR: 52-83), with a range from 19 to 93 years, with 69 cases (41%) of females. The rate of acute coronary syndromes hospital diagnosis, ICU-admission, percutaneous coronary intervention, and hospital-mortality (30-day follow-up) were 28 cases (16.6%), 27cases (16%), 5 cases (2.9%), and 2 cases (1.1%). The AUROC of prehospital troponin, myoglobin, and CK-MB were 0.843 (95%CI: 0.75-0.93), 0.775 (95%CI: 0.66-0.88), and 0.804 (95%CI: 0.7-0.9) (p<0.001 in all cases). Troponin showed statistically significant differences compared to myoglobin (p=0.279), but not between troponin and CK-MB (p=0.228).
Conclusions: rapid screening of patients with chest pain who eventually develop acute coronary syndrome is a challenge for EMS-providers. The use of specific on-scene biomarkers such as troponin or CK-MB yields very interesting results, which may help to stratify risk in these patients.
This work was supported by the Institute of Health Carlos III (Spain) and co-financed by the European Union [grant numbers DTS23/00010] for FM-R.
Francisco MARTÍN-RODRÍGUEZ, Carlos DEL POZO VEGAS (Valladolor, Spain), Raúl LÓPEZ-IZQUIERDO, Rubén PÉREZ GARCÍA, Ana RAMOS RODRÍGUEZ, Inmaculada GARCÍA RUPEREZ, Berta TIJERO RODRÍGUEZ, Raquel TALEGÓN MARTÍN, Irene CEBRIÁN RUÍZ, Virginia CARBAJOSA RODRÍGUEZ, Jesús ÁLVAREZ MANZANARES, Angela AREVALO PARDAL, Laura MELERO GUIJARRO
00:00 - 00:00
#41752 - Can Probe-Guided Carotid Artery Compression During Chest Compressions Predict Return of Spontaneous Circulation?
Can Probe-Guided Carotid Artery Compression During Chest Compressions Predict Return of Spontaneous Circulation?
Background and Aim
The timely identification of Return of Spontaneous Circulation (ROSC) during cardiopulmonary resuscitation (CPR) is critical for determining the appropriate resuscitation strategy. If ROSC can be identified during chest compressions, then the next step can be determined more rapidly. We aimed to investigate carotid artery compressibility using ultrasound as a method to predict ROSC during ongoing chest compression.
Methods
This prospective observational study was conducted over an 18-month period from June 2022 to December 2023 at a tertiary care hospital in Korea. Adult patients aged 18 and older who experienced cardiac arrest and underwent CPR were enrolled. To evaluate intra-CPR ROSC prediction, point-of-care ultrasound–carotid artery compression (POCUS-CAC) was applied every 30 seconds, and carotid artery compressibility was assessed by probe compression. A complete compression of the carotid artery indicated an absent pulse (arrest), while incomplete compression suggested a present pulse (ROSC). A second physician, blinded to the ultrasound findings, performed manual femoral artery palpations every two minutes in accordance with existing Advanced Life Support guidelines. Outcomes from ultrasound predictions were then compared with the results from immediate manual pulse checks and final ROSC assessments.
Results
The study included 39 patients, from whom 274 POCUS-CAC images were analyzed. The median age of these patients was 76.5 years (interquartile range 66.8–82.5), including 16 men and 20 women. Intra-CPR predictions using POCUS-CAC identified 103 instances of potential ROSC and 171 non-resuscitative events. Statistical analysis revealed the area under the receiver operating characteristic curve (AUR) for ROSC predictions after two minutes was 0.867 (p<0.001), with a sensitivity 0.904 and a specificity 0.817. The final ROSC AUR was 0.580 (p=0.043), with a sensitivity 0.566 and a specificity 0.563.
Discussion and Conclusions
POCUS-CAC demonstrated moderate to good predictive value for immediate ROSC but was less effective in predicting final ROSC. The technique presents challenges due to the dynamic environment of active chest compressions but shows potential for enhancing CPR strategies. Further research and validation in various clinical settings are necessary. Integrating POCUS-CAC with noise-corrected ECG monitoring might enhance the efficacy of CPR by allowing continuous compressions and potentially improving patient outcomes.
Trial Registration: None
Funding Information:
This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Ministry of Science and ICT (MSIT) (NRF-2022R1C1C1011864), and the Future Medicine 20*30 Project of the Samsung Medical Center (SMX1240781).
Seung Jin MAENG (Seoul, Republic of Korea), Hee YOON, Subin PARK
00:00 - 00:00
#41976 - Can the poor social network of many elderly people in Italy delay correct management of the patient by the emergency doctor?
Can the poor social network of many elderly people in Italy delay correct management of the patient by the emergency doctor?
The emergency doctors know very well that the state of consciousness of many patients, especially the elderly, is often influenced by many variables and is affected by the patient's various comorbidities to an extent that is not always clear in the acute phase.
In this regard, relatives play a fundamental role.
The: "It has never been like this" or "it has changed compared to yesterday" are phrases that hide an important help for the emergency doctor in identifying alarm situations earlier.
But what happens when the patient is an old granny without a family network behind her?
A 90-year-old woman, with multiple comorbidities including IA and dyslipidemia and resident in a nursing home was evaluated at our Emergency Department for rapidly worsening dyspnoea and fever.
After having diagnosed a case of pneumonia, the patient was supported with NIV and antibiotics. .
The situation apparead serious since the first moment, not only because of the age but also due to a poor perfomance status.
Our colleuges in ED struggled to trace the lady's relatives in order to talk to them about the possibile unfortunate prognosis.
Apparently, in fact, the patient had no close relatives and had been a guest of the nursing home since many years before.
The colleagues from the ED admitted the patient to our department- MIAC (Medicina interna Area critica)- where the appropriate therapy was set.
One of the characteristic elements of the patient was the presence of a significant alteration in her state of vigilance which appeared to fluctuate between the verbal and pain stages of the AVPU scale.
Although the antibiotic therapy was appropriate for the clinical case, the state of consciousness did not improve during the days of hospitalization.
During those days, none of the relatives or operators from the nursing home had ever come to visit the hospitalized patient and this fact made even more difficult to identify any changes in her state of consciousnes compared with her usual alertness.
With the aim of excluding an acute central neurological event, we requested a Brain CT ,which was negative, followed by an EEG. The EEG solved the mystery, since it showed an EEG's pattern identified by a frequent diffuse paroxysmal/epileptiform anomalies that we decided to treat with Valproic Acid, following the instructions of our Neurologist.
After this therapy, the patient's EEG and state of vigilance improved rather quickly, and she was than classifiable as Verbal in the AVPU scale.
She was discharged with indication to continue antiepileptogenic therapy and in stable clinical conditions.
This case report's highlight is to show the difficulty that us, Emergency Medicine Doctors, may have in carryng out our assessments regarding the cognitive state of patients with a poor social network behind them.
Very often, in Italy, the emergency departments are full of patients who live alone on the margins of the society and for that reason, a proper diagnosis may be delayed due to the lack of informations concerning the patient and his possible state of consciousness's variations.
Ennio LICHERI (MODENA, Italy), Federica GRANDI, Giuseppe IARIA, Riccardo ROGANTI, Marcello VEZZANI, Silvia VINCENZI, Francesca BRITTANICO, Luca RONCUCCI, Lucio BRUGIONI
00:00 - 00:00
#42361 - Can we get more benefit from Triage process? – a pilot study.
Can we get more benefit from Triage process? – a pilot study.
INTRODUCTION
Triage is essential step in Emergency Medicine, aimed to undertake first clinical assessment of vital parameters and symptoms at admittance in order to identify unstable or potential critical conditions and prioritize further examination and treatment. Triage is both, process performed by nurses and tool used to assess patients condition in short time. There are established many Triage systems internationally, aimed to prioritise severely ill patients, while there is presence of well recognised issues such as crowding and limited available resources. There are also Triage-related challenges such as high patient flow, workoverload for nurses, waiting time for patients. The aim of this study is to find beneficial way to release Triage-related work-overload for nurses and to reduce waiting time for less severe patients, with approach based on subjective beliefs and assumptions of nurses.
METHODS
Study is designed as prospective sample survey in Emergency Department at Regional Hospital Goedstrup between February - May 2024. 9 nurses were invited and 37 stable patients were selected. The patients underwent routinely used five-level triage system DEPT v.2.1, followed by application of conceptual Axigram web-app. Axigram is technological solution which facilitates documentation related to nurse's triage and enables patient-involvement for symptom screening and instant documentation of symptom development and their combination, prior to patient-emergency physician contact. Process is designed to reduce consumption of costly healthcare resources, however during pilot study it was unavoidable to carry double documentation, for study purpose.
At completion of triage, nurses were asked to answer closed questions whether it makes sense to record triage-related data through tablet-PC and Axigram; nurse's subjective assumption in regards to time consumption and possibility to reduce documentation related workload; subjective feeling about individual overload and belief about general overload at department.
RESULTS
Our previous studies between 2015-2020 revealed that patient activation, when it is clinically and ethically acceptable, makes sense for patient. However, healthcare staff, such as nurses not always were enough self-motivated to apply technology, despite of positive effect.
Our interest was directed at triage-nurses subjectivity and potential implementation obstacles. In all 37 cases it was answered that it makes sense to conduct triage applying Axigram-tablet-PC based method, and it varies between 'somewhat'(45%), 'highly'(37%) and 'very highly'(18%). In 30(81%) cases it would be 'somewhat'(45%), 'highly'(27%) or 'very highly'(8%) preferable to document triage using Axigram tool, and in 34(91%) cases it would reduce the workload 'somewhat'(56%), 'highly'(27%) or 'very highly'(8%).
Analysis of subjective belief of individual and common overload demonstrates that in all(100%) cases it was subjectively not busy period neither for nurse's own or assumption about departmental work-overload.
CONCLUSION
Results suggest, when nurses feel less work-overload, it correlates with increased frequency of new technology application, and in most cases, triage with tablet-PC-based Axigram technology application makes sense for nurses.
Thus, focus on work-overload reduction for nurses and activation of stable and capable patients at waiting area through technology, such as Axigram, with integration of both records can be beneficial approach to get more valuable result of Triage process, prior to patient-physician contact.
Central Region Denmark granted support to the study.
Nodirbek Husainov, is IT-expert and developer of the Axigram web-app solution.
Malik Kalmriz, as Emergency physician has contributed to development of Axigram-technology.
Malik KALMRIZ (Horsens, Denmark), Hanne CRAMON, Inger Tranberg THOMSEN, Martin Dons BOYSEN, Ingrid Buch HUNDEHVAD, Louise KALLESØE, Dan Nygaard PEDERSEN, Nodirbek HUSAINOV
00:00 - 00:00
#41213 - Can we Increase Efficiency in Head Injury Imaging? A Quality Improvement Project.
Can we Increase Efficiency in Head Injury Imaging? A Quality Improvement Project.
Introduction
Southend University Hospital in the United Kingdom is a busy district general hospital serving a population of about 330,000. To improve patient flow in the Emergency department (ED), we introduced a new proforma as an intervention so as to enable automatic vetting of computed tomography (CT) head scans for patients presenting with head injury and who fit the NICE criteria for imaging.
Methods
Pre-intervention, an ED clinician needed to verbally discuss the case with an on-call radiologists who would vet all computed tomography (CT) scans.
Postintervention, patients meeting NICE criteria had a proforma filled and scans were automatically performed and then reported by the Radiologist.
We audited the patient arrival times, scan times and report release times retrospectively for consecutive patients in May 2020, 2021 and 2022 and analysed the results.
Results
We processed data from 68 patients with head injury who had CT imaging performed in 2020 (pre-intervention), 30 in 2021 and 138 in 2022.
The mean times from a patient’s arrival to CT being done were noted to have increased. While mean times from arrival to report being available were also noted to have increased. The increase in time was statistically significant for CT performance.
Discussion
The proforma made access to CT easier as the time ED clinicians spent to have a CT approved was decreased with the new proforma’s introduction. However, there was an increase in the number of scans and a notable delay between the time of arrival of the patient and the scan/report. There were multiple confounders – an immediate one being (technical) availability of porters to transport patients to and from the scanners.
Conclusions
Study demonstrated its possible to improve ease in access to CT scanning for ED doctors when attending to patients with head injury however technical local confounders may impact patient journey times within a busy department.
Joel AKWENUKE, Michael ACIDRI (Southend on Sea, United Kingdom), Dalip KUMAR, Claire WILLIS, Sobethan NANTHAKUMAR, Olufajo OLUWANDE, Ionut NEGREA, Mohammad NOFAL
00:00 - 00:00
#42136 - Cannabidiol (CBD) oil poisoning - case report.
Cannabidiol (CBD) oil poisoning - case report.
The case of a 51-year-old man, for whom his wife calls 112 due to difficulty breathing, impaired consciousness and inability to speak, is presented.
Arriving at the apartment, we found a pale man lying on the bed, breathing shallowly on his own, responding to a painful stimulus by opening his eyes. Vital parameters were as follows: RR 12/min, BP 95/65, HR 48/min, oxygen saturation 87%, blood glucose 7.4, Tax 36.5C. During the physical examination, it can be seen that this is a man with a normal osteomuscular structure, who is somnolent, dysarthric, and the pupils are mydriatic. The ECG showed sinus bradycardia with a frequency of 48/min.
Heteroanamnestically, it is learned from the patient's wife that that day he bought CBD oil in a syringe, he doesn't know from whom, and that he put a little more than the recommended amount, he doesn't know how much. He has never been sick or used any addictive substances until now. At the same time, the patient points his finger to his mouth, tries to establish verbal contact, but fails. Now he opens his eyes on his own.
The patient was placed on oxygen at a flow rate of 2L/min via a nasal catheter, a venous line was established and fluid replacement was prescribed, and metoclopramide was prescribed due to the nausea he was reporting.
During transport to the hospital, the patient's condition worsens, he is again somnolent and now vomiting.
Upon arrival at the hospital and diagnostics being done, respiratory acidosis was detected, while the urine toxicology test was negative for cannabis.
During several days, the patient was treated with supportive measures, and was discharged from the hospital in good physical condition. During his stay in the hospital, he was provided with appropriate psychological help.
The presented case shows us the importance of considering cannabidiol oil poisoning in otherwise healthy individuals, considering its exceptional availability on the market both among adults and among children. The concise history taking and questioning about any kind of drugs is extremely important even in individuals with no history of substance abuse. The described toxicity is a characteristic example of cannabidiol overdose.
Branimira ZUJIĆ (Zagreb, Croatia), Iva ZADRO
00:00 - 00:00
#41373 - Cannabis hyperemesis syndrome and gastrointestinal beriberi in a chronic cannabis user: a case report.
Cannabis hyperemesis syndrome and gastrointestinal beriberi in a chronic cannabis user: a case report.
Cannabis hyperemesis syndrome (CHS) is a syndrome of cyclic vomiting related to chronic cannabis use. Due to The difficulty of diagnosis and treatment of this syndrome, lots of resources are used to rule out other diseases. Currently the exact mechanism of cannabinoid hyperemesis syndrome is still unclear. Gastrointestinal (GI) beriberi has been reported in chronic cannabis users who present with nausea, vomiting, epigastric pain and lactic acidosis. All these symptoms rapidly improve after thiamine administration. Thiamine deficiency produces lactic acidosis by disrupting pyruvate metabolism.
Here, we reported a case of cannabis hyperemesis syndrome and GI beriberi in a chronic cannabis user. His lactic acidosis was supposed to be fro. thiamine deficiency and gastrointestinal beriberi.
A 22 year-old Thai male, presented to emergency department with abdominal pain, nausea, and vomiting up to 20 times for 6 hours. He had history of chronic cannabis use more than 2 years. The extensive investigation including laboratory studies and imaging studies were done. The initial laboratory results showed wide gap metabolic acidosis with high lactate level. His initial arterial blood gas showed pH 7.37, partial pressure of oxygen of110 mmHg, partial pressure of carbon dioxide of 38 mmHg, oxygen saturation of 99% and lactate level of 4.5 mmol/L. He was treated by antiemetic agents (ondansetron and metoclopramide). The other treatments including hot water hydrotherapy, topical capsaicin cream, intravenous haloperidol, benzodiazepines were administered and his symptoms improved after these treatments. He was also treated witn intravenous thiamine 500 mg every 8 hurs according to the diagnosis of GI beriberi. After treatment by thiamine for 3 days, his symptoms improved and resolved. He did not have nausea, vomiting or abdominal pain. His lactate level decreased to 1.2 mmol/L. The GI symptoms in our patient responded dramatically to intravenous thiamine treatment. He was admitted for 3 days and finally discharged from the hospital.
Therefore, in case of GI symptoms (nausea, vomiting and abdominal pain) are refractory to the usual aggessive therapies of CHS, gastrointestinal beriberi should be suspected and treated. Our case report supports that chronic cannabis users are susceptible for GI beriberi.
Phantakan TANSUWANNARAT (Bangkok, Thailand), Suraphong PHONGSAWAD, Chanudda NGRAMPHAIBOOLSOMBAT
00:00 - 00:00
#42328 - Capecitabine-Associated Lipemic Pancreatitis: A Case Report.
Capecitabine-Associated Lipemic Pancreatitis: A Case Report.
Introduction:
Capecitabine, an antineoplastic agent, is predominantly utilized for treating gastrointestinal malignancies. This prodrug is metabolized into 5-fluorouracil. Although adverse events are infrequent, they can encompass severe conditions such as pancreatitis. This report details a case wherein a patient developed pancreatitis subsequent to the administration of capecitabine.
Case Presentation:
A 54-year-old female with a history of rectal cancer, currently under follow-up post-colostomy, presented with abdominal pain to the emergency department. She was on her fifth course of capecitabine. She reported persistent abdominal pain for ten days, localized to the upper left and middle quadrants and radiating posteriorly, without associated nausea, vomiting, fever, or diarrhea. Physical examination revealed periumbilical tenderness on palpation; however, neither guarding nor rebound tenderness was present. Laboratory investigations showed normal hepatic function and lipase levels, with slightly elevated C-reactive protein and leukocytosis but no other abnormalities. Abdominal ultrasonography was unremarkable. Given ongoing pain, a computed tomography (CT) scan of the abdomen was performed, confirming acute pancreatitis. Subsequent testing revealed normal control lipase levels. Elevated triglycerides at 2078 mg/dL led to a diagnosis of lipemic pancreatitis.
Conclusion:
Capecitabine, a prodrug of cytotoxic agent 5-fluorouracil, occasionally induces severe gastrointestinal symptoms, including abdominal pain, diarrhea, and pancreatitis, although the latter is infrequent. Case reports typically describe mild to moderate severity (1) . In our case, despite normal lipase levels, radiological findings were indicative of pancreatitis. The absence of typical etiological factors such as gallstones, alcohol misuse, or hypercalcemia was noted. The patient's high triglyceride levels were considered a potential cause of pancreatitis, a side effect possibly exacerbated by capecitabine, which has been reported to induce hyperlipidemia (2) Hypertriglyceridemia is an infrequent adverse effect associated with capecitabine therapy. According to the National Cancer Institute Common Toxicity Criteria, grade 3 or 4 hypertriglyceridemia occurs rarely, affecting between 0.1% and 1% of patients. The exact mechanism underlying chemotherapy-induced hypertriglyceridemia (CI-HTG) remains unclear, but it is suspected to involve a capecitabine-related decrease in the activities of lipoprotein lipase and hepatic triglyceride lipase. Severe hypertriglyceridemia, with triglyceride concentrations greater than 1000 mg/dL, can precipitate acute pancreatitis and contribute to cardiovascular pathologies such as coronary artery disease (3). Additionally, it should be noted that prior to the initiation of capecitabine therapy, the patient's triglyceride levels were measured at 1040 mg/dL six months earlier, without any clinical manifestations of acute pancreatitis.
Thus, it is crucial to consider acute pancreatitis in the differential diagnosis in patients receiving chemotherapy with capecitabine, even when lipase levels remain within normal limits.
References:
1. Yucel H, Warmerdam LV. Capecitabine-induced pancreatitis. J Oncol Pharm Pract. 2010 Jun;16(2):133-4. doi: 10.1177/1078155209344650. Epub 2009 Aug 21. PMID: 19700478.
2. Han GH, Huang JX. Hypertriglyceridemia and hyperglycemia induced by capecitabine: a report of two cases and review of the literature. J Oncol Pharm Pract. 2015 Oct;21(5):380-3. doi: 10.1177/1078155214532508. Epub 2014 Apr 29. PMID: 24781450.
3.Giacomuzzi Moore B, Durigova A, Lamine F, Chtioui H, Salati E. 5-Fluorouracil-associated severe hypertriglyceridaemia with positive rechallenge. BMJ Case Rep. 2023 Dec 19;16(12):e254871. doi: 10.1136/bcr-2023-254871. PMID: 38114295; PMCID: PMC10749153.
Dr Sadiye MIDIK (İZMİR, Turkey), Ozge CAN, Murat ERSEL
00:00 - 00:00
#42254 - Carbon monoxide poisoning : systemic manifestations and complications.
Carbon monoxide poisoning : systemic manifestations and complications.
Background:
Carbon monoxide poisoning (CMP) is the leading cause of death from accidental poisoning. The diagnosis is sometimes difficult due to its insidious characteristics and the polymorphism of clinical symptoms.
The aim of our study was to determine the epidemiological, clinical features and outcome of patients with CMP in an emergency department (ED).
Methods:
A prospective observational, monocentric study was conducted over 8 years [January 2016- March 2024]. Inclusion of patients aged over 18 years, admitted to the ED with the diagnosis of CMP. The diagnosis of CMP was based on the anamnestic context, clinical signs and carboxyhemoglobin >5%. We collected demographic, clinical, therapeutic, and outcome characteristics. The follow-up after one month was done by the psychologist.
Results:
We collected 1465 patients. The average age was 37+/- 15 years. Gender ratio=0.3. The most frequent comorbidities were (%): high blood pressure (9) and diabetes (7). The sources of exposure (%): brazier (48), gas water heater (41), gas heater (10). The median exposure time was 60 minutes and the median consultation time was 60 minutes. The poisoning was collective in 59% of cases. The symptomatology was dominated by neurological signs (81%) (%): headache (77), dizziness (56), initial loss of consciousness (16) and seizure (4). The average respiratory rate was 21 +/- 5 and pulse oxygen saturation was 98 +/- 2%. Mean systolic blood pressure was 107 +/-41 mmhg. The average Glasgow Coma Scale was 15. Hyperreflexia was found in 23% of cases. The average of carboxyhemoglobin value was 21 +/-10 mmol/L. The mean value of blood lactate was 2.3+/-1.7. All patients had benefited from normobaric oxygen therapy and 17% from hyperbaric oxygen therapy. The length of stay was 6+/-5 hours. The evolution at one month was marked by the occurrence of delayed neurological symptoms in 8% of cases (%): chronic headaches (26), anxiety (16), palpitations (11), memory problems (11), chest pain (8), difficulty integrating into the family or work environment (8).
Conclusion:
Complications are frequent after carbon monoxide poisoning. Indeed, it may cause considerable long term brain injury and neurological sequelae.
Raja FADHEL (Ain Zaghouan, Tunisia), Anas NACEJ, Firas CHABAANE, Hakim ATTIA, Yosra MEJDOUB, Rihab DAOUED, Hela BEN TURKIA, Sami SOUISSI, Ines CHERMITI
00:00 - 00:00
#41336 - Cardiac sarcoma masquerading as tuberculous pericarditis: a case of recurrent pericardial effusion with complex diagnostic challenges.
Cardiac sarcoma masquerading as tuberculous pericarditis: a case of recurrent pericardial effusion with complex diagnostic challenges.
Brief Clinical History:
A 48-year-old female presented with a complex clinical picture of recurrent chest discomfort and dyspnea, culminating in hypotension and tachycardia. Initial investigations revealed pericardial effusion, prompting drainage with transient relief. However, rapid symptom recurrence led to reevaluation, uncovering bilateral pleural effusions and laboratory abnormalities. Emergency pericardial drainage revealed hemorrhagic effusion, further complicating the diagnostic puzzle.
Misleading Elements:
The pericardial effusion analysis revealed a hemorrhagic exudate with a significant increase in nucleated cells, predominantly exhibiting monocytic predominance, and a partial response to anti-inflammatory agents initially misled the medical team towards infectious etiologies, particularly tuberculosis and viral pericarditis. These misleading elements diverted attention from a neoplastic etiology, delaying the definitive diagnosis.
Helpful Details:
Advanced imaging modalities, notably enhanced CT and PET-CT, played a pivotal role in raising suspicion of an intracardiac malignancy. Key clues such as the nature of the pericardial effusion (hemorrhagic) and rapid reaccumulation were instrumental in directing further investigation towards a neoplastic etiology.
Differential and Actual Diagnosis:
The diagnostic journey encompassed considerations of cardiac myxoma, intracardiac thrombus, and inflammatory or infectious processes. However, surgical exploration and histopathological analysis unveiled a primary cardiac sarcoma with metastases to the lungs, dispelling initial suspicions of infectious pericarditis.
Educational and/or Clinical Relevance:
This case underscores the imperative for a systematic approach to diagnosing patients with pericardial effusions in emergency settings, where atypical presentations can obscure sinister underlying pathologies. It accentuates the necessity for multidisciplinary collaboration and aggressive diagnostic strategies, including tissue biopsy, to achieve definitive diagnoses. Furthermore, it highlights the rare but critical consideration of cardiac tumors in the differential diagnosis of pericardial effusions, emphasizing the importance of vigilance and thorough investigation in challenging clinical scenarios. This case offers invaluable insights for emergency medicine practitioners, reinforcing the need for astute clinical acumen and comprehensive diagnostic strategies in managing complex cardiovascular presentations.
Yuxin DONG (China, China), Fang CHEN, Songtao SHOU
00:00 - 00:00
#41479 - Cardio version for the treatment of generalized tonic-clonic seizures.
Cardio version for the treatment of generalized tonic-clonic seizures.
Introduction:
Generalized tonic-clonic seizures can be triggered by brain hypoperfusion. Moreover, cases of generalized tonic-clonic seizures have also been described in cardiac arrest (CA) patients. Therefore, European Resuscitation Council latest guidelines underline the importance of CA confirmation (or exclusion) in patients with seizures. This is a case report of a patient who suffered generalized tonic-clonic seizures immediately after occurrence of atrial fibrillation with rapid ventricular response.
Case Description:
A 63yrs old male patient with BMI: 35 had been scheduled for triple coronary artery bypass grafting in extracorporeal circulation due to coronary disease. Preoperative echocardiographic findings included preserved ejection fraction (EF: 65%), enlarged left ventricle and diastolic dysfunction. Carotid triplex revealed several areas with stenosis, which however did not cause any hemodynamic disturbances.
After uneventful surgery patient was transferred to the Cardiothoracic Unit (CTU), where he was extubated at the same day. He remained there due to need of inotropic support. On the third postoperative day inotropic support was discontinued, patient was haemodynamically stable and it was decided to discharge him from CTU to the ward. Yet, just before transfer, patient suffered an episode of generalized tonic-clonic seizures. Immediately an order was given to administer diazepam to the patient. However, before diazepam administration, occurrence of atrial fibrillation with rapid ventricular response was screen detected accompanied by a severe drop on blood pressure. At this moment a synchronized shock of 270J was delivered. Synchronized cardio version was effective in establishing sinus rhythm and moreover blood pressure increased and seizures stopped. Thereafter, intravenous infusion of amiodarone was initiated.
Conclusion:
Under normal circumstances in healthy patients, contribution of atrial systole to cardiac output is approximately 15-20%. In pathological conditions this contribution is significantly higher and sinus node dysfunction results in hemodynamic collapse. According to guidelines, treatment of tachycardia in haemodynamically unstable patients is immediate synchronized cardio version. Furthermore, seizures management involves exclusion of CA before drug administration. In our case, successful recognition of the factor causing the seizures lead to safe and efficient treatment.
Varvara (Barbara) FYNTANIDOU (Thessaloniki, Greece), Ekaterini APOSTOLOPOULOU, Sofia-Chrysovalanto ZAGALIOTI, Sofia GKARMIRI, Konstantinos FORTOUNIS, Marianthi PERTSIKAPA, Adamantia NANO, Vasileios GROSOMANIDIS
00:00 - 00:00
#41228 - Cardiogenic Shock Team activation at the Emergency Department: a pilot study.
Cardiogenic Shock Team activation at the Emergency Department: a pilot study.
Background Observational studies have shown that the management of patients with cardiogenic shock (CS) by dedicated multidisciplinary teams improves clinical outcomes. Nevertheless, these studies reflect a specific organizational setting with most patients being transferred from referring hospitals, hospitalized in cardiac intensive care units or treated with mechanical circulatory support devices.
The purpose of this study was to document the experience of CS team activation in the Emergency Department (ED), offering holistic acute care management in an unselected population presented to the ED with CS.
Methods The study included the development of a dedicated multidisciplinary CS Team in a large academic tertiary institution. The role of the team was the rapid diagnosis and identification of the specific CS phenotypes, as well as the timely management through recommendation and facilitation of definitive interventions. The team consisted of emergency physicians, critical care cardiologists, interventional cardiologists, cardiac surgeons, intensivists and heart failure specialists. Team activation was performed physically or/and through an online, real-time communication platform, directly by the emergency physician. It was a cohort, prospective registry of consecutive CS patients and we present the results of the first year experience (January 2023 to December 2023). The diagnosis of CS was based on simple clinical criteria according to international guidelines and SCAI Shock stage classification was used for the evaluation of shock severity and risk stratification.
Results Seventy (70) patients with CS and a mean age of 69±13 years old (67% males) were included. 50% of the patients were classified as stage C, while 28% were in advanced shock (i.e., stages D and E), according to SCAI Shock stage classification. Acute Myocardial Infarction (AMI-CS) was the most common cause (64%); 31% of the patients presented as post-resuscitated cardiac arrest and 56% required invasive mechanical ventilation. The main CS cause was STEMI (47%), followed by NSTEMI (13%) and decompensated chronic heart failure (10%). Coronary angiography was performed in 70% and 53% underwent percutaneous coronary intervention. Mechanical circulatory support was applied in 10% and 6% were referred for urgent cardiac surgery. The in-hospital mortality was 40%. Of the non-survivors, 40% died within 24 hours of presentation. The 76% of the survivors were discharged at home.
Conclusions We described the first experience of a CS team at a national level. Our study is representative of the characteristics of unselected patients developing CS at a population level. In our institution, the ED physicians act as the first link in the chain of the shock team. The ED team apart from early identification and initial stabilization, activates the CS team facilitating prompt classification at the appropriate level of care.
This study signifies the unmet need for a timely approach, focused on early diagnosis and holistic management, provided by a multidisciplinary team. It could be used to define local needs and guide national health policy interventions.
It was an observational, non-interventional study, trial registration was not needed. This study did not receive any specific funding.
Grigoris KARAMASIS, Effie POLYZOGOPOULOU (ATHENS, Greece), Charalampos VARLAMOS, Antonios BOULTADAKIS, Vasiliki BISTOLA, Dimitrios ANGOURAS, Iraklis TSANGARIS, John PARISSIS, Gerasimos FILIPPATOS
00:00 - 00:00
#41811 - Cardiovascular effects in benzodiazepine overdose patients.
Cardiovascular effects in benzodiazepine overdose patients.
Introduction: Benzodiazepines (BZDs) are sedative-hypnotic drugs, and they activate the GABAA receptor in the CNS. Without co-ingestion it is well known that BZDs cause only mild CNS depression without airway or cardiopulmonary compromise except in extreme overdose. There are benzodiazepine binding sites outside the nervous system such as Tryptophan-Rich Sensory Protein (TSPO). TSPO produces neurosteroids that affect cardiac GABAA activity. In addition lorazepam has been found to interact with GPR68 which couples with Gs protein, then it causes accumulation of cAMP which later stimulates the calcium channels and causes vasoconstriction. Diazepam has been also reported to inhibit phosphodiesterase-4. From time to time, we have observed our patients had bradycardia or hypertension during the Emergency Department observation for their recovery. We did some research and found that most literature and textbooks hardly provide clinical details on cardiovascular effects from acute BZD overdose.
Objectives: This study aimed to investigate the prevalence and clinical findings of cardiovascular effects in acute benzodiazepine overdose patients in the emergency department.
Methods: This was a retrospective descriptive study. The target population was patients with ages > 15 years old with a history of acute benzodiazepine overdose treated in the emergency department of a University Hospital in Bangkok from October 1, 2012, until September 30, 2022. Data were collected from the electronic medical records including patient demographics, type of benzodiazepines, onset of ingestion, treatment, vital signs,12-leads ECG findings and treatment outcomes. Those overdosed on other drugs in combination with BZD were excluded.
Results: A total of 86 patients were included, 40 patients (46.5% (95% CI = 35.7-57.6)) had cardiovascular (CVS) parameter abnormalities or abnormal ECGs. Abnormal cardiovascular parameters were found in 44.2% (95% CI = 33.5-55.3) of cases, and abnormal ECG were found in 10.5% (95% CI = 4.9-18.9). All patients were discharged alive from the ED with a GCS score of 15. Risk factors for abnormal cardiovascular or ECG abnormalities were ages > 45 years old and taking 41-160 mg of lorazepam equivalence.
Conclusions: This retrospective cohort study showed that CVS abnormalities in acute oral benzodiazepine overdose were common, but benign. Those who were > 45 years old and taking a very high dose (41-160 mg of lorazepam equivalence) were at risk. Those who took more than one type of benzodiazepines could be at risk for bradycardia. However, the CVS effects in BZD overdose did not cause any life-threatening outcomes, and all patients could be discharged from the Emergency Department uneventfully.
This study was funded by the Navamindradhiraj University Research Funds.
Rittirak OTHONG (Bangkok, Thailand), Sareeya PEWKLIENG, Wisarut BUNCHIT
00:00 - 00:00
#41778 - Case report : Aluminium phosphide and toxic acute myocarditis.
Case report : Aluminium phosphide and toxic acute myocarditis.
Introduction:
Aluminium phosphide (PAl) is a solid fumigant pesticide used in grain storage and protection. It is an excellent autolysis agent. Its ingestion is highly morbid, causing death within 12 to 24 hours, generally due to imminent cardiovascular toxicity. There is no effective treatment for this intoxication, and no known antidote. The prognosis is mainly linked to cardiac damage, with mortality approaching 100% in patients with severe cardiogenic shock
Clinical case :
We report the case of a young female patient, who is a 21 years old farmer, with no medical history; no cardiovascular history, and in particular no psychiatric history, who was presented to emergency ward for sudden onset respiratory distress with chest pain without irradiation, occurring following voluntary ingestion of two pills (6 grams) of aluminum sulfide as part of a first suicide attempt following family conflicts. Physical examination showed a Glasgow Coma Scale of 15, intermidiate reflective pupils, polypnea with pulsed oxygen saturation at 90%, crackling rales at both pulmonary bases. The blood pressure was 60/40, the pulse rate was 120bpm with signs of peripheral hypoperfusion; cold extremities and mottling. After putting on a 6 liter facial mask to provide oxygen therapy, she received 0.5 liters of isotonic serum with a refractary hypotension. There for Noradrenaline was started intravenously at the electric syringe (IVSE) on a central venous catheter. An EKG was immediately done showing a sinus tachycardia with a regular rhythm at 130bpm with a transitory ST segment elevation in the anterior territory.
Dobutamine was then associated with it, at a rate of 15 gamma/kg/min with the objective of an average arterial pressure of 70mmHg. Initial biological tests showed normal liver function, spontaneously low prothrombin time at 31% without exteal bleeding, normal blood count. High-sensitivity cardiac troponin was 19.000ug/L. The arterial blood gas showed metabolic acidosis with a pH of 7.34, blood pressure in dioxide of carbon (PaCO2) at 29 mmHg, a level of HCO3- at 12 mmol/L and blood pressure in oxygen (PaO2) at 97 mmHg. Arterial lactates were 12 mmol/L. Transthoracic ultrasound was performed. It showed septal hypokinesia, with a left ventricular systolic ejection fraction of 30-35%.Grade 2 mitral regurgitation, no significant aortic disease, preserved right ventricle function. The pericardium was dry. The diagnosis of acute toxic myocarditis complicated by cardiogenic shock was made and the patient was then transferred to the ICU.
Conclusion :
Toxic myocarditis secondary to intoxication PAl is a serious and almost always fatal disease in the absence of a codified therapeutic strategy in an intensive care unit. Immediate introduction of inotropic and vasoactive drugs, guided by echocardiographic monitoring and multi-daily blood volume monitoring can improve the prognosis.
Sarra SOUA, Bouhamed CHAFIAA, Imen KETATA, Chaima MANAI, Khouloud KHEMILI (Tunisia, Tunisia)
00:00 - 00:00
#41212 - Case report : pre hospital consideration during sodium nitrite poisoning.
Case report : pre hospital consideration during sodium nitrite poisoning.
Case report : Pre-Hospital consideration during sodium nitrite poisoning
Ricetti Christian MD, Motti Alessandro MD, Schiavi Marco MD, Volontè Fabio MD
Croce Verde Lugano, Cantone Ticino , Switzerland
Sodium nitrite (NaNO2) is an inorganic compound that is commonly used in industrial chemistry (pharmaceuticals, dyes and pesticides, metallurgical products, …) but it is probably best known as a food additive used in processing meats and fish products because inhibit the germination of Clostridium botulinum spores and the ingestion of foods containing an excessive amount of this substance can also cause acute intoxication up to death.
The toxic effect of nitrites lies in their oxidizing power, causing the transformation of hemoglobin into methemoglobin, which, when it accumulates, induces tissue anoxia resulting in death. There has been an alarming increase in the number of cases (1,2) linked to suicide using nitrites or a nitrite suicide kit.. Methemoglobinemia (MHb) levels of 70% are generally lethal, but the existence of underlying anemia, acidosis, respiratory compromise, and cardiac disease may exacerbate the toxicity of MHb.
Methylene blue is used to treat symptomatic patients with Methemoglobin levels greater than 20% or patients with risk factors, such as anemia or congestive heart failure.
Methylene blue (3) is the first-line antidote for severe methemoglobinemia, and the standard dose is 1 to 2 mg/kg intravenously over 5 minutes (4) ; the Methemoglobin level decreases significantly within 1 to 2 hours after a single dose.
Clinical case
A 28 year old woman personally contacted Ticino Rescue 144 after having taken Sodium Nitrate at un unspecified dosage found online for self-harm pourposes : she’s found conscious, in a state of shock inside a hotel room.
Within a few minutes she’s intubated, ventilalated in CPPV with FiO2 1.00, and catecholamine support is started with norepinephrine 0.15 γ/Kg/min: the destination Hospital in quickly informed in case of suspicion of poisoning by methemoglobinizing substances.In the ED ,Methylene blue is administered IV 1 - 2 mg/Kg approximately every 10 minutes ( Tot : 400 mg ) ( Methemoglobin 90.2%,77.4%41.9% 37.2% ) with progressive improvement of the state of shock.
The next day she’s extubated and trasferred to the Suisse Psychiatric Clinic.
Conclusion
Early prehospital contact with the Poison Control Center and ED prenotification in poisoned patients is encouraged.
Early administration of methylene blue prevented fatal outcomes.
The fact that nitrites are readily available online underscores the importance of establishing effective preventive measures such as limiting the access and use of this chemical.
References
(1) Mudan A, Repplinger D, Lebin J, Lewis J, Vohra R, Smollin C. Severe methemoglobinemia and death from intentional sodium nitrite ingestions. J Emerg Med 2020;59:e85–8.
(2) Dela Cruz M, Glick J, Merker SH, Vearrier D. Survival after severe methemoglobinemia secondary to sodium nitrate ingestion. Toxicol Commun 2018;2:21–3
(3) Wright RO, Lewander WJ, Woolf AD. Methemoglobinemia: etiology, pharmacology, and clinical management. Ann Emerg Med 1999;34:646–56.
(4) McGraw-Hill Education, Nelson LS, Howland MA, Lewin NA. Goldfrank's Toxicologic Emergencies. 11th ed2019
Christian RICETTI, Marco SCHIAVI, Volontè FABIO, Alessandro MOTTI (Pregassona, Switzerland)
00:00 - 00:00
#41513 - Case report: euglycaemic ketoacidosis in a pregnant woman with Covid-19.
Case report: euglycaemic ketoacidosis in a pregnant woman with Covid-19.
Introduction:
Covid-19 is known to be associated with ketoacidosis, although data about pregnancy-related euglycemic ketoacidosis with concomitant Covid-19 is rare.
Clinical presentation:
A 41-year old woman G4P3M3 presented at the emergency department at 30 weeks gestation with a 6-day history of shortness of breath and anorexia. She had no significant medical background and no personal history of diabetes. On admission she was unwell, tachycardic en tachypnoeic with a respiratory rate of 35bpm, saturation 94% on 2L via non-rebreather. Initial arterial blood gas illustrated a raised anion gap metabolic acidosis: pH 7.28, pCO2 16.9mmHg, HCO3 8.1mmol/l, base excess 17.4mmol/l, lactate 0.8mmol/l. Urinary ketons measered 4+. CRP was 45mg/l and Covid-PCR was positive. Urinary infection was excluded. Mild proteinuria in combination with the absence of elevation of her blood pressure compared with outpatient values could not justify the diagnosis of preeclampsia. Gestational diabetes was excluded through non-fasting Oral Glucose Tolerance Test. Fetal movement and fetal heart rate were normal. She was diagnosed with ketoacidosis and initially received fluid resuscitation with electrolyte replacement followed by intravenous 10% dextrose with intravenous insulin infusion. Prophylactic dose low molecular weight heparin was administered daily throughout admission. After 3 days the patient could leave the ICU.
Literature key-points:
Euglycaemic ketoacidosis is characterised by increased anion gap metabolic acidosis, ketosis and normoglycemia. Covid-19 infection disrupts metabolic control through reduced insulin production, whereas pregnancy increases insulin resistance, enhances lipolysis and increases ketogenesis. Starvation stimulates breakdown of fatty acids which also leads to ketosis.
The primary goals of treatment are fluid resuscitation, insulin administration with consideration of dextrose addition and electrolyte correction. Nitroprusside-testing for ketons detects acetate and acetoacetate but not the predominant β-hydroxybutyrate. Therefore it is possible for the testing to be negative although the patient has elevated ketons. During treatment it is not useful to measure ketons because they will raise initially because of conversion of β-hydroxybutyrate to acetoacetate. As such it is recommended to test ketons only at presentation.
Conclusion:
Pregnant women with shortness of breath should always raise suspicion for ketoacidosis, even when they turn out to be Covid-positive, euglycemic and ketons on urine-analysis are normal.
Emilie DERDEYN (Antwerp, Belgium), Stéphane DEMAN
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#41779 - Case Report: Purpura Fulminans.
Case Report: Purpura Fulminans.
Introduction:
Purpura fulminans is a medical emergency characterized by intravascular coagulation
Acute disseminated and skin necrosis, often associated with serious bacterial infections.
It is a rare and serious condition, which requires rapid recognition and treatment to improve the chances of survival and reduce complications. It is often associated with infections by bacteria such as Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae.
This report describes the case of a patient who presented with this rare condition, clinical interventions carried out and the results obtained.
Case Presentation
25-year-old patient with no notable pathological history brought by a type B ambulance for a sudden change in neurological status in a febrile context
On examination confused agitated patient febrile at 39.4, BP=8/4, tachycard at 124bpm polypneic SpO2=99% on ambient air with presence of rapidly extensive purpuric lesions cutaneous and mucous membranes, and conjuctival hemorrhages GAD 1.12g on assessment presence of thrombocytopenia at 14,000
The patient immediately received antibiotic therapy: claforan 300mg/kg with physiological saline filling 30cc/kg/20 min
Faced with agitation and altered state of consciousness associated with hemodynamic instability, the patient was intubated, ventilated in VAC mode, sedated by hypnovel, fentanyl and placed on NAD 2 mg/h initially by increasing the speed given the non-improvement of the hemodynamic state. But the patient presented a cardiorespiratory arrest complicating the state of refractory shock. He was resuscitated but not recovered.
Discussion
Purpura fulminans was first described by Guelliot in the 19th century. Since then, it has been classified into neonatal purpura fulminans, idiopathic purpura fulminans, and acute infectious purpura fulminans. Our patient had acute infectious purpura fulminans, which is the most common form of the disease. Clinical features of this condition include fever, hypotension, and purpura in the setting of disseminated intravascular coagulation.
Although classically occurring in meningococcal infection, S. pneumoniae infection with purpura fulminans has also been described in the literature. Severe acquired protein C deficiency due to infection has been shown to contribute significantly to the development of this condition.
Patients with severe bacterial infection and purpura fulminans should be managed in an intensive care unit, with aggressive fluid resuscitation, inotropic support if necessary, and early administration of appropriate antibiotics. Other adjunct treatments such as protein C replacement therapy may play a role in the management of this disease. Unfortunately, this treatment option is not widely available; In our hospital setting, we only practice the use of fresh frozen plasma transfusion to correct the coagulopathy associated with this condition due to resource limitations.
Our patient was initially treated for purpura fulminans, which was presumed to be due to meningococcal septicaemia. It is important to determine the causative organism early in patients with purpura fulminans, as this would help the treating physician decide on the subsequent choice of antibiotic. Additionally, close contacts of a patient with meningococcal septicaemia would also benefit from antibiotic prophylaxis.
Conclusion :
Purpura fulminans is a critical condition requiring rapid and coordinated intervention. This case highlights the importance of clinical vigilance and a multidisciplinary approach in taking caring for such patients.
Imen KETATA, Bouhamed CHAFIAA, Khouloud KHEMILI (Tunisia, Tunisia), Sarra SOUA, Chaima MANAI
00:00 - 00:00
#41780 - Case Report: Rabies Encephalopathy.
Case Report: Rabies Encephalopathy.
Introduction:
Rabies is a viral zoonosis that affects the central nervous system. Prevention is vaccination. Rabies encephalopathy is a rare but serious condition. It is fatal in almost 100% of cases. Treatment is purely symptomatic.
Our work falls within this framework, which describes the case of a patient admitted to our emergency room for rabies enenphalopathy.
Case Presentation :
This is a 35-year-old patient without notable pathology who consulted for sudden onset of altered neurological status with extreme agitation associated with hydrophobia. Notion of bite by a dog for 3 months. He did not receive any serotherapy or anti-rabies vaccine.
On admission, the patient was agitated and confused with temporospatial disorientation, no sensory-motor deficit. The patient was hemodynamically stable with BP 131/72, pulse: 75bpm, no peripheral signs of shock. On the respiratory level: Respiratory rate was at 22 cpm, SpO2 at 86% in ambient air.
Temperature =37.9; GAD 1.25. The biology was without anomalies.
We completed a brain scan and a toxicological assessment which were normal.
At lumbar puncture: white elements were 4/mm3; red elements 50/mm3; a glucose/glucose ratio of 0.6.
For our patient, the diagnosis of rabies encephalopathy was confirmed by bacteriological examination of CSF
Faced with the double neurological and respiratory distress: the agitation and the alteration of the state of consciousness of the patient with a SpO2 86% at the AA, the patient intubated, immediately ventilated under the VAC mode with sedation by hypnovel , fentanyl.
Given the absence of specific treatment, the patient was confined for 3 days but without improvement he presented cardiorespiratory arrest on day 3 of treatment. Resuscitated for 30 minutes but without recovery.
Discussion:
The rabies virus (genus Lyssavirus) is present in the saliva of infected animals (dogs, cats, wild mammals, etc.). Transmission occurs by direct contact with the saliva of an animal contaminated by bite, scratch or even licking on the excoriated skin of a mucous membrane. Human-to-human contamination is exceptional.
This virus is neurotropic. After an incubation period of a few days to a few months, the affected patient develops a picture of encephalitis. Hydrophobia can sometimes be observed. The outcome is always fatal when the disease is declared. Survival after proven rabies infections is exceptional, most often associated with serious after-effects and no curative treatment has been identified to date.
Our patient was treated symptomatically. In the absence of specific treatment, prophylaxis remains the only solution to prevent rabies encephalopathy. Post-exposure prophylaxis itself includes vaccination, accompanied by the administration of an anti-rabies serum for the most severe exposures. Treatment must be carried out quickly after exposure, before the appearance of the first symptoms which indicate a fatal outcome.
Conclusion :
Rabies encephalopathy is a critical condition requiring rapid and coordinated intervention.
Its treatment is purely symptomatic. This case highlights the importance of prophylaxis through vaccination of domestic animals as well as post-exposure prophylaxis through vaccination associated with anti-rabies immunoglobulin to prevent the fatal progression of this disease.
Imen KETATA, Sarra SOUA, Bouhamed CHAFIAA, Khouloud KHEMILI (Tunisia, Tunisia), Chaima MANAI
00:00 - 00:00
#40904 - Case Report: The Use of Andexanet Alpha in the Reversal of Rivaroxaban in Gastrointestinal Hemorrhage.
Case Report: The Use of Andexanet Alpha in the Reversal of Rivaroxaban in Gastrointestinal Hemorrhage.
Background:
In the prevention of thromboembolism due to atrial fibrillation, direct oral anticoagulant agents (DOACs) have been identified as having a good safety profile and very effecient. In fact, the European Society of Cardiology (ESC) guidelines recommend DOACs over vitamin K antagonists (VKAs) for stroke prevention1. However, these agents may cause gastro intestinal bleeding. In cases of life threatening bleeding anticoagulant reversal should be considered. Andexanet alpha has been the first approved antidote for direct factor Xa inhibitors when urgent reversal of anticoagulation is required2,3. It is a recombinant modified version of human activated factor X (FXa) which works by binding to rivaroxaban and apixaban.
Case:
A 64-year-old woman presented to the emergency department with a two-week history of recurrent lower gastrointestinal bleeding. There was an unusual increase in the amount of bleeding on the day of presentation. Her past medical history included atrial fibrillation for which she was taking rivaroxaban. She was found to have laboratory results that showed significant anemia, elevated lactate levels, and coagulopathy on admission.
Management:
The patient received resuscitative measures, including intravenous fluids, tranexamic acid, antibiotics, and blood transfusion. Given her life-threatening gastrointestinal bleed (while on rivaroxaban), the decision was made to administer Andexanet alpha. This antidote was given in two doses: 400mg IV over 5 minutes, followed by 480mg IV over 120 minutes. Within 2 hours of treatment, her vital signs improved, and her laboratory parameters showed stabilization. The patient underwent gastroscopy and sigmoidoscopy the next day, which revealed no active bleeding. The gastroenterology consultant assessed her as medically optimized for discharge.
Discussion:
The use of Andexanet alpha in this case resulted in a favorable outcome, with the patient's bleeding being successfully controlled. Her vital signs stabilized, her hemoglobin levels improved, and the need for further blood transfusions was reduced.
The antidote played a crucial role in reversing the anticoagulant effect of rivaroxaban and managing the life-threatening gastrointestinal bleed. The effectiveness of andexanet alfa for non-gastrointestinal bleeding has not been demonstrated. This case highlights the importance of prompt and appropriate interventions to manage gastro intestinal bleeding complications associated with anticoagulant therapy.
Mahmoud SHAGABI (CAMBRIDGE, ), Michael ACIDRI, Dalip KUMAR, Ionut NEGREA
00:00 - 00:00
#42306 - Cashew-Induced Kounis Syndrome.
Cashew-Induced Kounis Syndrome.
A 72-year-old female with a background of COPD and bronchial asthma, who had a known allergy to seeds, was brought to the Emergency Department via ambulance following the ingestion of cashew cake. Shortly after consumption, she developed generalized pruritus, urticaria, dyspnea, wheezing, and lingual edema, consistent with angioedema.
Upon initial assessment by EMT, she exhibited a Glasgow Coma Scale (GCS) score of 15 points. Vital signs recorded at the scene included a heart rate of 78 beats per minute, blood pressure of 85/61 mmHg, oxygen saturation of 89% on room air, temperature of 36.2 degrees Celsius and a blood glucose level of 124 mg/dL. The initial electrocardiogram (ECG) showed Sinus Rhythm with no significant ST-T changes.
In the prehospital setting, treatment was started with parenteral corticosteroids and intravenous volume replacement, antihistamine, and intramuscular epinephrine. Serial monitoring of vital signs and continuous cardiac monitoring were conducted.
Upon initial assessment in the ED, the patient presented with a GCS score of 15, hypotensive, with a BP of 82/38 mmHg, oxygen saturation levels were recorded at 98%, she was administered oxygen via nasal cannula (FiO2=36%, Oxygen flow= 3L/min), a first generation antihistamine (Dyphenhydramine 30mg iv) and normal saline (100ml).
The medical team performed an ECG that showed ST depression in inferior leads II, III, and aVF, and lateral leads V4-V6 and ST elevation in aVR and aVL leads, prompted by the alterations in cardiac markers (Troponin I high sensitive 80 ng/L, D-dimers >5 ug/ml). Creatine phosphokinase and creatine kinase-MB were normal. The patient was administered acetylsalicylic acid (250mg po).
The second troponin measurement showed a significant elevation (Troponin I high sensitive 2453 ng/L). On reevaluation, the ECG showed the normalization of the ST segment and the subsequent monitoring of the cardiac enzymes indicated a descending trend.
She was hospitalized for monitoring her hemodynamic condition and managing any subsequent episodes. Laboratory tests, such as complete blood count, basic metabolic panel, and serial troponin tests, yielded normal results. Sequential ECGs displayed regular sinus rhythm without notable ST segment alterations. A formal transthoracic echocardiogram indicated a normal ejection fraction with no regional wall motion abnormalities. The diagnosis of Kounis syndrome, type 1 variant, was established based on transient ischemic ECG changes, which fully resolved with anaphylaxis treatment.
This case underscores the significance of promptly recognizing and appropriately managing Kounis syndrome, particularly in patients with known allergies. Kounis syndrome, though rare, can present with potentially life-threatening manifestations, such as acute coronary events triggered by allergic reactions. Furthermore, raising awareness among healthcare providers about the diverse clinical presentations of Kounis syndrome and its potential triggers is imperative for ensuring timely diagnosis and appropriate management. By highlighting the importance of vigilance and comprehensive evaluation in patients presenting with allergic reactions and associated cardiac symptoms, this case emphasizes the critical role of early recognition and intervention in optimizing patient outcomes.
Andra MIHUT (Cluj-Napoca, Romania), Oana BRANGA
00:00 - 00:00
#41492 - Cauda Equina syndrome, clinical assessment in the ED.
Cauda Equina syndrome, clinical assessment in the ED.
Suspected cauda equina compression (CEC) is an common referral to the ED. If present urgent surgical decompression is required, so there is a low threshold for ordering a diagnostic MRI. Our departmental perception was that most MRI are negative for CEC.
We aimed to understand which features in an unselected population are most sensitive. We studied 27 salient clinical features both patient reported symptoms and signs elicited.
Patients met the following criteria.
- Age >16 years
- Attending one general hospital ED in North-eastern England
- Attended within 6 months from 01/02/22 to 31/07/22
- Had an MRI lumbar spine querying CEC.
120 patients were included, 38% male and 62% female with an overall mean age of 51 years.
MRI confirmed CEC in 26% of patients and of these 11 (8% of total) underwent urgent surgery.
The features recorded in >50% of cases, with a sensitivity of >50% were.
- Sciatica of any duration whether unilateral or bilateral (sensitivity 91%)
- Bilateral sciatica of any duration (84%)
- Sciatica with duration of under 2 weeks (53%)
- Any urinary symptoms (81%)
- Any weakness in the L2 myotome (52%)
No registration number applicable
No funding was provided.
Joshua BECK (Newcastle Upon Tyne, ), Mark HARRISON
00:00 - 00:00
#41245 - CBD – not just CBD…….
CBD – not just CBD…….
The use and availability of Cannabidiol (CBD) has increased and the product are readily available in headshops to be bought all around the world. It is use by inhalation, by oral ingestion or skin application in aim to enhance the feeling well-beingness, to treat anxiety, help with the relaxation and sleep.
It is often marketed as an ecologic, even vegan product, hemp extract oil, but a recent analysis carried out by the French Agence Nationale de Sécurité du Médicament et des Produits de Santé which analysed the CBD products available on market found that only 45% of the products sold were in conformity with the ingredient declarations, and tetrahydrocannabinol (THC) was present in 21% of the products.
Case report
A 31-year-old patient in transition with PMHx of transition surgery and ongoing oestrogen supplementation, with occasional use of alcohol and recreational drugs, but denied actual use of cannabis. The evening before she had taken 50 cc (???) of a CBD containing product due to anxiety and to help her to sleep. She denied concomitant use of other recreational drugs or medicines. The next morning, she woke up anxious, and with visual and auditive hallucinations, with a sensation of deformation of objects in her visual field and an internal voice that claimed that she had cancer or stroke. On her presentation at ED her vital signs were GCS 15/15 , 36.2, BM 6.3 mmol, BP 116/67, HR 85/min, SaO2 100% on RA. She was anxious and crying, her neurological examination was normal
She was given BDZ to treat her anxiety, and blood tests with WBC, RFT, LFT and CRP came back normal, U-toxicology screen was positive for THC with THC 2.276 ng/ml, 11-hydroxy-THC 2.729 ng/ml and Δ9THC acid 65.187 ng/ml, no other drugs or NPS drugs were found in urine screen. A CT head was also done which was normal.
Her clinical condition improved after anxiolysis, and she was discharged from hospital the day after
Discussion
The CBD distilled from hemp oil or its synthetic version is considered as a ‘safe’ dietary supplement, but the purity of products on the market with correct identification of ingredients is not always up to regulations. The French study showed 55 % of inaccurate product disclaimers with the CBD concentration on products sold, and in 21% THC was present in products sold as CBD. It is important for clinicians to be aware of the ‘not so pure and vegan’ side effects of these products that are widely available on the market.
Thomas ROUDAUT, Hanna OVASKA (CRETEIL), Charlotte DE ABREAU, Mehdi KHELLAF
00:00 - 00:00
#41309 - CBRNE Medicine Training Project for Medical Staff – the Polish Experience.
CBRNE Medicine Training Project for Medical Staff – the Polish Experience.
The augmented risk of incidents involving CBRNE agents as a consequence of the war in Ukraine and possible terrorist activities requires proper preparation of Polish medical personnel to provide specialist medical care. The research conducted by the authors in 2021-2022 uncovered inadequate readiness of the Emergency Medical Services (EMS) and the Health Care System in Poland for CBRNE threats.
The urgent need to address this grave problem inspired a specialist educational programme for medical personnel, CBRNEmedicine (Real Action) Training Project, completed as part of the Strengthening CBRNE Safety and Security – Coordination and Standardization project financed by the Norwegian Financial Mechanism 2014-2021.
The agenda of each two-day workshop (dedicated to biological, chemical and radiation/nuclear agents) focused on three key areas: pre-hospital care, medical decontamination and in-hospital treatment. The CBRNEmedicine (Real Action) Training Project offered comprehensive training in emergency and disaster management, CBRNE triage and initial treatment, rapid detection and identification of CBRNE agents, the use of personal protective equipment (Level C), and providing advanced (CBRNE) life support. A vital element of these workshops involves acquiring the capacity to rapidly detect and identify CBRNe agents in direct proximity to the patient “CBRNE Point of Care Testing initiative”. Today, rapid detection and identification are unavailable within the EMS, Medical Hubs and the Health Care System (Emergency Departments, Trauma Centres).
Between 2022-2023, twenty-three specialist training workshops were run for the benefit of selected EMS and hospital personnel (EM doctors, nurses, paramedics), paramedics from a CBRNE fire brigade and the Polish armed forces. Additionally, we trained two medical teams from Kyiv (Ukraine). Medical teams participating in the simulations successfully conducted the fast bedside detection and identification of CBRNE agents procedure (incident site, decontamination cabin, ED) for triage and initial treatment, thus confirming their capacity to perform this task. The availability of easy-to-use mobile measuring devices enabled and greatly facilitated these procedures directly at the patient’s bedside.
Overall, the CBRNEmedicine (Real Action) Training Project shaped a new perception of CBRNE threats by the medical staff, set a new direction in the education of civilian medical staff and military professionals, as well as proved invaluable in the preparation of specialized CBRNE medical procedures.
The „Strengthening CBRNE safety and security – Coordination and Standardization” project financed by the Norwegian Financial Mechanism 2014-2021 (within „Internal affairs” program) aims at increasing emergency services’ capability to respond the abovementioned incidents.
Polish Internal Security Agency is the leader and beneficiary of the program. Partners of the Project are, aside the Jagiellonian University Medical College:
Polish Ministry of Health
Military University of Technology
The Main School of Fire Service
Polish Atom Agency
Department of Disaster and Emergency Medicine is active in implementing the Project.
Tasks of our Department are:
Analyzing the gaps in the way National Emergency Rescue System is prepared for CBRNE hazards.
Analyzing the CBRNE on-scene procedures for emergency services, procedures regarding trasnport and hospitalization of casualties, including triage, early diagnostics and treatment procedures.
Creating Polish conditions based procedure set of treating CBRNE patients from the accident scene all the way to specialist hospital ward.
Analyzing personal protective equipment available, creating personal protection standards and guidelines of using personal protection in various types of CBRNE incidents.
Organizing training for State EMS medical personnel in the field of CBRNE rescue action, in cooperation with National Firefighting Rescue System services and special police and military units.
Arkadiusz TRZOS, Karol ŁYZIŃSKI (Krakow, Poland)
00:00 - 00:00
#41068 - Cerebral Herniation into Nasal Cavity and Sinuses: An Unusual Cause of Seizure.
Cerebral Herniation into Nasal Cavity and Sinuses: An Unusual Cause of Seizure.
A 42-year-old male patient was brought to the Emergency Department (ED) due to witnessed generalized tonic-clonic seizures, occurring for the first time in his life, each lasting less than 1 minute. Upon review of systems, he reported subjective on-and-off fever and continuous fluid leakage through his nostrils for 3 months, exacerbated by forward bending. There was no history of trauma, headache, weakness, vision changes, neck pain, chest pain, shortness of breath, vomiting, or other gastrointestinal or urinary symptoms, and no history of alcohol or substance abuse.
On examination, his vital signs were normal, and he returned to baseline Glasgow Coma Scale (GCS) between seizures. Cranial nerves examination was normal, as was the central nervous system (CNS) motor and sensory examination. There was no facial or periorbital swelling, no neck stiffness, and ENT examination with fiberoptic revealed crust in the left nasal cavity with polyps and severe deviation of the nasal septum to the right.
Blood laboratory tests showed a white blood cell count of 18.8 x10^3/uL (84% neutrophils), with normal electrolytes and random blood sugar levels. A lumbar puncture was performed due to suspicion of meningoencephalitis, revealing clear cerebrospinal fluid (CSF) with no evidence of infection on gram stain, cell count, or cultures.
CT head findings indicated features of chronic sinusitis with sinonasal polyposis possibly complicated by a fungal infection, along with a suspected bony defect within the superior wall of the left compartment of the frontal sinus, suggestive of intracranial extension of the sinus infectious process (see Image 1). MRI head imaging revealed a large defect in the left base of the skull anteriorly, with significant herniation of the brain and surrounding CSF into the left nasal cavity, left ethmoid, and frontal sinuses, leading to the diagnosis of a large left nasal and paranasal encephalocele (see Image 2).
The patient was evaluated by the neurosurgery team, who recommended treatment for cerebritis without immediate surgical intervention. He was subsequently admitted for intravenous antibiotics, seizure precautions, and later discharged for outpatient department (OPD) follow-up with neurology and neurosurgery.
Misleading elements: CT head was not able to identify the brain herniation, and only MRI was able to.
Educational relevance: History of suspected CSF leak should raise concern about other differential diagnosis leading to seizures. Additionally, NGT insertion in such cases (was avoided here) would be possibly catastrophic in such cases.
Dr Basel ELMEGABAR (Doha, Qatar), Mostafa DAYRAKI
00:00 - 00:00
#42278 - Cerebral tuberculoma: A case report in a 30-year-old woman.
Cerebral tuberculoma: A case report in a 30-year-old woman.
Introduction:
Tuberculous encephalitis is a serious condition of the central nervous system caused by the Mycobacterium tuberculosis, responsible for tuberculosis.
Cerebral tuberculoma represent a particular form of extrapulmonary tuberculosis.
Therapeutic failure is often encountered due to diagnostic delays, primarily stemming from the extensive clinical variability, particularly owing to misleading presentations.
We report a case of cerebral tuberculoma in a young woman to highlight the diagnostic challenge it poses.
Observation:
This concerns a 30-year-old unmarried female, with antecedents of Pulmonary tuberculosis discovered 1 month ago and not yet treated , with a smoking history of 7 packs per year.
She presented to the emergency department with a four-day history of subacute holocranial headaches unrelieved by symptomatic treatment, without vomiting or nausea, no photophobia or phonophobia.
Additionally, she reported blurred vision and dizziness during examination.
On physical examination, the patient was febrile at 38°C, Glasgow Coma Scale score was 15/15, no signs of meningeal syndrome or neurological localization were observed, and no papillary edema was found on fundoscopy.
A cerebral Computed tomography (CT) scan was performed, which returned with no anomalies.
Brain MRI showed multiple nodular lesions above and below the tentorium with isosignal T1, hyposignal T2, and FLAIR, surrounded by perilesional edema, without diffusion hypersignal, enhancing ring-shaped after gadolinium injection consistent with tuberculomas, the largest being a left thalamic lesion measuring 10*10*10 mm. The ring-shaped enhancement above and below the tentorium primarily suggested cerebral tuberculosis without meningeal involvement.
Thoracic CT scan showed a miliary tuberculosis appearance with a small amount of left pleural effusion.
Conclusion:
In conclusion, cerebral tuberculoma represents a rare but significant neurological complication of tuberculosis. Its varied clinical presentation and unpredictable course pose a diagnostic and therapeutic challenge for clinicians. However, with advancements in medical imaging, microbiological diagnostic techniques, and improvements in therapeutic strategies, the management of patients with cerebral tuberculoma has significantly improved over time.
Asma JENDOUBI, Yessmine KARRAY (, Tunisia), Khairedine JEMAI, Lamis JAAFAR, Maissa TEJ, Marouen SANAI, Sarra JOUINI
00:00 - 00:00
#41985 - Cerebral venous air embolism after dental procedure, a case report.
Cerebral venous air embolism after dental procedure, a case report.
An air embolism is a potential deathly event, mostly caused iatrogenic (by surgical manipulation or vascular procedures). This case report presents a 55-year-old woman, with no medical history, that underwent a dental procedure (removing dental plaque by scaling and root blading with sandblasting, with a local anesthetic), and had an uncommon but serious side effect. During the procedure there was a sudden onset of dyspnea and shortly after the patient became unconscious with respiratory and circulatory insufficiency. ECG, chest X-ray, and bloodwork didn’t show any abnormalities. A brain CT-scan was performed which showed multiple intracerebral venous air embolisms in the plexus venosus carotis, and subcutaneous emphysema in the soft tissue of the jaw. She remained unconscious for a few hours. She gradually regained her consciousness and had anterograde amnesia for the event. Because of this quick resuscitation there was chosen not to transport the patient to a hospital with hyperbaric oxygen therapy. After a brief observation at the intensive care unit, she went home without any complaints.
The pathophysiology is not well known. The hypothesis is that with sandblasting; air is injected in the soft tissue close to vessels, and because of the high pressure it’s able to get into the bloodstream through the plexus venosus carotis. We would like to highlight this unlikely event because it’s an uncommon and not well known but potentially deadly side effect of a dental procedure. In this case there was chosen not to start hyperbaric oxygen therapy, where in former cases that have been published hyperbaric oxygen therapy was started.
Eline LAUMEN (, The Netherlands), Jorgos ALEXANDRIDIS
00:00 - 00:00
#42248 - Chalk-Stick Fracture: A Rare Case in the ED.
Chalk-Stick Fracture: A Rare Case in the ED.
A 66-year-old male patient was found on the floor after getting up in the morning. Due to loss of sensation, the patient was taken to the state hospital by ambulance, intubated, and referred to our hospital for differential diagnosis after the change of consciousness and altered mental status. The patient's vital signs were blood pressure 143/85mmHg, pulse 113/min, Spo2 %98, and fever 36 C. Glasgow coma scale was E4M5Vt. There was a motor deficit of 2/5 in both upper extremities. We performed the cranial and cervical computed tomography (CT); the cranial CT was normal. In the cervical spine scan, the C3 vertebra appeared to be dislocated posteriorly, and the facet joints at the level of the C3-4 vertebrae were bilaterally dislocated (Picture 1). The spine was similar to a bamboo spine. He had no ankylosing spondylitis in his medical history. The patient was taken into surgery, and the motor deficit did not improve.
Chalk stick fractures are vertebrae fractures. These are rare but serious complications that can occur in patients with ankylosing spondylitis (AS). They are also known as carrot stick fractures. The vertebrae are shaped like a bamboo spine at ankylosing spondylitis due to fused, ankylosed spines (1). The nature of the disease is that osteoporosis can occur, and fractures can present even minor trauma. These types of fractures are particularly devastating because they can lead to severe neurological damage, including paralysis and even death. The most common fracture site is the C5-C6 level and is often associated with the ossification of the posterior longitudinal ligament (2,3). Involvement of the cervical spine is high in ankylosing spondylitis; 75% of cases occur in the thoracic spine and 15% in the lumbar spine (4). Chalk stick fractures are highly unstable and can result in devastating neurological injuries, including spinal cord damage. Rapid diagnosis and appropriate treatment are critical (4).
Diagnosis of chalk fracture is difficult due to its rarity and the potential for plain radiographs to miss minor fractures (5). Multislice CT with three-dimensional reconstruction helps define the fracture's location, size, and severity. MRI scanning is also valuable for identifying ligament injuries, edema, and spinal cord injury (4). Treatment of chalk stick fractures is often complex and requires a multidisciplinary approach (5). The prognosis of patients with chalk stick fractures is generally poor, and there is a high risk of long-term neurological damage and even death (4,6). There is no history of ankylosing spondylitis in our case. The minor trauma caused life-threatening injury to the patient.
Özge CAN (İzmir, Turkey), Şadiye MIDIK, Sercan YALÇINLI
00:00 - 00:00
#42412 - CHALLENGES IN THE DIAGNOSIS AND MANAGEMENT OF AORTIC SYNDROME: CASE STUDY.
CHALLENGES IN THE DIAGNOSIS AND MANAGEMENT OF AORTIC SYNDROME: CASE STUDY.
Introduction
Acute aortic syndrome is a rare entity with high morbidity and mortality in which early diagnosis and treatment are essential to improve the prognosis. The typical clinical picture of this syndrome is sharp chest pain, which may present many other symptoms. It is diagnosed through various imaging tests such as echocardiogram (transthoracic or transesophageal), computed axial tomography and magnetic resonance imaging. It is a medical emergency that in most cases will require surgical treatment.
Methodology
The case of a 72-year-old man is presented, who has a history of arterial hypertension and Dusseldorf stent placement for aortic aneurysm. He attended the Emergency Department due to oppressive chest pain and abdominal distension, upon admission with neurological deterioration, hypotension, respiratory distress, delayed capillary filling with necrotic areas in the pelvic limbs and genital region; Advanced airway management, quality volume replacement and initiation of vasopressor were decided.
Results
Abdominopelvic angiotomography is performed where the growth of the abdominal aorta can be seen in the diameter before the bifurcation with a diameter of 65x67mm in a section of 115mm, lumen 31mm thick. The patient was admitted to the intensive care unit, and hemodynamics performed aortography with endovascular exclusion of paravisceral aneurysm. An endoprosthesis was placed, with no evidence of rupture or endoleaks. He died 48 hours later.
Conclusion
The mortality of aortic dissection without treatment is very high. According to most authors, more than a third of patients die in the first 24 hours, half in the next 48 hours, two-thirds in the first week and almost 90% die in the first month. In the primary care clinic or in out-of-hospital emergency services, the evaluation of a patient with acute chest pain represents a diagnostic challenge because the complementary tests available are limited. Therefore, the fundamental tools are the clinical history and physical examination, and based on them we must do an early investigation of those pathologies that may compromise the patient's life.
Alejandra BLAS HERNANDEZ (Veracruz, Mexico), Manuel De Jesus CASTILLO MONTES, Enrique Alejandro COLORADO PEÑA, Eduardo MARQUEZ ROSALES
00:00 - 00:00
#42088 - Changes in Diagnosis, Treatment, and Recurrence Frequency of Intussusception Over the Past Fifteen Years: Awareness? Treatment Modality?
Changes in Diagnosis, Treatment, and Recurrence Frequency of Intussusception Over the Past Fifteen Years: Awareness? Treatment Modality?
Introduction: Intussusception is one of the most common surgical emergencies in children and constitutes a life-threatening intestinal obstruction. Our aim is to determine the changes in treatment success and recurrence frequency of children presenting to the tertiary pediatric emergency department (ED) with a diagnosis of intussusception over the past 15 years and identify the factors influencing them.
Materials and Methods: Patients presenting to the pediatric ED and diagnosed with intussusception via ultrasound within three time periods (2009-2013, 2014-2018, 2019-2023) were retrospectively included. Demographic data, presenting complaints, clinical findings, symptom duration, number of ED visits before diagnosis, type of intussusception, segment length, treatment modality, recurrence frequency, and pathology results were recorded. Changes in treatment success and recurrence over the years and factors influencing them were analyzed.
Results: In this study, 448 patients with episodes of intussusception were examined; the median age was 23.0 months (min 1 month - max 14 years), with 30.8% being <1 year old and 65.6% being male. The most common symptoms were abdominal pain (99.8%), vomiting (55.1%), restlessness (48%), and bloody stools (23.7%). The classic triad of symptoms was observed in 33% of episodes. Diagnosis was most commonly made within 1-3 days (32.3%) and 12-24 hours (26.1%) from symptom onset; the mean number of ED visits was 2 (min 1–max 4). Only 19% of patients had abnormal findings on abdominal X-rays. Ileocecal (40.4%) and ileocolic (39.5%) types were most common, with a mean length of the intussuscepted segment being 4.0 cm (IQR 3-6), and ≥2.5 cm was found in 82.4% of cases. Hydrostatic reduction was performed in 58.9%, surgical reduction in 18.8%, and barium reduction in 4.2% of cases, while spontaneous reduction was observed in 18.1%. Over time, the use of hydrostatic reduction increased, while the rate of surgical reduction decreased. Reduction failure was 12.5%, and the recurrence rate was 20.2%. Over five years, reduction failure rates decreased from 18.5% to 7.9% (p=0.006), while recurrence rates increased from 9.8% to 20.0% (p=0.028). Age and gender did not affect reduction success, while the type of intussusception and segment length were significant factors (p<0.001). The time to diagnosis was significantly longer in patients undergoing surgical reduction (median 18-72 hours) (p<0.001). There was no change in the time to diagnosis over the three time periods.
Conclusion: This study demonstrates a significant decrease in the frequency of unsuccessful reduction and surgical reduction in the treatment of intussusception over the past fifteen years, while there has been a notable increase in recurrence rates. During this period, there has been no change in the time to diagnosis of intussusception in emergency departments. The prolonged time to diagnosis is directly associated with an increased need for surgical intervention.
Funding: None
Caner TURAN, Elif ERGIN (izmir, Turkey), Ulgen CELTIK, Ali YURTSEVEN, Eylem Ulas SAZ
00:00 - 00:00
#42308 - characteristics of acute abdominal pain in elderly subjects admitted to the emergency room.
characteristics of acute abdominal pain in elderly subjects admitted to the emergency room.
Introduction:
The elderly subject is a fragile subject, with multiple comorbidities and variable symptoms,
particularly in the case of abdominal pathologies.
Objective:
Describe semiological characteristics of acute abdominal pain in elderly subjects admitted to
the emergency room.
Materials and method:
Single-center prospective descriptive study which took place in the emergency department
over 6 months.
Inclusion criteria: elderly subject; two kinds
Non-inclusion criteria: patient in ACR, traumatic context
Results:
Fifty-two patients collected; gender ratio=1.2; mean age=74±8 years; asthenia (13.5%);
vomiting (35%); diarrhea (8%); stopping of materials and gases (6%); general condition
alteration (25%); burning when urinating (13.5%); fever (8%); epigastric pain (52%); right
iliac fossa pain (31%); left iliac fossa pain (25%); flank pain right (25%); left side pain
(25%); left hypochondrium pain (35%); left hypochondrium pain (25%); hypogastric pain
(29%); navel (25%); pelvic (25%); lumbar right (11.5%); left lumbar (8%); bilateral lumbar
(10%); flexible abdomen (48%); sensitive (50%); defense (8%); contracture (2%); hernia
(4%); mass (4%); ascites (6%).
Conclusion:
The major functional sign was vomiting, half of the abdominal pain was epigastric and the
abdomen was tender in the majority of cases in the elderly.
Khaireddine JEMAI (Tunis, Tunisia), Dhekra HOSNI, Safia OTHMANI, Hana HEDHLI, Marouane SANAI, Chedhe BEN HMIDA, Yasmine BENZARTI, Sarra JOUINI
00:00 - 00:00
#42233 - Characteristics of chest pain in an emergency department: an epidemiological study.
Characteristics of chest pain in an emergency department: an epidemiological study.
Introduction:
Chest pain is a common reason for consultation in emergency departments. This symptom regroups a wide variety of etiologies ranging from somatization to potentially serious cardiovascular conditions such as myocardial infarction and aortic dissections.
Methodology:
We conducted a prospective descriptive study over one month based on the records of patients presenting to the emergency department with chest pain.
Results:
We collected data from 70 patients. The mean age was 46±19 years with a gender ratio of 1,2. Regarding medical history, 31% of the patients were overweight, 57% were smokers, 18% had hypertension, 13% were diabetic, and 4% had known coronary artery disease. 63% of patients presented with atypical chest pain, with 33% also experiencing dyspnea. 52% of the pain occurred at rest with an average pain intensity of 6±2 on a visual analog scale. Concerning the location of pain, 33% were retrosternal, 30% were lateral, and 26% were basal, with irradiation in 71% of cases. 41% of patients described the pain as tingling, 24% as pressure, and 19% as burning. Troponin was positive in 14% of cases, and ECG abnormalities were described in 29% of cases. The mean clinical scores were 1.35±0.88 for the Manchester Acute Coronary Syndromes (MHS) and 0.97±0.97 for the Canadian Acute Coronary Syndrome (ACS). The average emergency department waiting time was 3±1.4 hours. After establishing a final diagnosis for each patient, it was observed that psychogenic causes of pain predominated in 38% of cases followed by parietal origins (26%). In one-
third of cases, a cardiac disorder was found: 10% had ST-segment elevation myocardial infarction, 9% had acute pulmonary edema, and 3% had arrhythmias. A pulmonary cause was documented in 5% of patients related to pneumonia.
Conclusion:
Chest pain is a symptom responsible for a significant number of emergency department consultations. We noticed that psychogenic and parietal etiologies are commonly involved.
Fatma HEBAIEB, Syrine TROJETTE, Saloua HOUIMLI (la Marsa, Tunisia), Nour El Houda MAATOUG, Mohamed ASSADI, Nessrine YAHYAOUI, Sarra AKKARI
00:00 - 00:00
#42017 - Characteristics of elderly patients assessed in the Emergency Department and discharge to Hospital at Home.
Characteristics of elderly patients assessed in the Emergency Department and discharge to Hospital at Home.
Background:
Geriatric assessment in the Emergency Department (ED) is important due to the complexity of the older patients. The Hospital at Home (HaH) units provides medical care at home, enhancing patient comfort and quality of life, also reduces the risk of hospital complications and promotes better continuity of care with the benefit of generate a significant savings by optimizing resources and reducing costs associated with hospital care. For these reasons, our aim was to describe the clinical characteristics, diagnoses, discharge rate, readmission rate, mortality rate and days of stay in the Hah.
Methods:
Descriptive study of patients aged 80 years and older assessed in the ED by the Geriatric Emergency Unit (GEU) of a second level university hospital in Madrid, Spain, the patients were assessed from January 1st, 2023 to December 31st, 2023. The selection of the study population was obtained through consecutive patient sampling.
The patients were classified in the emergency department according to the Manchester Triage System. A Comprehensive Geriatric Assessment (CGA) was performed and included the Barthel Index (BI), Functional Ambulation Category (FAC), the presence of cognitive impairment, delirium y diagnoses to discharge. Admission rate, readmission rate, and mortality rate, causes and days of stay in HaH were evaluated.
Descriptive statistics were used as the statistical method, the results were represented using the mean as a measure of central tendency and the standard deviation as a measure of dispersion. Rates were expressed as percentages of the total population included in the study. The data analysis was conducted with Microsoft Excel® 2021 (18.0)
Results:
A total of 1443 patients were assessed in the ED by the GEU from January 1st, 2023 to December 31st, 2023, 67 patients were discharge to HaH and included in the study (72% females), with a mean age of 89,5 years (SD: 4,57), 63% of the patients were classified as 3 according to the Manchester Triage System.
In the CGA performed, the mean BI was 35,9/100 (SD: 33), mean FAC was 1,5/5 (DS: 2), 27% of the patient did not have cognitive impairment, 21% had mild cognitive impairment, 37% had moderate cognitive impairment and 15% had severe cognitive impairment, 30% of the patient were diagnosed of delirium during de assessment.
Of all the patients assessed 5% were able to discharged home with HaH follow-up, with a mean hospitalization of 7,5 days (SD: 3,4) and the main diagnosed was respiratory infection in 48%. Of The 67 patients followed in HaH, 87% were discharged, 12% required readmission, and 1% died during the follow-up.
Conclusion:
Patients assessed in the ED by GEU are very elderly, severe dependency, and with moderate cognitive impairment, most of whom were discharged at home with a low rate of readmission and mortality associated. Those who required HaH follow-up had a short admission. In conclusion, the HaH unit for geriatric patients assessed in the ED can avoid hospital admissions, provide a personalized care and optimized the resource utilization.
Martha CHOQUEHUANCA LEÓN, María Auxiliadora CASTILLO DELGADO, Cristina ZUÑIGA BARTOLOME, Christian Pohol SAAVEDRA GARCÍA, Concepción LOBATO CASSINELLO, Marco Antonio CASTILLO (Valdemoro, Madrid, Spain)
00:00 - 00:00
#42221 - Characteristics of patients treated for chest pain in an emergency department. An analysis based on gender.
Characteristics of patients treated for chest pain in an emergency department. An analysis based on gender.
Background.
Non-traumatic chest pain is a very common reason for consultation in emergency departments. It is important to know the differences that will appear in this entity depending on the sex of the patients, which can make it possible to establish targeted strategies in each case, estimating the risk of suffering an acute coronary event.
Aim.
To know the characteristics of patients treated for non-traumatic chest pain depending on the sex of the patients.
Methods.
Prospective descriptive study of patients over 18 years of age treated in the emergency department of two hospitals in the same city in whom a possible coronary origin was suspected in the initial triage. Exclusion: patients with ST segment elevation on the ECG, patients with non-traumatic chest pain, patients with chest pain not suggestive of coronary artery disease. Variables: age, previous pathologies, comorbidity (Charlson Index (ChI), final diagnosis: acute coronary syndrome or unstable angina, stable angina, mechanical pain, atypical chest pain, hemodynamic angina, heart failure, digestive, others. A study was carried out based on sex. Description of the sample: quantitative variables: median and interquartile range (IQR), qualitative variables: frequency and percentage. Univariate study through comparison of quantitative (U-Man-Whitney) and qualitative (Chi-square) variables. 95% confidence interval (95% CI). SPSS 29.0 software. Statistical significance p<0.05.
Results.
N: 201 patients. median age 65 (55-76); Female: 81 patients (40.3%); Charlson index: 3 (1-4). median age male: 62 (51-73), female: 68 (58-78) (p<0.05). ChI: male: 2.5 (1-4), female: 3 (1-4) (p>0.05). History: (male vs female): smoker: (33.3% vs 21.0%) (p>0.05); dyslipidemia: (63.0% vs 49.2%) (p>0.05); hypertension: (54.2% vs 56.8%) (p>0.05); diabetes: (19.2% vs 17.3%) (p>0.05); obesity (18.3% vs 16.0%); (p>0.05); ischemic heart disease (30.5% vs 25.9%) (p>0.05); heart failure (5.8% vs 11.1%) (p>0.05); chronic respiratory disease: (11.7% vs 2.5%) (p<0.05); Final diagnosis: Male: ACS: 11.7%, stable angina: 3.3%, mechanical: 5%, atypical: 57.5%, digestive: 5%, hemodynamic: 7.5%, heart failure: 1.7 %, others: 8.3%. women: ACS: 16.0%, stable angina: 4.9%, mechanical: 4.9%, atypical: 56.8%, digestive: 3.7%, hemodynamic: 8.6%, heart failure: 0% , others: 4.9%.
Conclusions.
The majority of patients included in the study are male and are significantly younger than female. There are no differences between cardiovascular risk factors, male have a greater chronic respiratory disease. No statistically significant differences are observed in the diagnoses made, although we have verified that ACS is diagnosed in almost the same number of male as female and atypical pain is much higher in the group of male.These data make us think that ischemic heart disease is still more suspected in men, although in the final diagnosis ACS is not much more prevalent than in women.
This study was supported by unconditional funding from BIOTEC MEDICA.
Dr Raul LOPEZ IZQUIERDO, Carlos DEL POZO VEGAS (Valladolor, Spain), Daniel ZALAMA SÁNCHEZ, Francisco MARTÍN RODRIGUEZ, Ancor SANZ GARCIA, Leyre Teresa PINILLA ARRIBAS, Javier PRESENCIO DOMINGUEZ, Pedro Angel SANTOS CASTRO, Marin Perez BEATRIZ, Raúl ALONSO AVILES, Jose Ramón OLIVA RAMOS, Alberto GOMEZ DE DIEGO, Hernando Fernandez RAQUEL, Virginia CARBAJOSA RODRIGUEZ, Ana GARCIA RODRIGUEZ
00:00 - 00:00
#42252 - Characteristics, treatment, and outcomes of patients hospitalised with FXa inhibitor-related major bleeds: Preliminary findings from REVERXaL.
Characteristics, treatment, and outcomes of patients hospitalised with FXa inhibitor-related major bleeds: Preliminary findings from REVERXaL.
Background
Direct oral anticoagulants (DOACs) are among the most commonly prescribed anticoagulants in clinical practice. Among them, rivaroxaban, apixaban, and edoxaban achieve anticoagulation effects by direct inhibition of factor Xa (FXa) in the coagulation pathway. While approximately 2-6% of patients treated with FXa inhibitors experience a major bleed, data from routine clinical practice on the characteristics and treatment outcomes of patients with FXa inhibitor-related major bleeds are limited. REVERXaL (NCT06147830) is a multinational observational study of patients hospitalised with FXa inhibitor-related acute major bleeds (i.e., intracranial haemorrhage [ICH], gastrointestinal bleeds, and other bleeds). The primary objectives are to describe: 1) patient characteristics, 2) healthcare interventions during hospitalisation, and 3) associations between timing of reversal agent administration and in-hospital outcomes. Secondary/exploratory objectives focus on clinical and patient-reported outcomes (PROs) at 30 and 90 days. Here, the baseline demographics, clinical characteristics, and outcomes of patients enrolled in REVERXaL are described.
Material and methods
REVERXaL includes two cohorts of adult patients (≥18 years) hospitalised with FXa inhibitor-related major bleeds in the United States, Germany, the United Kingdom, and Japan. The first cohort (Cohort A) is a historical cohort including patients hospitalised for FXa inhibitor-related bleeds, utilising information from medical charts from admission to discharge. The second cohort (Cohort B) includes prospectively enrolled patients administered any reversal agent when hospitalised for FXa inhibitor-related bleeds. Patients are followed up to 3 months, including data collection on clinical and patient-reported outcomes. A standardised case report form is used to extract data on demographics (e.g., age, sex, race), clinical characteristics (e.g., bleed location, medical history (e.g., comorbidities, risk factors), FXa inhibitor (including type, indication, and time since last dose), bleed severity, laboratory measurements (e.g., anti-FXa activity, estimated glomerular filtration rate, partial thromboplastin time at admission), treatments/interventions (e.g., hemostatic agents, blood product transfusions, surgical procedures) and clinical outcomes (e.g., hemostatic effectiveness, length of hospital stay, intensive care unit stay, all-cause mortality), whilst PROs are collected directly from patients. Descriptive analyses are performed.
Results
As of 3 May 2024, 18 clinical sites had been activated across the included countries and are actively enrolling patients into the study; 59 patients (about half of whom had an ICH) had been enrolled, including 47 in Cohort A and 12 in Cohort B. At EUSEM 2024, the data on the demographics and clinical characteristics of patients enrolled in Cohort A at an interim data cutoff in June 2024 will be presented. Additional data to be presented will include treatment patterns and in-hospital clinical outcomes. If patient numbers permit, analyses will be provided for the overall cohort and stratified for patients with and without ICH.
Conclusions
Emerging data from REVERXaL will provide important real-world insights on the characteristics, treatment approaches, and associated clinical outcomes in patients hospitalised with varying types of FXa inhibitor-related major bleeds.
This study was funded by AstraZeneca.
Marc MAEGELE (Cologne, Germany), Andreas TIEDE, May NOUR, Richard OFORI-ASENSO, Masahiro YASAKA, Hungta CHEN, Vinay SEGHAL, Shoji YOKOBORI, Bruce KOCH, Onivefu ODELADE, Brooks D. CASH, Raza ALIKHAN, Adam J. SINGER
00:00 - 00:00
#41831 - Characterizing STEMI in the Prehospital Environment in Kairouan: A Retrospective Study.
Characterizing STEMI in the Prehospital Environment in Kairouan: A Retrospective Study.
Introduction:
STEMI is a major cause of illness and death globally, requiring fast and effective care, especially before reaching the hospital. Emergency medical services (EMS) are vital in quickly identifying, prioritizing, and starting the right treatments for STEMI patients. Calling EMS promptly, and providing fast prehospital care can greatly improve patient outcomes by cutting down ischemic time and allowing timely reperfusion therapy.
Methods:.
We conducted a retrospective study in Kairouan, Tunisia, involving 82 patients who presented to peripheral hospitals with chest pain and persistent ST-segment elevation and were transferred by EMS. Data collection occurred over a period of one year and seven months, from August 2022 to February 2024. Epidemiological, clinical, and therapeutic data were collected from filled-in charts filled by intervention doctors. This study aims to outline STEMI management in EMS, emphasizing strategies to enhance prehospital care, reduce treatment delays, and enhance patient outcomes in this crucial group.
Results:
The study population's mean age was 64.8 years, with a standard deviation of 14.0 years. Male participants comprised the predominant group, with a prevalence of 81.7%.The majority of participants were from Bouhajla (24.4%) and Hajeb Layoon (20.7%). The prevalence of cardiovascular risk factors within the study population was notably high, reaching 95.1%. Hypertension emerged as the most prevalent risk factor, affecting (39%), followed closely by diabetes (28%). The prevalence of smokers was 61%, 19.2% of them quitted smoking. Among individuals with a history of coronary artery disease (22%), 78.9%of them underwent coronary stenting procedures. Chest pain was reported in 92.7% of participants, with 73.4% experiencing typical pain and 38.5% noting modifications. Additionally, 41% experienced paroxysmal pain episodes. Associated signs were observed in 30% of participants, among which dyspnea was the most common (41.7%).
In the study, 31.7% of patients arrived in a state of shock. Anterior STEMI was diagnosed in 51.2% of cases, while 48.8% had an inferior STEMI. Primary angioplasty was performed in 37% of patients, and thrombolysis was utilized in 43.2% of cases. However, thrombolysis was contraindicated in 9.8% of cases, and it failed in 60% of cases.
Conclusion:
STEMI, a primary cause of global mortality, disproportionately affects low- and middle-income countries. The ESM strives to enhance diagnosis and prompt treatment in prehospital settings, navigating diverse factors influencing outcomes. Shortening door-to-balloon time remains pivotal for effective STEMI management.
Imen KETATA, Manel KHADHRANI, Sarra SOUA, Khouloud KHEMILI (Tunisia, Tunisia), Bouhamed CHAFIAA
00:00 - 00:00
#41225 - Chest ultrasound for acute dyspnea – a case report.
Chest ultrasound for acute dyspnea – a case report.
Clinical history: A 79-year-old male patient presented to the emergency department (ED) via ambulance after a ground-level fall with tachypnea, dyspnea, and a Glasgow-Coma-Scale (GCS) of 11 points. Due to the patient’s altered mental status, it was not possible to take a more extensive medical history.
Misleading elements: Physical exam (ABCDE= airway, breathing, circulation, disability, exposure) revealed the following: A = no abnormal findings. B= diminished breath sounds on the right side compared to the left, respiratory rate 26/min, SpO2 88%. C=heart rate 110bpm, mean arterial pressure 68 mmHg. D= agitated, GCS 11. E =abrasions to the forehead, no active bleeding, no further signs of trauma.
The FAST exam showed no free intraabdominal fluid, a regular ejection fraction, no pericardial effusion, no right heart strain but a right sided pleural effusion with echogenic structures inside (Figure 1 A). In addition, a consolidation with dynamic aerobronchogramm was seen on the right side. Furthermore, an absorption atelectasis could be observed in the anterior part of the right lung (Figure 1B).
Helpful details: The blood results showed a markedly elevated CRP 427mg/l (norm <5mg/l), WBC 31/nl and procalcitonin 8.62 µg/l (norm < 0.5). A computed tomography (CT) of head and s-spine showed no pathologies. The arterial blood gas analysis (ABG) indicated a respiratory acidosis (pH 7.17, pCO2 50.9mmHg, pO2 214mmHg). To estimate the extent of the pleural empyema and to exclude a pulmonary abscess, a computed tomography of the thorax with contrast media was performed (Figure 2, A-D).
Differential and actual diagnosis: The initial differential diagnosis for the patient presenting with dyspnea after falling, was a traumatic pneumothorax. This could be excluded by initial FAST exam. Lung ultrasound lead to the differential on pneumonia with absorption atelectasis and concomitant empyema, which was supported by ABG and CT findings. Testing did not reveal any signs of traumatic injury. Due to severe dyspnea and a respiratory acidosis, noninvasive ventilation and antibiotic treatment were started immediately. After a surgical consultation, the patient was planned for a video assisted thorascopic surgery.
Discussion/Educational/clinicalrelvance: Point of care ultrasound protocols such as the eFAST can help shorten the time to correct diagnosis. In this case of a patient with a supposed fall and dyspnea a pneumothorax was rapidly excluded. Instead, a pleural effusion with consolidations could be observed. This lead to a change in diagnostic and therapeutic considerations. Lung ultrasound can distinguish between absorption and compression atelectasis by looking at the distribution of air bubbles in the lung tissue. An absorption atelectasis is defined by distributed air compared to compression atelectasis, where air only remains in the more central aspects of the lung.
Figure 1. A-B. Pleural ultrasound. A-A’. Right sided pleural effusion (red star) with partial organization (yellow arrow) and positive aerobronchogramm/compression atelectasis (green arrow). B-B’. Right sided pleural effusion (red star) with absorption atelectasis (green arrow).
Figure 2. A-D. Computed tomography of the thorax with contrast media, pulmonary empyema in the right lung. A-B. Sections from upper to lower thorax in transverse plane. C. Frontal plane. D.Sagittal plane.
Fabian GLEIBS (Hamburg, Germany)
00:00 - 00:00
#41341 - Chlorophyllum Molybdites Poisoning: A Case Report.
Chlorophyllum Molybdites Poisoning: A Case Report.
Chlorophyllum molybdites is one of the most common causes of mushroom poisoning worldwide. The majority of cases are from consumption of misidentified mushrooms while foraging. To date, there have been no reported cases of mushroom poisoning in Singapore.
We describe the first reported case of Chlorophyllum molybdites poisoning in Singapore who presented to the emergency department with acute gastroenteritis, complicated by hypovolemia and several laboratory abnormalities, including lactic acidosis, deranged liver enzymes and elevated creatine kinase. The patient received supportive treatment with intravenous fluids, analgesia and anti-emetics. The patient made a complete recovery with the resolution of all symptoms and laboratory abnormalities after 48 hours.
Chlorophyllum molybdites is known to be a gastrointestinal irritant, and ingestion is often associated with a rapid onset of profound gastrointestinal symptoms, including abdominal cramps, nausea, vomiting and diarrhea. Treatment is mainly supportive, and the majority of patients improve rapidly within 24 hours although children and the elderly can be more susceptible to complications such as dehydration and electrolyte abnormalities.
However, Chlorophyllum molybdites can be confused for other species of more toxic mushrooms, such as amatoxin-containing Lepiota, which can present similarly with acute gastrointestinal symptoms but subsequently develop severe delayed toxicity such as hepatic failure and multisystem organ failure. Hence clinicians managing patients with mushroom poisoning should be aware of the potential for delayed toxicity. Close monitoring for at least 24 hours is recommended for all cases of mushroom poisoning, especially if there is doubt regarding the identity of the mushrooms ingested or if there was ingestion of multiple species of mushrooms.
Kristopher KOW (Singapore, Singapore), Ranjeev KUMAR NANTA KUMAR
00:00 - 00:00
#42385 - Chronic obstructive pulmonary disease and its prognostic impact.
Chronic obstructive pulmonary disease and its prognostic impact.
Introduction:
Monitoring chronic obstructive pulmonary disease allows background treatment to be adapted depending on the level of disease control. The objective of our work was to study the impact of disease monitoring on the clinical presentation and prognosis of COPD.
Methods:
This is a prospective study including 45 COPD patients who consulted the emergency department of the Charles Nicole hospital in Tunis between January 2023 and April 2024.
The patients were divided into two groups:
G1: COPD monitored
G2: COPD not monitored
Results:
Forty-five patients were included. Most were aged over 65 (73.3%). Group 1 is made up of 8 men and 3 women, including 2 active smokers, 8 weaned smokers and 1 non-smoker.
Group 2 is made up of 14 men and 7 women, including 5 active smokers, 15 weaned smokers and 1 non-smoker.
By comparing the different clinical and biological parameters, the elderly patients followed
presented less severe exacerbation than those not followed (5 vs 15) with a P = 0.29, less
of use of oxygen at home during their discharge (1 vs 9) with a P = 0.05.
Conclusion:
Monitoring of COPD disease has a positive impact on both the severity of the exacerbation and the use of long-term oxygen therapy.
Marouane SANAI, Asma JENDOUBI, Maissa TEJ, Nadia BOURAOUI, Khaireddine JEMAI (Tunis, Tunisia), Sarra JOUINI
00:00 - 00:00
#41874 - Circulating microvesicles in acute carbon monoxide poisoning.
Circulating microvesicles in acute carbon monoxide poisoning.
Background: Carbon monoxide (CO) is responsible for several accidental intoxications and deaths every year worldwide. CO poisoning can induce cellular damage due to hypoxia and inflammation, which might be associated with severe delayed neurological sequelae (DNS), but the underlying mechanisms are still poorly understood. Hence, we aimed to investigate the role of microvesicles (MVs) in CO-related damage pathogenesis.
Materials and methods: The approval of the Ethics Committee was obtained, and all participants provided written informed consent. Patients admitted to the Emergency Department (ED) with a documented CO-intoxication and scheduled for hyperbaric oxygen therapy (HBOT) were enrolled. Two blood samples were taken: on ED admission (T0), and after HBOT (T1). Twelve age-, sex- and smoke habit-matched subjects were enrolled as control group. Population characteristics and clinical data were collected, and a 45-day follow-up for DNS was performed. Plasma MVs were analyzed with flow cytometry, and subpopulations of leukocyte, endothelial, and platelet origin were identified.
Results: Between June 2022 and June 2023, 26 CO-intoxicated patients were enrolled, showing a median age of 57 (43–71) years, with 13 (50%) men and 7 (27%) active smokers. All poisonings were accidental, and median intoxication time was 12 (interquartile range IQR:2.8–21) hours, with 13 cases classified as mild-moderate, the other 13 as severe. Median carboxyhemoglobin (COHb) level measured on arterial blood gases (ABG) was 24% (IQR: 16.6–27.4). Twenty-five out of the 26 patients were treated with HBOT, while one patient could not undergo treatment due to an unfavorable risk-benefit ratio. Our data showed a significant increase in platelet-derived MVs at T0 in CO-intoxicated patients compared to controls (6107 (IQR: 1548-9183) vs 2391 (IQR: 1739-3261) MVs/μL, Mann-Whitney test p=0.04), but no differences in MV subpopulations were found after HBOT. Endothelial and platelet-derived MV levels at T0 positively correlated with intoxication time (Test for correlation coefficient p=0.0028), while COHb showed a positive relation with MVs of platelet origin only (Test for correlation coefficient p=0.0021). These results might reflect CO-induced hypoxic damage and platelet activation. Lastly, the only patient who did not undergo HBOT after CO intoxication developed DNS at follow-up.
Conclusions: CO intoxication seems to induce an increase in platelet-derived MVs, while HBOT might not have an influence on MV levels. However, further research and validation studies with an adequate sample size are necessary to confirm our results and potentially translate these findings into clinical practice.
Angelo PUGGIONI, Sara NEMBRINI, Alessia BURGENER, Teresa ESPOSITO, Annalisa CHIOCCHETTI, Giuseppe CAPPELLANO, Marcello MANFREDI, Chiara DE LUCA, Lucrezia MESIANO, Gaia Francesca MASSIDDA, Lorenza SCOTTI, Gian Luca VIGNAZIA, Gianmaria CAMMAROTA, Andrea GIOVANNIELLO, Pr Francesco DELLA CORTE (Novara, Italy), Rosanna VASCHETTO
00:00 - 00:00
#42203 - Civil Preparedness in Asymmetric Conflicts: A Bystander Mass Casualty Training Concept by Israel’s Emergency Medical Services.
Civil Preparedness in Asymmetric Conflicts: A Bystander Mass Casualty Training Concept by Israel’s Emergency Medical Services.
Background / Introduction:
The October 7, 2023, terrorist attack in Israel and the 2022 Russian invasion of Ukraine have
highlighted the need for lay bystanders to be able to assist victims during mass casualty
incidents (MCIs) prior to the arrival of Emergency Medical Services (EMS). The “First Seven
Minutes” (F7M) training has been developed by Israel’s EMS to train lay bystanders to respond
medically in this context by teaching a seven-step approach to administering an MCI scene.
Objectives:
A programmatic study was conducted to understand if F7M increased the self-assessed ability
among participants to respond and whether this varied with the participants’ level of personal
resilience.
Method / Description:
This was a survey-based before-after intervention study where all F7M participants from 2018-
19 were offered to participate. A 5-point Likert scale questionnaire was administered before
and after training to investigate self-assessed ability to respond medically in conflict-related
MCIs. Personal resilience was assessed using a modified Brief Resilience Scale. The Wilcoxon
Signed Rank test was used to test for significance between mean scores.
Result / Outcomes:
The analysis included a total of 128 participants. Following training, self-assessed ability to
respond increased significantly (Mean Difference 0.5, p<0.05). Low-resilience participants
benefited more than participants with normal or high resilience (MD 1.14, p<0.05 vs MD -0.38,
p<0.05, CI: 0.73 – 1.56 vs CI: -0.52 – -0.23).
Conclusion:
In contemporary armed conflicts with escalating violence against civilians, F7M may be a
useful tool for building capacity in bystanders to assist during MCIs. Further, it may be of
benefit in wider preparedness efforts to mitigate civilian loss of life during armed conflicts. The
relevance of F7M in this context will be more extensively discussed during an oral or poster
presentation.
Maximilian NERLANDER, Abigail KLEIN, Raphael HERBST, Eli JAFFE, Maximilian NERLANDER (Växjö, Sweden)
00:00 - 00:00
#41736 - Clinical outcomes and hospital stay duration for patients with cellulitis in the emergency department: a retrospective study.
Clinical outcomes and hospital stay duration for patients with cellulitis in the emergency department: a retrospective study.
Cellulitis is a common condition seen in the emergency department (ED). Once the diagnosis is made, one needs to decide if the patient can receive outpatient treatment or will require admission for intravenous antibiotics. At our centre, patients requiring admission may either be admitted to the ED Observation Unit (EDOU) for a maximum duration of 24 hours or admitted to the inpatient ward. We review the clinical outcomes of patients seen in the ED for cellulitis, including disposition, re-attendance rate and hospital length of stay (LOS). We also evaluated risk factors associated with increased hospital LOS.
Method.
This was a single centre, retrospective review over a period of 1 year (1 Jan 2022 – 31 Dec 2022). All patients aged 18-years old and above with a diagnosis of cellulitis were included. Patients diagnosed with complicated soft tissue infections in ED (e.g. abscess, gangrene, and necrotising fasciitis) were excluded. Data abstracted from electronic health records included demographical data, disposition, re-attendance within 72 hours, hospital LOS, and biomarkers such as vital signs in ED, laboratory tests.
Results.
There were 1846 patients diagnosed with cellulitis in the ED during the review period. The median age was 64 years old (IQR 49-74), and 62.7% were male.
A total of 511 patients (27.7%) were discharged from the ED for outpatient treatment. There were 1247 patients (67.7%) who were admitted - 86 (4.7%) to EDOU and 1161 (63%) to the inpatient wards. A total of 80 patients (4.3%) refused admission and were discharged against medical advice (AMA). Five patients (0.3%) left prematurely without notifying ED staff, while 3 patients requested for transfer to another hospital for further care.
Of the 86 patients admitted to EDOU, 28 (32.6%) required an extended stay beyond 24 hours and were converted to inpatients. The average length of stay (LOS) of patients admitted to the ward was 6.9 days. Of note, 129 of 1161 (11.1%) patients directly admitted to inpatient wards were discharged within 1 day, and 182 (15.7%) were discharged within 2 days.
Risk factors associated with significantly increased hospital LOS included elderly patients (aged >=65), and the presence of fever (>=38.0 degrees Celsius), hypotension (BP<90/60mmHg), or tachycardia (HR>100/min) in the ED. Patients with elevated CRP (>=100mg/L) were also found to have a greater significantly longer LOS.
Re-attendance rate amongst those discharged from the ED was 3.5%, while patients who were discharged AMA had a re-attendance rate of 12.3%.
Discussion and Conclusions.
A sizeable percentage of patients directly admitted to inpatient wards were discharged from the ED within 1 day. These patients should be considered for EDOU admission or discharge from ED with early follow up to optimize inpatient bed utilization.
The risk factors we identified as correlating with increased LOS included elderly patients, abnormal vital signs in ED (fever, tachycardia, hypotension) and high CRP. Early identification of these risk factors can guide clinicians on choosing the appropriate disposition for these patients.
Ivan LIM (Singapore, Singapore), Wenjian CHAN, Rupeng MONG
00:00 - 00:00
#41774 - Clinical, radiological and therapeutic characteristics of patients treated for hypoxemic pneumonia.
Clinical, radiological and therapeutic characteristics of patients treated for hypoxemic pneumonia.
Introduction :
Acute community-acquired pneumonia represents a common pathology and a frequent reason for consultation and hospitalization in emergency departments and represents a major cause of morbidity and mortality in adults. The challenge is to recognize severe forms in time and manage them appropriately according to clinical, radiological and biological criteria. And in order to implement adequate antibiotic therapy which targets the suspected germs.
It is in this context that a study was carried out in the Ibn Jazzar Kairouan emergency departments which consists of determining the radiological and therapeutic clinical characteristics of patients admitted for treatment of hypoxemic pneumonia.
Methods :
This is a descriptive and prospective study involving 32 patients admitted to the IBN Jazzar emergency department. The study period was 3 months, from December 1, 2023 to February 29, 2024.
Any patient consulting for dyspnea in the context of hypoxemic pneumonia with an age greater than or equal to 17 years was included in our study with exclusion of those arriving in cardiorespiratory arrest.
Results :
Our study involving 32 cases of hypoxemic pneumonia divided into 18 men, i.e. 56.3%, and 14 women, i.e. 34.8%, with a sex ratio of 1.2.
The average age was 66.8 +/15 years with ranges ranging from 17 years to 88 years. 43.8% were diabetic, 43.75% hypertensive, 59.4% had a history of respiratory failure, 53.1% were smokers with 21.9% having morbid obesity. The clinical picture was dominated by fever for 15 patients or 46.9% with an average temperature of 38.1 °C, dyspnea was present in all patients, cough in 28 patients or 87.5% with 71.9% wet cough and 28.1% dry cough. . Hypoxia was detected in all patients with an average saturation of 82.6%.
All patients had a chest a bronchial syndrome in 5 patients 15.6%. The average hospitalization time in the emergency room was 3.35 days +/-2.63.
For the management of hypoxia, oxygen therapy by glasses was prescribed in 10 patients or 31.3%, 3 patients benefited from oxygen therapy by MHC or 9.4% and 19 patients by mechanical ventilation or 59.3% including 17 patients by Ventilation. non-invasive or 89.4% and 2 cases or 10.6% were intubated due to respiratory distress.
8 patients or 25% received paracetamol for fever. For antibiotic therapy, 13 patients, or 40%, were placed on monotherapy: Augmentin and 19 patients, or 60%, on dual therapy: Claforan + Tavanic. No microbiological investigation was carried out. 6 patients were referred to a medical service including 1 patient 3.1% to a medical intensive care unit and 5 patients or 15.6% to the pulmonology department. The evolution was favorable in 27 patients or 84.37% with clinical worsening in 5 patients 15.6% including 1 death or 3.1%. 26 patients or 81.25% were discharged after clinical and radiological improvement.
Conclusion :
Our study highlights the importance of evaluating patients on all levels as well as the importance of microbiological data for optimal care. However, additional studies are necessary to refine our knowledge and optimize therapeutic strategies.
Bouhamed CHAFIAA, Imen KETATA, Sarra SOUA, Khouloud KHEMILI (Tunisia, Tunisia), Chaima MANAI, Ines DALI
00:00 - 00:00
#42009 - CLOCCs Case report.
CLOCCs Case report.
Corpus Callosum Cytotoxic Lesion (CLOCCs) once rarely seen in the literature has been more often diagnosed in emergency services nowadays with widespread use of cranial magnetic resonance imaging (MRI). A clinical and radiological spectrum condition is known as CLOCCs. After the condition begins, the patient's neurological symptoms typically go away entirely in a month without any recurrence. This is typically linked to splenium corpus callosum cytotoxic edema. It is crucial to look into the main factors that contribute to this illness and to begin the right course of treatment in accordance with the official diagnosis. We report a case that was admitted to our emergency care with a diagnosis of CLOCCs related to Clozapine.
The 18-year old patient, who was given an Asperger syndrome and bipolar disorder diagnosis, was brought to the emergency room with the intention of killing herself after consuming 18 clozapine shots. Elective intubation was performed on the unconscious patient, whose development evaluation revealed weakness in the right upper extremity.
The outcomes of the lab tests were normal.
The patient's follow-up brain MRI revealed no bleeding on brain tomography, and no diffusion restriction was found in the areas of the brain parenchyma in the supra and infratentorial regions, which could be consistent with acute ischemia. A millimetric FLAIR hyperintense focus at the level of the corpus callosum splenium is seen, which limits diffusion. It might be connected to the corpus callosum cytotoxic lesion that occurred in the patient whose medical history included a history of clozapine toxicity.
Because of the clozapine ingestion, the patient was first diagnosed with CLOCCs and admitted to the intensive care unit.In the MRI image taken on the 17th day for control purposes, the hyperintensity in the corpus callosum was seen to have disappeared. In the literature, the average disappearance time of the lesion in CLOCCs cases is stated as 21 days.
When CLOCCs are observed, one should be vigilant and the underlying main causes should be looked into, particularly in individuals with mixed and nonspecific symptoms that are challenging to diagnose.
With the increasing use of cerebral magnetic resonance imaging (MRI) in emergency services, corpus callosum cytotoxic lesions (CLOCCs), which were hitherto uncommonly reported in the literature, are now more frequently diagnosed.
The emergency physician should promptly detect this lesion, begin looking into the fundamental cause, and arrange the necessary consultations for an accurate diagnosis connected to the patient's clinic.
Kadir YENAL (Yenimahalle, Turkey), Yaren AGAR, Ibrahim DILEKCAN, Alper GÖK
00:00 - 00:00
#42001 - CLOCCs Case report.
CLOCCs Case report.
Corpus Callosum Cytotoxic Lesion (CLOCCs) once rarely seen in the literature has been more often diagnosed in emergency services nowadays with widespread use of cranial magnetic resonance imaging (MRI). A clinical and radiological spectrum condition is known as CLOCCs. After the condition begins, the patient's neurological symptoms typically go away entirely in a month without any recurrence. This is typically linked to splenium corpus callosum cytotoxic edema. It is crucial to look into the main factors that contribute to this illness and to begin the right course of treatment in accordance with the official diagnosis. We report a case that was admitted to our emergency care with a diagnosis of CLOCCs related to Clozapine.
The 18-year old patient, who was given an Asperger syndrome and bipolar disorder diagnosis, was brought to the emergency room with the intention of killing herself after consuming 18 clozapine shots. Elective intubation was performed on the unconscious patient, whose development evaluation revealed weakness in the right upper extremity.
The outcomes of the lab tests were normal.
The patient's follow-up brain MRI revealed no bleeding on brain tomography, and no diffusion restriction was found in the areas of the brain parenchyma in the supra and infratentorial regions, which could be consistent with acute ischemia. A millimetric FLAIR hyperintense focus at the level of the corpus callosum splenium is seen, which limits diffusion. It might be connected to the corpus callosum cytotoxic lesion that occurred in the patient whose medical history included a history of clozapine toxicity.
Because of the clozapine ingestion, the patient was first diagnosed with CLOCCs and admitted to the intensive care unit.In the MRI image taken on the 17th day for control purposes, the hyperintensity in the corpus callosum was seen to have disappeared. In the literature, the average disappearance time of the lesion in CLOCCs cases is stated as 21 days.
When CLOCCs are observed, one should be vigilant and the underlying main causes should be looked into, particularly in individuals with mixed and nonspecific symptoms that are challenging to diagnose.
With the increasing use of cerebral magnetic resonance imaging (MRI) in emergency services, corpus callosum cytotoxic lesions (CLOCCs), which were hitherto uncommonly reported in the literature, are now more frequently diagnosed.
The emergency physician should promptly detect this lesion, begin looking into the fundamental cause, and arrange the necessary consultations for an accurate diagnosis connected to the patient's clinic.
Kadir YENAL (Yenimahalle, Turkey), Yaren AGAR, Ibrahim DILEKCAN, Alper GÖK
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#41954 - Closed Reduction in Subtalar Dislocation: The Crucial Role of Early Diagnosis.
Closed Reduction in Subtalar Dislocation: The Crucial Role of Early Diagnosis.
Introduction:
Subtalar dislocations involve the simultaneous dislocation of the talo-calcaneal and talo-navicular joints, excluding associated fractures. Accounting for only 1-2% of all dislocations due to the foot's inherent stability, this rare injury, affecting mainly middle-aged males, is usually caused by low-energy mechanisms. Early recognition is crucial to prevent complications requiring open reduction, as conservative management may be viable, especially in cases without associated bone injuries. Existing studies often include patients with osseous injuries, making this case noteworthy for its conservative management following a low-energy mechanism.
Case report: A 28-year-old male presented to the emergency department with closed injury of the right ankle. The patient reported intense pain and ankle deformity post-injury, recounting a slip and fall from a 2-meter height noting that his right foot was plantar-flexed and inverted. The patient couldn't stand or walk on the injured foot. He had an unremarkable past medical history with no history of ankle sprains or ligament laxity. Clinical examination revealed a deformation of the right foot: medial displacement, dorsal-lateral prominence of the talar head, and stretched skin over the talus protrusion, without any wound.
Anteroposterior and lateral radiographs, along with a CT scan, were conducted on the right foot, revealing a subtalar joint dislocation (medial type) without associated fractures. Urgent closed reduction of the dislocation was performed in the operating room under spinal anesthesia, achieving good stability. A below-the-knee splint was applied, followed by X-ray examination.
Conclusion : Subtalar dislocations, while uncommon, should be considered in patients with foot/ankle deformity. Early diagnosis and reduction are crucial for favorable functional outcomes. Closed reduction is typically successful, and post-reduction CT is advisable to confirm anatomical alignment and rule out fractures. Excellent results are achievable with isolated dislocations and short-term immobilization. Conversely, dislocations with associated injuries, especially fractures, often lead to poorer outcomes and increased complications like stiffness or degenerative changes.
Firas BOUGHATTAS, Khouloud KHEMILI (Tunisia, Tunisia), Jacem SAADANA, Hatem BELGACEM, Amine SIOUD, Moez JELLALI, Kais KHARROUBI, Insaf BEN MESSAOUD, Bilel FAIZI, Iheb NTICHA, Aymen FEKIH, Abderrazek ABID
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#40419 - Clot in Transit- Identification of a Right Atrial Thrombus on Bedside Echocardiography in the Emergency Department.
Clot in Transit- Identification of a Right Atrial Thrombus on Bedside Echocardiography in the Emergency Department.
A 32-year-old Asian male presented to the Emergency Department with a one day history of mild chest pain and significant dyspnoea. At triage, he was comfortable with HR 112, respiratory rate of 16 and oxygen saturations of 95% RA.
CT-PA showed large volume bilateral central PE resulting in occlusion of the left upper lobe pulmonary artery and near complete occlusion of the left lower lobe pulmonary artery. Evidence of right heart strain. Small foci of consolidation in the right lower lobe potentially representing small pulmonary infarctions. Troponin, D-dimer and BNP were all elevated at 105 ng/L, 0.99 mg/L and 745 ng/L respectively.
Bedside TTE was done in ED to evaluate for signs of right heart strain. This showed a highly mobile right atrial thrombus, dilated RV, McConnell’s sign and mid-systolic notching of the RVOT doppler envelope. These findings were consistent with elevated pulmonary vascular resistance and a diagnosis of high intermediate risk PE with RA thrombus was made.
The patient was anti-coagulated with IV heparin and transferred to HDU. Right atrial thrombus was aspirated in IR lab using a Inari Flowtriever device while under direct procedural ultrasound guidance. The patient continued to improve and was transitioned from unfractionated heparin to NOAC on hospital discharge. Dedicated Level 2 echo is recommended.
Will include images of the *RA thrombus *post aspiration image *echo signs of RV strain
Learning Points
1. Large volume or bilateral pulmonary artery embolus should be further risk stratified to high or intermediate risk using TTE at the point of care, according to ESC guidelines
2. Combining the strengths of each imaging modality to build a more complete assessment (ie. contrast bolus obscuring RA/RV thrombus on CT)
3. TTE in the ED is a useful non-invasive hemodynamic monitoring tool in the hands of appropriately trained personnel
Conclusion
We present the case of a young male who presented with signs and symptoms of PE without previous risk factors. TTE in the ED identified a highly mobile right atrial thrombus which was not visualised on CTPA. The patient received IV heparin and subsequently, underwent aspiration of the thrombus using an Inari Flowtriever.
Leah FLANAGAN (Dublin, Ireland), Cian MCDERMOTT, Eduard TURCUMAN
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#40735 - Colonic intussusception cause by juvenile polyp.
Colonic intussusception cause by juvenile polyp.
A 7-year-old boy arrived at the emergency department complaining of abdominal pain and experiencing two episodes of vomiting several hours prior. He did not have a fever, and there were no signs of watery diarrhea. Upon physical examination, his abdomen was soft, with slight tenderness noted in the left upper quadrant.
Laboratory tests revealed a C-reactive protein (CRP) level of 1.6 mg/L, which fell within the normal range. Abdominal sonography revealed the presence of a doughnut sign (refer to Figure 1) in the left upper quadrant. Subsequent abdominal CT scan confirmed the presence of two concentric enhancing rings at the descending colon (refer to Figure 2), suggestive of colocolic intussusception with obstruction.
After discussing the situation with the parents, we proceeded with a reduction procedure using single-contrast barium enema. During the procedure, we observed a lobulated filling defect with a coiled-spring appearance in the sigmoid colon at the level of the hepatic flexure, consistent with intussusception. The reduction of the colocolic intussusception was successfully performed. Subsequently, the patient was admitted to our pediatric ward for further observation.
Two days later, following bowel preparation, a colonoscopy was conducted, revealing a sizable 3cm polyp with a long and thick stalk located on the cranial aspect of the transverse colon (refer to Figure 3). Subsequent polypectomy was performed, and biopsy results confirmed the presence of a juvenile polyp.
Colo-colonic intussusception is a less common condition that cause intestinal obstruction in school-aged children. Among 1.5 to 12% of the cases of intussusceptions, pathological leading point (PLP) can be found, such as Meckel’s diverticulum, lymphoma, tumor, polyps, duplication cysts, parasites, and inflamed appendix [1]. The patients may have abdominal pain, bloody stool, vomiting, and/or abdominal mass. However, these signs and symptoms can overlap with other common diseases. Point-of-care ultrasound (POCUS) is a modality of choice to help us make the diagnosis because of its high sensitivity (94.9%) and specificity (99.1%) [2]. There are two typical image which can be seen in intussusception: pseudokidney sign on longitudinal plane and doughnut/target sign on a transverse plane [1,2]. Our case demonstrates a typical image of doughnut sign (Figure 1). Without peritonitis nor bowel perforation, hydrostatic barium reduction is a nonoperative option for intussusception. After the successful reduction, a colonoscopy is recommended for detecting PLP within the colon [3]. In our case, a juvenile polyp was found and resected in the transverse colon.
Hon Pheng TAM (TAINAN, Taiwan), Yu-Hui LIN, Wei-Jing LEE
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#41060 - Comparative anatomy of esophagus and trachea in endotracheal intubation performed on a cadaver with the radiopaque custom bougie technique under fluoroscopy.
Comparative anatomy of esophagus and trachea in endotracheal intubation performed on a cadaver with the radiopaque custom bougie technique under fluoroscopy.
Background: Airway management is a core competency in emergency medicine (EM). The endotracheal intubation skill set is a high stakes learning curve. The difficult airway remains a clinical challenge to the EM physician. Advancement of difficult airway techniques, materials, skills and understanding should be valuable. We show further evidence for potential clinical and teaching utility with the primary author’s custom bougie technique in endotracheal intubation initially described at EUSEM 2018 Congress in Scotland, further explored in 2019, and 2023. The purpose of this innovation is to expand the endotracheal intubation domain for EM physicians with visual comparison of tracheal and esophageal radiographic anatomy by use of a radiopaque custom device technique performed under portable fluoroscopy on a cadaver.
Methods: We obtained the following: SunMed Introducer Adult Bougie 15Fr x 70cm with Coude Tip, Hillman Group Ook 18 Gauge Steel Galvanized Wire, MAC 3 laryngoscope, trauma shears, tegaderm, single cadaveric cephalus and torso specimen. We used shears to cut the bougie at the 55cm mark. The proximal segment of the bougie was removed to allow insertion of the guide wire into the distal hollow bougie. The proximal segment was then replaced back over the guide wire modification of the distal segment and sealed together with tegaderm to create the custom device. Anatomy was visualized with the MAC blade and by portable fluoroscopy. Endotracheal intubation and relative fluoroscopic views of the custom device in the esophagus and trachea were obtained. Sensation of tracheal rings was used as tracheal confirmation.
Results: The custom device created a dynamic relative radiopaque posterior signal within the esophagus, and a relative anterior signal when placed in the trachea. Endotracheal placement was confirmed with sensation of tracheal rings. Static fluoroscopic comparative images were obtained. (Figure 1)
Conclusion: The biomechanical laboratory simulation experience with a custom device for endotracheal intubation performed with the modified bougie technique demonstrated an anatomic signal discrepancy between esophageal and tracheal placement. Educational and clinical utility of this innovative technique in the appropriate setting would warrant further evaluation. Expanding the domain of endotracheal intubation cognitive and material resources could have the potential to positively impact the core competency of airway management in emergency care.
Matthew VASEY (Tampa, USA)
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#42256 - Comparative study of qSOFA and NEWS scores in sepsis in emergency room.
Comparative study of qSOFA and NEWS scores in sepsis in emergency room.
*Introduction :
Severity scores in sepsis aim to classify patients in terms of initial severity and subsequent prognosis. Several clinical scores have been developed to assess the severity of patients admitted to the emergency room for sepsis..
*Goals :determine the contribution of qSOFA and NEWS scores in the assessement of the severity of patients admitted to the emergency room for sepsis.
*Material and methods :
This is a prospective comparative and single-center descriptive study which took place over a period of 24 months in the emergency department.
Inclusion criteria: both sexes, age > 18 years, admitted for sepsis.
Non-inclusion criteria: patient in ACR, pregnant women.
A comparative study between the contribution of qSOFA and NEWS scores was carried out.
*Results :305 patients hospitalized in the emergency room for sepsis were collected. The average age was 62 years with extremes ranging from 19 to 95 years and a gender ratio of 1.47. The main reasons for consultation were: fever (209; 68.5%), asthenia (210; 68.9%), confusion (35; 11.5%), dyspnea (120; 39.3%), cough (53). ; 17.4%), chest pain (22;7.2%), palpitations (199;65.2%), urinary signs (47;15.4%) and digestive signs: abdominal pain (20.7%, vomiting (18.4%), diarrhea (7.9%) The sepsis severity scores were calculated. The averages of the qSOFA, NEWS, MEWS and SOFA scores were respectively 7.71; and 4.63.
The factors associated with a qSOFA score≥ 2 are: male gender (p=0.019), hypertension (p=0.016), chronic renal failure (p=0.001), hemodialysis (p=0.001), cough (p=0.001), confusion (p=0.05), urinary tract infection (p=0.018), worsening (p=0.000), shock (p=0.001), use of norepinephrine (p=0.001), multiorgan failure (p= 0.005), acute renal failure (p=0.000) and death (p=0.001). The factors associated with a qSOFA score≥ 7 are: Dyspnea (p=0.000), confusion (p=0.025), pulmonary infection(p=0.000), urinary infection (p=0.011), skin infection (p=0.014), worsening (p=0.000), shock (p=0.001), ARDS (p=0.003), multiorgan failure (p=0.001) death (p=0.000).
*Conclusion :In the management of sepsis in the emergency room, the classification of the initial severity as well as the risk of secondary deterioration of patients is essential. Alongside qSOFA, the use of the National Early Warning Score (NEWS) appears to be an important tool for the triage of patients admitted for sepsis.
Sirine KHABOUCHI, Dhekra HOSNI, Hana HEDHLI, Safia OTHMANI, Khaireddine JEMAI (Tunis, Tunisia), Aymen ZOUBLI, Sarra JOUINI
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#41239 - Comparative Study of Tracheal Intubation with Only the Epiglottis Visible: Macintosh and Hyperangulated Videolaryngoscope, Bougie, and Videostylet in Simulated Cadavers.
Comparative Study of Tracheal Intubation with Only the Epiglottis Visible: Macintosh and Hyperangulated Videolaryngoscope, Bougie, and Videostylet in Simulated Cadavers.
Background:
Cormack-Lehane grade 3B conditions, where only the epiglottis is visible, present significant challenges for direct laryngoscopy. The specific effectiveness of videolaryngoscopy devices in such cases remains underexplored due to their rarity.
Objectives:
To assess the efficacy of different intubation devices—standard geometric videolaryngoscope (SGVL), SGVL with bougie, videostylet (VS), and hyperangulated videolaryngoscope (HAVL)—in simulated Cormack-Lehane grade 3B airways.
Design, Settings, and Participants:
Thirty-three second-year inexperienced residents from various specialties were trained and then randomized to intubate two prepared cadavers simulating Cormack-Lehane grade 3B conditions using the four devices. Intubation success rates, times, and difficulty (via VAS scores) were recorded.
Main Outcome Measures:
Primary outcome was intubation success or failure, with secondary outcomes including intubation time and perceived difficulty.
Results:
Success rates within 90 seconds were: SGVL 57.6%, SGVL + bougie 60.6%, HAVL 63.6%, and VS 87.9%. VS significantly exceeded SGVL in performance, with a hazard ratio of 2.5 and an odds ratio of 5.4 (95% CI of 1.4 to 4.4 and 1.7 to 17.7, respectively). VAS scores significantly correlated with success rates and times.
Conclusions:
In a study using a cadaver model with novice clinicians, VS significantly improves intubation success rates and times in simulated Cormack-Lehane grade 3B conditions over SGVL, SGVL + bougie, and HAVL, suggesting it as the preferred device for difficult airways, albeit with additional training requirements. This study emphasizes the importance of videolaryngoscopy selection in managing Cormack-Lehane grade 3B.
Dr Tzu-Yao HUNG, Hsin-Ling CHEN (Taipei, Taiwan), Monrou LEE, Ya-Chin LIANG
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#41286 - Comparing Prognostic Scores: ANCOC vs. CURB-65 for Predicting Mortality in Pneumonia Patients.
Comparing Prognostic Scores: ANCOC vs. CURB-65 for Predicting Mortality in Pneumonia Patients.
Background: Emergency physicians needs a clinical scoring system that can quickly and precisely forecast the outcome of patients facing pneumonia. This helps in enhancing clinical decision-making and ensuring high-quality care for each patient. Back in March 2022, amidst the initial surge of the COVID-19 pandemic, we introduced the ANCOC score. This prognostic tool, examining five parameters (age, blood urea nitrogen, C-reactive protein, oxygen saturation, comorbidities), effectively predicted 60-day mortality risk in patients with COVID19, regardless of vaccination status and viral variant. However, as we move past the pandemic, pneumonia remains one of the most can arise from various causes beyond SARS-CoV-2 infection.
Traditionally, in such scenarios, the CURB-65 score has been employed, estimating mortality risk for community-acquired pneumonia and assisting in decisions regarding inpatient versus outpatient treatment. Our research aims to investigate whether the ANCOC score, originally designed for COVID-19-related pneumonia, is applicable to all pneumonia cases and how it stacks up against the CURB-65 score.
Methods: We conducted a retrospective analysis of 461 patients (280 females and 141 males) admitted to our emergency department (ED) with a diagnosis of pneumonia. We collected demographic data, comorbidities, immunization status, and various laboratory, radiographic, and blood gas parameters for all patients. Additionally, we documented treatment modalities administered and the necessity of oxygen therapy for each patient. Subsequently, both the ANCOC score and the CURB-65 score were calculated for every individual.
Results: In our multivariate analysis, several parameters were significantly associated with an increased risk of mortality. These included male gender, advanced age, low systolic blood pressure, elevated urea levels, reduced Glasgow Coma Scale (GCS) scores, high serum LDH levels, and the presence of chronic obstructive pulmonary disease (COPD). Conversely, parameters significantly linked with an increased risk of admission to the intensive care unit included age, low PaO2/FiO2 ratio, low GCS scores, high LDH levels, elevated neutrophil-to-white blood cell ratio, and the presence of COPD as a comorbidity. To evaluate the accuracy of mortality prediction, we constructed receiver operating characteristic (ROC) curves. The area under the ROC curve was 0.672 for the ANCOC score and 0.708 for the CURB-65 score. No significant difference in accuracy between the ANCOC and CURB-65 scores was observed.
Conclusion: In an increasingly aged and vulnerable population, even a case of pneumonia can have serious consequences. Hence, it's imperative for emergency physicians to utilize scoring systems that can swiftly and precisely predict mortality risk to provide appropriate attention and treatment right from the diagnosis of penumonia in the emergency department. Even if the ANCOC score showed no difference when compared to the CURB-65 score in predicting mortality among patients with pneumonia, its performance seems to be inadequate for clinical practice.
Marta SACCO, Andrea EGIZI (Rome, Italy), Chiara BENNET, Giulia PIGNATARO, Maria LUMARE, Ilaria BALSAMO, Andrea PICCIONI, Francesco FRANCESCHI, Marcello CANDELLI
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#41866 - Comparing the prevalence of occupational burnout among non-physician personnel in the emergency department and other inpatient departments.
Comparing the prevalence of occupational burnout among non-physician personnel in the emergency department and other inpatient departments.
Introduction: The prevalence of occupational burnout among emergency department (ED) nurses is high. We aimed to compare the prevalence of burnout among non-physician personnel in the emergency department with other inpatient departments in three hospitals affiliated to Iran University of Medical Sciences.
Methods: A cross-sectional study was conducted in three hospitals in Tehran, Iran. The demographic characteristics of the personnel were measured using a checklist and the level of occupational burnout was measured using the Persian version of the Maslach Burnout Inventory.
Results: 200 personnel completed the questionnaires with a response rate of 76.9%. The ED nurses and paramedics scored higher on all the dimensions of occupational burnout except one, as well as the level of conflict they experienced. The non-ED nurses and paramedics experienced a higher intensity of personal inadequacy. Among ED personnel, the level of emotional exhaustion was significantly higher in the evening shift than in the morning and night shifts. Nurses were more affected by burnout compared to their paramedic colleagues. Age, work experience, and gender were significantly related to burnout dimensions.
Conclusion: ED nurses and paramedics are vulnerable to occupational burnout, and measures to reduce this high prevalence should be among the priorities of the managers' future planning.
Samira VAZIRI, Kourosh JAVDANI ESFEHANI (Dubai, United Arab Emirates)
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#40709 - Comparison between Quality of Chest Compression by Foot and Hand in Middle School Children: A Randomized, Crossover Manikin Study.
Comparison between Quality of Chest Compression by Foot and Hand in Middle School Children: A Randomized, Crossover Manikin Study.
Introduction:
Cardiopulmonary resuscitation (CPR) by a stander can increase the survival rate of patients experiencing out-of-hospital cardiac arrest (OHCA). However, in cases where the bystander is a child, performing CPR using the standard hand-only technique may not be possible due to factors such as lower body weight or increased fatigue. To enhance the effectiveness of CPR in special situations, it has been found that using the feet for chest compressions is equally effective as using hands in adults. However, there is limited research on the effectiveness of this method when the bystander is a child. So, it is still unclear whether using the feet for chest compressions when the bystander is a child can significantly improve the efficiency of chest compressions.
Objectives:
Primary object: To investigate the effectiveness of chest compressions using the feet as compared to that using the hands in school-aged children under 15 years old, including 1. Compression rate 2. Compression depth 3. Percentage of fully chest recoil over 2 minutes. Secondary object: To study the relationship between the body weight and the effectiveness of chest compressions, considering both the method of using feet and hands.
Method :
In this crossover randomized controlled trial study, we recruited a total of 44 participants who were students aged 13-15 years. We used CPR Training Manikins that provide feedback data. Subject were randomly selected through a simple draw. Afterward, they performed chest compressions using the assigned method. After completing 2 minutes, the participants switched to the other method.
Results:
The compression rate by hands is greater than that by feet, at 11.3±14.2 bpm (P<0.001) and the percentage of fully chest recoil by hands is higher than that during foot compressions, at 26.2±23.9% (P<0.001). In contrast, the compression depth by feet is greater than that by hands, measuring 14.7±7.4 mm (P<0.001).
Conclusion:
In school-aged children, chest compressions by feet have an advantage over chest compressions by hands in terms of compression depth. However, manual chest compressions still exhibit a faster compression rate and a higher percentage of chest recoil, which align with established standards. The weight of the chest compressor does not significantly impact the overall efficiency of chest compressions.
Thai red cross society
Narong JONGARAMRUENG (, Thailand), Warathathai PHUSINAKKARAGUL
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#41997 - Comparison of analgesic efcacy of ibuprofen and dexketoprofen in pain management of long bone fractures: a prospective, randomized, double blind study.
Comparison of analgesic efcacy of ibuprofen and dexketoprofen in pain management of long bone fractures: a prospective, randomized, double blind study.
Acute pain represents a pervasive challenge within emergency departments, impacting nearly 80% of patients . Particularly in the context of acute trauma, pain can exacerbate central sensitivity, underscoring the imperative to address it efectively with analgesia tailored to this unique consideration . Managing pain associated with emergency scenarios not only enhances patient comfort but also upholds a fundamental human right. Moreover, persistent pain and associated emotional states can trigger heightened chemical release and stress responses postinjury
Despite the wealth of experience among emergency physicians, instances of oligoanalgesia may arise due to suboptimal dosing and selection of analgesics . A study revealed that 33% of acute trauma patients received analgesic treatment, often misaligned with the severity of their pain . Shockingly, only a third of individuals presenting to the emergency department with extremity fractures received appropriate analgesic intervention . Long bone fractures (LBF), encompassing tibial, femoral, and humerus fractures, constitute approximately 4% of emergency department visits in the USA, amounting to 2 million visits annually . These fractures frequently induce severe pain, and efcacious pain control signifcantly contributes to the enhancement of patients’ quality of life . The landscape of pain management in the context of LBF is multifaceted, considering the diverse reasons for their occurrence, the varied patient populations afected, and the need for a comprehensive array of approaches in their treatment . Non-steroidal anti-infammatory drugs (NSAIDs) are frequently employed in the emergency department for pain management, specifcally in patients with bone fractures . Despite their common usage, there exists no defnitive evidence-based recommendation regarding the choice of NSAIDs for this indication. Dexketoprofen (Dex) and ibuprofen (Ibu) stand as illustrative examples within this drug category, with current literature suggesting similarities in their pharmacodynamic properties while hinting at potential distinctions in specifc indications . The objective of this randomized, controlled, doubleblind study was to assess the pain-controlling efectiveness of Dex 50 mg and Ibu 800 mg in the context of LBF, utilizing the visual analog scale (VAS) as the primary evaluation metric.
Methods Conducted between August 10, 2023, and January 17, 2024, the study included 100 eligible patients randomized into Dex and Ibu groups. Visual analog scale (VAS) scores were measured at baseline and at 30, 60, and 120 min. DeltaVAS (ΔVAS) values and ΔVAS percentages (ΔVAS%) were calculated. Primary endpoints were ΔVAS scores (ΔVAS 30-60-120) and ΔVAS% for comparative analysis.
Results Statistical analysis showed no signifcant diference in ΔVAS30 (p=0.359). However, ΔVAS60 exhibited a signifcant diference (p=0.027), as did ΔVAS120 (p=< 0.001). ΔVAS%30 showed no signifcance (p=0.224), but ΔVAS%60 and ΔVAS%120 were clinically and statistically signifcant (p=0.017 and p=< 0.001, respectively).
Conclusion Ibuprofen 800 mg demonstrated superior analgesic efcacy at 60 and 120 min compared to Dex in long bone fractures. These fndings suggest ibuprofen’s potential as an efective pain management option in emergency departments.
Safa DÖNMEZ, Alp SENER, Kadir YENAL (Yenimahalle, Turkey)
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#42195 - Comparison of disaster preparedness systems in four major events in the Pyrenean cross-border territories.
Comparison of disaster preparedness systems in four major events in the Pyrenean cross-border territories.
Background:
In the face of challenges related to health management and security, crowd gatherings require the implementation of specific emergency preparedness measures. For large-scale events in the cross-border Pyrenees area, cooperation among French, Spanish, and Andorran territories, along with the harmonization of procedures and pooling of resources, would optimize medical care. The aim of this study is to describe and compare the risks faced by the disaster preparedness systems (DPS) deployed during four major events in the cross-border area as well as their organization : the "Encierro" of the San Fermin festivities in Pamplona, the Catalan national holiday in Barcelona, the Bayonne festivities and the Fête de la Musique in Toulouse.
Methods :
We conducted a descriptive cross-sectional, comparative study on four large-scale DPS implemented in 2022 during major annual events across the France-Spain border area. The data were collected through a survey sent to the organizers of the DPS set up for the event. The main health risks and associated injuries were identified and compared according to the characteristics of the four events.
Results:
The main aim of the system set up for the Encierro in Pamplona is to deal with serious penetrating injuries, that cause severe uncontrollable bleeding, most of which cannot be tourniqueted. Concerning the system set up in Toulouse music festival and Catalonia National Day in Barcelona, the objective is to deal with the risks of crowd movements in confined spaces, minor traumas, collapsing mobile structures (numerous scenes), heatstroke, malaise and alcoholism over one day. The same risks are observed during the Bayonne festival, but over 5 full days.
Discussion and conclusion:
The organization of each DPS is based on an analysis of the foreseeable risks specific to each event. For the four gatherings studied, a coordination of healthcare and emergency services was observed, bringing together representatives of the various services concerned in an operational command post for the duration of the event. These command posts usually also include representatives of law enforcement agencies and local politicians.
The medical call center may be strengthened (Bayonne, Toulouse) or not (Pamplona, Barcelona). All four systems systematically include extraction points and dedicated routes for evacuating victims to emergency department. All DPSs, with the exception of Catalonia's National Day, have set up Mobile Field Hospitals, which aim to reduce the demand for hospital care and mitigate the impact of events on the activity of emergency units, thus avoiding the need for additional hospital professionals during the event.
Finally, the medicalization of the four systems is ensured by specialized medical and paramedical teams, experienced in emergency medicine and skilled in the management of critically ill patients. This comparative analysis reveals fundamental organizational principles shared by the partners, and encourages cross-border cooperation for optimal territorial response in exceptional health situations. However, differences persist among the studied measures, and broader-scale efforts are needed to develop common procedures.
Trial Registration: This study has not been registered because it was not a clinical work
Funding: This study did receive funding from EGAL-URG project (FEDER, INTERREG-POCTEFA)
Ethical approval and Informed consent: Not needed
Vanessa HOUZE-CERFON (TOULOUSE), Anna RIBERA CANO, Nicolas HARCAUT, Emilie LAROSA, Fabrice DESRUES, Jorge MORALES, Tomas BELZUNEGUI, Vincent BOUNES
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#41534 - Comparison of management practices for ST-segment elevation myocardial infarction within emergency departments of various hospitals in Wallonia and Brussels.
Comparison of management practices for ST-segment elevation myocardial infarction within emergency departments of various hospitals in Wallonia and Brussels.
Introduction
The optimal management of ST-segment elevation myocardial infarction (STEMI) involves the prompt administration of pharmacological treatments and transfer to a coronary angiography unit. European and American guidelines exist regarding these treatments, which involve the administration of antiplatelet agents and anticoagulants. This study focuses on comparing the management practices in Wallonia and Brussels with the existing guidelines.
Methods
To collect the necessary data, a survey using a "Microsoft Form" was emailed to various heads of emergency departments in hospitals in Wallonia and Brussels. This survey includes questions about the type of management, the presence or absence of standardized protocols, and the use of various drugs described in the literature. The collected data was organized in percentages and graphs, and compared to study the differences between the administered treatments and existing guidelines.
Results
26 hospitals participated in this study. The majority have a written protocol for managing STEMI, which is in the majority of cases (72.73%) a consensus between emergency physicians and cardiologists at the respective hospital. Administration of aspirin is unanimous and systematic. In 11.54% of protocols, a second antiplatelet drug is not routinely added to aspirin. Ticagrelor is the most commonly administered antiplatelet agent, followed by Clopidogrel and Prasugrel. 92.31% of participating emergency departments administer heparin, with unfractionated heparin being the most commonly given (83,33%), followed by low molecular weight heparin (16,67%). Two emergency departments consider the administration of Fondaparinux (7.69%).
Conclusion
The management of STEMI infarctions is a widely studied topic in the scientific literature. Treatment upon diagnosing a STEMI involves administering dual antiplatelet therapy consisting of Aspirin and a P2Y12 inhibitor. The choice of this inhibitor is not standardized neither in the literature nor in the surveyed hospitals, but the administration of Aspirin is unanimously agreed upon. Anticoagulant therapy is not administered in all hospitals but mainly consists of unfractionated heparin.
Despite the existence of recognized guidelines, differences are still found in the practices of in-hospital and pre-hospital care. Currently, there is no standardized Belgian protocol. The creation of such a protocol is an interesting prospect for standardized patient care, as well as for the training of young physicians.
Natacha DELRUELLE, Dr Thierry PRESEAU (Brussels, Belgium)
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#42318 - Comparison of patients with multiple body injuries before and after COVID-19 pandemic based on data from Trauma Center in Lodz (Poland) - the observational retrospective study.
Comparison of patients with multiple body injuries before and after COVID-19 pandemic based on data from Trauma Center in Lodz (Poland) - the observational retrospective study.
Background: Patients suffering multiple body injuries are the most demanding cases in Emergency Department. Although profile of such patients have already been changing over the years, COVID-19 outbreak hastened those changes considerably. This study presents the most significant differences.
Methods: The analysis includes patients with multiple body injuries admitted to Trauma Center in Lodz pre- and post-pandemic. Time frames for this study were established to 19th of March 2019 to 19th of March 2020 and 16th of May 2022 to 16th of May 2023. Pandemic period has not been included. A total of 149 patients has met the criteria of severe body injuries (rated accordingly to ICD-10 classification).
Data was compared in regard to total amount of patients, their age, gender, severity of injuries and external causes of injuries. The goal was to create a modern model of a standard injured patient admitted to Trauma Center.
Results: Study have shown a decrease in total number of patients suffering multiple body injuries. Female to male ratio has increased. Median of age remained the same for the whole patient sample, but it changed when accounted for gender. It was noted that total amount of injuries of each type did not change significantly. Number of motorcycle accidents and falls (including suicide attempts) have increased. No significant differences have been noted in number of car occupant and pedestrians injured in collisions. Mortality rate in Intensive Care Unit of trauma patients initially treated in Emergency Department in Lodz has lowered.
Conclusion and discussion: The profile of trauma patient has changed after COVID-19 in regard to number, gender ratio and external causes of injuries. It is suspected that people simply paid less attention to their own safety after the end of pandemic. There are numerous potential factors which could have influenced the final outcome, e.g. traffic regulations, car safety, morbidity of psychiatric diseases. Such changes may require adjustments to the approach to treatment of trauma patients. Further observations and data collection from several centers are recommended.
Ethical approval in progress / This study did not receive any specific funding.
Agnieszka BARTYKA (Łódź, Poland), Anna PAWLICA
00:00 - 00:00
#41806 - Comparison of postcontrast acute kidney injury incidence according to diagnostic criteria following cerebral angiography in patients with acute ischemic stroke at the emergency department.
Comparison of postcontrast acute kidney injury incidence according to diagnostic criteria following cerebral angiography in patients with acute ischemic stroke at the emergency department.
Background: This study aimed to compare the previous and current diagnostic criteria for postcontrast acute kidney injury (PC-AKI) in patients with acute ischemic stroke (AIS) who underwent cerebral angiography in the emergency room (ER), confirm the changes in the diagnostic rate of PC-AKI, and determine whether the revised criteria accurately reflected PC-AKI. The goal was to provide physicians with evidence to make decisions regarding proactive intervention and treatment in the ER.
Methods: This retrospective study used data from patients registered in the Brain Salvage through Emergent Stroke Therapy (BEST) protocol at a tertiary university hospital in Seoul, South Korea. The BEST protocol was designed for prompt diagnosis and rapid thrombolysis in patients suspected of having AIS in the ER. The study focused on adult patients aged ≥18 years who presented to the ER and underwent cerebral angiography after activating the BEST protocol from October 2018 to June 2023. Specifically, this study targeted patients who underwent cerebral angiography after BEST protocol activation and were subsequently diagnosed with PC-AKI. The updated diagnostic criteria are in accordance with the 2018 European Society of Urogenital Radiology guidelines.
Results: The PC-AKI incidence rate significantly decreased in the updated criteria compared to that in the previous criteria (p = 0.048). Specifically, the use of the relative criterion resulted in a nearly threefold decrease in the incidence of PC-AKI (p = 0.002). Patients with baseline estimated glomerular filtration rate (eGFR) ≥90 mL/min/1.73 m2 also demonstrated a significant decrease in PC-AKI incidence under the updated criteria (p = 0.030). The PC-AKI diagnosis rate was significantly lower under the updated criteria for patients with baseline eGFR 60–<90 and ≥90 mL/min/1.73 m2 (p = 0.009 and 0.030, respectively). Changes in the diagnostic criteria, especially modifications in the relative criterion, had a significant impact on the PC-AKI incidence.
Conclusions: The incidence of PC-AKI in patients with AIS undergoing cerebral angiography has significantly decreased by nearly half in conjunction with changes in the diagnostic criteria. Particularly, patients with a baseline eGFR of ≥90 mL/min/1.73 m² exhibited a substantial reduction in PC-AKI incidence. When focusing solely on the relative criteria, a decrease in PC-AKI incidence was observed in patients with a baseline eGFR of ≥60 mL/min/1.73 m². These results enhance the robustness of the current diagnostic criteria and may encourage more proactive interventions without hesitation about weighing the risks and benefits when patients with suspected AIS present to the ER.
Chaeryoung PARK (, Republic of Korea)
00:00 - 00:00
#41545 - Comparison of the protective effects of uridine, therapeutic hypothermia and a combination of both in experimental traumatic brain injury.
Comparison of the protective effects of uridine, therapeutic hypothermia and a combination of both in experimental traumatic brain injury.
Background
Traumatic brain injury (TBI) is regarded as an emergency situation with high morbidity and mortality rates worldwide. Although most of the patients admitted to the hospital are diagnosed with mild traumatic brain injury, permanent damage could be seen in the long term period. The physiopathological processes of traumatic brain injury are classified as; primary injury and secondary injury period. While primary brain injury occurs immediately after trauma, secondary injury occurs hours and days after primary injury. The aim of this study was to examine the changes in oxidative, inflammatory and apoptotic parameters within the secondary injury period in an experimental model of traumatic brain injury and to compare the neuroprotective effect of uridine, hypothermia and their combination.
Methods
In our study, the free weight drop model defined by Marmarou et al. was used and mild hypothermia (32-34.0±1°C) was applied for 4 hours. Uridine was administered intraperitoneally in 500mg/kg dose for 7 days following traumatic brain injury. Subsequently, brain tissue analyzes were performed using TTC, Western Blot and ELISA kits.
Results
Among the oxidative parameters, Glutathione Peroxidase was increased with the combination therapy, while Catalase and Myeloperoxidase were decreased. Levels of the inflammatory markers Interleukin-1β and Interleukin-6 were decreased with combination therapy. Poly ADP-ribose polymerase-1, which is involved in the necrotic process, was increased after TBI and decreased with hypothermia, uridine and combination therapy.
Discussion & Conclusions
The main goal in the approach to traumatic brain injury is to protect the patient against the effects that occur during the secondary injury period. In our study, the efficacy of uridine-hypothermia combination therapy was demonstrated after seven days of treatment, which is the first in the literature in this respect. If these effects could be confirmed with further studies, this combination could be considered a treatment approach that can be used in routine practice in mild traumatic brain injury and to be included in trauma patient management guidelines.
This study received funding from the Bursa Uludag University Medical Faculty Scientific Research Project Coordination Unit (DDP (T)- 2018/14- BAP).
Vahide Aslıhan DURAK, Aysen CAKIR, Birnur AYDIN, Mehmet CANSEV, Tulin ALKAN (BURSA, Turkey)
00:00 - 00:00
#41421 - Concurrent cardio-cerebral infarction.
Concurrent cardio-cerebral infarction.
Brief Clinical History: This case report presents a complex and intriguing scenario of concurrent cardio-cerebral infarction in an 84-year-old female with a notable medical history. The patient, with a background of hypertension, chronic kidney disease stage 3, essential thrombocythemia, exudative age-related macular degeneration, and monoclonal gammopathy, was brought by ambulance with sudden onset of right-sided weakness and dysphasia while attending a funeral service. She didn't sustain any head trauma and was brought in with markedly decreased level of consciousness which necessitated urgent medical assessment. She had a gcs of 11 and NIHSS of 23 .Her blood pressure was elevated to 226/120 otherwise respiratory and cardiovascular examination was unremarkable .
Misleading Elements – History, Examination, Investigations: The initial clinical assessment was confounded by the subtle and atypical presentation of concurrent cardio-cerebral infarction. Patient wasn't able to communicate due to which detailed history taking was not possible , The absence of typical cardiac symptoms obscured the diagnosis of acute myocardial infarction (AMI), with initial focus directed towards identifying the etiology of acute neurological deficits. This diagnostic challenge underscores the importance of maintaining a broad differential diagnosis and considering multifactorial etiologies in elderly patients with complex medical histories.
Helpful Details – History, Examination, Investigations: Detailed neurological examination revealed focal deficits consistent with acute ischemic stroke, corroborated by neuroimaging demonstrating a hyperdense left middle cerebral artery indicative of thrombosis. Simultaneously, electrocardiography unveiled ST-segment elevation in the inferior leads, confirming the diagnosis of acute inferior AMI. Comprehensive laboratory investigations, including blood samples cardiac markers and bedside echocardiography and imaging studies such as non-contrast CT head, facilitated accurate diagnosis and informed subsequent management decisions.
Differential and Actual Diagnosis: The differential diagnosis encompassed a spectrum of acute neurological and cardiovascular pathologies, with concurrent cardio-cerebral infarction emerging as the most likely diagnosis. Other differentials include Acute Aortic syndrome predominant dissection ..Clinically, there are generally three types: the first is when AIS and AMI occur at the same time, the second is when AIS occurs after subacute myocardial infarction, and the third is that AMI occurs at the early stage of systemic thrombolysis in AIS The definitive diagnosis of concurrent cardio-cerebral infarction was established based on clinical, radiological, and laboratory findings, highlighting the importance of a systematic and comprehensive diagnostic approach.
Educational and/or Clinical Relevance: This case report offers valuable insights into the diagnostic and therapeutic nuances of concurrent cardio-cerebral infarction, a rare and challenging clinical entity. It underscores the importance of interdisciplinary collaboration, timely intervention, and individualized treatment strategies in optimizing outcomes in such complex clinical scenarios. Furthermore, the case highlights the need for heightened awareness among healthcare professionals regarding the potential coexistence of cardiovascular and cerebrovascular pathology in elderly patients with multiple comorbidities. This case serves as a poignant reminder of the diagnostic challenges and therapeutic dilemmas encountered in the management of concurrent cardio-cerebral infarction and emphasizes the importance of continued research and clinical vigilance in this evolving field.
Mohd PAREY (Lancaster, )
00:00 - 00:00
#41398 - Construction and evaluation of a predictive model for liver injury associated with heatstroke: A multicenter retrospective study.
Construction and evaluation of a predictive model for liver injury associated with heatstroke: A multicenter retrospective study.
Abstract
Background: Liver injury related to heatstroke plays a pivotal role in secondary multi-organ damage and is a direct cause of mortality in affected patients of heatstroke. This study was designed to identify independent risk factors associated with liver injury in heatstroke and to construct a clinically applicable predictive model.
Methods: We conducted a retrospective analysis of 188 patients diagnosed with heatstroke, treated in the emergency departments of eight medical institutions from July 1, 2022, to September 30, 2023. Patients were categorized into a liver injury group (n = 80) and a non-liver injury group (n = 108), based on liver function indices recorded during hospitalization. Lasso regression was employed for variable refinement, while multifactorial logistic regression was utilized to identify independent risk factors for liver injury in heatstroke and to construct a nomogram model. The model's efficacy was evaluated using the C-index, calibration curves, and decision curve analysis, examining its discriminative ability, calibration, and clinical utility.
Results: The nomogram included predictive factors such as the Glasgow score, absolute lymphocyte count, lactate dehydrogenase levels, and creatine kinase isoenzyme. The model showed high accuracy and discriminative capability. The C-index was 0.852 (95% CI 0.80-0.905) with a calibration index of 0.843. Decision curve analysis revealed significant clinical applicability for this nomogram.
Conclusion: The study identified four key independent risk factors for liver injury in heatstroke patients. The constructed nomogram, based on the four clinical indicators, demonstrated robust predictive accuracy, discriminative power, and clinical relevance.
This work was supported by the National Key Research and Development Program of China (2021YFC2501800 )
Hongguang GAO (Chengdu, China), Rong YAO
00:00 - 00:00
#41862 - Continuously and non-invasively monitor CPR quality through bedside ultrasound of carotid and femoral artery in Emergengcy Department.
Continuously and non-invasively monitor CPR quality through bedside ultrasound of carotid and femoral artery in Emergengcy Department.
BACKGROUND: International guidelines recommend the administration of high-quality cardiopulmonary resuscitation (CPR) during the rescue of cardiac arrest(CA). The end-tidal carbon dioxide(ETCO2) measurement is regarded as the gold standard index for assessing CPR efficacy. However, more and more clinical cases have found the limitaions of ETCO2 during CPR. It is necessary to implement a new non-invasive hemodynamic monitoring method to evaluate the CPR efficacy in real time.
METHODS: This prospective study enrolled CA patients in the emergency department(ED) and healthy volunteers as controls. Those who were younger than 18 years old, pregnant , or diagnosed as neck, chest or extremities trauma were excluded. A physician, who was not involved in resuscitation team, started to perform bedside ultrasound for bilateral carotid and femoral artery blood flow during chest compressions within the first 10 minutes of CPR in ED. We measured the pulse, peak systolic velocity(PSV) and end-diastolic velocity(EDV) of each artery, and calculated the resistance index (RI) and pulsatility index (PI). EtCO2 values during the same period were also recorded for further analysis of chest compressions efficacy. The clinical data and presumed CA cause of patients were recorded. This research meets the standards of medical ethics and has been approved by the Ethics Committee of Zhongnan Hospital of Wuhan University. Approval number: LINYANLUN [2022133]. All detection and clinical data collection have obtained informed consent from heathy volunteers or patient’s families.
RESULTS: We enrolled 31 CA patients and 13 heathy volunteers. 2 patients achieved final restoration of spontaneous circulation(ROSC). Although there was no statistical difference, CA patients showed lower PSV in bilateral carotid artery compared with healthy volunteers. According to EtCO2 data, LUCAS chest compression system performed better than manual chest compressions. There was no statistical difference in PSV(RCA 62.73±8.17cm/s, LCA 80.74±9.04cm/s, RFA 65.05±6.44cm/s, LFA 72.16±11.59cm/s) and EDV between bilateral carotid and femoral artery in CA patients. Meanwhile, there was no obvious correlation between PSV and EtCO2 during the same period of CPR.
CONCLUSIONS: There are certain limitations in EtCO2 feedback on CPR quality, especially in patients with pulmonary disease or prolonged arrest. Bedside ultrasound detection for PSV and EDV of carotid and femoral artery during chest compressions is non-invasive, continuous and easy to operate, and can act as a feasible observation index for clinical real-time monitoring of chest compression efficacy.
This protocol has been registered in Clinical Trials website: NCT05859516(Application of Point-of-care Ultrasound in Rapid Assessment of Cardiac Arrest Patients).
Feihong YANG (, China), Jiaohong GAN, Hao ZOU, Xiaopeng TU, Cheng JIANG, Jian XIA
00:00 - 00:00
#41438 - Contrast-induced nephrotoxicity, true or myth? Real world data from an observational single center study.
Contrast-induced nephrotoxicity, true or myth? Real world data from an observational single center study.
Introduction:
Although, Contrast enhanced Computed Tomography (CT) is often mandatory, acute kidney injury (AKI) remains a major concern, especially in patients with pre-existing renal disease, creating a debate between clinicians and radiologists. A recent Consensus statement recommends the division of patients with AKI following intravenous contrast media administration in two categories; patients with Contrast-induced Acute Kidney disease (CI-AKI) and patients with Contrast-associated Acute Kidney Disease (CA-AKI), suggesting that other nephrotoxic agents may have contributed to the development of AKI.
Purpose:
We sought to explore the effect of intravenous contrast media administration on renal function in patients who underwent a contrast CT scan in an emergency setting.
Methods:
In a retrospective observational study, between February 2024 and April 2024, we included patients who presented to the Emergency Department of Attikon University Hospital and underwent a contrast CT scan. Baseline variables referring to demographics, medical history, medication as well as the recent use of nephrotoxic agents and during stay in the ED (eg b-lactams, aminoglycosides, vasoactive agents, furosemide, non-steroidal anti-inflammatory drugs), were collected. Moreover, we measured creatinine levels upon presentation and 48 hours after hospitalization and we determined the proportion of patients who developed AKI. Statistical analysis was performed in order to investigate the effect of clinical and nephrotoxic factors on the development of AKI, according to the Kidney Disease Improving Global Outcomes(KDIGO) AKI classification.
Results: We evaluated 255 patients who needed an urgent enhanced CT scan [40,8% females, median age 69 years (IQR 25)]. Most frequent comorbidities were hypertension (36,5%), diabetes mellitus (14,5%) and chronic kidney disease (8,6%). 20,4% of patients were receiving angiotensin II receptor blockers and 16,1% diuretics. 12,5% of patients presented with hemodynamic instability. Most frequent symptoms requiring a CT examination with intravenous contrast media were abdominal pain (36,1%), dyspnea 24,7%, traumatic injuries (13,7%), altered level/loss of consciousness (9,8%) and thoracic pain (4,7%).
In total, 20 patients (7,8%) developed AKI. Chi-square test revealed significant correlations for the development of AKI with hypertension (Rho 0.144, x2(1) 5,243,p=0,022), history of dialysis (Rho 0.147, x2(1) 5,458,p=0,019), diuretic therapy (Rho 0.149, x2(1) 5,649,p=0,017), and chemotherapy with platins (Rho 0.139, x2(1) 4,907,p=0,027), as well as with the presence of hemodynamic instability at the ED (Rho 0.203, x2(1) 10,375,p=0,001) and with the administration of noradrenaline (Rho 0.142, x2(1) 5,106,p=0,024), and furosemide (Rho 0,175, x2(1) 7,710,p=0,005). In a multivariable binary regression model, hemodynamic instability remained the most significant factor for AKI [OR 0.301 (95% CI 0.94-0.949,p=0.044).
Conclusion: Undifferentiated patients presenting to the ED with hemodynamic instability are more vulnerable to renal dysfunction after administration of intravenous contrast media. The direct causality of these agents on AKI seems to be multifactorial. Larger studies including unselected patients, like our population, are needed in order to identify the real risk of contrast-induced nephropathy. Even though this study may not comment on the exact association of contrast media on the development of AKI, it indicates that multiple factors other than contrast media may interfere with renal dysfunction.
Trial registration ΤΕΠ,ΕΒΔ77/31-0Ι-2024
Melina KARAOLIA (ATHINA, Greece), Sofia BEZATI, Panagiota DAMOULAKI, Rakel SASON, Maria KIOUSI, Diana VRIZIDOU, Maria VELLIOU, Maria-Panagiota ALMYROUDI, Antonios DIAKANTONIS, Christos GEORGIOU, Aikaterini MOUTOUPA, Lambros MARKOS, Estela KIOURI, Christos VERRAS, John PARISSIS, Effie POLYZOGOPOULOU
00:00 - 00:00
#42260 - Contribution of the NEWS score in elderly patients admitted for sepsis.
Contribution of the NEWS score in elderly patients admitted for sepsis.
*Introduction :The NEWS score makes it possible to assess the severity of patients admitted to the emergency room for sepsis.A NEWS score ≥7 correlates with high risk.
*Goals :determine the contribution of the NEWS score in assessing the severity of patients aged over 65 admitted to the emergency room for sepsis.
*Material and methods : This is a prospective comparative and single-center descriptive study which took place over a period of 24 months in the emergency department.
*Results :We collected 159 elderly patients hospitalized for sepsis in the emergency room. The average age was 75 years with extremes ranging from 65 to 95 years. The main reasons for consultation were: fever (111; 69.8%), asthenia (110; 69.2%), dyspnea (64; 40.3%), cough (25; 15.7%), urinary signs ( 24;15%). The sepsis severity scores were calculated. The factors associated with a high NEWS score were: infectious site: pulmonary (p=0.015), cutaneous (p=0.046), endovascular (p=0.005), the use of volume expansion ( p=0.021), Noradrenaline (p=0.003), worsening (p=0.000), shock (p=0.003), liver failure (p=0.042), use of hemodialysis (p=0.001) and ventilation mechanical (p=0.002).
*Conclusion :The NEWS score is a crucial tool in assessing the severity of elderly patients hospitalized for sepsis.
Sirine KHABOUCHI, Dhekra HOSNI, Aymen ZOUBLI, Hana HEDHLI, Safia OTHMANI, Khaireddine JEMAI (Tunis, Tunisia), Seif OUERGHI, Asma JENDOUBI, Sarra JOUINI
00:00 - 00:00
#42264 - Contribution of the qSOFA score in the evaluation of sepsis in elderly patients.
Contribution of the qSOFA score in the evaluation of sepsis in elderly patients.
*Introduction :Severity scores in sepsis aim to classify patients according to initial severity. Several clinical scores have been developed.
*Goals :determine the contribution of qSOFA scores in the assessment of the severity of patients aged over 65 years admitted for sepsis to the emergency room.
*Material and methods : This is a prospective descriptive study taking place over a period of 24 months in the emergency department.
*Results :We collected 159 elderly patients hospitalized for sepsis. The average age was 75 years with extremes ranging from 65 to 95 years. The main reasons for consultation were: fever (111; 69.8%), asthenia (110; 69.2%), confusion (35; 11.5%), dyspnea (64; 40.3%), cough (25). ; 15.7%), urinary signs (24;15%) and digestive signs: abdominal pain (13.8%), vomiting (11.9%) Sepsis severity scores were calculated. The means of qSOFA, NEWS, MEWS and SOFA scores were 2.05, respectively; 7.83; 4.58 and 4.7. The factors associated with a qSOFA score ≥2 are: urinary sepsis (p=0.014), acute renal failure (p=0.047), platelet level (p=0.014), creatinine (p=0.011). ) .
*Conclusion :the SOFA q score appears to be an essential tool in estimating the risk of patients admitted for sepsis.
Sirine KHABOUCHI, Khaireddine JEMAI (Tunis, Tunisia), Dhekra HOSNI, Hana HEDHLI, Safia OTHMANI, Ibtihel AISSAOUI, Aymen ZOUBLI, Mahrez BELAID, Sarra JOUINI
00:00 - 00:00
#42089 - Convergence of crisis: A case report of diabetic ketoacidosis masking an impending thyroid storm and periodic paralysis.
Convergence of crisis: A case report of diabetic ketoacidosis masking an impending thyroid storm and periodic paralysis.
Diabetic Ketoacidosis (DKA) is a severe complication of diabetes mellitus characterized by hyperglycemia, metabolic acidosis, and ketonemia. Thyroid storm, an extreme manifestation of thyrotoxicosis, presents with a myriad of symptoms, including hyperthermia, tachycardia, and altered mental status. Periodic paralysis, although rare, can be precipitated by various metabolic disturbances, including thyrotoxicosis, and may lead to life-threatening episodes of muscle weakness or paralysis. We present a case of a 41-year-old female with a history of type 1 diabetes mellitus & hyperthyroidism, who presented with DKA complicated by an impending thyroid storm and likely periodic paralysis being exacerbated due to hypokalaemia. Prompt recognition and aggressive management of each component of this triad were essential for positive patient outcomes.
In a patient with coexisting type 1 DM and hyperthyroidism, compensatory mechanisms of DKA cause cortisol and catecholamine release, which, when combined with rapid metabolic shifts, trigger a thyroid storm. (1) Another theory suggests that excess thyroid hormone causes an impairment of carbohydrate metabolism, causing an increase in intestinal carbohydrate absorption and hepatic glycogen breakdown, aggravating insulin resistance, and triggering DKA, ultimately leading to thyroid storm (2). This case underscores the importance of a comprehensive approach to managing complex metabolic emergencies, particularly in patients with multiple comorbidities. Our patient presented to the emergency department with symptoms of severe vomiting, shortness of breath, and altered mental status. Laboratory investigations revealed profound metabolic derangement indicative of DKA, alongside impending thyrotoxicosis and hypokalaemia periodic paralysis. Management involved aggressive fluid resuscitation, insulin therapy, anti-thyroid medications, and potassium supplementation, with a multidisciplinary approach to stabilize the patient's condition.
Abizar RANGOONWALA (Boston, ), Abhishek SINHA, Aditya JAIN
00:00 - 00:00
#42339 - Convulsive seizures of known epileptics in emergency departments: epidemic-clinical, therapeutic and prognostic studies.
Convulsive seizures of known epileptics in emergency departments: epidemic-clinical, therapeutic and prognostic studies.
INTRODUCTION :
Adult seizures are a frequent reason for admission to emergency departments, often with significant morbidity. Seizures are one of the most worrying symptoms in people with epilepsy, a chronic neurological disease affecting a large population worldwide.
This abstract examines the epidemiology of seizures in patients with epilepsy, highlighting demographic data.
METHODS : We conducted a prospective descriptive study over a three-year period. We included patients over 14 years of age, with known epilepsy, admitted to the emergency department for a convulsive seizure. Epidemiological, clinical, therapeutic and prognostic characteristics were collected. Therapeutic management was codified according to 2018 French recommendations.
RESULTS :
We included 163 patients. The mean age was 42 ± 18 years. The sex ratio was 1.8. Civil protection referred 29% of patients (n=47).
Hypertension, stroke and diabetes were the most common co-morbidities, accounting for
comorbidities (16%, 14% and 7.4% respectively). Status epilepticus (SE) was diagnosed in 13% of patients (n=22). Forty-five patients (27.6%) had a recurrent seizure in the emergency department. Brain imaging was normal in 60 patients (38.5%).
Therapeutic management was as follows n(%): one dose of clonazepam 40(24.7), two doses of clonazepam 15(9.3%), sodium valproate 21(13%), phenytoin 6(3.7%), orotracheal intubation (OTI) 9(5.6%).
The aetiologies were as follows n(%) : discontinuation of antiepileptic treatment 99 (61.1%), cerebrovascular disease 19 (11.7% ) , infection outside the CNS 10 (6.2%) , metabolic disorders 8 (4.9%) .
Patient referral was as follows n(%) : 77 patients returned home (47.5%), transfer to neurology 40 (27.7%), admission to emergency 22 (13.6%) and admission to intensive care 8 (4.9).
CONCLUSIONS :
Ultimately, this epidemiological analysis reveals an alarming trend : the majority of seizures in patients with epilepsy are attributable to discontinuation or non-adherence to their anticonvulsant treatment. These findings underline the urgent need for intensive patient education on the importance of compliance. Greater awareness among patients, their families and healthcare providers of the risks associated with premature discontinuation of treatment can make a significant contribution to reducing the incidence of seizures and improving the quality of life of people with epilepsy.
Ines CHERMITI (Ben Arous, Tunisia), Donia FEKI, Jihene JELLALI, Imen BEN ABDALLAH, Hela BEN TURKIA, Fadhel RAJA, Hanene GHAZALI, Sami SOUISSI
00:00 - 00:00
#41579 - Correlation of the number of suicide attempts and weather changes in the emergency department.
Correlation of the number of suicide attempts and weather changes in the emergency department.
Purpose: This study was conducted to investigate the correlation between various meteorological factors and the number of suicide attempters.
Methods: We conducted a retrospective analysis study of 359 suicide attempters who visited a regional emergency medical center from January 1, 2016 to December 31, 2016. We used Poisson regression model to analyze the relationship between the daily number of suicide attempters and Meteorological factors (daily mean temperature, diurnal temperature, relative humidity, solar radiation). We recorded information on age, gender, prior history of psychiatric illness, number of previous attempts, method of suicide attempt, patient disposition.
Results: There was a total of 359 suicide attempters. For the number of suicide attempters, the daily mean temperature has a positive correlation, the daily relative humidity and the solar radiation has a negative correlation.
Conclusion: Suicide attempts occur frequently from summer to early autumn. But, in highly industrialized and urbanized society, suicide attempts may be affected by other risk factors such as depression, socio-economic conditions and biological factors than traditional climatic effects.
Juneyoung LEE (Incheon, Republic of Korea)
00:00 - 00:00
#41117 - Could Senior Nursing Staffs of Emergency Room and Critical Care Unit Be More Vulnerable after Coronavirus Disease 2019 Infection: Retrospective Cohort Study.
Could Senior Nursing Staffs of Emergency Room and Critical Care Unit Be More Vulnerable after Coronavirus Disease 2019 Infection: Retrospective Cohort Study.
Background:
The deficiency of nursing man-power about emergency and critical care always be expected in pandemic. The shortage couldn’t be replaced with junior nursing staffs within the pandemic period time. Under the arrangement of nursing directors these infected emergency and critical nursing staffs have to return to work after de-quarantine without buffers. The depressed emotion would be expected. There are no documents describing the progression and change of emotion about these emergency and critical nursing staffs in the local hospital of Taiwan when they face the high-intensity labored working stress. The questionnaire will expound the down- cast change of the emotion after Coronavirus Disease 2019 (COVID 19) infection.
Methods:
COVID-19 infected nurses (n = 50) of our hospital are included in this study. They come back their duty position to care the patients after de-quarantine from February 2020 to May 2022. The emotional questionnaire with Likert scale is used to assess the psychological progression after COVID-19 infection. The questionnaire is arranged under the transitions theory of Meleis. The multiple factors for the depressed emotion are explored: emotional sadness with lonely sensation, emotional fearing with repelling sensation, physical fearing with frustration sensation and downcast with unjoyful sense. The Mann-Whitney test, Spearman correlation and multivariable linear regression analyses are used to find the interactions between work site, age, depressed emotional sense, physical fearing sense and downcast with unjoyful sense. The 23th ed. SPSS is used for static of data.
Results
In the dimension of downcast with unjoyful sense the mean rank is 3.29. The nursing staffs, which is older than 30 year-old have more remarkableness at emotional sadness and downcast sense and no difference between emergency room and critical care unit groups. The dimension of emotional sadness show correlation with downcast sense. The p valve is 0.005. Besides the emotional sadness will make prominent effect on the downcast. The p valve is 0.017.
Discussion and Conclusion
This study shows that COVID-19 infected nurses always have the negative emotion such as emotional sadness with lonely, emotional fearing with repelling and physical fearing with frustration sense from the peer group. They are confronted with the adverse situations due to COVID-19 infection. The understanding and comfort among peers are more yearned and social support will be necessary. When nursing directors request these post-infected nursing staffs coming back to work immediately after infection, their emotional changes might be subtle. Due to the domestic pressure senior nursing staffs may be more vulnerable and might need more attention than expected. Emotional soreness may be masked by external manifestations. Nursing directors should take more attention on the mental health of infected nurses during the occurrence of pandemic. In healthcare policies development the anticipation of nurse protection should be the focus in the global health emergencies
Approved number of St. Martin De Porres Hospital Institutional Review Board (IRB): 23B-003
ClinicalTrials.gov ID: NCT05908058
This study did not receive any specific funding
Chia-Hsi CHEN (Chiayi, Taiwan, Taiwan), Hsiu-Chun CHEN, Yu-Ting HUANG, Su-Lan WU, Mong-Ping DAI, Hung-Wen CHEN, Jui-Fang HUANG, Jou YEONG-CHIN
00:00 - 00:00
#42081 - Creating a neurodiversity-friendly environment in an adult Emergency Department.
Creating a neurodiversity-friendly environment in an adult Emergency Department.
Introduction
Neurodivergent individuals encounter multiple unique challenges in emergency departments (ED), from sensory overload to difficulty communicating their needs.
Methods
A quality improvement project was undertaken in Tallaght University Hospital ED in Ireland using the Lean Six Sigma methodology. The ED is an academic adult hospital which has 53,000 presentations per year. Our ED is frequently challenged with crowding and ambulatory patients are typically treated in open seating areas which are full capacity. We developed in conjunction with patient advocacy representatives, a clinical practice guideline on enabling a neurodiversity-friendly environment in the ED. The guideline included information on communication tools for staff and tips on how to enhance the environment to reduced noise and light stimulation. In our ED, we designed a sensory room which ensured a quiet environment and the patients had access to the dimmer switches within the cubicle for the lighting design. Multidisciplinary team training and awareness sessions were conducted at ED medical and nursing education sessions.
To evaluate the quality improvement initiatives, a number of evaluations were performed. Staff and patient/ carer satisfaction surveys were conducted. These surveys consisted of multiple choice, Likert-scale and open ended questions. Total waiting times were collated pre and post opening of the sensory room. In the pre-implementation phase, patients were included if they registered as having a "special needs" over a one year period. Special needs broadly encompassed autism spectrum disorder, sensory processing disorder and intellectual disability. In the post implementation loops, patients were included if they were in the sensory room for a significant proportion of their ED assessment over a 6 week period in December 2023 and January 2024.
Results
70 patients were included in the pre-implementation phase and 39 in the post implementation loop with respected mean total ED times reduced (852 minutes versus 615 minutes, p< 0.01)
11 individuals completed a sensory room user survey with 7 (64%) filled by patients and 4 (36%) by their carer. No patient had previously used a sensory room and all strongly agreed or agreed that the sensory room and its' features improved the experience they had in the ED. All individuals also strongly agreed or agreed that the noise levels, lighting features and seating in the SR improved their experience. Staff satisfaction surveys found that staff strongly agreed that the facilitating neurodiverse patients in a sensory room enhanced patient experience.
Conclusion
Recognising the diverse needs of neurodivergent patients, our ED has implemented innovative strategies such as comprehensive guidelines for staff, equipping them with the necessary tools to effectively communicate with patients who identify as neurodivergent. At an ED level, we have raised multidisciplinary awareness of the needs of our neurodivergent patients through our internal staff education programmes and we have enhanced our environment with development of a bespoke sensory room. Evaluation of these strategies have found that they enhanced patient experience and reduced ED wait times.
Nil
Reidy MAIREAD (Galway, Ireland), Aileen MCCABE, Suzanne KENNEDY, Maeve KINGSTON, Alannah O'REILLY
00:00 - 00:00
#42286 - Crisis Resource Management training programme from the first year of residency.
Crisis Resource Management training programme from the first year of residency.
Background
The beginnings of the care activity in the emergency department take place from the very first moment of the interns' career. During their working days, they experience critical situations that can sometimes lead to feelings of frustration, uncertainty and blockage in complex situations. All of this complicates care and risks the safety of the patient and the professional.
To minimize this insecurity and uncertainty, generating a more comfortable environment, we believe that training from the beginning of the residency through clinical simulation is necessary for better performance.
Methods
Observational study carried out with a sample of first-year residents, by means of satisfaction surveys carried out before and after the clinical simulation training during the month of October 2022.
The training sessions used clinical simulation based on the Crisis Resource Management (CRM) methodology, in which objectives were also set according to their level of clinical experience.
The importance of information transfer through systematised techniques, the identification and acquisition of roles, as well as the orderly clinical assessment of critical patients using the ABCDE, are some of the elements that were the subject of training during these days of intense work.
Participants detailed their simulation experience by answering questionnaires and evaluated the activity in two post-day questionnaires. Variables were collected through non-validated questionnaires on practitioner satisfaction.
Results
The results of their responses showed that more than 88% of the first-year residents do not feel capable of dealing with a critical event, despite working in the emergency department.
After training, a large percentage of participants reported feeling more skilled in teamwork (100%), effective communication (76.5%), leadership (64.7%) and knowledge of their work environment (94.2%).
In terms of the objectives set, 100% said they felt able to transfer information in a systematised way, compared to 37.1% who felt this was the case prior to the workshops. In the use of clinical assessments ordered according to the ABCDE, a scant 31.4% stated that they were familiar with the tools and up to 91% stated that they felt prepared after the session. On the other hand, 91.2% said that debriefing critical situations helped them to understand behaviours and improved their own and the team's performance.
Conclusions
Including CRM training through clinical simulation in the training programme of resident interns from their first year, adapting it to their level of competence, generates greater training in non-technical and technical skills, contributing to the safety of the professional and the patient.
Trial Registration: The study wasn´t registered because no patients involved.
Funding: This study did not receive any specific funding
Ethical approval and informed consent: Not needed
Adriana GIL-RODRIGO (Alicante, Spain), José Alejandro NAVARRO, Melina YEDRO, Pablo MELGUIZO-ÁBALOS, Juan MOYA-CORREAS
00:00 - 00:00
#42368 - Critical post-traumatic ischeamic section of humeral artery by humeral fracture.
Critical post-traumatic ischeamic section of humeral artery by humeral fracture.
Introduction:
Severe vascular trauma is frequent in high velocity induced injuries encounterd by emergency physicians as well in the pre hospital field and the very early stage of emergency management. Immediate ischaemic presentation remains rare when velocity is not high. Total section of artery humeral within plexus injury and fracture dislocation of the humeral head is a complex situation requiring optimal resuscitation protocol and rapid multidisciplinary activation management.
Case report:
We report the case of a 55-year old man in whom left arm was trapped while farming by his tractor wheel. Patient was admitted to the emergency department by the prehospital emergency system with immediate compression of hemorrhagic lesion of the plexus brachial. On arrival to the emergency department patient was conscious with pale conjunctives. Hemodynamic parameters were stable with Blood pressure about 105/60 mmHg but tachycardia. No radial pulse was Blood sample Gaz noticed high level of lactate. Damage resuscitation protocol with massive transfusion was adopted and patient underwent immediate full body computed tomography showing a complete section of the humeral artery by a fracture dislocation of the humeral head and humeral diaphysis responsible of full ischemia of the left arm. Patient was transferred to the surgical ward to hemostatic act and revascularization.
Discussion and conclusions
High severe injuries could happen without high-velocity criteria of trauma. Nevertheless, emergency physician must be aware of rapid and adequate multidisciplinary necessity management with activation of the damage resuscitation protocol, use of tranexamic acid, permissive hypotension and rapid transfusion while treating the etiology of bleeding.
Rym HAMED (Tunisie), Alaa ZAMMITI, Laurent LAUMAILLER, Bassem CHATBRI, Amel CHALLAKHI, Alberto AL OMAIRI, Nasser AL AWAD, Akim SADDAR
00:00 - 00:00
#40564 - Cross-sectional survey of CPR practices of Healthcare providers during the COVID-19 Pandemic in Gauteng, South Africa.
Cross-sectional survey of CPR practices of Healthcare providers during the COVID-19 Pandemic in Gauteng, South Africa.
Introduction:
COVID-19 was declared a worldwide pandemic by the World Health Organization in March 2020. The risk of transmission of this disease is of particular concern to frontline healthcare workers, especially those performing aerosolising procedures such as Cardiopulmonary resuscitation. Very little research has been done to assess the CPR practices among healthcare workers during the pandemic.
Methods:
This was an analytical, cross-sectional study that was conducted in 4 public service hospitals in Gauteng that were at the epicenter of the COVID-19 pandemic. Data was collected using an online survey platform.
Results:
A total of 131 responses were received. Overall there was no significant difference reported among the hospitals surveyed with regards to equipment and PPE available during CPR. Of the respondents, 72.9% reported performing CPR on COVID-19-positive patients. The average number of people present at the bedside during CPR was reported as 4. CPR was continued for more than 10 minutes in 93.9%. Frequent breaches in PPE were reported to be observed by our respondents. The re-use of certain personal protective equipment was conveyed by 68.7%.
The majority of respondents reported being aware of specific national or international guidelines for CPR in COVID-19. Among our respondents who had tested positive for COVID-19, 20.2% reported symptom onset within 5 days of performing CPR on a COVID-19-positive patient.
Conclusion:
A high percentage of healthcare workers reported performing CPR on COVID-19 positive patients. The study found that despite respondents reporting awareness about international and local guidelines for CPR in COVID-19, compliance with these guidelines were poor. The guidelines were reportedly not followed particularly with regards to compliance with PPE and measures for prevention of transmission of COVID-19. Of particular concern is that a high number of respondents testing positive for COVID-19 reported symptoms within 5 days of performing CPR on COVID-19-positive patients.
Ethical Approval from the Faculty of Health Sciences, Ethics Committee,
University of Pretoria
Smit ALMIEN, Andreas ENGELBRECHT (Pretoria, South Africa)
00:00 - 00:00
#42245 - De Winter ST-T syndrome: an early sign of ST segment elevation myocardial infarction.
De Winter ST-T syndrome: an early sign of ST segment elevation myocardial infarction.
Background: A ST elevation myocardial infarction (STEMI) equivalent electrocardiogram (ECG) pattern reflects an acute thrombotic occlusion of a large epicardial coronary artery without ST-segment elevation. In recent studies, one of these STEMI equivalents, is de-Winter T waves defined by an upsloping ST segment depression (> 1mm) beginning from J-point, and symmetrical, long and significant T waves seen in precordial leads.
CASE PRESENTATION:
A 32-year-old male presented to the ED with retrosternal chest pain radiating to left arm within the first hour. He had a history of smoking (10 Pack per year). The examination in the triage area showed a patient who was hemodynamically stable with no clinical evidence of heart failure. He scored his pain as 10/10 according to the Numeric Pain Scale (NPS). The first ECG taken 5 min after arrival showed a sinus rhythm at a rate of 92 bpm, ST-segment elevation in right leads (V1, V2, V3R, V4R), 3mm upsloping ST segment depression in leads V3-V6 at the J point which continued into tall, positive symmetrical T-waves and 1.5mm ST-segment depression in leads II, III, aVF, V7-9. The patient was categorised on a very urgent level of priority and was immediately oriented to the emergency room. During the first assessment, the patient lost consciousness and had seizures. He presented a cardiac arrest with a ventricular fibrillation on the monitor. An immediate shock was delivered. Vital signs after resuscitation were stable: a respiratory rate of 21 breaths/min and the oxygen saturation was 98% on air room, a blood pressure of 120/60 mmHg and a regular pulse rate of 102 beats/min, a Glasgow Coma Scale of 14/15 without any neurological impairment, a pain score of 7/10 according to the NPS. The ECG performed after the cardiac arrest recovery showed a sinus rhythm at a rate of 100 bpm, ST-segment elevation in leads I, aVL and V1-3, with ST depression in leads II III, aVF and V7-9.
The diagnosis of a STEMI in the anterior territory was made. He was treated with aspirin, clopidogrel, subcutaneous dose of low molecular-weight heparin and intravenous titration of morphine according to the pain statement.
The patient was transferred to a cardiac department where a primary percutaneous coronary intervention (PCI) was performed. It showed a subtotal occlusive stenosis in the acute proximal left anterior descending artery (LAD). Successful coronary angioplasty was done. The patient was discharged 24 hours after with favourable outcome.
Conclusion: Repetitive ECGs monitoring is necessary for this type of patients with De Winter ST-T syndrome in order to track down the moment of ST elevation, especially when catheterization laboratory is not available for PCI.
Amira BAKIR, Raja FADHEL (Ain Zaghouan, Tunisia), Jihène SEBAI, Jihène JALELI, Hela BEN TURKIA, Inès CHERMITI, Amel BEN GARFA, Hanène GHAZALI, Sami SOUISSI
00:00 - 00:00
#41957 - Deceptive Gravity: A Unique Case of Acute Osteomyelitis with Multiple Localizations.
Deceptive Gravity: A Unique Case of Acute Osteomyelitis with Multiple Localizations.
Introduction: Acute osteomyelitis in children is a bone infection resulting from bacterial inoculation, often of hematogenous origin. Although rare, complex cases of osteomyelitis can manifest with multiple localizations, involving extra-osseous regions such as the lungs, cardiovascular system, and brain. Awareness of these unusual presentations is crucial, as they can have a significant impact on vital and therapeutic prognosis.
Clinical case: A 10-year-old girl, with no notable medical history, was admitted for left ankle bone pain evolving over a week in the context of fever without trauma or other obvious triggering factors. Initial clinical examination revealed a fever of 40°C, an elevated heart rate, and a compromised general condition. Due to the severity of the patient's condition, empirical antibiotic therapy with cefazolin and gentamicin was initiated after the first set of blood cultures. Initial radiological investigations included an ankle X-ray, which was normal, and an ultrasound revealing thickening of the soft tissues.
The patient underwent daily ultrasound for 48 hours, revealing no complications or collections. An MRI was subsequently performed, highlighting osteomyelitis of the lower end of the fibula in its postero-internal aspect, complicated by subperiosteal abscess.
Debridement with trepanation of the fibula was performed. Methicillin-sensitive Staphylococcus aureus (MSSA) was identified from blood cultures and intraoperative samples, and appropriate antibiotic therapy was prescribed. On the 8th day, the patient's condition deteriorated after a brief postoperative improvement. She was transferred to the intensive care unit, where a whole-body CT scan revealed multiple infectious foci (cerebral, pulmonary), as well as a pulmonary focus visible on chest X-ray. A heart murmur on auscultation turned out to be a valvular graft of MSSA, leading to the diagnosis of mitro-aortic valvulopathy.
Conclusion: Acute osteomyelitis in children is a potentially serious condition, jeopardizing vital prognosis. Our clinical case highlights the complexity of its clinical presentation, emphasizing the crucial importance of MRI in confirming the diagnosis at an early stage.
Firas BOUGHATTAS, Jacem SAADANA, Khouloud KHEMILI (Tunisia, Tunisia), Firas CHAOUECH, Said ABID, Bilel FAIZI, Ahmed MDAOUKHI, Moez JELLALI, Amine SIOUD, Kais KHARROUBI, Iheb NTICHA, Hatem BELGACEM, Aymen FEKIH, Abderrazek ABID
00:00 - 00:00
#41295 - Deep Vein Thrombosis Diagnostic Algorithm.
Deep Vein Thrombosis Diagnostic Algorithm.
Aim: We aimed to find out the role of serum homocysteine level in DVT in adult patients treated with a preliminary diagnosis of deep vein thrombosis (DVT), with the effect of three-point USG and thermal camera in the Emergency Department on the diagnostic priority and algorithm.
Materials and Methods: In our study, 65 patients who were evaluated in the emergency department with the diagnosis of DVT were evaluated prospectively. Patients with DVT included in the study were classified as developing Pulmonary Embolism (PE) (Group 1) and not developing PE (Group II). Demographic and clinical presentation of the patients, Wells scores, imaging characteristics, thermal imaging and three-point USG results, blood tests and complications were evaluated.
Results: The mean age of the patients in our study was 58.2±17.5 years, and 66.2% of the patients were male. While the frequency of dyspnea was high in cases with PE, the frequency of leg pain was found to be significantly higher in cases without PE (p<0.05). The number of smokers in the group with PE was found to be high (p<0.05). In our study, thrombus was detected most frequently in the popliteal vein (55.4%) and femoral vein (46.2%) in the USG of the patients, and the frequency of PE was significantly lower in patients with thrombus in the saphenous vein (p<0.05). In our study, homocysteine levels were high in 81.5% of the patients, and we evaluated no differences in the levels of patients with and without PE (p>0.05). In our study, we detected positive imaging in 62 (95.4%) patients in the thermal camera. Although the diagnostic rate of thermal imaging camera was higher in the group with DVT+PE, we evaluated this difference as statistically nonsignificant (p>0.05). We evaluated that the RBC count was significantly lower and the RDW level was significantly higher in cases with PE (p<0.05).
Conclusion: three-point USG, thermal imaging camera and homocysteine level were effective in the diagnosis of DVT. Also CRP, vitamin D, and lactate levels are other helpful methods in diagnosis. Additional studies are needed to demonstrate the specificities of these methods.
Onur GUNGOR, Zeynep KEKEC (ADANA TURKIYE, Turkey)
00:00 - 00:00
#40729 - Delay in inpatient admission at an Emergency Department in a private hospital in Beirut.
Delay in inpatient admission at an Emergency Department in a private hospital in Beirut.
Introduction. Emergency department (ED) crowding has been a major concern for the hospitals. Crowding is associated with higher morbidity, delayed time for patients care and negative patients experience. Many factors can be implicated. One major factor is the inpatient long waiting times to be admitted, which overcrowd the ED and overwhelm the staff. Methods. Our study is a retrospective study for 3163 inpatients in the ED waiting for a hospital bed. It will be conducted during the year 2023. Results. A total of 13894 patients were admitted to the ED in the year 2023 of which 3163 were inpatients. The average time for inpatients to be admitted to their room is 64 minutes from the approval to admit. Around 20% of the inpatients were considered as having a delay in the ED, as per the hospital policy for being transferred to a room in less than 30 minutes. Many reasons for this delay were found, medical logistics was the most common cause (6.43%), followed by overwhelmed unit nurse (4.32%), patient medical condition (2.74%), and room availability (2.38%). Discussion. Inpatients admission delays was found to be of various causes with percentage varying across hospitals and reaching up to 67% in some instances. More reasons for delay were reported in other studies: multiple consultations and file making process. It is imperative to identify and implement effective solutions to avoid ED overcrowding and improve patient care.
Dr Mariana HELOU (Lebanon, Lebanon), Mohamad KARAALI, Danielle ABOU KHATER, Alain KHOURI, Lina AOUN
00:00 - 00:00
#41586 - Delayed Traumatic Hemothorax.
Delayed Traumatic Hemothorax.
Learning Objective
To consider the delayed presentation of a pathological condition in
context with trauma. This may be evident from days to weeks.
Case Presentation
23 year old male presented to the Emergency department
Left lateral
chest wall pain for more than a month. This started and continued
after he hit his Left chest during futsal practice.
He was seen in another Emergency department & Chest X-ray was
performed which was normal He was treated for chest contusion.
The patient was discharged with analgesia.
He revisited ED after one month for worsening pain. There was no
shortness of breath or fever. His vital parameters were within
normal range.
Another chest X-ray and blood tests were performed and showed
Left Hemothorax with mass effect likely secondary to trauma
Chest tube was inserted and about a litre of collected Pus was removed.
The patient was referred to the Thoracic surgery team and underwent a left
UVATS drainage and decortication.
Post-Treatment
He was discharged well. Below are post-treatment and follow-up CXR
Discussion
Delayed Hemothorax is usually discovered ≥48 hours after
admission, initial chest CT may show either no or ‘minimal/trace of
blood. Usually, patients have associated rib fractures / diaphragmatic
injury.
Various studies have reported the incidence of delayed hemothorax
after blunt chest trauma range from 2.1%–33%
Once identified prompt drainage of traumatic Hemothorax is
recommended to prevent empyema and trapped lung.
Shobhit SWARUP, Shobhit SWARUP (SINGAPORE, Singapore)
00:00 - 00:00
#42358 - Delirium in patient with cognitive imaparement.
Delirium in patient with cognitive imaparement.
An 83-year-old woman, independently performing activities of daily living but living alone with daily family supervision. Relevant personal history includes mild cognitive impairment.
Presented to the Emergency Department accompanied by her daughter due to 24-hour altered behavior and disorientation, with no other accompanying symptoms.
Regular Treatment: Donepezil 10mg, mirtazapine 30mg, escitalopram 10mg, simvastatin 20mg.
Physical Examination:
Upon arrival: BP = 139/70 mmHg, HR = 71 bpm, Temp = 36.8 ºC, O2 Sat = 98% at baseline, RR = 16 rpm.
Conscious, partially oriented, and cooperative. Well-hydrated, normochromic, and normoperfused. Eupneic at rest.
rhythmic, no murmurs. Lungs: vesicular breath sounds preserved. Abdomen: soft, depressible, non-tender on palpation, no masses or hepatosplenomegaly appreciated. Negative bilateral fist-percussion test. Lower limbs: no edema or signs of DVT.
Neurological examination: unremarkable except for disorientation in time and space.
Complementary Tests:
Blood tests:
Hemogram: Leukocytes 11,500 (83.8% neutrophils), Hb 12.8, MCV 81, platelets 312,000.
Biochemistry: glucose 102, urea 42, creatinine and ions within normal limits, CRP 2, procalcitonin 0.
Coagulation: INR 1.2, otherwise normal.
Urinalysis: unremarkable.
Chest X-ray: no acute pleuropulmonary pathology.
Respiratory virus PCR: negative for SARS-CoV-2 and influenza A/B viruses.
Management Plan:
After ruling out more common infectious pathologies and considering the predominant neurological symptoms, a cranial CT scan is requested.
Cranial CT scan:
Left parietal intraparenchymal hyperdense collection approximately 43x36x36 cm (APxTRxCC), causing mild mass effect on neighboring parenchymal structures such as obliteration of the underlying cortical sulci, accompanied by mild vasogenic perilesional edema. Few layers of subarachnoid hemorrhage lining the central sulcus and some ipsilateral parietals are also noted.
Subtle hypodensity confluent in the periventricular white matter, consistent with chronic small vessel ischemic leukoencephalopathy.
Parenchymal atrophy with proportional enlargement of the ventricular system.
Calcified atheromatous plaques in the carotid siphons.
Conclusion: Left parietal intraparenchymal hemorrhage with a few layers of subarachnoid hemorrhage lining the central sulcus and some ipsilateral parietals.
Differential Diagnosis:
Delirium
Progression of primary degenerative cognitive decline
Psychomotor agitation
Viral encephalitis
Stroke vs. hemorrhage
Outcome:
Following imaging findings, the patient is assessed by the Neurology service and subsequently admitted to said unit. Given the lobar hemorrhage in a patient with known cognitive decline, myeloid angiopathy is assumed as the most likely etiology. During hospitalization, rehabilitative treatment is initiated with good clinical progress. Complications include acute febrile syndrome of respiratory origin treated with antibiotics and psychomotor agitation requiring antipsychotics.
At hospital discharge, residual symptoms include sensory aphasia, mild right central facial palsy, and mild right hemiparesis. Rankin score: 4.
Conclusion:
Patients with known cognitive decline often present subtle clinical symptoms, making diagnosis challenging. A thorough physical examination is essential, with particular attention to ruling out the most common causes of deterioration. However, neurological pathology should always be considered as a potential trigger for deterioration.
Olena ZHYGALOVA, Javier VARONA CASTRILLO (Burgos, Spain), Karla LÓPEZ LÓPEZ, Monica DE DIEGO ARNAIZ, Amanda IBISATE CUBILLAS, Luis Enrique GARCIA LÓPEZ, Jorge A OLANO FELIPE, Veronica Andreina CASTRO JIMENEZ
00:00 - 00:00
#41582 - Demographic, management practices, and outcome differences between air and ground transport of patients presenting with acute STEMI outside of a primary PCI center in northern Thailand.
Demographic, management practices, and outcome differences between air and ground transport of patients presenting with acute STEMI outside of a primary PCI center in northern Thailand.
ABSTRACT
Background: It is unclear whether inter-facility air transfer of STEMI patients in areas with limited medical aircraft is beneficial. This study aimed to study time and clinical outcomes differences between air and ground transport of patients presenting with acute STEMI in non-PCI-capable hospital in northern Thailand.
Methods: We conduct a retrospective observational study on patients who presented with acute STEMI in non-PCI-capable hospital in Chiang Mai and Mae Hong Son provinces. Electronic medical records provided patient demographics and outcomes. Participants who refused coronary angiography, did not receive PCI within 72 hours, incomplete medical records, normal coronary arteries, or mild disease on angiogram were excluded. We use multivariable linear regression to calculate mean time difference of primary outcomes and multivariable logistic regression analysis to calculate adjusted odds ratio for secondary clinical outcomes. We also conduct additional analysis utilizing multivariable linear regression, considering that the interaction between ground ETA and mode of transport may influence the time from STEMI diagnosis to PCI center.
Result: Two-hundred and seventy five patients were included in study. Air transport group had significantly shorter actual transport time and time from STEMI diagnosis to PCI center, with mean time differences of 168.23 minutes (95%CI -230.045, -133.415, p < 0.001) and 110.34 minutes (95%CI -155.112, -65.560 , p < 0.001) (95%CI -230.045, -133.415, p < 0.001) respectively. The additional analysis demonstrated no significant difference between modes of transport in areas where the ground ETA was within 3 hours. Air transport can shorten the time in areas where the ground ETA exceeds 3 hours.
Conclusion: In areas with limited medical aircraft, air transport could shorten actual transport time and time from STEMI diagnosis to PCI center. If the ground ETA was within 3-hour window, the benefits of reducing the time between STEMI diagnosis and PCI center remained inconclusive. Due to systemic delays, time from STEMI diagnosis to PCI center for air transport in Northern Thailand was still greater than 120 minutes. Early administration of fibrinolytics with urgent transfer is still an important strategy.
This research received funding from the Faculty of Medicine at Chiang Mai University.
Nattikarn MEELARP (, Thailand)
00:00 - 00:00
#41470 - DESCRIPTIVE ANALYSIS OF SUBSTANCE ABUSE IN PATIENTS ADMITTED TO THE EMERGENCY DEPARTMENT AFTER ROAD TRAFFIC CRASHES AND THEIR IMPACT ON PATIENTS MANAGEMENT.
DESCRIPTIVE ANALYSIS OF SUBSTANCE ABUSE IN PATIENTS ADMITTED TO THE EMERGENCY DEPARTMENT AFTER ROAD TRAFFIC CRASHES AND THEIR IMPACT ON PATIENTS MANAGEMENT.
Introduction: road traffic crashes (RTC) are a major cause of mortality and morbidity in the Western world. The aim of this study is to describe the percentage and the different type of substance abuse in subjects admitted to our Emergency Department (ED) after RTC and how the different positivities may impact on injury severity.
Materials and methods: we retrospectively enrolled 159 patients admitted to the ED for RTC and for which the judicial authority requested the chain of custody. We used the subsequent surrogate outcomes: major trauma dynamic, days of prognosis received, Total Body CT scan (TBCT) execution, admission to hospital departments and admission to Intensive Care Unit (ICU).
Results: in the population study there were 112 males and 47 females; mean age was 43.4 ± 16 years old. 38,3% of the subjects resulted positive for drugs; 27,6% were positive for only 1 drug, 8,1% for 2 drugs, 1,9% for 3 drugs and only one subject (0,6%) was positive for all 4 drugs analyzed. 27% of all patients tested positive for alcohol, 13,2% for cannabinoids, 8,8% for cocaine, 2,5% for opioids, 1,2% for methadone and only one for methamphetamine.
At univariate analysis we did not observe statistically significant associations between the finding of a test positive for drugs and major dynamic, execution of TBCT, reserved prognosis, hospitalization and ICU admission. The analysis between the association between the number of positivities found (1 positivity, 2 positivities, 3 positivities) and the surrogate outcomes did not highlight any statistically significant association. We found that alcohol positivity was associated with major trauma dynamics (CI 95% 1,207-5,699, OR 2,623, p .015) and TBCT execution (CI 95% 1,334-5,699, OR 2,750, p .006). We did not observe any significant association between positivity to cannabinoids and cocaine and the surrogate outcomes.
At multivariate analysis we found that alcohol positivity (CI 95% 1,286, OR 2,857, p .010) was associated with major dynamics independently from age and sex. Similarly, alcohol positivity (CI 95% 1,606, OR 3,501, p .002) and age (CI 1,002-1,047, OR 1,025, p .030) were significantly associated with TBCT execution independently from sex.
Discussion: results from our study show that more than one third of the chain of custody requested resulted positive for at least one abuse substance and that alcohol is the most commonly found. However, considering together substance positivities, seems that drugs are not associated to the surrogate outcomes considered in the study. Only alcohol positivity was independently associated with major trauma dynamics and Total-Body CT execution, suggesting that alcohol abuse may increase the risk of road traffic crashes severity. Understanding the effective impact of alcohol or other drugs on RTC severity is challenging; other factors such as weather, speed, and traffic patterns also contribute to RCT severity.
Conclusion: Among the tested substances alcohol abuse seems to be the most frequent and the most involved in RTC severity. RTC represent an important social and public health problem and a better understanding of how substance abuse impact on RTC severity could help in better preventing these events.
Stefano DE VUONO (Perugia, Italy), Stefano DE SANTIS, Laura SETTIMI, Sokol BERISHA, Pasquale CIANCI, Lorenzo VANNOCCHI, Giuseppe BATORI, Luca PARRETTI, Paolo GROFF
00:00 - 00:00
#41394 - Design and delivery of novel regional interprofessional simulation training for Emergency Medicine Higher Specialty Trainees taking on the role of Trauma Team Leader (TTL) within District General Hospitals (DGH) in Northern Ireland.
Design and delivery of novel regional interprofessional simulation training for Emergency Medicine Higher Specialty Trainees taking on the role of Trauma Team Leader (TTL) within District General Hospitals (DGH) in Northern Ireland.
Introduction: Effective trauma teams have been shown to improve care for trauma patients [1]. Effective team leadership is critical to providing high quality patient care. Managing major trauma in DGHs in Northern Ireland is uniquely challenging. EM higher specialty trainees are expected to take on the role of TTL and manage trauma teams within this setting. A regional training need was identified. Simulation provided a psychologically safe and effective method to address this.
Methods: We surveyed EM Higher Specialty Trainees prior to development of the training to ascertain confidence levels and specific training needs. These surveys used mainly rating scale and limited questions with free text boxes. A focus group of EM Consultants was used to identify training needs through incident reports and their experience. Based on the survey results and focus group findings learning objectives were created and a full day of trauma simulation training was designed around these. The faculty included EM consultants, senior nurses from six emergency departments and specialty trainees from orthopaedics and anaesthetics. This interprofessional faculty increased the range of experience and perspectives and also provided an opportunity to enhance interprofessional relations.
The simulation training was delivered with two simulation and debrief rooms running simultaneously covering a range of technical and non-technical topics identified in the pre-course surveys. There were six immersive simulation scenarios with each trainee getting at least one opportunity to act as TTL. The formal debriefs were facilitated by EM consultants and included relevant micro-teaching based on the Royal College of Emergency Medicine curriculum and signposts to regional and national resources and guidelines. Trainees completed post-course questionnaires using mainly rating scale and likert scale questions with free text boxes.
Results: The analysis of pre- and post-course surveys showed that trainee confidence in leading major trauma in a DGH setting increased from a mean score of 7/10 to 9/10. Their confidence level in leading paediatric major trauma in a DGH setting increased from a mean score of 5/10 to 8/10. The mean confidence score for leading traumatic cardiac arrest increased from 5/10 to 7/10. 100% of trainees ‘strongly agreed’ or ‘agreed’ that the day was relevant to their training needs and that they would recommend this training day to their colleagues.
Discussion: This simulation training day addressed regional training needs and significantly increased trainee confidence when leading trauma teams in DGHs in Northern Ireland.
N/A
Christina MULHOLLAND (Belfast, )
00:00 - 00:00
#40841 - Developing a simple field triage scheme compatible with the regional trauma situation using machine learning and based on the Japanese multicenter trauma database.
Developing a simple field triage scheme compatible with the regional trauma situation using machine learning and based on the Japanese multicenter trauma database.
Objective
The objective of this study was to establish a simple field triage guideline for identifying patients with severe injury, that reflect the regional features of trauma demographics and trauma management systems.
Methods
This was a retrospective cohort study using the Japan Trauma Data Bank (JTDB), which was a Japanese nationwide multicentre trauma data base. The main outcome was all-cause in-hospital mortality. Blunt trauma patients ≥18 years of age were enrolled. Thirty-five parameters (including demographic characteristics, mechanism of injury, vital signs on scene, ISS98, and injured parts) were assessed for each patient using a machine learning method. After calculating the feature importance of each variable from the JTDB 2019–2021 dataset, we selected variables and made schemes by including different combinations of variables. The schemes were analyzed by receiver operating characteristic curve and calculating area under the curve (AUC) and were validated using the JTDB 2004–2018 data set.
Results
We analyzed 48,194 subjects in JTDB 2019–2021. Eight variables were selected and scores calculated and evaluated using 185,728 cases in the JTDB 2004–2018 data set. The AUC of the most accurate and simplest score was 0.845. When the cut-off value was set at 6, the mortality rate of the positive group (i.e., score ≥6) was 31.8%, the undertriage rate was 4.6%, and the overtriage rate was 68.2%.
Conclusion
Using a machine learning method, we established an easy and reliable field triage scheme suited to the Japanese trauma system, which comprised disturbance of consciousness, respiratory failure, shock, head injury, chest injury, multiple injury, fall from height, and age.
Tanaka CHIE (Tokyo, Japan), Takashi TAGAMI, Kaneko JUNYA, Masamune KUNO
00:00 - 00:00
#41830 - Development of health passports for newcomer immigrants and refugees in Kingston, ON Canada: A mixed-methods approach.
Development of health passports for newcomer immigrants and refugees in Kingston, ON Canada: A mixed-methods approach.
Background: Newcomers face challenges within the Canadian healthcare context, including a lack of familiarity with the system, health literacy gaps, and miscommunication resulting in misdiagnosis, poor treatment plans, and unnecessary referrals. Health passports have been shown to minimize language barriers and improve the overall experiences of this patient population. In the emergency medicine context, studies have shown the successful usage of health passports for specific patient populations, including refugees, patients with intellectual disability, and children. With our community partners, we are co-developing a health passport tailored to the unique needs and challenges of newcomers in the greater Kingston area for future implementation/evaluation in the Kingston Health Sciences Centre’s emergency department (ED)/Urgent Care Centre (UCC) and family medicine clinics. The overall goal is to reduce communication barriers regarding pertinent social and health information between patients and providers.
Methods: Using a mixed-methods approach, quantitative and qualitative data on the essential elements of a health passport will be collected via surveys from staff and resident physicians from the Departments of Emergency Medicine and Family Medicine at Queen's University, as well as from clients and local service providers at KEYS and Immigrant Services Kingston and Area. Clients will be those who identify as newcomers to Canada within the last 5 years. Quantitative survey data will be analyzed using descriptive statistics; qualitative data will be thematically analyzed. Results will be taken back to community partners to member check findings in focus group discussions comprising of newcomer clients and service providers (N=8-10 participants each) and to delve deeper into participant perspectives. Focus groups will be held in different languages with the use of interpreters. The health passport will be iteratively refined and finalized for future evaluation.
Next Steps: This study is under research ethics board review at Queen's University. Once approved, next steps include distribution of an online survey to healthcare providers in the Departments of Emergency Medicine and Family Medicine, and, subsequently, to clients and service providers in order to gather feedback on the utility, content, and acceptability of the health passport. Findings will be available for presentation at EUSEM 2024.
Anticipated Study Implications: The co-development of a health passport will help to meet the informational needs of newcomer patients in their interactions with ED/family medicine providers. Feedback from both patients and providers will inform strategies for the effective rollout of health passports within the ED/UCC and family medicine clinics. Findings from this development phase will inform a future implementation and evaluation study.
NA
Melanie WALKER (Kingston, Canada), Firdus ISMAEL, Kendra ZHANG, Ken CHOI, Darwin JIMAL, Nikoo AGHAEI, Erin BRENNAN, Eva PURKEY
00:00 - 00:00
#41838 - Diagnosis of Pneumonia in Children Using Point of Care Ultrasonography.
Diagnosis of Pneumonia in Children Using Point of Care Ultrasonography.
Introduction: Pneumonia is one of the leading causes of death in children under 5 years of age worldwide. Timely diagnosis and treatment are critical to reduce morbidity and mortality. Clinicians primarily diagnose pneumonia in children based on clinical findings. Chest x-ray (XR) can be used to confirm suspicion of pneumonia, but its use is limited in resource-limited settings and remote facilities because radiographic imaging is often unavailable. In cases where radiographs are insufficient, imaging with computerized tomography (CT) can be performed for diagnosis. There is radiation exposure in both XR and CT imaging. Radiation can cause cancer in children. Lung ultrasound is an effective imaging tool in the diagnosis of pneumonia in both adults and children.
Case: A 2-year-old male patient was admitted to the emergency department with complaints of cough and fever. In the history taken from the patient's family, it was learned that he was given oral antipyretic medication before coming to the hospital. The patient's general condition was good, he was conscious, respiratory rate: 25/min, pulse: 134 beats/min, blood pressure: 80/40 mmHg, SO2: 97%. On physical examination, heart sounds are rhythmic and tachycardic, and there are coarse crackles in the left basal lung sounds. In the laboratory, WBC: 13.53 103 /mm3, HB: 12.1 g/dL, RBC: 4.66 103 /mm3, platelet: 274 103 /mm3, CRP: 11.3 mg/L (0-5), other parameters were normal. The patient underwent PA chest XR. Chest XR was evaluated as normal (Figure 1). Next, bedside Point of Care Ultrasonography (POCUS) was performed according to the protocol currently used in the clinic. According to POCUS, findings consistent with pneumonia were detected in the lower zone of the left lung (Table 1, Figure 2). Pediatric consultation was requested. The patient was prescribed medications and outpatient follow-up was recommended.
Conclusion: Ultrasound is easily portable, readily available in many facilities, and has no radiation exposure. It is easy to learn and apply. Although the XR was normal in our patient, there was clinical suspicion of pneumonia. When systematically evaluated with POCUS, the diagnosis of pneumonia was quickly confirmed. In this case, there was no need for CT imaging. POCUS is an imaging method that can be easily applied under emergency conditions in the diagnosis of lung diseases in pediatric patients. It may also reduce the need for CT imaging.
Nalan KOZACI, Ismail Erkan AYDIN, Hasan PAKIR (Antalya, Turkey), Mehmet ACAR
00:00 - 00:00
#41288 - Diagnostic accuracy of alternative biomarkers for acute aortic syndrome: a systematic review.
Diagnostic accuracy of alternative biomarkers for acute aortic syndrome: a systematic review.
BACKGROUND
D-dimer is the only biomarker currently recommended in guidelines for the diagnosis of acute aortic syndrome (AAS). We undertook a systematic review to determine whether any alternative biomarkers could be useful in AAS diagnosis.
METHODS
We searched electronic databases (including MEDLINE, EMBASE and the Cochrane Library) from inception to February 2024. Diagnostic studies were eligible if they examined biomarkers other than D-dimer for diagnosing AAS compared with a reference standard test in people presenting to the ED with symptoms of AAS. Case-control studies were identified but excluded due to high risk of bias. Selection of studies, data extraction, and risk of bias assessments using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool were undertaken independently by at least two reviewers. We used narrative synthesis to summarise the findings.
RESULTS
We identified 2017 citations, included 13 cohort studies (N=76 to N=999), and excluded 38 case-control studies. Methodological quality was variable, with most included studies having unclear or high risk of bias and applicability concerns in at least one item of the QUADAS‐2 tool. Only two studies reported biomarkers with sensitivity and specificity comparable to D-dimer (i.e. >90% and >50% respectively). Wang et al reported 99.1% sensitivity and 84.9% specificity for soluble ST2, but this conflicted with estimates of 58% and 70.8% respectively from another study. Chun et al reported 95.6% sensitivity and 56.1% specificity for neutrophil count, but this has not been confirmed elsewhere.
CONCLUSION
There are many potential alternative biomarkers for AAS but few have been evaluated in more than one study, study designs are often weak, and reported biomarker accuracy is modest or inconsistent between studies. None are ready for routine clinical use.
This study was funded by the United Kingdom National Institute for Health and Care Research Health Technology Assessment Programme (project number 151853). The views expressed in this paper are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Any errors are the responsibility of the authors. The funders had no role in the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication
Joshua WREN (Sheffield, United Kingdom), Steve GOODACRE, Abdullah PANDOR, Munira ESSAT, Mark CLOWES, Graham COOPER, Robert HINCHLIFFE, Matthew REED, Steven THOMAS, Sarah WILSON
00:00 - 00:00
#42095 - Diagnostic challenges and emergency management in a patient with Systemic Manifestations of Infectious Endocarditis.
Diagnostic challenges and emergency management in a patient with Systemic Manifestations of Infectious Endocarditis.
Brief clinical history:
A 40-years-old male patient, smoker (20-40 cigarettes/day), with no relevant previous medical history, is brought to the emergency department (ED) by wife at 08:30 with stroke symptoms (left upper limb motor deficit) for the last two and a half hours. During the previous night, the patient presented impaired coordination of upper limbs, hyperglycemia, and left upper limb muscle fasciculations with 4.5 hours previous to ED arrival. During the examination, the patient was tachycardic, with neurological impairment (slight left facial asymmetry, left upper limb motor deficit) and hyperglycemic (278mg/DL). Additional complaints of fatigue and epigastric pain were reported.
Misleading elements – history, examination, investigations:
The patient was initially triaged as an acute stroke syndrome eligible for intravenous thrombolysis, and therefore immediately referred to non-contrast head CT, before the information regarding the overnight neurological symptoms became available. Upon return from radiology, the patient accused slight chest discomfort and left flank pain and as such, supplementary tests were performed (cardiac and inflammatory markers, full abdominal pannel), including a cardiology consult and a trans-thoracic echocardiography, prompted by the alterations in cardiac markers (Troponine I high sensitive=1692,1 pg/ml, D-dimers= 687 ng/ml and NTproBNP= 1025pg/ml).
Helpful details – history, examination, investigations:
With patient and wife being medical doctors, the history was detailed and accurate. During the previous night, the patient received intravenous fluids and subcutaneous insulin, to lower his glycaemia. Ten days earlier, the patient underwent a minor upper respiratory tract infection, with one episode of subfebrility and only symptomatic treatment needed.
During the cardiac ultrasound, the diagnosis of endocarditis was made, as a vegetation mass was visible on the aortic valve. This prompted the need for further Imagistics (thorax, abdomen, and pelvis CT angiogram), which made the diagnosis possible. The blood samples revealed sever thrombocytopenia and mild hyponatremia, alongside inflammatory syndrome.
Differential and actual diagnosis:
The initial differential diagnosis was made between an ischaemic stroke (due to a trombotic event) with secondary hyperglycemia and newly diagnosed diabetes.
The final diagnosis was formulated as Infectious Endocarditis. Acute Embolic Stroke. Multiple Splenic and Bilateral Renal Embolic Infarcts. Partial Celiac Trunk Oclussion. Severe Thrombocytopenia. Mild Hyponatremia. Newly Diagnosed Diabetes/ Secondary Hyperglycemia.
Due to the hematologic alterations, surgical removal of the cardiac vegetation was not possible, leading to intensive care unit admission and a secondary infectious disease transfer.
What is the educational and/or clinical relevance of the case(s)?
The peculiarity of this case resides in the unique clinical presentation of an infectious endocarditis, a not-so-common cardiac disorder one would manage nowadays in the ED. Furthermore, the presence of the aortic valve vegetation triggered the investigation for systemic damages, such as splanchnic infarction, leading to the positive diagnosis. Both the final diagnosis and the magnitude of the multiorgan alterations were not anticipated based on the patient’s lack of specific symptoms or previous medical history. As such, there is significant educational value, bringing into attention the distinctiveness of the clinical presentation, with symptoms visible only in the late stage, subsequent to the systemic involvement, with life-threatening risks.
Roxana Mihaela ROSU (Cluj- Napoca, Romania), Ionut CONSTANTIN, Eugenia- Maria LUPAN- MURESAN
00:00 - 00:00
#41299 - DIAGNOSTIC PERFORMANCE OF A MOLECULAR HOST RESPONSE TEST TO DETECT SEPSIS ON EMERGENCY ADMISSION.
DIAGNOSTIC PERFORMANCE OF A MOLECULAR HOST RESPONSE TEST TO DETECT SEPSIS ON EMERGENCY ADMISSION.
Sepsis is one of the main health priorities worldwide. There are 48.9 million cases of sepsis annually worldwide and 11.0 million deaths annually. Sepsis is the main cause of ICU deaths. Early identification of sepsis is essential to affect morbidity and mortality.
SeptiCyte Rapid is a molecular test to distinguish sepsis from non-infectious systemic inflammation, and to estimate the probabilities of sepsis. It could have a clinical utility.
Objective:
Evaluate the diagnostic performance of a molecular host response assay (SeptiCyte LAB) designed to distinguish between sepsis and non-infectious systemic inflammation in critically ill adults and compare with the usual biomarkers, including procalcitonin and lactate.
Methods
A prospective, observational and non-interventional design and recruited a heterogeneous cohort of adult emergency patients in a period of 4 weeks.
The cartridge-based SeptiCyte RAPID test accepts a blood RNA sample from PAXgen. The test result (SeptiScore®) is reported as a value (0 to 15) in three interpretation bands, which represents an increase in the risk of sepsis. The results are available in approximately 1 hour directly from blood samples. Clinical data were collected during the standard of patient care and evaluations of the severity of the disease that led to admission. PAXgene® blood samples were analysed with SeptiCyte® RAPID on the Biocartis Idylla™ platform. Hospital stay, leucocyte count, absolute lymphocyte count, creatinine on admission, C-reactive protein, procalcitonin, lactate, pH, ultra-sensitive T troponin, qSOFA and SOFA, admission diagnosis and diagnosis at discharge were recorded.
Results
Patient samples (n=17) were obtained in the first 12 hours from admission to the emergency room. There were 58.82% (10) of women. The average age was 66 years (20.72 years) (22 to 98 years). The average hospital stay was 13 days (min. 3 to max. 50 days).
In the analysis of the operative characteristic curve of the receptor, SeptiCyte LAB had an estimated area under the curve of 0.82-0.89 to discriminate sepsis from non-infectious systemic inflammation. It was found that the relative probability of sepsis against non-infectious systemic inflammation increases with the increase in the test score (range, 0-10). In a logistic regression analysis, the diagnostic performance of the trial was improved only marginally when used in combination with other clinical and laboratory variables, including procalcitonin. The performance of the trial was not significantly affected by demographic variables, such as age or sex
The patients were classified into critical, severe, moderate and mild categories. There was no correlation between the sepsis rate or SRIS by SeptiCyte and the qSOFA, the SOFA, the hospital stay or the final diagnosis.
SeptiCyte LAB, in this small series, seems to have little value to complement the medical evaluation in the emergency room.
Dr Wojciech ROJEWSKI-ROJAS (Reus, Spain), Alicia ALVAREZ-GALARRAGA
00:00 - 00:00
#41270 - Diagnostic POCUS of a dead fetus in utero due to diabetic ketoacidosis in pregnancy in the emergency department.
Diagnostic POCUS of a dead fetus in utero due to diabetic ketoacidosis in pregnancy in the emergency department.
Introduction: Diabetic ketoacidosis (DKA) in pregnancy is an obstetric emergency. If not diagnosed and treated early, it may cause death of mother and fetus. Maternal acidosis, dehydration, reduced uteroplacental perfusion, electrolyte imbalance, or a combination of these may lead to fetal death. Therefore, continuous maternal and fetal monitoring is essential.
Case: A 23-year-old female patient admitted to the emergency department with a complaint of vomiting. In the patient's history, it was learned that she was 26 weeks pregnant and was using insulin for diabetes. It was learned that the patient could not feed because she vomited and therefore did not take insulin. Her general condition was fair, she was conscious and anxious. On physical examination, his heart was rhythmically tachycardic and tachypneic, and other system examinations were normal. In the laboratory, blood sugar was: 480mg/dL, arterial blood gase pH:7.21, PO2: 136mmHg, PCO2: 14 mmHg, HCO3: 9.6%, lactate: 1.4, base(Ecf)c: -21.5. B-Hcg: 28824 mIU/mL, WBC: 16.99 103/uL, RBC: 4.12 106/uL, platelet: 278 103/uL, PT: 9.5 sec, INR: 0.9, aPTT: 24.9 sec. The patient was started on fluid and insulin therapy. When the patient was asked when she last felt baby movements, she said that he had been moving until a few hours ago. Therefore, the fetus was evaluated by the emergency physician using bedside point of care ultrasound (POCUS). Intrauterine pregnancy was observed in POCUS, and biparietal diameter was compatible with 24 weeks of pregnancy at measurement. There was no heartbeat in the fetus. Fetal movement was not observed. Obstetric consultation was requested. The patient was transferred to the delivery room and the stillborn fetus was delivered via spontaneous vaginal birth. The patient's clinical condition improved when isotonic and insulin treatment was continued. The patient was discharged on the 3rd day.
Conclusion: In our case, diabetic ketoacidosis resulted in the fetus dying. Dead fetus in utero may cause maternal death by causing disseminated intravascular coagulation if not diagnosed in the early period. Nowadays, disseminated intravascular coagulation in the context of stillbirth is very rare due to early diagnosis and treatment. In our case, evaluation of the fetus with POCUS in emergency department enabled an accurate diagnosis to be made in a short time. Studies have shown that POCUS is effective in diagnosing intrauterine pregnancies safely and accurately and identifying pregnancy-related complications. Signs of a dead fetus on ultrasound (US): absence of fetal heartbeat, absence of fetal movements, overlapping of skull bones (Spalding sign), gross distortion of the fetal anatomy (maceration), soft tissue edema: skin >5 mm, echogenic amniotic fluid (fetal death fragments), thrombus in the fetal heart and gas shadow in the fetal heart (Robert's sign) may be observed. In our case, fetal death had just occurred. Therefore, there were early findings on US. There was no fetal heartbeat and no fetal movements. POCUS is a method that is easy to learn and apply. Emergency physicians' recognition of a dead fetus in utero with POCUS will save lives.
Nalan KOZACI, Ismail Erkan AYDIN, Onur GURKAN (Alanya, Turkey), Mustafa Burak BULBUL
00:00 - 00:00
#42319 - Diagnostic procedures in prehospital.
Diagnostic procedures in prehospital.
Introduction : Medical regulation constitutes a primordial task in the management of pre-hospital emergencies. The role of the regulating doctor is delicate given that telephone semiology does not always make it possible to assess the degree of emergency.
Goals : the objective of this work is to determine the factors associated with a diagnostic concordance between the diagnosis of medical regulation and the diagnosis after medical intervention.
Materials and methods : Prospective descriptive study carried out over a period of 2 months at the SAMU01 emergency mobile aid service. Primary discharges were included. A univariate study was carried out identifying the factors associated with the concordance between the diagnosis of the regulation and the diagnosis of the intervention physician.
Results : We collected 82 patients transferred by SMUR to primary missions. The mean age was 59 years ± 20 years with extremes ranging from 17 to 93 years. A male predominance was noted (63.4%) with a gender ratio of 1.73. The status of the regulating doctor: Public health doctor (90.2%), AHU (9.8%). The calls received mainly came from patients' relatives (61%) while 30.5% of calls were received from doctors. The response time ranged from 16 to 120 minutes with an estimated average of 69 minutes. The main pathological antecedents were: hypertension (41; 50%), diabetes (33; 40.2%), dyslipidemia (24; 29.3%) coronary insufficiency (16; 19.5%) with history of angioplasty in 13 patients (15.9%), Atrial fibrillation (12;14.6%) and heart failure (4;4.9%), renal failure (6;7.3%) under hemodialysis (5; 6.1%) . The main reasons for consultation were: chest pain (22; 26.8%), dyspnea (24; 29.3%), altered state of consciousness (33; 40.2%), convulsive seizures (13). ;15.9%), neurological deficit (12;14.6%), dysarthria (5;6.1%). The clinical examination found an average SpO2 of 89.9%, an average SBP of 145mmHg, an average DBP of 79.5mmHg and an average heart rate of 91bpm. The GCS varied between 3 and 15 with a mean of 13.27 and a mean of GAD of 1.8 g/l. The main diagnoses mentioned by medical regulations are: Hypoglycemia (7; 8.5%), NSTEMI (15; 18.3%), STEMI (5; 6.1%), arrhythmia (8; 9.8%) ), Conduction disorders (6; 7.3%), OAP (13; 15.9%), Pneumonia (15; 18.3%), seizure (11; 13.4%), stroke (16; 19.5%) %), Acute exacerbation of COPD (10; 12.2%), Intoxication (5; 6.1%), Neuromeningeal infection (4; 4.8%), perimyocarditis and aortic dissection (2; 2.4% ).In a univariate study, the factors associated with concordance between the diagnosis made by the regulating physician and the diagnosis retained are: sex (p=0.004), age (p=0.003), intervention time (p=0.048), history: AF (p=0.003),
heart failure =0.05), symptoms: altered state of consciousness (p=005), dysarthria (p=0.05).
Conclusion : Medical regulation is a central medical act in the orientation and management of pre-hospital emergencies. It requires demanding professionalism, solid knowledge and rigorous experience.
Sirine KHABOUCHI, Khaireddine JEMAI (Tunis, Tunisia)
00:00 - 00:00
#40928 - Diaphragmatic hernia presentation after strenuous physical activity.
Diaphragmatic hernia presentation after strenuous physical activity.
42 years old female patient presented to ED due to severe sudden onset left sided chest pain, started during her regular "Zumba" session. Pain was localized, non-radiating, constant, worsening with deep breathing. There was no shortness of breathing, no cough, no fever, no vomiting, no palpitation, no fainting. Patient denies any direct trauma to her chest or abdomen. She has no past medical or surgical history. On Examination, she had normal vital signs. Chest expansion was reduced on the lower left side. Normal vesicular breathing without crackles or wheezes but had diminished breath sounds in the left lower zone. Chest XR [Image 1] showed air fluid level in the left lower lung zone. CT thorax with contrast [Image 2] was done and identified a defect of left hemidiaphragm with herniation of the stomach, spleen, tail of pancreas.
Patient got admitted to the hospital and underwent Laparoscopic diaphragmatic hernia repair with mesh repair.
The case illustrates the importance of having a differential diagnosis when patient presents with exertional chest pain and findings of air fluid level on Chest XR.
Helmy ELHAG, Dr Basel ELMEGABAR (Doha, Qatar)
00:00 - 00:00
#41739 - Different visual attention patterns between a doctor and a nurse during a simulated emergency: utilising AI technology for automatic gaze and object detection.
Different visual attention patterns between a doctor and a nurse during a simulated emergency: utilising AI technology for automatic gaze and object detection.
Background:
Trauma leaders’ gaze behaviours have been recognised as a key factor for successful trauma team interactions (Härgestam et al., 2016; Weinberg et al., 2019). However, less attention was paid to members’ gaze, which is also crucial for collective competence for team performance and resilience. Utilising AI technology for automatic gaze annotation and object detection, this preliminary study compares visual attention patterns between a doctor and a nurse in an emergency care simulation session. This is part of a UK-Japan multidisciplinary research project on emergency care team interactions, involving researchers and practitioners in medicine, linguistics and computer science engineering.
Methods:
A small-scale simulation session with an experienced ED consultant and an experienced ED nurse, both wearing eye-tracking glasses (Tobii Pro Glasses 2) was filmed in a large teaching hospital in the UK as a pilot study. The scenario was a collapse in a ward, which involved two simulated patients (a female patient aged 72 and her sister). The first two-minute data footage were extracted from the two eye-trackers and synchronized. Objects where their gaze were fixed more than 40 milliseconds were automatically annotated with the programme incorporating the feature point detection technology, which was developed at the Department of Artificial Intelligence, Kyushu Institute of Technology. The accuracy of the automatic annotations was manually validated.
Results:
Different visual attention patterns were observed between the doctor and the nurse. The doctor gazed at the patient for more than half of the two-minute footage, which is twice of the total time length of the nurse’s gaze fixation on the patient and includes joint attention to the patient (approx. 11 seconds), e.g., attracting the doctor’s gaze attention when the nurse’s putting an oxygen mask on the patient. Object types automatically detected in the nurse’s gaze date were more diverse (27 types) than the doctor’s (17 types), but the accuracy of automatic object annotations is higher in the doctor’s gaze data (approx. 50%) than the nurse’s (approx. 30%). Medical equipment the nurse gazed at while administrating medical procedures was incorrectly detected by the application programme (e.g., annotating a blood pressure cuff as a book).
Discussion & Conclusions:
It is still an early stage of the study, but even this small data analysis provides a description of the umwelt, in other words, individuals’ distinctive subjective-sensory perceptions of the environment even when sharing a spatiotemporal space, through the multiple eye-tracking data. Trauma team members gaze differently as a doctor and a nurse, simultaneously interacting with each other and object materials around to pursue medical treatment as a joint action. Analysing trauma team interactions inevitably involves multiple sensory data, and the method of automatic gaze and object detection would make the research feasible with a finer adjustment to improve accuracy.
Trial registration:
N/A (Non-clinical work, no patient involved).
Funding:
This work was supported by JSPS KAKENHI Grant Numbers 22H03318, 23K24576.
Ethical approval and informed consent:
This research project was approved by the ethics committees of Nottingham University Hospitals NHS Trust and Yokohama City Medical Centre. Informed consent was obtained from all the participants.
Frank COFFEY (No, United Kingdom), Andrew MACKENZIE, Kazuya BISE, Takeshi SAITOH, Stephen TIMMONS, Keiko TSUCHIYA
00:00 - 00:00
#41750 - Direct Current Cardioversion (DCCV) is safe in Pregnancy.
Direct Current Cardioversion (DCCV) is safe in Pregnancy.
Atrial Fibrillation (AF) is uncommon in pregnancy but is associated with significant mortality. Direct current cardioversion (DCCV), despite being safely used in non-pregnant arrythmias, has not been well studied in pregnancy and typically avoided in non-maternity emergency setting. Whilst lacking in controlled studies, current international guidelines suggest that DCCV is safe in cases of maternal arrhythmia with hemodynamic compromise and poses minimal risk to foetal development.
We present a female patient at 22-weeks gestation who presented to the emergency department with acute onset symptomatic AF. Diagnosis was made clinically, past history of recurrent palpitations during pregnancy and electrocardiogram (ECG) findings. Following consultation with both cardiology and foetal-maternal medicine specialists, rhythm control was favoured for immediate management. Standard doses analgesia and sedation were administered. A single 200 joules synchronized shock resulted in successful reversion to sinus rhythm with no adverse events. Therapeutic anticoagulation was commenced following cardioversion and continued for six weeks. Differential diagnosis including pulmonary embolism were ruled out via examining features on ECG post-reversion and computed tomography angiography of the lungs (CTPA). The patient had an uneventful inpatient course and was discharged on day three with close outpatient cardiology and obstetric follow up.
This case highlights the safe and successful use of DCCV in managing AF in pregnant patient presenting to the emergency department. Regular medications used for analgesia and sedation in cardioversion are safe at usual doses to be administered in pregnancy. Multidisciplinary team approach is key in managing AF in pregnancy in the acute setting.
Haleeda HILMI (Dublin, Ireland), Bibi Ayesha BASSA, Deirdre MCELWEE, Eamon MURPHY
00:00 - 00:00
#41488 - Disentangling dual pathologies: Intersecting symptomatology due to lithium toxicity, immunotherapy induced hyperthyroidism.
Disentangling dual pathologies: Intersecting symptomatology due to lithium toxicity, immunotherapy induced hyperthyroidism.
This case report details the complex clinical presentation of a 62-year-old female with an extensive medical history including hypertension, bipolar disorder, and metastatic melanoma with lung metastases. She presented to the emergency department (ED) with acute neurological and systemic symptoms that had progressively worsened over the past week, including persistent slurred speech, ataxia, upper limb tremors, increased lethargy, mobility issues, palpitations, anasarca, and transient episodes of loose stools. These symptoms, escalating rapidly over two days, necessitated urgent medical evaluation.
The patient's comprehensive medical regimen and her recent pharmacological additions posed challenges in immediate diagnostic processes. Initial differential diagnoses considered were lithium toxicity, thyroid storm from pembrolizumab-induced hyperthyroidism, cerebral metastases, and other intracranial pathologies. Clinical assessments showed the patient to be alert and oriented, albeit with mild slurred speech, pronounced tremor, ataxia, and a heart rate of 110 beats per minute. Systemic examinations were largely unremarkable. Diagnostic tests including a normal CT head scan and an ECG showing sinus tachycardia with normal intervals provided no further clarity. However, laboratory findings revealed elevated lithium levels (1.44 mmol/L) and a markedly suppressed TSH (<0.01mIU/L) with elevated FT4 (64 pmol/L), indicating significant hyperthyroidism.
Employing the Burch-Wartofsky Point Scale pointed to a potential impending thyroid storm, yet the presentation was confounded by overlapping symptoms possibly attributable to both lithium toxicity and the effects of pembrolizumab. Management strategies included adequate hydration, cessation of lithium, and psychiatric consultation for bipolar management adjustments. Diagnoses concluded lithium toxicity compounded by pembrolizumab-induced hyperthyroidism.
Subsequent coordination with acute oncology, psychiatry, and the medical team facilitated comprehensive management, leading to marked symptomatic improvement after lithium normalization. Adjustments in cancer therapy were made by oncology team to mitigate pembrolizumab-related thyroid issues.
The case exemplifies the diagnostic and management complexities faced in the ED when treating patients with multiple, active pathologies and concurrent drug therapies. Particularly challenging was the differentiation of symptoms common to both lithium toxicity and hyperthyroidism, such as tremor, ataxia, and tachycardia, which necessitated judicious evaluation and treatment modifications. This case highlights the critical need for broad differential diagnoses, tailored investigative strategies, and the careful balancing of treatment options in multifactorial medical presentations, underscoring the pivotal role of integrating multidisciplinary approaches in acute care settings.
Siva Kumar AYTHA (Kolkata, India)
00:00 - 00:00
#40976 - Disparity in guideline adherence for prehospital care according to patient age in emergency medical service transport for severe trauma.
Disparity in guideline adherence for prehospital care according to patient age in emergency medical service transport for severe trauma.
Objectives
The aim of this study was to investigate the association between patient age and guideline adherence for prehospital care in emergency medical services (EMS) for severe trauma.
Methods
This was a retrospective observational study that used a nationwide EMS-based trauma database from 2016 to 2019. Adult major trauma patients whose injury severity score was greater than or equal to nine were screened, and those with cardiac arrest or without outcome data were excluded. The enrolled patients were categorized into four groups according to patient age: young (<45 years), middle-aged (45-64 years), old (65-84 years), and very old (>84 years). The primary outcome was guideline adherence, which was defined as following all prehospital care components: airway management for level of consciousness below verbal response, oxygen supply for pulse oximetry under 94%, intravenous fluid administration for systolic blood pressure under 90 mmHg, scene resuscitation time within 10 minutes, and transport to the trauma center or level 1 emergency department. Multivariate logistic regression was conducted to calculate the adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs).
Results
Among the 430,365 EMS-treated trauma patients, 38,580 patients were analyzed—9,573 (24.8%) in the young group, 15,296 (39.7%) in the middle-aged group, 9,562 (24.8%) in the old group, and 4,149 (10.8%) in the very old group. The main analysis revealed a lower probability of guideline adherence in the old group (aOR 95% CI=0.84 (0.76-0.94)) and very old group (aOR 95% CI=0.68 (0.58-0.81)) than in the young group.
Conclusion
We found disparities in guideline adherence for prehospital care according to patient age at the time of EMS assessment of severe trauma. Considering this disparity, the prehospital trauma triage and management for older patients needs to be improved and educated to EMS providers.
Ahn EUN SEON, Ahn EUN SEON (Seoul, Republic of Korea)
00:00 - 00:00
#41456 - Do-Not-Attempt-Resuscitation Decision Making: Physicians' recommendations differ from the GO-FAR score predictions.
Do-Not-Attempt-Resuscitation Decision Making: Physicians' recommendations differ from the GO-FAR score predictions.
Aim: To compare three consultants' do-not-resuscitate (DNR) decisions with the GO-FAR score predictions of the probability of survival with good neurological outcome following IHCA.
Methods: This is a retrospective study of all patients 18 years or older placed on a DNR order by a consensus of three consultants in a tertiary institution in the United Arab Emirates over a 12-month period. Patients' socio-demographics and the GO-FAR variables were abstracted from the electronic medical records. We applied the GO-FAR score and calculated the probability of survival with good neurological outcome for each patient.
Results: A total of 788 patients received a DNR order, with a median age of 71 years and a majority being males and expatriates. The GO-FAR model categorized 441 (56%) of the patients as having low or very low probability of survival and 347 (44%) as average or above. There were 219 patients with a primary diagnosis of cancer, of whom 148 (67.6%) were in the average and above-average probability groups. There were more In-hospital deaths among patients in the average and above-average probability of survival group compared with those with very low and low probability (243 (70%) versus 249 (56.5%) (P<0.0001)). The DNR patients with an average or above average chance of survival by GO-FAR score were more likely to be expatriates, oncology patients, and did not have sepsis.
Conclusions: The GO-FAR score provides a guide for joint decision-making on the possible outcomes of CPR in the event of IHCA. The physicians' recommendation and the ultimate patient's resuscitation choice may differ due to more complex contextual medico-social factors.
Not applicable
David ALAO (United Arab Emirates, United Arab Emirates), Sneha ABRAHAM, Emad DABABNEH, Roxanne ROBY, Mohammed FARID, Nada MOHAMMED, Natalia ROJAS-PERILLA, Arif CEVIK
00:00 - 00:00
#41829 - DOAC blood dosage: a new technology for a quick evaluation in the acute setting.
DOAC blood dosage: a new technology for a quick evaluation in the acute setting.
Introduction
Direct oral anticoagulants (DOACs) are becoming increasingly common thanks to their ease of use and relative lack of adverse effects. The main long-standing issue with DOACs was the lack of antagonists to be used in case of emergencies, such as trauma, hemorrhage and emergency surgery. In the last couple of years antagonists have begun to enter the market, but the main limitation to their widespread use in emergency scenarios is the time needed to evaluate blood DOAC levels in laboratories. Consequently, the DOAC Dipstick ™ and DOASENSE Reader have been developed to produce reliable, qualitative evaluations of blood concentrations from urine samples in 10 minutes. This application could drastically reduce wait times for antidote administration, potentially saving many lives in the acute setting.
Materials and Methods
38 participants were enrolled in the study, 37 of which were under DOAC therapy and the remaining 1 was used as a negative control. All participants were patients admitted to the Emergency Room due to trauma or evidence of hemorrhage. Blood was sent to the lab to evaluate blood DOAC concentrations concurrently to the collection of fresh urine to be immediately tested with the DOAC Dipstick. Results were subsequently compared: as the DOASENSE Reader reports a qualitative positive/negative therapeutic range, for the blood dosage a cutoff of 13ng/mL was used to determine if there was a therapeutic quantity of DOAC in circulation for which an antidote may be considered. Data was then processed in Python with the use of Pandas to extract the similarities between the DOAC Dipstick and the Gold Standard. The McNemar Test and Cohen’s Kappa were calculated. All patients signed and informed consent form and the study was approved by the internal ethical committee of Istituto Clinico Humanitas.
Results
While the DOAC Dipstick never returned a positive result when circulating blood DOAC levels were null, 7 false positives were returned when blood levels were below the therapeutic threshold, indicating no anticoagulant activity and hence no need for antidote administration. No false negatives were recorded, nor any errors in distinguishing between Thrombin and Factor Xa inhibitors were recorded. The McNemar test resulted statistically significant for differences between the DOASENSE Reader and blood test results. Preliminary investigations have not yet found an explanation for the false positives, other than a greater-than-necessary precision of the DOASENSE Reader.
Discussion
Our population sample was rather small, and a larger sample size may provide more nuanced results. Notwithstanding, the evidence of false positives must be taken into account when considering the widespread use of such a machine. Larger studies may also provide an explanation for such false positives, as well as provide more accurate estimates for the sensibility and sensitivity of the DOASENSE Reader.
Conclusion
While the DOAC Dipstick ™ and DOASENSE Reader have proved to produce some false positives, which would possibly result in an over-administration of DOAC and put patients at risk of adverse effects, the development of such technology is crucial in the future management of patients in acute hemorrhagic and traumatic conditions.
Dr Silvia PAIARDI, Francesca SERAZZI, Gaia FILIBERTI, Antonio DESAI, Dana SHIFFER, Elena GENERALI (Milan, Italy), Luca LIBRÈ, Corrado LODIGIANI, Antonio VOZA
00:00 - 00:00
#41574 - Does age influence the utilization of external defibrillators in women with out-of-hospital cardiac arrest?
Does age influence the utilization of external defibrillators in women with out-of-hospital cardiac arrest?
Introduction
Out-of-hospital cardiac arrest (OHCA) patients treated with an automated external defibrillator (AED) have better outcomes than their counterparts. We have shown that women are less likely to have an AED installed than men, but the mechanisms underlying that difference have not been explored. This could be explained by bystander being concerned about exposing the breasts, which is required to install an AED. Younger women may be more at risk of not receiving the available treatments because of this possible concern. Temporal trends could also help explain that difference. Therefore, we examined the interaction between age, gender and rates of AED usage amongst OHCA patients.
Methods
Using a North American OHCA registry, we included adult patients with nontraumatic bystander witnessed OHCA in a public location who received BCPR. We excluded OHCA events witnessed by emergency medical services personnel or with missing critical data. The primary outcome was the installation of an AED by a bystander. In a multivariable logistic regression adjusting for relevant covariates (age, Cardiac Epistry version), we tested for an interaction between the installation of an AED, patient gender, age and the Cardiac Epistry version (1-2: 2005-2010; 3: 2010-2015). We planned to perform additional regressions if an interaction was found.
Results
Of the 229,637 OHCAs in the registry, we included 6,086 patients (installation of an AED: 23%; women: 15%; mean age: 62 years [SD 14]; initial shockable rhythm: 66%; survival to discharge: 38%). As shown previously, women were less likely than men to have an AED installed (AOR: 0.84 [95%CI 0.71-0.99], p=0.043). No three-way interaction (patient gender, age, and Cardiac Epistry Version, p=0.69) or two-way interaction (patient gender and age, p=0.61; patient gender and Cardiac Epistry Version, p=0.39) was observed.
Conclusion
Bystanders providing BCPR are less likely to use an AED when they treat a woman. Contrary to our hypothesis, younger women are not more affected by this phenomenon than older women. There was no temporal trend which could help us better understand that phenomenon. Future studies should explore if the patient gender is a proxy of another characteristic which could explain a difference in treatment between men and women, as well as which bystander characteristics predict the provision of BCPR and the use of an AED on women.
This program has received financial support from the ‘Département de médecine familiale et de médecine d’urgence de l’Université de Montréal’ in the form of salarial support.
This program has received in-kind support from the ‘Fonds des urgentistes de l’Hôpital du Sacré-Coeur’ in the form of logistical support.
This manuscript was prepared using the data from the ROC Cardiac Epistry 1, 2 and 3 from the NHLBI Biologic Specimen and Data Repository Information Coordinating Centre and does not necessarily reflect the opinions or views of the ROC Cardiac Epistry 1, 2 and 3, ROC-PRIMED, ROC-CCC and ROC-ALPS or the NHLBI.
Dr Alexis COURNOYER, Zoé GARCEAU-TREMBLAY, Samuel BLAIS, Raoul DAOUST, Justine LESSARD, Rodrigo FLORES-SOTO, Yiorgos Alexandros CAVAYAS, Jean PAQUET, Martin MARQUIS, Judy MORRIS, Véronique CASTONGUAY, Éric PIETTE, Sylvie COSSETTE (Montreal, Canada)
00:00 - 00:00
#41665 - Does clinical frailty scale help to predict outcomes in older major trauma patients? - a retrospective study at a major trauma centre.
Does clinical frailty scale help to predict outcomes in older major trauma patients? - a retrospective study at a major trauma centre.
Frailty is a marker of vulnerability. When people age, they often lose their ability to adapt in the face of ‘acute’ events such as physical injury. Frailty has been shown in multiple systematic reviews and meta-analysis’ as a predictor of mortality, complications, and discharge disposition. Evidence indicates that the clinical frailty scale (CFS) score has a strong predictive ability in the emergency department setting. It has been suggested the use of the CFS in assessments, may encourage more tailored management of the older trauma patient, in turn improving outcomes for these patients.
This study aims to retrospectively evaluate the impact of frailty on major trauma patients, (injury severity score ≥13), over the age of 65 presenting to a New Zealand major trauma emergency department. Across the year 2022, 135 patients were identified for inclusion.
Data including the pre-injury clinical frailty scale score recorded by the trauma nursing team were collected retrospectively, alongside data from the trauma registry and electronic patient notes. Statistical analysis including a mediation analysis was carried out. The primary outcome was a composite outcome of in hospital mortality or increased care requirements on discharge.
The median age was 77, 87% of patients were of New Zealand European ethnicity (4% New Zealand Māori), and 60% were male. Fall from standing was the most common mechanism of injury (43%). The median triage on arrival was 3 and the median pre-injury clinical frailty scale score was 4. Both the clinical frailty scale score and age were shown to have a significant impact on the primary outcome. When increased care or in hospital mortality was regressed on age only, there was an odds ratio of 1.09 (95% CI 1.04-1.15, p < 0 .001). When frailty was added to the model, the odds ratio between age and the primary outcome dropped to 1.06 (95% CI 1.01-1.12, p = 0.03). The mediation effect of frailty was shown to be significant with 38.1% (95% CI 8.76%-97%) mediated through frailty (p= 0.013).
Though a relatively small sample size, these results add to the evidence that age alone can’t be used to create pathways of care for older major trauma patients. To the authors knowledge this is the first study of its kind based in Australasia. This evidence will be used to build a case for a frailty driven trauma service at this major trauma hospital.
Charlotte UNDERWOOD (Sheffield, United Kingdom), Laura JOYCE, Andrew MCCOMBIE, Maria NONIS
00:00 - 00:00
#41852 - Does fast track reduses emergency department revisits?
Does fast track reduses emergency department revisits?
Introduction
Fast Track(FT) is designed for patients presenting to the Emergency Department(ED) with low acuity complains.It is well known that this process improves quality indicators of ED such as overcrowding,length of stay(LOS),overuse on hospital resources and patients satisfaction.While the effectiveness of FT areas in expediting patient care is well-documented,there exists a discernible research gap concerning the frequency of revisits for the same complain
Purpose
This study endeavors to assess the efficacy and quality outcomes associated with the management in FT
Methods
This is a retrospective observational single-center study.The study population was patients over 16 years old,presented to the ED of an academic tetrtiary hospital,which receive approximately 85.000-95.000 visits/year.All included patients were categorized as level 4 and 5 according to the local triage protocols(Emergency Severity Index,Manchester,Australasian triage systems)and they were managed in the FT.The study period was February 2024 till April 2024.Collected data were:presenting symptom ,discharge from FT,admission to the hospital,unilization of laboratory testing.Final outcome was defined as revisit or not to the ED for the same reason in the next fifteen days ,as reported in a follow-up telephone contact
Results
A total of 1120(14%) out of 18740 patients who presented total to the ED for the same period, were accessed in FT.Discharged from FT was 81,5%(n:911) .Admitted to the hospital was 3.75% (n:42).The most common presenting symptoms were abdominal pain 12.77% (n:143),low grade fever 9.20%(n:103),non-traumatic joint pain (knee,shoulder,hip):6.43% (n:72) and patients presenting with minor wound injuries 1.43%(n:16).Patients discharged without any additional laboratory test was 22.86%(n:256)Patients were only perfomed point-of-care testing (POCT),urine,blood.ultra sound(u/s) was 7.95%(n:89).Only 0.54%(n:6)reported revisit to the ED for the same reason
Conclusion
The finding,at the above short-term ,single-center study suggest tha FT hold promise in facilitating promp and seems a safe process for the management of low-acuity patients presenting to the ED.Thus it can reduse overcrowding without risk in the ED.
ΤΕΠ,ΕΒΔ74/31-01-2024
This study did not receive any
specific funding
Ioanna RITA, Christina KALTSIDOU (Athens, Greece), Fereniki GASPARAKI, Sofia BEZATI, Maria VELLIOU, Evmorfia DIALETI, Antonios DIAKANTONIS, Dimitrios MAVROLIAS, John PARISSIS, Effie POLYZOGOPOULOU
00:00 - 00:00
#41906 - Does simulation based medical education improve technical and non technical skills training in undergraduate medical students?
Does simulation based medical education improve technical and non technical skills training in undergraduate medical students?
Background
Simulation based medical education has a strong evidence base to support its use and is incorporated into the curriculum for undergraduates at a number of institiuitons. In our University Teaching Hospital, simulation based medical education is not currently incorporated into the curriculum. There is a national student simwars competiiton where students from every medical school compete in a series of emergency medicine based simulation scenarios and are judged with standardised marking schemes by subject matter experts on their technical and non technical skills performance. We sought to analyse feedback from the undergraduates at our institution participating in training to evaluate the training they received and determine if they found the training relevant and engaging and if they achieved the required learning outcomes.
Methods
Students were invited to attend a once weekly standardised high fidelity simulation based medical education training programme on emergency medicine presentations with technical and non technical skill learning outcomes for a period of 6 months (September 2023 to February 2024).
A 12 question anonymous online survey including open questions was piloted and amended for ambiguity and errors.Following the training, the survey was administered to all participants in student simwars competition training (n=28) and the results were analysed using Kirkpatrick levels 1 and 2.
Results
All participants responded n=28
63% were year 4 and 37% were year 5 of medical school
Participants signed up for simwars to gain knowledge and skills not taught in their current undergraduate curriculum and to prepare for exams and for working as a junior doctor
Participants stated they learned technical skills (oxygen delivery, airway adjuncts, intubation technique, chest drain insertion, pelvic binder application, log roll technique, use of a rapid infuser and insertion of an intraossesous device)
Participants listed non technical skills learned in communication, teamwork, crisis resource management, leadership, prioritisation and calling for help early.
100% had never practical done teamwork training before
100% felt simulation based education should be incorporated into their curriculum
100% felt more confident in their exams as a result of simulation training
100% felt more prepared to be a junior doctor and deal with emergencies as a result of their sim training
100% felt they retained knowledge from the training; supported with a 100% pretest to post-test improvement in knowledge
Summary
Undergraduate medical students at our university teaching hospital are unanimously in favour of simulation based medical education for improved technical and non technical skills training and knowledge retention (Kirkpatrick level 2). Students felt simulation should be incorporated into their curriculum and improved their knowledge and skills but also their confidence in exam performance and also in the transition to becoming a junior doctor and dealing with emergencies.
This evidence has been presented to the medical school which is currently under curriculum reform to include simulation based medical education.
Conclusion
Victoria Claire MEIGHAN (Dublin, Ireland)
00:00 - 00:00
#41676 - Does the clinical severity of acute bronchiolitis impact physicians' adherence to clinical practice guidelines while working in the PED? A quality improvement study.
Does the clinical severity of acute bronchiolitis impact physicians' adherence to clinical practice guidelines while working in the PED? A quality improvement study.
Introduction - Aim: There is a significant variability among healthcare providers in the diagnosis and treatment of acute bronchiolitis. Despite guidelines recommending diagnosis based on history and physical examination and only supportive treatment, numerous studies have reported the implementation of many unnecessary tests and treatments. With this study, we aimed to evaluate the changes in the diagnosis and treatment process of patients with acute bronchiolitis resulting from interventions aimed at reducing unnecessary tests and treatments implemented by the "Multidisciplinary Acute Bronchiolitis Team" established at our hospital.
Material-Method: In July 2022, the "Multidisciplinary Acute Bronchiolitis Team" in our pediatric emergency department (PED) developed an acute bronchiolitis diagnosis and treatment algorithm according to current guidelines. Trainings were conducted for the physicians working in the PED, and the algorithms were displayed in the examination rooms in poster format and also qr codes. Family information forms were prepared. Infants under 1 year of age diagnosed with acute bronchiolitis were compared in terms of diagnostic tests and treatments before (January 1, 2017 - June 30, 2022) and after (October 1, 2022 - March 30, 2023) the training. This study was approved by the Hacettepe Ethics Committee (SBA 24/087).
Results: In the pre-intervention period, girls accounted for 35.2% (n=25) of the participants, with a mean age of 8.4±3.3 months. In the post-intervention period, the percentage of girls was 44.6% (n=78) and the mean age was 5.1±2.7 years. The rates of diagnostic tests (laboratory tests, chest X-ray, viral tests) were 19.6%, 66%, and 8.4% in the pre-intervention period, and 17.5%, 66.7%, and 29.8% in the post-intervention period (p=0.22; p=0.94; p<0.001). The treatments administered (bronchodilator therapy, steroid therapy, antibiotic therapy) were 92.4%, 37.3%, and 42.8% in the pre-intervention period, and 59.9%, 4.3%, and 23.4% in the post-intervention period, respectively (p<0.001; p<0.001; p<0.001). When the diagnostic tests and treatments were categorized as mild-moderate and severe according to bronchiolitis severity, it was observed that the rate of requesting chest X-rays was 65.8%, 81.5%, and 100.0%, respectively. Comparing treatments, in patients with mild clinical severity, salbutamol was used in 35%, systemic steroids in 10%, and antibiotics in 5.9%. In patients with severe clinical severity, these rates were 83%, 67%, and 66%, respectively.
Conclusion: As a result, it was seen that the training and treatment algorithm was effective in reducing unnecessary treatment, but the desired reduction was not achieved, especially in reducing unnecessary tests. When the frequency of diagnostic tests was evaluated according to the severity of the acute bronchiolitis attack, it was seen that clinical severity led physicians to perform more laboratory tests and imaging. For this reason, the study revealed that disease severity should also be taken into account when evaluating initiatives in quality improvement studies.
This study was approved by the Hacettepe Ethics Committee (SBA 24/087).
Burcu AKBABA (Ankara, Turkey), Didem ALBOĞA, Umut Berk MERCAN, Nagehan EMIRALIOĞLU, Ozlem TEKSAM
00:00 - 00:00
#41290 - Domino effect: anaphylaxis-induced acute coronary syndrome – non-ST elevation myocardial infarction (kounis syndrome) and diabetic ketoacidosis as a consequence of scombroid poisoning in a filipino man: A case report.
Domino effect: anaphylaxis-induced acute coronary syndrome – non-ST elevation myocardial infarction (kounis syndrome) and diabetic ketoacidosis as a consequence of scombroid poisoning in a filipino man: A case report.
Managing life-threatening conditions is a day-to-day job of healthcare providers in the emergency department. However, there are limited reports that medical emergencies may co-exist and be the consequence of the other and intervention of one may exacerbate the other. This is a case of a 50-year-old hypertensive and diabetic man presenting in the emergency department as chest pain. History and further work up revealed three coincidentally occurring medical emergencies: anaphylaxis and acute coronary syndrome (Kounis syndrome), and diabetic ketoacidosis that was triggered by Scombroid syndrome from the ingestion of milkfish or bangus. This case is reported because of the under recognition of Kounis syndrome, the therapeutic dilemma in managing concomitant anaphylaxis and acute coronary syndrome, as well as the atypical trigger of diabetic ketoacidosis. Part of the standard management of ACS is the use of beta-blockers, and opioids for pain. However, use of beta-blockers for ACS in the setting of Kounis syndrome is avoided due to coronary vasospasm, opioids are avoided due to mast cell degranulation which can aggravate anaphylaxis. Epinephrine is the corner stone of anaphylaxis management but can cause coronary vasospasm potentially further decreasing blood flow to the heart. In the absence of its symptoms, diabetic ketoacidosis was recognized and delay of treatment was avoided. A key and unusual trigger in its development was anaphylaxis. Only two published reports have been recorded of this correlation. Awareness of such syndromes and atypical causes would aid the clinician in the proper work-up and management in patients presenting with more than one emergency condition as decisions in the treatment plan is modified.
Korina ROSARIO (Metro Manila, Philippines)
00:00 - 00:00
#41076 - Don't let your pregnancy belly distract you.
Don't let your pregnancy belly distract you.
A 38-year-old female patient with no history described,multiparous with 3 previous pregnancies without complications and eutocic deliveries in 2017,2019 and 2021,on treatment with vitamin complex, came to the emergency room.
She has been on relative rest due to metrorrhagia in the 2nd trimester, but she did household chores and picked up the kids from school.She reports that 48 hours earlier she began with pain at the base of the right hemithorax that worsened with movements and breathing,as well as increased dyspnea,until minimal effort was made.Denies other symptoms.
On arrival at the emergency room,saturation 98%,HR 82bpm,BP 105/70 mmHg and discrete tachypnea (18).Afebrile.Physical examination revealed rhythmic cardiac auscultation without murmurs or rubbing;Pulmonary auscultation with tenderness on the right side,without skin lesions.Hypoventilation at the right base.Abdomen of a pregnant woman corresponding to gestational age.No alterations in the lower extremities.
Gynaecology assessed,which referred to haematic remains,with minimal bleeding from the cavity,closed cervix and uterus that corresponds to amenorrhea.Spontaneous movements,posterior placenta.
Blood tests showed D-dimer 3.93 mg/L,creatinine 0.63 m/dl,74 ng/L,C-reactive protein CRP <154.74 mg/L, hemoglobin 10.5 g/dL,31.50% hematocrit with leukocytosis of 14100(neutrophilia 87.9%).Normal clotting.Electrocardiogram:sinus tachycardia.Echocardiogram-color Doppler:Compatible with normality.
Thoracic ultrasound:Small right pleural effusion with a maximum thickness of 15mm in the posterior costophrenic sinus.Atelectasis in the right lower lobe with images suggestive of gas in the sinus.No left pleural effusion is observed.
Doppler ultrasound of the lower extremities:No signs of deep or superficial vein thrombosis.Thoracic computed tomography(radiation dose optimization):Filling defects in the bifurcation of the right main pulmonary artery extending to the inferior lobar artery,killed the right lower lobe segmental branch,the middle lobe artery,and the lateral and medial segmental branches.Filling defects are also observed, although smaller,in the bifurcation of the left inferior lobar artery,anterior and lateral segmental branches of the left basal pyramid and in the lingullary artery,compatible with pulmonary thromboembolism.Alveolar pulmonary condensation with areas of tarnished glass of peripheral location with triangular morphology in the middle lobe and anterior and lateral segments of the right lower lobe compatible with extensive infarction was observed.
After diagnosis,treatment with low molecular weight heparin is initiated,which will be maintained until 6 weeks after delivery.
Pulmonary embolism is an obstetric emergency and is the second leading cause of maternal death in developed countries.Both in pregnancy and in the puerperium,the three components of Virchow's triad are manifested:venous stasis,endothelial injury and hypercoagulability.Maternal hemostasis is characterized by being a prothrombotic state,with the aim of preventing possible bleeding during the early stages of pregnancy,childbirth and puerperium,but this also predisposes to an increased risk of venous thromboembolism by 4 to 50 times compared to non-pregnant women.Given the physiological changes inherent in pregnancy, it is necessary to focus more on the clinical history, signs, symptoms, laboratory data and imaging tests, such as helical axial tomography with its high specificity and sensitivity to reach the diagnosis and establish the appropriate treatment. In the event of diagnostic doubts, timely treatment with low molecular weight and unfractionated heparin should be initiated.
Cristina BARREIRO MARTÍNEZ, Blanca GUERRERO MOÑUS, Noemi SOTO TOSTADO, Marta HUEDO JIMÉNEZ, María REDONDO LOZANO, Pilar VARELA GARCÍA, Miriam UZURIAGA MARTÍN (Madrid, Spain), Vanesa NATALIA ISAAC
00:00 - 00:00
#41247 - Double N2O toxicity.
Double N2O toxicity.
N2O use is escalating amongst the young adults in Europe, with serious neurotoxic side effects secondary to its use. The French Poisons centres network reported a tripling of the cases reported between 2020-2021, and 5.5% of the population 14-15 years in 2021 reported lifetime use of the gas. EMDDCA has published a report concerning the growing concern of its recreational use in Europe in 2022. N2O can cause severe demyelinating lesion, but also cutaneous lesion secondary to ice burns from the cylinders.
Case report
20-year-old female who smokes tobacco and cannabis, occasional alcohol use, and long-term misuse of N2O, which had escalated to 2-3 cylinders 2-3 times a week. She seeks ED after a binge of 6 cylinders/day. The day after her binge of N2O she experienced walking difficulties and skin lesions due to freezing on the inner side of her thighs.
On examination she was GCS 15/15, temp 37.4, BP 107/57n HR 120/min, SaO2 99% on RA, RR 16/min. The neurological examination found ataxic walk wit motor weakness 2/5 of psoas and 4/5 anterior hamstring bilaterally, no reflexes were found in lower limb. Bilateral Babinski was found together with extensive sensitive levels on the examination of lower limb
The skin exam revealed 10x15 cm lesions on the inner thighs bilaterally due to 2nd degree ice burns, for having kept the N2O cylinders in between her thighs while inhaling the N2O.
The blood works showed Hb of 14 G/L, MCV 84 fl, WBC 15.8 G/l, platelets 359 G/l, the coagulation was normal, as well as RFT and LFT, CRP 408 mg/L, Creatinine kinase 108 U/l, folic acid > 20 mcg/L (ref > 3.9 mcg/l) and Vitamin B12 235 ng/l (ref 200-700 ng/L), homocysteine 232.9 mcmol/l(ref < 15) and Urine -methylmalonic acid 75.8 mcmol/mmol (ref < 2)
She was started on Cyanocobalamin treatment 1mg IM once a day during 10 days, then 1mg every ten days for 1 month, then 1 mg every month during 6 months.
For her 2nd ice burn, the blisters where drained and local treatment with silver sulfadiazine applications with sterile paraffin tulle gras dressing were prescribed.
Discussion
The increasing use of N2O and the binge manner with which is consumed can lead to severe neurotoxicity due to dysfunction in vitamin B 12 metabolism. There is also a risk of freezing burns, when the N2O supersize canisters are squeezed between the thigs during a prolonged period of time, when patients binging on N2O with masks connected to these canisters.
The epidemy of N20 use and toxicity is escalating amongst the young adults in Europe, there has been a 35-fold increase in the French Addictovigilance notification in between 2018-2022. Different legislatives measures have been undertaken around the world to regulate the sell and use of N2O, but the impact of these regulations is not yet to be seen in our clinical reality, and it remains as a public health threat given the long-term negative health effects in young population risking serious neurological sequels.
Hanna OVASKA, Hanna OVASKA (CRETEIL), Thierry GENDRE, Alix DUSSORT, Mehdi KHELLAF
00:00 - 00:00
#41924 - Dysphagia as a primary symptom of cervical spinal cord hemangioblastoma.
Dysphagia as a primary symptom of cervical spinal cord hemangioblastoma.
A 24-year-old woman presented to our emergency department (ED) with symptoms of dysphagia that lasted for one month showing no other acute symptoms. She reported an occasional symptom of dizziness and headache with no other complaints. Clinical examination didn’t show any obvious findings and patient had been referred to gastroenterologist and otorhinolaryngologist for further evaluation. No pathologic conditions were found on gastroscopic and direct laryngoscopy evaluation. Neck ultrasound and cervical spine x-ray were diagnostically unremarkable. Antibiotic therapy and corticoid inhalations were prescribed and patient was discharged. Seven days later patient was transported by paramedic service to our ED because of the head trauma after transitional consciousness loss. During an examination in the ED she was conscious, communicative, oriented, feeling a mild numbness and weakness in the right hand. neurological status showed discrete right hand paresis and positive Romberg sign. She received CT scan of the head which didn’t show intracerebral bleeding and skeletal discontinuation. As a coincident finding under the fourth brain chamber in the area towards the spinal canal the zone of cerebrospinal density was detected. Patient received magnetic resonance imaging of the brain and the cervical spine showing intramedullary tumor at the level of C3-C4 vertebra. Multiple minor intramedullary lesions of the same density along the thoracic spinal cord were also detected. Patient was further referred to a neurosurgeon who decided to perform a tumor resection. Major tumor lesion located in the cervical spinal cord (14x7,5x10 mm) was totally resected. Other lesions were not resected due to small size (1-2 mm), and the MRI follow ups on the six month basis will be performed. Histopathologic specimen evaluation confirmed hemangioblastoma. After the surgery patient received a physical therapy. Recovery process was successful and no neurological deficits were present.
Presence of multiple CNS hemangioblastomas suggests association with Von Hippel Lindau disease and further genetic tests are required. Lifelong follow up, including MRI of the whole CNS, retinal examination and abdominal ultrasound every six month is necessary due to an increased risk of tumor relapse. Hemangioblastomas are benign, highly vascularized neoplasms of the central nervous system (CNS), most commonly located in cerebellum, but might appear in any part of CNS. Spinal hemangioblastomas usually arise within the medulla. The most frequent symptoms of cervical spine hemangioblastoma include headache, dizziness, neck and shoulder pain, numbness or pins and needles in the arms, weakness in the hands. Diseases that are most commonly accompanied with dysphagia are mouth and throat tumors, gastroesophageal reflux disease and stroke. Although dysphagia is a rare symptom of cervical spinal cord hemangioblastoma in our case it proved to be a primary symptom of this tumor.
Elma DEMIROVIC (Sarajevo, Bosnia and Herzegovina), Kenan DEMIROVIC, Maja DEDIC, Zehrina HUSNIĆ, Mirjana MALENICA, Merima SISIC
00:00 - 00:00
#41448 - Early In-Hospital Mortality of Pulmonary Embolism: Predictive Factors.
Early In-Hospital Mortality of Pulmonary Embolism: Predictive Factors.
Introduction: Pulmonary embolism (PE) remains a major challenge in medicine despite advancements in prevention, diagnosis, and treatment. It is often underestimated, underdiagnosed, and consequently undertreated. Managing these patients requires clinicians to know the predictive risk factors for early mortality.
Objective: Identify predictive risk factors.
Materials and Methods: A descriptive retrospective study was conducted over 3 years (January 2020 to December 2023), including patients aged 14 years and older with a diagnosed PE, in an the emergency department, regardless of severity. Epidemiological, clinical, radiological, and outcome data were recorded on a data collection form designed for this study. Oral consent was obtained from patients before completing the form.
Results: We included 121 patients. The mean age was 60±16 years. The gender ratio was 0.93. The mean length of hospital stay was 5.7±5 days. On admission, the mean shock index (SI) was 0.83±0.22. The mean Simplified Pulmonary Embolism Severity Index (PESIs) score was 1.12±0.96. The PESIs in these patients predicted a low risk of mortality (0 points) in 39 cases, accounting for 32.2%, and a high risk of mortality (1-->6) in 82 cases, accounting for 67.8%. Troponin levels were elevated in 46.8% of cases, and the right ventricle/left ventricle (VD/VG) ratio was greater than 1 in 15.7% of cases. The in-hospital mortality rate was 21.5% (26 cases). Independent risk factors for in-hospital mortality were lactates > 2 mmol/l (P=0.003), the use of inotropes and vasopressors (P=0.012), positive troponins (P=0.015), VD/VG ratio > 1 (P=0.047), and the need for orotracheal intubation (P=0.04). There was a significant correlation between a PESIs score >=1 with elevated troponin levels and in-hospital death (P=0.015). Among patients classified according to this score, 6 of those classified as low risk (15.4%) died within 30 days compared to 20 of those classified as high risk (24.4%).
Conclusion: The mortality rate from pulmonary embolism remains high. Risk stratification factors for mortality dictated by international recommendations remain applicable in our study population.
Yasmine BENZARTI (tunis, Tunisia), Khairi JEMAI, Safia OTHMANI, Sarra JOUINI
00:00 - 00:00
#41907 - Early mortality in patients admitted to the emergency department: associated factors.
Early mortality in patients admitted to the emergency department: associated factors.
Background:
The mission of emergency departments is to care for patients with acute life-threatening pathologies. The vital emergency reception room is a reception unit for patients in vital distress. The aim of this study was to investigate early mortality in the first twenty-four hours following admission to the emergency department and to analysis the associated factors with a view to improving the quality of care.
Methods:
This was a monocentric, prospective, observational study carried out in the emergency department of the Beja regional hospital over a two-year period [january 2021-december 2022], which included all patients over 16 years of age who were admitted to the emergency department for vital distress, whatever the causes.
Results:
Our sample comprised 473 patients. Mean age was 62±18 and sex ratio 1.05. The reasons for admission were cardiovascular and respiratory emergencies, mainly affecting men in the 56-85 age group. Toxicological and traumatic emergencies were mainly in the 16-35 age group. The average length of stay was 24 hours±28. The mortality rate was 6.9%. The mean age of death was 64±18 years, with no significant gender differences. 54.5% of deaths occurred in the 65-85 age group. 67.9% of patients came directly from home and 57.6% arrived at emergency by their own means. The main reasons for consultation were chest pain and dyspnea. Hhypertension (27.3%) and diabetes (21.2%) were the main médical conditions in deaths. The diagnoses of death were cardiac in origin in 30.3%, infectious in 15.1% and neurological in 15.1%.
The majority of deaths (39.4%) occurred within the first six hours of hospital admission.
In logistic regression, the associated factors with early mortality were: deterioration of general condition (p=0.002; OR:3.69), extensive burns (p=0.047; OR:5.67), sepsis (p=0.005; OR:5.29),
Conclusion:
Our study shows that deterioration of general condition, extensive burns, sepsis, were associated with the early mortality in patients admitted to the vital emergency reception room.
Amina JEBALI, May ZNATI (Béja, Tunisia), Mourad SAADAOUI, Zaineb KSOURI, Wejdene ZAIRI, Souhayla RIGHI
00:00 - 00:00
#41776 - Ebstein anomaly : unexpected discovery of congenital heart disease.
Ebstein anomaly : unexpected discovery of congenital heart disease.
Introduction :
Ebstein anomaly (EB) is a rare congenital abnormality and a malformation of the tricuspid valve (significant apical displacement of the tricuspid valve causing tricuspid regurgitation[1]) with myopathy of the right ventricle (RV) with an incidence of <1% of congenital heart defects[2].
Clinical presentation can vary from the most extreme neonatal form, to asymptomatic form diagnosed lately in adult life and exceptionnaly in elderly[3].
The Ebstein anomaly prognosis varies widely.
Case report :
We report the case of a young female patient aged 25 years old with no medical history except for microcytic hypochromic anaemia, especially cardiovascular disease, no family history of sudden cardiac death or death in young age, who was brought by civil protection to our emergency ward for sudden onset of fatigue and palpitations following an emotional event.
Physical examination showed a Glasgow coma scale at 15, no cyanosis with a normal pulmonary examination, cardiac rythm at 80 beat per minute (bpm), no signs of right-sided heart failure, no digital clubbing systolic pulmonary and tricuspid murmurs on cardiac auscultation.
ECG showed a regular sinus rythm at 80 bpm, prolongation of the PR interval (170ms) small R waves in leads V1 and V2 with complete right bundle-branch block with negative T waves in the anterior, inferior and right territory.
The chest X-rays was normal. Echocardiography was performed and showed : high insertion of the septal leaflet of the tricuspid valve with structural abnormalities of the latter. Right-sided dilatation of the cavities with atrialization of the right ventricle.
That relaters to type A Ebstein anomaly.
Biological test showed hemoglobin level at 8, the other results remained normal, in particulary normal liver function, normal creatine kinase and lactate dehydrogenases, 2 normal high-sensitivity cardiac troponin levels.
The diagnosis of Ebstein anomaly type A was made, the patient was haemodynamically stable, An expert report from the on-call cardiologist was solicited and the patient was discharged after 24 hours of uneventful monitoring, and referred to the cardiology consultation with an appointment for a rhythmic holter and cardiac MRI.
Conclusion :
Ebstein’s anomaly is a rare and complex congenital anomaly with a variety of clinical manifestations. It can be diagnosed from the fetal life to elderly.
The unexpected discovery of this disease in its asymptomatic form is not common. Once diagnosed, with a well-coded treatment, rigorous follow-up and better management strategies, it is hoped that survival of patients with this anomaly of all ages will continue to improve.
Bouhamed CHAFIAA, Khouloud KHEMILI (Tunisia, Tunisia), Sarra SOUA, Imen KETATA, Chaima MANAI, Imen MABROUK
00:00 - 00:00
#42055 - Echinococcosis - rare and overlooked?
Echinococcosis - rare and overlooked?
Brief clinical history
A 29-year-old male presented to our emergency department with an afebrile cough, pleuritic pain and chills over the past 2 days. 3 weeks earlier he had been in inpatient treatment for middle lobe pneumonia that was treated with antibiotics. After discharge he still complained of consistent symptoms, therefore the general practitioner prescribed a second antibiotic.
A chest x-ray taken on the day of admission showed consistent right-sided lung infiltrates. The patient was admitted again with antibiotic therapy for further diagnostics. A chest-CT revealed a wall-invading tumor of unknown malignancy in the right lung.
An exploratory thoracoscopy with frozen section procedure showed a pleuritic echinicoccal cyst which was then removed with a partial excision of lung, pleura and ribs. Postoperative, an anthelmintic treatment with Albendazol was initiated for 6 months.
The postoperative recovery was without complication and the patient was refered to a specialized infectious disease clinic.
Helpful details
Due to progression of pneumonia findings after antibiotic treatment, a CT was performed which demonstrated a partitioned, liquid cyst at the dorsal thoracic wall and pleura. The pathological findings showed necrotic histiocytic granuloma with echinococcus components.
Differential diagnosis and actual diagnosis
The first differential diagnosis was prolonged antibiotic-resistant pneumonia due to an unclear immunosuppressed state, a pulmonary embolism or tuberculosis. With a negative Wells Score and the performed CT, an echinoccosis became more likely and was confirmed with the frozen section.
Educational and clinical relevance
Echinoccosis occures world-wide but is rare in the european countries. It is important to discuss these potentially life threatening cases we are presented, to practice expertise to give the patients the best available treatment. Because of the unspecific symptoms there is a need of improved diagnostic tests including RNA specifications in blood tests. The general awareness in the broad public is necessary to prevent further cases.
Esther KLEMPERER (Hamburg, Germany), Dorothea SAUER, Johannes ROETTGEN
00:00 - 00:00
#41340 - ED consultations for attempted suicide in adolescents in 2022: clinical profile and episode characteristics.
ED consultations for attempted suicide in adolescents in 2022: clinical profile and episode characteristics.
BACKGROUND:
Suicidal behaviours and self-harm are increasing in children and adolescents since the covid-19 pandemic. Suicide is the leading cause of death in young people and adolescents between 12 and 29 years of age in Spain. In 2022 there were 12 suicides in Spain in children under 15 years of age and 75 suicides among adolescents aged 15-19 years.
The objectives of the study were to assess the characteristics of adolescents who consulted the emergency department for attempted suicide in 2022 and the characteristics of the autolytic episode.
METHODS:
Retrospective cross-sectional study between January 1st and December 31st 2022. Demographic and clinical variables were included (psychiatric disorders, follow-up in Mental Health, previous autolytic attempt, substance abuse) and characteristics of the episode (mechanism, triggers, destination). Non-parametric tests were applied with a statistical significance threshold of p < 0.05. The statistical spreadsheet Jamovi 2.2.5 was used.
RESULTS:
45 adolescents aged 12 to 19 years consulted for attempted suicide in 2022, 80% were girls. Age distribution: 12 years, 3; 13 years, 2; 14 years, 2; 15 years, 2; 16 years, 9; 17 years, 9; 18 years, 5; 19 years, 13. No medical history 41 (91.1%). History of psychiatric disorders: 0 (22.2%), 1 (40%), 2 (26.7%), 3 (11.1%); the most frequent was personality disorder 14 (31.1%), anxiety 12 (26.6%). Previous self-harm attempt: yes, 22 (48.9%), no, 23 (51.1%). Follow-up in Mental Health 29 (64.4%). No consumption of toxic substances 35 (77.8%), use of toxic substances 10 (22.2%), 9 consumed THC.
71.1% of the attempts were by drugs (benzodiazepines 65.6%, antidepressants 18.75%), self-harm 26.7%, toxics 11.1%. There were no triggers in 71.1% of cases, and the most frequent cause was family problems 17.8%.
Discharge: follow-up in Mental Health 75.6%, discharge 11.1%, leakage 2.2%, 5 admissions to the Psychiatric Unit.
DISCUSSION & CONCLUSIONS:
There were 45 consultations for suicide attempts in adolescents in 2022, representing 24.4% of all ED visits for this reason.
Suicide attempts are more frequent in females both in adulthood and adolescence, more frequent among older adolescents and more frequent in patients with previous psychiatric problems, as in our study: the majority were girls, over 16 years old, most of them had a psychiatric history, were being followed up in Mental Health and 48.9% had made a previous attempt.
71.1% were for drug use, especially benzodiazepines. Most of the adolescents were referred to Mental Health at discharge.
Suicide attempt in adolescents is a major health problem and more research is needed to learn more about it and to take action.
Josep GUIL SÀNCHEZ (Mollet del Vallès, Spain), Pedro Alejandro GONZALES FLORES, Sebastián MELGAR TORENA, Giancarlo Jesús ORMEÑO VICTORERO, Núria POMARES QUINTANA
00:00 - 00:00
#42340 - Effect of changing the position of the arm on the diameter of the subclavian vein: preliminary study using vascular ultrasound.
Effect of changing the position of the arm on the diameter of the subclavian vein: preliminary study using vascular ultrasound.
The canulation of the subclaviar vein may seem difficult due to the proximity of the clavicle and the pleura. Changing the arm position amend the anatomical relationship between the clavicle and the vein and could amend its access. To confirm this hypothesis, we conducted a preliminary anatomical study on the hospitalized patients.
The aim of this study was to compare the subclaviar vein diameter in two arm positions: neutral position (PN) and 90° abduction and 90° external rotation position (ARE).
This prospective study was conducted during 3 months. Patients older than 18 years old, hospitalized consecutively in the ED were included. A unique expert operator performed the ultrasound exams with a vascular probe. The probe was placed perpendicularly to the skin, parallel to the clavicle in its median third portion. The measures were realized for the right side exclusively. At each time, after obtaining a cross section of the vein, the depth and the diameter of the vein were measured, as well as the distances vein-pleura and vein-artery.
thirty five patients were included. The mean age of patients was 62 years olds [18-72].The subclaviar vein diameter increased significantly after the arm mobilization (11mm vs 14mm, p=0.03). The artery, the pleura and the brachial plexus were viewed as frequently in both positions without a significant difference in the distance between these structures and the subclaviar vein (p=0.06).
Changing the position of the arm in 90° abduction and 90° external rotation enhances significantly the cross section area of the vein which can make the ultrasound guided cannulation easier and safer.
Hamza TOBI (RABAT, Morocco), Aziz BERTUL, Tahir NEBHANI, Mosaab ELABBADI, Naoufel CHOUAIB, Ahmed BELKOUCH, Saad ZIDOUH, Lahcen BELYAMANI
00:00 - 00:00
#42033 - Effect of COVID pandemic on responsiveness to treatment and survival in patients with in-hospital cardiac arrest.
Effect of COVID pandemic on responsiveness to treatment and survival in patients with in-hospital cardiac arrest.
Background: Survival from in-hospital cardiac arrest (IHCA) depends on the quality of care and time to response. There is high variability in survival among these patients. With the COVID pandemic, there were changes to responsiveness and quality. The purpose of this study was to review the effects of the pandemic on responsiveness to care for IHCA.
Methods: This was a retrospective study from a single site urban hospital study. Patients 18 years and over were included who sustained an IHCA. Patient demographics, time to arrival of physician, time to first medication, and time to first shock were studied over two periods: the first was pre-pandemic (July 2018-January 2020) and the second was during the height of the pandemic (June 2020-December 2021). The initial rhythm type was also captured. Survival rates to discharge from hospital were compared.
Results: A total of 314 patients were included in the study, of which 153 were prior to the pandemic. The average ages were 43 years (SD: 9.9) and 66 years (SD: 4.9) respectively (P<0.0001). PEA was the most common rhythm at time of arrest in the pre-pandemic group (41%), and other rhythm (48.4%) during the pandemic. Epinephrine was the most common first medication administered in both groups (88.9% and 67.6%). Median time to physician presence at the code and time to administration of first medication was similar in both groups - 1min (IQR:0-1 for both) for time to physician and 4 minutes (IQR:2-6 in group 1 and IQR 1-5 min in group 2) for medications. Time to first shock was slightly better during the pandemic period at 10 min (IQR: 7-17) versus prepandemic at 11 min (IQR:6-16). Survival was worse during the pandemic (11.0% versus 26.8%).
Discussion and Conclusion: The COVID pandemic brought on many challenges, including performance during IHCA. Our results show that there were differences in age groups, initial rhythm during arrest, and survival. Prepandemic codes were primarily in younger patients and therefore would be expected to have improved survival rates. However, there was no difference in time to first medication or first shock.
Ethical approval and informed consent: REB approved from William Osler health system. Consent was waived.
Trial registration: N/A
Funding: None
Swara PATEL, Denis PATEL, Isma AKRAM, Nidhi SAINI, Shaveta GUPTA, Suheera SIDDIQUI, Shayan SIDDIQUI, Therese BICHAY, Gurjap DEOL, Diana MATHEW, Michael MILETIN, Dr Rahim VALANI (Toronto, Canada)
00:00 - 00:00
#40394 - Effectiveness of Innovative Chest Compression on the Emergency Department Stretcher by an Alternative Method: A Randomized Controlled Crossover Trial.
Effectiveness of Innovative Chest Compression on the Emergency Department Stretcher by an Alternative Method: A Randomized Controlled Crossover Trial.
Backround: Comparison of the three methods (standing-on-a-stool (SS), one knee kneeling on a stretcher (KS), and kneeling at the same height as the patient’s bed on the kneeling stool (KK) to evaluate the yielded of highest CPR quality and rescuer comfortability.
Methods: A prospective randomized cross-over study which compares the three different rescuer positions for their effectiveness of chest compression. Conducted at a tertiary care between 19 Aug and 22 Aug 2022. Participants are emergency personnel aged 18 years or older, who completed the AHA-approved BLS course. We investigated the chest compression quality data was obtained by the ALIVE AED manikin® and AED reporting system. Main outcome measures is the information on the CPR quality and post-test questionnaires assessing the participants’ preference, satisfaction and modified Borg’s scale score was collected.
Results: The three methods shown no statistically significant difference in adequate chest compression depth (percentage). KK was not superior than SS at chest compression rate (P=0.05). The adequate full chest recoil achieved with KK and KS were significantly higher than that of SS. However, there were no statistical difference between the three methods in the modified Borg’s scale score. Based on the satisfying score, the rescuers preferred KK to either SS (p 0.007) or KS (p 0.012).
Conclusions: The three methods shown no statistically significant difference in adequate chest compression depth (in percentage). However, both KK and KS provided more adequate chest recoil, so we would recommend using these two methods in the ED.
Ethics approval: Research Ethics Committee of the Faculty of Medicine, Chiang Mai University approved the research protocol on 6 Sep 2021 (study code: EME-2564-08366).
Trial Registration: This study was retrospective registration in thaiclinicaltrials.org (TCTR20230119002, 19/1/2023).
Funding: This work was supported by Faculty of Medicine, Chiang Mai University (grant number MC022-65) on 5 May 2022.
Nawaphon CHARUNGWATTHANA, Borwon WITTAYACHAMNANKUL (Chiang Mai, Thailand), Pavita LAOHAKUL, Theerapon TANGSUWANARUK
00:00 - 00:00
#41794 - Effectiveness of simulation training in preparing hospitals for mass casualty management.
Effectiveness of simulation training in preparing hospitals for mass casualty management.
Background: Since the beginning of full-scale hostilities in Ukraine in 2022, mass incidents among civilians, unfortunately, have become a routine practice. First of all, this is connected with the daily shelling of cities in Ukraine by missiles and drones by the russian military. During 2023, more than 500 cases were recorded and classified as mass casualty cases. The training of hospital medical staff in such conditions is essential. In recent years, much training on managing mass incidents has been held in Ukraine. Most of such exercises are mainly theoretical and reveal only general issues of organizing the medical triage of victims in hospitals. Therefore, in our opinion, it is ineffective from the point of view of practical use. We have developed a training program, the main element of which is a simulation scenario conducted during one day. The main difference in the program is that the scenario is adapted depending on the capacity of the hospital and the available resources.
Methods: Questionnaires before training contained 5 questions, after 8 questions. Before the exercises, the opinion regarding the readiness to conduct medical triage and preliminary training on these issues was evaluated. After the training, the quality of the training was assessed, and their readiness for medical triage was reassessed. The maximum value of evaluation questions was 5. A total of 760 questionnaires from 40 hospitals where training was conducted were analyzed. The data obtained were statistically processed. We used STATISTICA software ("StatSoft, Inc.", USA).
Results: The pre-study questionnaire showed the following results: 1) Have you received training before? – 68 % (yes), 2) Are you familiar with the hospital's response plan in case of a mass incident? – 78,9% (yes), 3) Do you know your role in case of a mass incident? – 73,3% (yes), 4) Assess your readiness to respond to a mass incident - 3,21±0,09, 5) Assess your hospital's preparedness to respond to a mass incident – 3,29±0,06.
After training, the questionnaire results were as follows: 1) How helpful was the training for you? - 4,68±0,06, 2) Does the information taught at previous trainings differ? - 4,34±0,05, 3) Assess the need for similar training each year - 4,81±0,08, 4) Will you change your actions, in a mass case, after the training? - 4,52±0,04, 5) Do you need to change how you respond to mass incidents at your hospital based on the information you learned during the training? - 4,81±0,08, 6) Assess your hospital's preparedness to respond to a mass incident, taking into account the information obtained during the training - 3,97±0,05, 7) Evaluate the quality of the practical part of training - 4,98±0,02 8) Evaluate the quality of the theoretical part of training - 4,92±0,06.
Discussion & Conclusions: Simulation training is one of the best methods for preparing medical workers for medical triage. Using this approach makes it possible to train many medical personnel relatively quickly and qualitatively, which is essential in the conditions of a full-scale war.
Vitaliy KRYLYUK (KYIV, Ukraine), Halyna TSYMBALIUK
00:00 - 00:00
#40758 - Effectiveness of the red cell distribution width for mortality in elderly patients with non-traumatic coma.
Effectiveness of the red cell distribution width for mortality in elderly patients with non-traumatic coma.
Background: Elevated red blood cell distribution width (RDW) can be associated with disease severity. However, studies on RDW for the prognosis of elderly patients with non-traumatic coma (NTC) are lacking. This study aimed to examine the relationship between RDW and outcome in elderly patients with NTC.
Methods: This case-control study included elderly patients (≥ 65 years) with NTC between January 2022 and December 2022. We measured RDW upon patient arrival to the emergency department (ED). We conducted a multivariable analysis using logistic regression of relevant covariates to predict in-hospital mortality. Survival curves based on 30-day mortality were designed using the Kaplan–Meier method. The primary outcome was in-hospital mortality, and the secondary outcome was 30-day mortality.
Results: A total of 689 patients were included in the study, and in-hospital mortality was 29.6% (n=204). Our results found that the RDWs of non-survivors were significantly greater than those of survivors (14.6% vs 13.6%). Multivariable analysis showed that RDWs at ED arrival were independently associated with in-hospital mortality (odds ratio, 1.130; 95% confidence interval, 1.050–1.216; P < 0.001). The Kaplan–Meier curve indicated that the survival probability of patients with a low RDW was greater than those with a high RDW.
Conclusion: Having a high RDW at ED arrival was associated with in-hospital mortality in elderly patients with NTC.
N-A
Dong Hun LEE (Gwangju, Republic of Korea)
00:00 - 00:00
#41749 - Effectiveness of two feedback modalities following Virtual Reality training in paediatric emergencies.
Effectiveness of two feedback modalities following Virtual Reality training in paediatric emergencies.
Introduction: The increasing number of paediatric residents in Italy has led to fewer code leadership exposures. Virtual reality (VR) provides the possibility to increase exposure and practice in the management of simulated paediatric emergency clinical scenarios. We aimed to evaluate the most effective feedback modality following single-player VR training for Paediatric Emergencies.
Methods: We conducted a quasi-randomized, two arms, cross-over pilot study enrolling 1-2° year paediatric residents at the University of Padua (Italy). All participants, in groups of 8, underwent the MetaQuest 2VR headset (San Jose, CA, USA) and Resuscitation VR software(i-Solve, Luton, UK) orientation module. In Phase I residents in the Intervention arm performed a single VR scenario of advanced Status Epilepticus (SE), followed by a facilitator-led in-person group debriefing. Debriefing focused on the systematic ABCDE approach to emergencies and on specific management features of SE. The Control arm performed the SE scenario twice (Basic/Advanced) and received automatic feedback provided by the software after the VR scenario. One month later, all participants underwent a high-fidelity simulation scenario of SE, in teams of 4 (all belonging to the same VR study arm). One year later (Phase II), the two study arms crossed over with respect to the study intervention (i.e. facilitator-led in-person group debriefing following the VR scenario) undergoing a VR simulation of anaphylactic shock. All residents went through a high-fidelity simulation scenario of anaphylactic shock one month later.
Primary outcome: comparison of “non-technical skills” (NTS) of the teams (T-NOTECHS scale) during high-fidelity simulations between the study arms.
Secondary outcomes: rating of technical skills (quality of assessments/interventions and time to critical actions) during high-fidelity simulations, evaluation of VR Perceived Ease of Use/Usefulness (TAM Questionnaire), participants’ satisfaction (5-point Likert Scale) and subjective preference for one of the two proposed VR feedback modalities.
Results: The study involved 80 residents, 77/80 (96%) in Phase I, 63/77 (82%) in Phase II. In Phase I, the T-NOTECHS score was not significantly higher in the intervention arm (Median 13,5; IQR 13-18) vs (Median 12; IQR 11-14), (p=0.18). In Phase II, the T-NOTECHS score was significantly higher in the intervention arm. (Median 18; IQR 15,5-19) vs (Median 12,5; IQR10,5-15), (p =0.02). Teams from the intervention arm performed better in the individual T-NOTECHS items of “Leadership, “Cooperation/Resource Management”, “Communication/Interaction” although the difference was not significant. The rating of technical skills did not significantly differ between the study arms in both phases. Participants’ satisfaction was high (Median 5, IQR 4-5); VR Ease of Use was rated as suboptimal (66.7 out of 100), and Perceived Usefulness as very high (93.4%). 47/59 (80%) of participants preferred the facilitator-led in-person debriefing as a VR feedback modality.
Discussion/Conclusions: Although based on a limited number of participants our study shows that facilitator-led in-person debriefing following VR scenarios of paediatric emergencies is the preferred feedback modality by participants and can improve NTS in a high-fidelity simulation setting. While familiarization with the equipment and software should be optimized, the perceived usefulness of VR simulation was very high and the training module was highly appreciated by participants.
Marianna COSTA, Veronica CASOTTO, Sara ROSSIN, Francesco CORAZZA, Valentina STRITONI, Giulia MORMANDO, Sandro SAVINO, Paolo NAVALESI, Todd P. CHANG, Silvia BRESSAN, Marianna COSTA (Padova, Italy)
00:00 - 00:00
#41884 - Effects of holiday admission on the outcome of patients admitted to Emergency Department.
Effects of holiday admission on the outcome of patients admitted to Emergency Department.
Introduction:
Some studies have shown that the mortality rate of patients hospitalized during holidays is higher than those who are hospitalized during working days, and the outcome of these patients is also poor. The aim of the present study is to compare mortality and outcome of patients hospitalized in holidays with those who hospitalized in working days in a teaching hospital. It could show the strength of weekend effect (or in the better word “holiday effect”) and can help reducing it via recognition of weaknesses and improving them.
Materials and Methods:
This analytical case-control study performed based on the data collected of the teaching Emergency Department (ED). The ED of this hospital provides services 24 hours of the day in two morning (7.5 AM-7.5 PM) and evening (7.5 PM-7.5 AM) working shifts and in whole days of a year. In this hospital, admitted patients in the ED are classified based on their indication to be discharged or hospitalized in Intensive Care or ordinary wards. All patients who were admitted to the ED of Firoozgar Hospital (from March 18, 2023 to April 2, 2023), were included in this study. A control group was used to compare. The control group was patients that admitted to the ED of hospital from 5th to 21th days of May 2023 of the year.
Results:
Totally, 792 patients were admitted to the hospital in two 16-day time ranges. 369 patients (46.6%) were admitted to the ED in holidays and 423 patients were admitted in working days. 405 patients (51.1%) were admitted in the morning shift (7.5AM - 7.5 PM), and 387 patients (48.9%) were admitted in the night shift (7.5PM - 7.5 AM). The percentage of LAMA during holidays and working days, were 27.1% and 29.5%, respectively; that were not statistically significant (p=0.446). The percentage of mortality on holidays was 3.79%, and on working days was 2.36% that was not statistically significant (p=0.242). Regards to secondary goals, the mean length of stay was 17.5±0.91 days, in which, the length of stay on holiday was 11.92±0.98 days, and on working days was 22.46±0.464 days. In fact, the hospital stay was significantly lower in holidays. (p <0.001).
conclusion:
The results of this study rejected the “holiday effect” hypothesis in our hospital, and showed that the outcomes of patients in two periods of holidays and working days did not have any significant difference.
Dr Mahdi REZAI (Tehran, Islamic Republic of Iran), Davood FARSI, Hassan AMIRI, Roya GHAFOURY, Babaknejad AFSANEH, Roxana HESSAM
00:00 - 00:00
#40556 - Effects of medicines on the nerve cells in hypoxia.
Effects of medicines on the nerve cells in hypoxia.
Introduction: Hypoxia occurs in shock due to respiratory failure, bleeding, and severe trauma in patients visiting the emergency center, resulting in severe brain damage. Therefore, we would like to investigate the effects of pentoxifylline, steroid, and hypertonic saline on hypoxia and the effects of injection time of medicine in SH-SY5Y cells.
Method: After exposure to hypoxic state (1% O2) for two hours using SH-SY5Y cells, incubation at normoxic state (20% O2) for 24 hours, cell viability, apoptosis, and hydrogen peroxide were measured and compared to normal groups. In addition, various combinations of pentoxifylline, steroid, and hypertonic saline were injected simultaneously with hypoxia and after hypoxia to compare each condition.
Results:
1. Cell viability, apoptosis, hydrogen peroxide in hypoxic condition
Cell viability decreased in hypoxia at 2 hours and apoptosis, hydrogen peroxide increased compared to the control group.
2. Cell viability, apoptosis, hydrogen peroxide according to various combinations of medicines and injection time of medicines
Most medicines had no effect on cell viability, a little reduced apoptosis without statistical significance, but had a significant effect on injection at the same time as hypoxia. Although overall the generation of hydrogen peroxide in injections of medicines was reduced compared to the control group, it had statistical significance when HTS, combination of HTS and PTX were injected simultaneously with hypoxia.
Conclusion: PTX, HTS were able to have a preventive effect on cell damage when applied at the earliest time of hypoxia in SH-SY5Y cells
no
Sung-Hyuk CHOI (korea, Republic of Korea), Lee SUN-HONG
00:00 - 00:00
#40875 - Electrical storm and Acute Cardiac Ischemic - ECPR.
Electrical storm and Acute Cardiac Ischemic - ECPR.
A forty-year-old male, incarcerated, known case of HTN, DM, Ischemic heart disease s/p PCI five years ago in India, brought by the police in the ambulance with the complaint of severe central chest pain associated with nausea and vomiting for last one hour. Aspirin 300 mg and Clopidogrel 300 mg are administered before transfer in police clinic. Due to severe chest pain and shortness of breath it was challenging to get detailed history initially; However, with high suspicion of acute coronary syndrome based upon risk factors and presenting complaint, cardiology on call is consulted immediately. Initial rythm on cardiac monitor was atrial fibrillation with rapid ventricular response, changing dynamically intermittently to ventricular tachycardia, second degree heart block, and right bundle branch block on subsequent several EKGs. Due to persistently low blood pressure with A Fib and ventricular tachycardia, electrical cardioversion decision is taken but before shock is delivered he spontaneously reverted to sinus rythm with improvement of his blood pressure. Chest examination revealed bilateral basal coarse crackles with the requirement of oxygen support to maintain oxygen saturation more than 94%. Subsequent EKG showed ST elevation in AVR and ST depression in lateral and anterior leads, pointing towards proximal left anterior descending artery (LAD) occlusion. POCUS is done by the ED Physician and Cardiologist, showing akinetic anterior wall and severely decreased ejection fraction. He dropped his blood pressure with agitation and fluctuating ventricular tachycardia, he was started on noradrenaline and dobutamine infusions. Amiodarone 300 mg and magnessium 2 gram were administered and he was intubated for transfer to cath lab, after intubation, 3 DC shocks were given also for VT. In cath lab he sustained cardiac arrest and started on ECPR with revascularization of proximal LAD and LCX. He later developed multiple organ failure and died in intensive care unit after decannulation from ECMO. It highlights the complexity and interplay of limited clinical background and life threatening arrythymias with the high suspicion of cardiac ischemia making emergency care difficult. Dynamically changing rythms in EKG are concerning and must be taken in clinical context for possible acute coronary syndrome. POCUS is always helpful in such confusing scenarios and must be used if available to get clues. Safe patient transfer is mandatory if the travel time to cath lab is significant and patient is unstable.
Tahir SHAHZAD (Toledo, USA), Fatema Jaber A A ALMARRI
00:00 - 00:00
#42015 - Elevated NEWS preceding unplanned ICU transfers in a Norwegian hospital population.
Elevated NEWS preceding unplanned ICU transfers in a Norwegian hospital population.
Background: The National Early Warning Score (NEWS) is widely implemented for in-hospital monitoring, designed to identify patients at risk for hospital death, cardiac arrest, and unplanned transfers to an intensive care unit (ICU) within 24 hours. It has been superior to other risk identification tools in several clinical settings, e.g., in predicting hospital or disease-specific mortality and escalation of care. However, data regarding patients who experience such events, but are not identified by NEWS as being at risk for them, is scarce.
Aim: To investigate the proportion of patients with an unplanned ICU transfer from an adult, somatic ward, who was identified by a NEWS of 5 or more at any point during the 24 hours leading up to the transfer. Secondly, to characterize this patient population, and the circumstances of the transfer.
Methods: Single-center study of retrospective case record reviews (RCRRs). We reviewed electronic health records for all adults who experienced an unplanned ICU transfer, including both a general ICU and an intermediate ICU, from a ward 6 hours or more after hospital admission, for one year, 2019.
Results: Among 12591 admissions for 9478 patients to adult, somatic wards using NEWS for in-hospital monitoring, there were 294 unplanned ICU transfers for 246 patients (22% of all ICU admissions). NEWS was available in 93% of cases. 60% of these were identified by a NEWS of 5 or higher, 69% if the patients died during the admission following the transfer. 19 died in the ICU, and 28 died at a ward following discharge from an ICU, resulting in a 19% hospital mortality among unplanned ICU transfers vs. 2% all-over-hospital mortality. Those identified by NEWS were significantly younger. There were no significant differences in sex, clinical frailty scale, or advanced (end-stage) comorbidity. There were significant differences in conditions leading to the ICU transfers, with respiratory failures and sepsis among those identified by NEWS, and arrhythmias, acute coronary syndromes, and internal bleedings among those not identified.
Conclusions: Only 60% of patients who experienced an unplanned ICU transfer were identified as being at risk by a NEWS of 5 or more. Those identified by NEWS were significantly younger than those who were not, and the conditions leading to ICU transfers differed significantly.
Funding: This study was funded by the Northern Norway Regional Health Authority (Helse Nord).
Ethical approval: Evaluated by the Regional Committee for Medical and Health Research Ethics in Northern Norway (case number 102804), before approved by the hospital trust data protection officer (case number 149).
Marianne TORVIK (Bodø, Norway)
00:00 - 00:00
#41727 - Emergency department patients requiring emergency general surgery: association between age and time-to-OR.
Emergency department patients requiring emergency general surgery: association between age and time-to-OR.
Introduction
Emergency general surgery carries a high risk of mortality, particularly among older patients. Previous studies have suggested an association between time-to-operating room (OR) and mortality. However, it remains unclear whether older patients experience prolonged time-to-OR. This study aimed to investigate the association between patient age and the time-to-OR for patients presenting to the Emergency Department (ED) and requiring emergency general surgery.
Methods
This retrospective cohort study included adult patients presenting to Geneva University Hospitals' ED between January 2015 and December 2019, who subsequently underwent emergency general surgery. Emergency general surgery was defined as general surgery within three days of ED admission. The primary exposure was patient’s age at the time of the procedure. The primary outcome was the time-to-OR, defined as the time between ED admission and OR admission, obtained from electronic medical records. Multivariable linear regression was performed to explore the independent association between patient age and time-to-OR, adjusting for confounding factors. Additionally, a sensitivity analysis was conducted using multiple imputation to address missing data at baseline.
Results
A total of 3592 patients were included, with a mean age of 50 years (SD: 20.2), and 51.5% were female. Over 77% underwent low-risk procedures, such as appendectomies or cholecystectomies. The mean time-to-OR was 14 hours (SD: 16.8, IQR: 7.3, 26.3). Patient age was associated with a longer time-to-OR (+12.3% by 10 years, 95%CI: 10.7-13.9), after adjusting for sex, admission by ambulance, triage level, fever, positive shock index, CRP level, and type of surgery. The sensitivity analysis showed similar results.
Discussion and conclusion
This study highlights an independent association between patient age and time to OR admission among ED patients requiring emergency general surgery. Potential explanations may include diagnostic complexities, residual confounding, or subconscious biases among emergency physicians, surgeons, and anaesthesiologists that would delay patient care. Given the growing proportion of older patients in ED settings, ensuring equitable treatment is imperative. In summary, older patients appear to experience prolonged waits for emergency general surgery compared to their younger counterparts, potentially contributing to elevated mortality rates.
Romeo RESTELLINI, Stephan VON DURING, Frederic ROUYER, Thibaut DESMETTRE, Christophe A. FEHLMAMN (Geneva, Switzerland)
00:00 - 00:00
#42069 - Emergency department utilization of patients with dementia in Germany – routine data analysis from the INDEED project.
Emergency department utilization of patients with dementia in Germany – routine data analysis from the INDEED project.
Background: In Germany, there were around 1.8 million people diagnosed with dementia in 2021. Due to aging societies emergency departments (EDs) will face increased numbers of patients living with dementia whose medical care poses specific challenges to ED personnel. The aim of our study was to compare the demographic and clinical characteristics of patients aged ≥70 years living with and without dementia who presented to EDs in Germany.
Methods: INDEED (utilization and cross-sectoral patterns of care for patients admitted to emergency departments in Germany) was a retrospective study that collected routine clinical data from 16 EDs across Germany in 2016. The data from the ED patients were linked to outpatient care data from the German statutory health insurance physicians associations between 1st January 2014 and 31st December 2017. The INDEED dataset contains 454.747 ED cases. This analysis focussed on older patients aged ≥70 years (n=138.652). An individual was defined as living with dementia if an outpatient diagnosis of dementia was documented in any two quarters of the four quarters preceding the ED visit. The at least two quarters criterion (M2Q criterion) is used to validate diagnoses in outpatient care (OPC) data. Only patients with available OPC diagnoses could be included in this analysis. Dementia was defined as ICD-10 codes F00, F01, F02, F03, or G30.
Results: There were 82,806 individuals that met the inclusion criteria (≥70 years and available outpatient care data). Of these, 14,514 patients (17.5%) had a validated diagnosis of dementia. Patients diagnosed with dementia were older (median age 83 years [IQR 78;88] vs. 78 [IQR 75;83]) and the proportion of female patients was higher 62.0% vs 55.5%. They arrived more often to ED medically accompanied, e.g. by ambulance, (81.7% vs. 59.1%). Patients with and without dementia presented with similar characteristics in terms of ED triage categories, time and day of ED admission and the proportion of subsequent inpatient admission rates. The in-hospital mortality was slightly higher in patients living with dementia (8.2% [95%-CI 7.7-8.8] with vs. 6.1% [95%-CI 5.8-6.3] without dementia). The distributions of ED diagnoses differed between the groups. The Charlson Comorbidity Index (CCI) was comparable for a CCI scoring of 1-2 (both groups 37.0%), but more patients with dementia had a CCI of 3-4 and a CCI ≥5 with 38.5% and 27.6%, respectively, compared with 16.4% and 6.6% in ED patients without dementia.
Conclusion: In the elderly ED population (≥70 years), patients with dementia were older and had a higher comorbidity burden than those without dementia. Transportation to the ED was predominantly medically accompanied pointing to either more urgent presentations or reduced mobility. Prospective studies are needed to understand the reasons that drive ED utilization in this vulnerable patient group.
The trial was registered at the German clinical trials registry (DRKS00022969). The ethics committee of Charité - Universitätsmedizin Berlin approved of the study (EA4/086/17). INDEED was funded by the Innovation Fund of the Federal Joint Committee (G-BA: Gemeinsamer Bundesausschuss, 01VSF16044). As this was a routine data analysis no separate patient consent was required.
Kristina HARTL, Anna C. SLAGMAN, Antje FISCHER-ROSINSKÝ, Thomas KEIL, Martin MÖCKEL, Dorothee RIEDLINGER (Berlin, Germany)
00:00 - 00:00
#41426 - Emergency Departments sentinel role in setting up a nationwide outpatient antimicrobial register in adult and pediatric UTI.
Emergency Departments sentinel role in setting up a nationwide outpatient antimicrobial register in adult and pediatric UTI.
Introduction:
In emergency medicine settings, the recognition and subsequent treatment of urinary tract infections are one of the most common problems in the everyday adult and pediatric care. Antibiotic stewardship renders to use the narrowest possible spectrum of antimicrobials for the shortest possible duration in the correct indication. Good clinical practice can mitigate not only growing resistance but also the risk of side effects and complications.
Objectives
We aimed to identify the urinary tract pathogens and their resistance profiles in outpatient care and to help informing clinicians countrywide and to assess the feasibility of sentinel model in lieu of a national outpatient antibiotic register.
Methods: In a prospective multicentre cross sectional study we analysed microbilogy results collected in May 2023 in four level one and two level two emergency departments (ED) in Hungary.
Results: Our data demostrated that either fosfomycin or nitrofurantoin have the least resistance in the outpatient UTI population in both the adult and pediatric population. The costs (material and human resources) were negligeable justifying the benefits of rotating a sentinel role among ED-s in a country where no outpatient register is available.
Discussion:
Our research is of increased clinical relevance because our experience shows that the national antibiotic prescribing patterns are quite variable, with unfortunately broad-spectrum antibiotics still forming the backbone of outpatient care for both adult and paediatric UTIs in Hungary. We therefore believe that an evidence-based recommendation could significantly improve patient safety. We also sought answer whether a potential regional sentinel strategy has financial and human resource constraints in the current funding environment and proved no major burden/disruption in services but ont he contrary improved procedural awareness.
Conclusion: As our pilot was successful we hope to extend the model to cover the whole country to help reviewing the current antibiotic use practices in the country.
4523/2023 Ethical Approval
Gabor Zoltan XANTUS (Pecs, Hungary)
00:00 - 00:00
#41429 - Emergency Management of a Rare Tuberculoma in the Fourth Ventricle Presenting with Acute Obstructive Hydrocephalus and Elevated Intracranial Pressure: A Case Report.
Emergency Management of a Rare Tuberculoma in the Fourth Ventricle Presenting with Acute Obstructive Hydrocephalus and Elevated Intracranial Pressure: A Case Report.
A 39-year-old male with no significant medical history experienced sudden onset headaches, dizziness, nausea, and vomiting lasting for three days. Initial CT of the head at a local hospital revealed obstructive hydrocephalus with a suspicious space-occupying lesion in the fourth ventricle. During transfer to a tertiary care facility, a positional change from sitting to lying down precipitated a sudden decline in GCS and the onset of decorticate posturing, indicative of a drastic rise in ICP and brainstem compression. Emergency surgical intervention involved the placement of an EVD to manage hydrocephalus and alleviate pressure. Subsequent MRI raised suspicions of tuberculoma. A positive QuantiFERON-TB Gold test confirmed tuberculosis etiology. The patient started antitubercular therapy tailored to his clinical and diagnostic findings.
Discussion:
The case of tuberculoma in the fourth ventricle illustrates several critical points about the management and implications of CNS infections and obstructions. The fourth ventricle's location at a juncture crucial for CSF flow means any lesion here can lead to significant disruptions in CSF dynamics. This can manifest rapidly as obstructive hydrocephalus, a condition where fluid accumulates due to a blockage in the pathways that normally allow fluid to circulate and absorb. The rapid progression to hydrocephalus in our patient underscores the dynamic and potentially volatile nature of intracranial pressure (ICP) in such cases.
This patient's acute deterioration upon a change in position from sitting to lying down is particularly noteworthy. It highlights the hydrodynamic shifts that can occur with changes in body posture, which can have dramatic effects on patients with ventricular obstructions. This sensitivity indicates that the brain's compliance, or its ability to adapt to volume changes, is severely compromised. In the emergency setting, understanding, and manipulating these dynamics can be lifesaving, as evidenced by the immediate relief provided by the external ventricular drain (EVD). The use of an EVD in this context not only alleviated the mechanical obstruction but also allowed for direct monitoring and management of ICP.
Furthermore, this case emphasizes the importance of a high degree of clinical suspicion for infectious causes of CNS lesions. Tuberculosis, though primarily a pulmonary disease, can manifest in the CNS without any pulmonary symptoms. This highlights the need for comprehensive diagnostic strategies, including imaging, immunological testing (like the QuantiFERON-TB Gold test used in this case), and consideration of the patient's epidemiological background [5].
Finally, the multidisciplinary approach to treatment, involving neurosurgeons, infectious disease specialists, radiologists, and critical care teams, reflects the complexity and severity of managing such rare but serious presentations. This case illustrates not only the need for acute medical and surgical interventions but also the importance of early and appropriate antimicrobial therapy, which in the case of tuberculosis involves multiple agents over an extended period.
Learning Points:
The importance of considering rare infectious causes like tuberculoma in cases of obstructive hydrocephalus.
The critical role of patient positioning and its impact on ICP in patients with ventricular obstructions.
The effectiveness of EVD in managing acute rises in ICP and stabilizing patients for further diagnostic and therapeutic interventions.
Shumaila Muhammad HANIF (Doha, Qatar), Thirumoorthy Samy KUMAR
00:00 - 00:00
#41530 - Emergency Medical Information System in Chemical Disaster.
Emergency Medical Information System in Chemical Disaster.
1. Objective
The purpose of this study is to create the basis for a chemical emergency medical information system that can be immediately applied to pre-hospital and in-hospital settings in the event of chemical exposure emergency.
2. Background
There are many dababase sets and websites which provide chemical information, but they don`t perform adequate role for emergency medical support in chemical disaster.
3. Method
Authors reviewed the dababase sets, mobile applications and websites in the world which provide chemical database and emergency medical response from prehospital chemical accident or disaster site to hospitals. Also we examined chemical accident cases which developed to disasters. A chemical dababase set for emergency medical response was proposed and the algorithm for elicitation of chemicals suitable for each emergency medical response and information providing. We performed survey about chemical emergency medical information system to related personnel.
4. Results
By four steps of elicitation of chemicals, number of chemicals more than 100,000 was decreased to less than 1,000. The standard steps include accident preparedness, toxicity and circulating amount and expert consultation. Algorithm for elicitation of chemicals was made and 82.0% of related personnel wanted chemical emergency response algorithm. Emergency medical real-time consultation system for chemical disaster was made under control of call center.
5. Conclusion
When mass exposure by toxic chemical occurs, chemical emergency medical information system will be helpful for acute identification of chemical, protection of related personnel and emergency medical response. Also it can be possible to guide residence immediately in case of chemical disaster.
[Acknowledgement]
1. This work was supported by the National Research Foundation of Korea(NRF) grant funded by the Korea government(MSIT) (No. NRF-2023R1A2C1002938).
2. This subject is supported by Korea Ministry of Environment(MOE) as "The Chemical Accident Prevention Technology Development Project."
Soon-Joo WANG (Hwaseong city, Republic of Korea), Jihyun KIM, Dawoon CHOI
00:00 - 00:00
#42376 - Emergency Medical Teams (EMT) Clinical Governance and Preparedness: The Portuguese Emergency Medical Team (PT EMT) Experience.
Emergency Medical Teams (EMT) Clinical Governance and Preparedness: The Portuguese Emergency Medical Team (PT EMT) Experience.
The Portuguese Emergency Medical Team (PT EMT), type 1 Fixed with X-ray, is the national capacity to emergency assistance in disaster, outbreaks, and can be the support during mass gathering events to reduce the flow of patients sent to the hospital emergency department, as well as leveraging international capacity when needed to support the local health systems.
National emergency medical teams are the best option to offer the most effective, immediate, and appropriate surge response for emergencies directly affecting communities, while international teams may help relieve overwhelmed health systems.
Health services provided upon emergency response should be safe, people centred, timely, equitable, integrated, and efficient. The EMT Initiative supports deploying teams and developing the structures and processes needed to provide quality health services in host countries.
Implementing the EMT methodology has the potential to enhance the quality of clinical care, improving coordination and health outcomes for the population served. Similarly, adhering to clinical care standards can reduce care variations, harm, and inefficiencies, safeguarding healthcare professionals in the process.
There are 27 clinical standards that represent support and key clinical processes. Key clinical processes consist of the act of providing care per se, while the support processes offer support or essential elements/actions to the delivery of care.
Although the Classification and Minimum Standards for Emergency Medical Teams (Bluebook) establish baseline technical standards and recommendations for optimal patient care, the Portuguese team recognized the importance of enhancing their clinical performance through standardized procedures. Therefore, we developed 25 clinical guides, to supplement the WHO’s Minimum Standards. On the other hand, this approach also facilitated a more precise assessment of clinical consumables needs, ensuring the module's self-reliance and self-sufficiency.
The clinical guides allow the support to medical teams in the mass gathering events scenarios and helped to develop clinical supplies kits, that have been helping to reduce material wastage, control expiry dates and timely replacement. Also, the kits organization facilitates the preparation of cargo manifests when projecting the module to the host countries and made it possible to optimise the packaging and transport of all the clinical consumables, ensuring all safety conditions.
Using WHO's Essential Medicines List and, due to the high probability of response to disaster emergencies in Portuguese-speaking countries, the official lists of essential medicines in those countries, the PT EMT established a robust inventory of essential clinical consumables. This inventory supports authorized entry into host countries and ensures continuity of care post-deployment.
A meticulous approach was taken in organizing clinical supplies, resulting in three clinical kits designed to sustain autonomous care for five days each, supporting 100 patients daily over 15 days. This level of preparedness and self-sufficiency was recognized and integrated into WHO's revised Bluebook in 2021.
This methodology, refined since 2019, was successfully tested at major events like the annual mass gathering event in Fatima and World the Youth Day 2023, showcasing increased operational efficiency and user-friendly processes. The streamlined approach to consumable replacement and module re-operation ensures sustained operational capacity for the PT EMT, enhancing emergency response capabilities.
Not Aplicable
Ana CORREIA, Andrea FIGUEIREDO (Lisbon, Portugal), Elisabete REIS, Luis LADEIRA, Hélder RIBEIRO, Susana SANTOS, Patricia BYANT, Ivo CARDOSO
00:00 - 00:00
#41110 - Emergency Preparedness Plan Analysis in a Low Resource Country: The Beirut Blast.
Emergency Preparedness Plan Analysis in a Low Resource Country: The Beirut Blast.
Objective. Mass Casualty incidents come unannounced, mandating the immediate shift from the daily routine to crisis mode through the implementation of an emergency preparedness plan. On August 4, 2020, a massive explosion devastated the Lebanese capital, Beirut causing 8643 injuries and 200 deaths.1 The Lebanese American University Medical Center is a private university hospital in Beirut with an estimated 10,000 emergency department visits per year. The purpose of this study is to analyse the Emergency preparedness plan of a private hospital in a low resource country in response to an MCI. Methods. This is a retrospective analysis of the expected outcome of the plan. Results. Major flaws were noted, and adjustments were made to the new Emergency plan. Triage was impossible using the START tool. Later, triage will be done outside the Emergency, dividing patients into walking and non-walking. Identification and registration of patients was impossible. Patients should be assigned a number and be registered later. Colored jackets were created to recognize the team members and avoid chaos. Radiological tests will be ordered only when they change the patients’ disposition. Conclusion. This analysis showed failure of the Emergency Plan at different levels. Periodic sectoral drills and annual revision are needed.
Dr Mariana HELOU (Lebanon, Lebanon), Yara MOUAWAD, Danielle ABOU KHATER, Joelle KALAJI
00:00 - 00:00
#41669 - Emergency services and public health priorities on pandemic course collision: road traffic accidents and the COVID-19 pandemic in Romania.
Emergency services and public health priorities on pandemic course collision: road traffic accidents and the COVID-19 pandemic in Romania.
Road safety is a strategic public policy. Road traffic accidents (RTAs) are a public health priority. What happened during the COVID-19 pandemic, especially during the lockdown period, on the Romanian roads? Aim: to explore the 2-month lockdown of the COVID-19 pandemic in Romania (15 March to 15 May 2020) and evaluate the immediate impact on emergency services. Objectives: 1) to describe RTA events during 2019 and 2020 in line with temporal patterns: day of the week, time of day and place (U/R); 2) to evaluate the temporal patterns; 3) to place results in pandemic context. Methods and methodology: Romanian Police database on RTA events for 15 March-15May, years 2019 and 2020; COVID-19 data from the National Institute of Public Health (NIPH) Romanian reports of the same period. Descriptive analysis/statistics with CI95% for differences (two samples, unpaired case, Newcombe method) was used to highlight the information which can be used in an epidemiologically-based emergency health services needs assessment; day-night temporal pattern considered used the intervals: 07:00-21:00 (day) and 22:00-06:00 (night) with latter being analysed and reported. Results: WHO declared a Public Health Emergency of International Concern (PHEIC) in February 2020, followed by a pandemic level with a 2-month lockdown from 14 March 2020. This resulted in a substantial reduction of RTAs in Romania from 4,557 (15 March-15 May 2019) to 1,891 (15 March-15 May 2020). April 2020 recorded the lowest total number of events in 2020 (808), compared with 2,227 in 2019. Of all the RTAs registered in the two months 48% were recorded in urban areas. Proportions with occurrence at night (22:00 to 06:00) showed a statistically significant increase for 15 to 31 March 2020 (from 10.1% in 2019 to 14.3% in 2020); and a statistically significant decrease in April (from 13.7% in 2019 to 9.9% in 2020). This proportion almost levelled off in the first two weeks of May from 12.4% (2019) to 11.8% (2020). CI95% for differences are calculated for the three periods (2019 as base): 1) 15-31 March: -4.17% (CI95% from - 7.49 to - 1.24%); 2) April: 3.75% (CI95% from 1.25 to 6.25%); 3) 1-15 May: 0.64% (CI95% from -0.27 to 0.71%). During the month of April 2020 emergency services were fully stretched and deployed to deal with the sustained increased number of COVID-19 cases, too ( there were up to 400 cases/day on a 7-day rolling basis). Variations of RTAs for day of the week (Monday-Sunday) were calculated for both years. Results are benchmarked against August statistics (2019; 2020). Conclusion: there was a decrease of night RTAs in April 2020; it may have been a cause of the imposed lockdown and road traffic restrictions. This was preceded by an increase in RTAs in the last two weeks of March. Pre-pandemic phases can induce resource consumption shock waves across health services. Preparedness is an essential public health planning function which assists emergency services with needs assessments. The RTA analysis for 2019 and 2020 can help emergency services with strategic modeling and planning.
Andreea STERIU (Bucharest, Romania), Geovana CALINOIU
00:00 - 00:00
#42382 - EMERGENCY WAITING TIMES AND PATIENT SATISFACTION.
EMERGENCY WAITING TIMES AND PATIENT SATISFACTION.
Introduction:
The emergency department is a medical structure designed to receive patients 24/7. This causes congestion with an increase in waiting time. Indeed, this waiting time in the emergency room constitutes an essential indicator for judging the quality of a health system as well as patient satisfaction. In this context, we carried out this work whose objective was to evaluate patient satisfaction in relation to the different waiting times.
Methods:
We carried out an observational, prospective, mono-center, longitudinal study which took place from May 1 to 31, 2023 in the consultation boxes of the emergency service. A collection of clinical and paraclinical data was carried out. The different waiting times were researched. Patient satisfaction with the different waiting times was sought and analyzed according to the Likert scale.
Results:
Two hundred patients were included. The mean age was 44 ± 17 years. The gender ratio is 0.86.
Reasons for consultations (%): traumatic (14), cardiac (12), respiratory (12), abdominal (12).
The Mean ± SD [min-max] of check-in at the counter – Triage (T1) was 4 ±1,35 min [2-10] with 100% of patients satisfied. The Mean ± SD [min-max] of triage – Consultation (T2) was 15 ± 10,27 min with 95% of patients satisfied. The Mean ± SD [min-max] of request for exams complementary – their realization (T3) was 15 ± 4,13 min with 82 % of patients satisfied. The Mean ± SD [min-max] of carrying out exams organic supplements - their obtaining (T4) was 177 ± 64 min [90- 192] with 67 % of unsatisfied patients. The Mean ± SD [min-max] of realization of a radiography – interpretation (T5) was 41 ± 15,36 min with 58 % of unsatisfied patients. The Mean ± SD [min-max] of request for specialist advice - Obtaining it (T6) was 120 ± 58,15min [90-160] with 84% of unsatisfied patients. The Mean ± SD [min-max] of obtaining specialist advice - Decision to hospitalize or output (T7) was 30 ± 11,56 min [20-30] with 59% of unsatisfied patients.
The overall length of stay in the box was 185 ± 149 min [32-282].
Conclusions:
After analyzing the main failures concerning waiting times, it would be necessary to integrate new technologies to optimize the management of patient flow and improve their satisfaction with the health system.
Marouane SANAI, Asma JENDOUBI, Hana HEDHLI, Yassmine KARRAY (, Tunisia), Safia OTHMANI, Sarra JOUINI
00:00 - 00:00
#42380 - Emergency waiting times current situation.
Emergency waiting times current situation.
Introduction:
Emergency departments are responsible for caring for anyone who has felt the need to consult for an urgent or non-urgent medical problem. The increase in emergency departments activity has become a global phenomenon. It follows, a congestion of emergency structures which leads to an increase in waiting times. In this context, we carried out this work whose objective was to study the different waiting times at emergency departments.
Methods:
We carried out an observational, prospective, mono-center, longitudinal study which took place from May 1 to 31, 2023 in the consultation boxes of the emergency department. A collection of clinical and paraclinical data was carried out. The different waiting times were researched and analyzed.
Results:
Two hundred patients were included. The mean age was 44 ± 17 years. The gender ratio is 0.86. The majority of patients (n=137;68%) had an average socio-economic level. Medical History (%): hypertension (32), diabetes (26.5). Sixty-two patients had no history. Reasons for consultations (%): traumatic (14), cardiac (12), respiratory (12), abdominal (12). It was noted that 28.5% of check-ins at the counter were done in the morning. One hundred and thirty-four patients required further investigations. The complementary examinations carried out were (N): biochemistry analysis (76), blood count (63), chest x-ray (22), scanner (1). All patients completed their additional biological examinations within 30 minutes. A specialist opinion was considered necessary for only 30 patients. Hospitalization was only indicated in 13% of cases. The overall length of stay in the box was 185 ± 149 min [32-282].
Check-in at the counter – triage waiting time 4 ±1,35 min [2-10]
Triage – Consultation waiting time15 ± 10,27 min.
Request additional examinations - their
realization waiting time was 15 ± 4,13 min
Carrying out additional biological examinations
- their obtaining waiting time was 177 ± 64 min [90- 192]
Request for a chest x-ray – Their
realization waiting time was 78,3 min
Performing an x-ray – interpretation waiting time was 41 ± 15,36 min
Request for specialist advice - Obtaining it waiting time was 120 ± 58,15min [90-160].
Obtaining a specialist opinion - hospitalization or discharge decision waiting time was 30 ± 11,56 min [20-30].
The majority of our population (n=48, 35.85%) obtained the results of additional examinations at H4.
Conclusions:
Our study highlighted the need for a proactive and holistic approach to optimize waiting times in emergency departments. This work helps raise awareness of the importance of this issue and encourages the implementation of positive changes.
Marouane SANAI, Asma JENDOUBI, Hana HEDHLI, Khaireddine JEMAI (Tunis, Tunisia), Chedha BEN HMIDA, Sarra JOUINI
00:00 - 00:00
#41729 - Enhancing Emergency Department Performance in Mental Health Care: A Quality Improvement Project.
Enhancing Emergency Department Performance in Mental Health Care: A Quality Improvement Project.
Enhancing Emergency Department Performance in Mental Health Care: A Quality Improvement Project
Srivastava S, Syed N, Saifudheen S, Redknap I, Murugappan S, Burkert J
Objective:
This Quality Project aimed to improve care for patients presenting to the Emergency Department with Mental Health problems, considering recommendations from the Royal College of Emergency Medicine and examples of care in other healthcare systems.
Methodology:
A multidisciplinary team was assembled in an urban Emergency Department in the UK to undertake this project.
Performance data were collected and analyzed using a bespoke platform developed by the Royal College of Emergency Medicine (RCEM), with data entry occurring fortnightly. Utilizing Statistical Process Control (SPC) charts with automatic trend recognition allowed initial gap analysis and measurement of effects of improvement din a dynamic fashion. Stakeholder meetings were held, resulting in an identification of root causes for shortcomings in mental health care and improvement interventions. Interventions were conducted and evaluated employing the Plan-Do-Study-Act (PDSA) methodology.
The team focused on improving the mental health triaging system, education for ED staff, creation of a systematic approach template for mental health patients, and implementation of visual aids and educational initiatives within the department.
Results:
Initial data analysis revealed a mixed picture of performance against suggested standards, with areas for both commendation and improvement. Implementation of a new and simplified MH triage system in resulted in notable enhancements in timeliness, documentation, and appropriate streaming of mental health patients. The results indicated improved clarity in identification of high-risk patients.
Conclusion:
Significant progress was achieved in enhancing the Emergency Department's adherence to the clinical standards for mental health care set by the RCEM. The refinement of the mental health triaging system allowed for a more precise focus on high-risk patients, leading to notable improvements. Furthermore, employing data-driven methods like Statistical Process Control (SPC) analysis was crucial in recognizing patterns and guiding effective decision-making. These targeted interventions collectively contributed to the improved performance of the department in managing mental health care.
While some metrics demonstrated improvement following our interventions, areas for further improvement were also identified, highlighting the ongoing need for vigilance and innovation in mental health care provision. Moving forward, sustained efforts to address documentation deficiencies, reduce variations in performance metrics, and promote equitable care delivery remain paramount.
Improved documentation now includes a pamphlet offering self-referral guidance, complete with a crisis number and detailed instructions. This initiative aims to empower individuals by providing accessible resources, ensuring they can readily seek assistance and navigate the process independently when needed.
Embracing a culture of continuous improvement and learning enables emergency departments (EDs) to enhance their ability to deliver high-quality, timely, and equitable care to all individuals with mental health concerns. This commitment ensures optimized capacity to meet diverse needs and promote overall well-being within the community.
Registered with Royal college of emergency medicine National quality improvement program - QIP Registration Number: NCA226
This QIP did not receive any specific funding.
This QIP doesn't need ethical approval
Siddhi SRIVASTAVA (London, ), Naqueeb SYED, Saifudheen SHIHANA, Redknap IANTO, Murugappan SRINIDHII, Burkert JULIA
00:00 - 00:00
#41221 - Enhancing Prehospital Care During the Conflict in Ukraine: NATO's Role in Global Health Engagement.
Enhancing Prehospital Care During the Conflict in Ukraine: NATO's Role in Global Health Engagement.
Introduction: The conflict in Ukraine, ongoing since 2014 and escalating with the Russian invasion in 2022, has unveiled profound challenges in prehospital care essential for the survival and recovery of warfighters and civilians alike, necessitating a detailed examination of the current medical response mechanisms and their effectiveness.
Materials and Methods: This study provides an overview of these challenges and examines how these critical vulnerabilities have impacted the delivery of medical care in war-torn regions. It also explores the role of NATO and its member states in addressing these challenges, focusing on the efforts to standardize prehospital care, enhance training, and foster interoperability among medical services. Furthermore, it explores the role of global heath engagement through NGOs in addressing these prehospital care gaps within the Ukrainian conflict zone, drawing from direct observations, expert testimonials, and secondary data.
Results: Findings reveal significant enhancements in prehospital care through improved training, interoperability, and logistics management, despite ongoing challenges in medical infrastructure and extended evacuation times, which continue to impact the quality of care.
Conclusions: The study underscores the critical role of international collaboration and standardized protocols in bolstering prehospital medical responses in conflict settings, highlighting the need for continuous adaptation and support to mitigate the complexities of modern warfare. The insights gained from the Ukraine conflict offer valuable lessons for future military and humanitarian medical responses in similar conflict settings.
n/a
Anna ONDERKOVA (London, ), John QUINN, Michael MEOLI, Daniel TAYLOR, Sergiy NESTERENKO, Jessica SCHRAMM, Aj GIMPELSON, Aebhric O’KELLY, Steven PARKS, Jamla RIZEK, Terri DAVIS, Denys SURKOV, Cherniawski BOHDAN, Rajeev FERNANDO
00:00 - 00:00
#41657 - Epidemiological Analysis of Respiratory Viral Infections in an Emergency Department.
Epidemiological Analysis of Respiratory Viral Infections in an Emergency Department.
Introduction.
Respiratory viruses are a primary cause of acute respiratory infections. Since the emergence of Covid-19, there has been a shift in the surveillance of these infections, particularly focusing on SARS-CoV-2, influenza viruses, and respiratory syncytial virus (RSV). These pathogens lead to a significant number of hospital admissions associated with substantial morbidity and mortality.
Aim: To examine the prevalence, hospitalization rate, and 30-day mortality among patients diagnosed with acute respiratory infections due to SARS-CoV-2, influenza A, and RSV in a hospital emergency department.
Methods:
Observational study of patients diagnosed in the emergency department of Río Hortega Hospital with viral infections during the period from October 1 to December 31, 2024. The viral infection diagnosis was confirmed using PCR or antigen tests. The univariate analysis was conducted by comparing quantitative variables using Mann-Whitney and Kruskal-Wallis tests, and qualitative variables using the Chi-square test. Survival analysis was performed using Kaplan-Meier curves and Cox regression. Statistical significance was defined as p<0.05. The analysis was conducted using SPSS 29.0 software.
Results:
A total of 532 patients were included, with a median age of 70.4 years (range 49-83). Of these, 53.4% were women. Regarding the type of viral infection: Influenza A affected 208 patients (39.1%), SARS-CoV-2 was found in 292 patients (54.9%), and RSV in 32 patients (6.0%). There was a significant association between age group and type of respiratory infection (p<0.0001). Influenza A was more prevalent in the younger age group (14-50 years), while SARS-CoV-2 and RSV occurred more frequently in patients over 75 years of age (54.5% and 68.8%, respectively). The diagnosis of pneumonia was confirmed in 8.6% of patients. Among them, 45.1% required hospital admission. There was a significant association between the type of viral infection and hospital admission, with RSV showing the highest admission rate (78.1% for RSV, 51.7% for SARS-CoV-2, and 39.1% for Influenza A; p<0.001). The 30-day mortality rate was 5.1%. SARS-CoV-2 infection was associated with a higher 30-day mortality rate with a relative risk of 4.62 (95% CI: 1.08-19.7; p=0.03), after adjusting for age, sex, hospital admission, and comorbidity compared to influenza A. However, RSV infection did not reach statistical significance in terms of mortality.
Conclusions:
The most frequently isolated virus was SARS-COV-2 (54.9%). Influenza A affects the younger population, with no differences with respect to sex. SARS-COV-2 infection was associated with higher mortality compared to influenza A after adjusting for age, sex, comorbidities, and hospital admission.
Dr Raul LOPEZ IZQUIERDO, Del Campo FELIX, Carlos DEL POZO VEGAS (Valladolor, Spain), Tomas RUIZ ALBI, Ingelmo Astorga ELISA, Jesus ALVAREZ MANZANARES, Claudia BEIGVEDER DURANTE, Angela ALVAREZ SUAREZ, Karla Margarita CORDERO CAMACHO, Marta DOMINGUEZ-GIL GONZALEZ, Serrano Herrero DANIEL, Laura MELERO GUIJARRO, Berta TIJERO RODRIGUEZ, Mª Antonia UDAONDO CASCANTE, Francisco MARTÍN RODRIGUEZ
00:00 - 00:00
#41723 - Epidemiological and clinical characteristics of severe scorpion poisoning.
Epidemiological and clinical characteristics of severe scorpion poisoning.
Scorpionic envenomation (SE) is a relatively frequent occurrence, a public health concern, and a significant threat in numerous countries worldwide, particularly in our own. The objective of our study is to evaluate the epidemiological and clinical characteristics of severe scorpionic envenomations treated by the Eljem SMUR in Mahdia.
A retrospective study was conducted over a three-year period, from January 1, 2020 to December 31, 2022, and included all patients treated for stage II and III severe scorpion envenomations.
A total of 339 patients presented with scorpion envenomation during the study period. Of these patients, 33 (9.7%) were treated by the elJem SMUR and included in the study. The average annual incidence was calculated to be 11 cases per year.
The age group most represented was that of patients over 14 years of age, with a percentage of 54.5%. The study population included 45.5% children under the age of 14.
The study population was predominantly female, with 13 males (39.4%) and 20 females (60.6%). The male-to-female sex ratio was 0.65.
A total of 30 patients exhibited no previous pathological history, while 2 (6.1%) were hypertensive and 1 (3%) was epileptic.
A notable observation was the prevalence of rural areas (72.7%) in terms of the geographical distribution of the stings.
The majority of patients were stung during the summer and autumn months, which are typically hotter and more humid. A greater proportion of patients (54.5%) were stung during the day.
The scorpion in question was predominantly yellow in color (60.6%).
The majority of stings occurred on the upper limb (58%). Only one patient was stung on the head (3%), and two were stung on the abdomen (6%).
All patients were treated within three hours of the sting.
The clinical picture most frequently encountered was a combination of hypersudation and vomiting (81.8%) with or without abdominal pain (45.5%). Furthermore, respiratory distress was more frequently encountered (66.7%).
The prescription of local analgesics and anti-scorpionic serum was systematic in all patients. In 72.7% of cases, antipyretics were prescribed. Dobutamine was administered in 7 patients (21.2%). Antiemetics and antispasmodics were administered in 3% of cases. Local analgesics and anti-scorpionic serum were systematically prescribed for all patients.
Medical transport was provided without complications in 31 patients, while two patients (6%) experienced complications.
With regard to the final destination, 18 adult patients (54.5%) were transferred to the Mahdia emergency department, while 15 children (45.5%) were transferred to the Mahdia pediatric department.
The severity of scorpionism is contingent upon the clinical manifestations identified. However, several factors can influence the evolution of cases, including age, the timing of symptoms and their intensity. These factors can facilitate the establishment of an early prognosis. Consequently, the assessment and classification of the severity of cases, as well as the early and appropriate management of patients, can influence the prognosis.
Wael KAMMOUN, Haifa BRADAI, Sondes LAAJIMI, Chebbi NABIL (Tunisie-Sousse, Tunisia), Dorra LOGHMARI, Rabeb MBAREK, Naoufel CHEBILI
00:00 - 00:00
#41823 - Epidemiological and etiological profile of dyspnea in the Kairouan emergency room.
Epidemiological and etiological profile of dyspnea in the Kairouan emergency room.
Introduction :
Dyspnea is a common reason for referral to the emergency room. The potential seriousness that this implies requires that it be systematically explored. This card includes our work which aims to describe the epidemiological and etiological particularities of dyspnea in the IBN Jazzar emergency room, Kairouan.
Material and methods :
We carried out a descriptive study on 44 patients hospitalized in the emergency room of Ibn Jazzar hospital, Kairouan for dyspnea during the period from December 2023 until February 2024.
Results
Our study included 44 patients, 56.8% of whom were men with a sex ratio of 0.76. The median age of the patients was 69.0 [60.0; 75.0]. Most of the consultants were from the northern Kairouan region (23.3%), followed by the Haffouz region (20.9%).
Concerning the symptoms associated with admission, we found that cough was the most reported sign (63.6%), followed by asthenia (46.5%) then fever (31.8%).
On examination: 61.9% of patients had signs of struggle, crackles were the most noted on auscultation, the median saturation on ambient air was 85.0 [80.0; 90.0]. On gasometry: the median PH was 7.37 [7.31; 7.42], most cases had hypercapnia 39.5%.
In our work, dyspnea was of respiratory origin in 72.7% of cases, of cardiac etiology in 18.1% and of renal etiology in 9%. The respiratory causes were distributed as follows: acute hypoxemic pneumonia was observed in 47.7% of cases and an acute exacerbation of chronic obstructive pulmonary disease in 50.0%.
Conclusion :
Dyspnea is a common reason for consultation in the emergency department. The respiratory origin is the most common without forgetting the renal and cardiac causes.
Khouloud KHEMILI (Tunisia, Tunisia), Chaima MANAI, Ines KETATA, Sarra SOUA, Imen KETATA, Bouhamed CHAFIAA, Manel KHADHRANI
00:00 - 00:00
#42320 - Epidemiological and progressive aspects of epilepsy in patients with renal insufficiency admitted to emergency departments.
Epidemiological and progressive aspects of epilepsy in patients with renal insufficiency admitted to emergency departments.
The convulsive crisis is a therapeutic emergency whose management is well codified but the
occurrence of these crises in a very specific area such as those with renal insufficiency
requires the determination of its epidemiological, clinical and progressive characteristics.
Objective :
Determine the epidemiological, clinico-biological and progressive aspects of epilepsy in
patients with renal failure admitted to the emergency room.
Materials and method:
This is a comparative, prospective, single-center study which took place over a period of four
years in the emergency department. Inclusion criteria: both sexes, age > 15 years.
Non-inclusion criteria: pregnant women. Two groups: renal failure group + and renal failure
group-.
Results :
One hundred and fifty-two patients were collected, among whom 19 patients were in renal
failure, gender (p = 0.095); mean age=57.7±20.1 years (p=0.118); cardiovascular risk factors
(p=0.000); coronary insufficiency (p=0.005); hypertension (p=0.000); previous insulin
therapy (p=0.003); anti-hypertensive (p=0.000); isolated crisis (p=0.951); EME (p=0.802);
mean GAD=4.53 mmol/l (p=0.033); mean serum calcium =1.95±0.47 mmol/L (p=0.009);
isolated crisis (p=0.951); EME (p=0.802); poor therapeutic compliance (p=0.055);
hypocalcemia (0.188); worsening (p=0.203); death (p=0.056).
Conclusion :
the presence of hypertension and coronary insufficiency were significantly associated with the
occurrence of seizures in those with renal insufficiency, the GAD was significantly higher, the
main cause was poor therapeutic compliance.
Khaireddine JEMAI (Tunis, Tunisia), Dhekra HOSNI, Hana HEDHLI, Safia OTHMANI, Ghada MARZOUGUI, Ismail SAHNOUN, Assawer BEN DHAOU, Sarra JOUINI
00:00 - 00:00
#41988 - Epidemiological profile and injury assessment of motorcyclists involved in road accidents in the region of Gabes.
Epidemiological profile and injury assessment of motorcyclists involved in road accidents in the region of Gabes.
Introduction: Road traffic accidents remain a major public health issue despite numerous prevention programs. In Tunisia, the number of reported road accidents in 2023 was 5796, with 42% involving motorized two-wheel vehicles. To our knowledge, no study on the epidemiological and injury profile of victims involved in accidents with this type of vehicle has been conducted in Tunisia.
Objective: The aim of our study was to describe the epidemiological profile and injury assessment of motorcyclists involved in road accidents in the Gabes governorate.
Patients and Methods: We conducted a descriptive cross-sectional study over a period of 2 months from January 7th to March 8th, 2024, including all drivers of motorized two-wheel vehicles involved in accidents, initially received and treated at the emergency department of Gabes University Hospital.
Results: 117 accident victims were included. In the majority of cases, injuries were caused by motorcycle collisions with a car (40.2%) or another motorcycle (40.2%), occurring in 47% in the delegations of Greater Gabes in urban areas (79.5%) and mainly affecting the age group of 15 to 29 years (35%) with a clear male predominance (Sex ratio at 8). 62.4% of accidents occurred during the day with a clear prevalence on weekends (30.8% of accidents occurred on a Saturday and 18.8% on a Sunday). 62.4% of victims were evacuated from the accident site by civil defense agents. 97.4% of victims were not wearing helmets, 64% reported speeding, and 42.1% reported poor road conditions at the time of the accident. 44.4% of the injured had minor injuries such as abrasions, superficial wounds, and/or bruises. Among the remaining 55.6% victims of moderate to severe trauma, 47.1% had upper limb injuries, 39.7% had lower limb injuries, 17.6% had head injuries, and 16.2% had thoracic injuries.
Discussion : In our study, individuals aged 15 to 44 represented 62.4%, predominantly male, due to their greater exposure to road traffic and propensity for reckless driving. The most frequent injuries were to the limbs, followed by head trauma, consistent with the mechanism of injury on asphalt and the severity of impacts. Motorcycle-car collisions were common, as were motorcycle skids, contrary to what is described in the literature, partly explained by the state of the region's road network. The widespread use of two-wheelers in Gabes is associated with risky behaviors such as not wearing helmets and speeding. The majority of accidents occurred during the day and on weekends, likely due to daytime activities and leisure pursuits. Contrary to other studies, most evacuations were conducted by civil defense, possibly due to the severity of injuries.
Conclusion: Road traffic accidents involving motorized two-wheel vehicles remain a public health problem and constitute a fairly common reason for emergency department visits for moderate to severe trauma. The characteristics of these vehicles highlight the vulnerability of their users, emphasizing the need for preventive measures and road safety reinforcement to reduce morbidity and mortality associated with these accidents.
Mohamed Taher GHANNOUCHI, Mohamed Ali NBAYA (Gabès, Tunisia), Khaireddine BEN AMOR, Nessrine FTIRICH, Hedi Moez BEN AYED, Imene REJEB
00:00 - 00:00
#42271 - Epidemiological-clinical and biological profiles of patients admitted to the emergency room for sepsis.
Epidemiological-clinical and biological profiles of patients admitted to the emergency room for sepsis.
Introduction :Sepsis is a frequent reason for consultation in the emergency room, the functional signs are multiple, and the treatment regimens are well established according to recommendations.
Objective :Describe the epidemiological and evolutionary profiles for patients admitted to the emergency room for sepsis.
Materials and methods :This is a prospective descriptive study which took place over 24 months in the emergency department. Sepsis is considered based on a SOFA score > 2 on admission.
Results :213 patients were collected, mean age=61.5±16.9 years with a sex ratio of 1.4. History: hypertension (36.2%); diabetes (37.1%); COPD (7.5%); smoking (19.25%). Clinical signs: fever (n=144; 67.6%); asthenia (n=155; 72.8%); dyspnea (n=88; 41.3%); urinary signs (n=26; 12.2%); vomiting (n=44; 20.7%); abdominal pain (n=47; 22.1%); confusion (n=29; 13.6%). On examination: mean GAD=2± 1.23 mg/L; Mean FR=25.8±6.18 cyc/min Mean SPO2=90.16±9.66%; Mean SBP = 120 +/- 32mmHg, mean DBP = 66.4± 16.6 mmHg; Average HR=106.4± 20.67 bpm. In biology: mean lactatemia = 3.01± 2.28; Mean Phi=7.39±0.12; Mean Pao2=70.49 ± 28.7 mmHg; HGB=10.96± 2.85 mg/L; Average GB = 15,230± 9937 elem/mm³; average AST = 282.1 IU/L; average creat = 282.1 mg/L; Average BIL T=19.14 mg/L; CRP=226.6±123.3 mg/L; ECBU positive (35.7%); Pathological chest x-ray (40.4%), improvement (66.2%), death (25.8%).
Conclusion :Sepsis, being a generalized inflammatory response, is characterized by a diversity of clinical and biological parameters.
Sirine KHABOUCHI, Khaireddine JEMAI (Tunis, Tunisia), Dhekra HOSNI, Hana HEDHLI, Safia OTHMANI, Salma FATFOUTI, Sarra JOUINI
00:00 - 00:00
#42313 - Epidemiological-clinical and therapeutic profiles of peripheral trauma in patients admitted to emergency departments.
Epidemiological-clinical and therapeutic profiles of peripheral trauma in patients admitted to emergency departments.
Introduction:
Trauma is a frequent reason for consultation in the emergency room, the main symptom is
pain, the diagnosis seems easy and the treatment is most often well codified.
Objective:
Describe the epidemiological, clinical, paraclinical and therapeutic characteristics of
peripheral trauma in the context of polytrauma.
Materials and methods:
This is a single-center prospective descriptive study which took place over six months in the
emergency department.
Inclusion criteria: Age over 18 years, both genders, patients admitted for multiple trauma and
with peripheral trauma
Non-inclusion criteria: pregnant woman, patient in cardio-respiratory arrest
Peripheral trauma was defined: trauma to the four limbs, clavicle, pelvis, spine, ribs, scapula.
Results:
Two hundred multiple trauma patients were collected, one peripheral trauma (n=77), mean
age=41.7±15.3 years; Gender ratio=3.3; the circumstances of the accident were: AVP (n=69;
89.6%); domestic (n=6; 5%); work (n=2;6%); the mechanisms were: collision (n=13; 16.9%)
skidding (n=11; 14.3%) rollover (n=6; 7.8%) fall greater than 3 meters (n=2; 2, 6%); the
injury assessment showed thoracic deformation (n=2; 2.6%); open fracture (n=1; 1.3%); limb
wound (n=4; 5.2%); dislocation of the limb (n=17; 22.1%); clavicle fracture (n=4; 5.2%); rib
fracture (n=11; 14.3%); fracture of the scapula (n=4; 5.2%); spinal fracture (n=43; 5.2%);
vertebral fracture (n=2; 2.6%); vertebral dislocation (n=12; 15.6%); unstable fracture (n=2;
2.6%); multiple fractures (n=3; 3.9%); glasgow=14±1; SBP=128.8±17mmHg;
DBP=77.14±9.2mmHg; HR=83.6±11.6 bpm; FR= 18.3±3 cyc/min; Spo2=97.4±2.6%;
creat=71.2±13.6 µmol/L; serum sodium=136.9±3.2mmol/L; HGB=13.9±1.57 g/L; analgesic
means are: paracetamol (n=40; 51.9%); morphine (n=2; 2.6%).
Conclusion :
Peripheral trauma is a condition that frequently involves emergency room visits and whose
complaint is essentially pain, which must be properly treated.,,sd
Khaireddine JEMAI (Tunis, Tunisia), Dhekra HOSNI, Hana HEDHLI, Safia OTHMANI, Assawer BEN DHAOU, Roua HAJJI, Yasmine BENZARTI, Sarra JOUINI
00:00 - 00:00
#41403 - Epidemiology and outcome of non-traumatic critically ill patients treated in resuscitation rooms in German and Danish Emergency Departments.
Epidemiology and outcome of non-traumatic critically ill patients treated in resuscitation rooms in German and Danish Emergency Departments.
Background:
In contrast to trauma, information on epidemiology and outcome among patients who arrive at the emergency department (ED) with a severe non-traumatic condition is rare. For trauma patients, there are standardized procedures, education concepts and registers have existed for decades, but there is a lack of data for non-traumatic critically ill (NTCI) patients. The mortality in trauma patients treated in the resuscitation room ranges between 7.6 % and 12% in Denmark and Germany
The aim is to describe epidemiology, frequency, and outcome among NTCI resuscitation room patients in nine different German and Danish EDs.
Material:
In the German study centres, between 2018 and 2022, all adults (≥18 years) were included who fulfilled the local non-trauma team activation criteria from the following four EDs: Leipzig (university hospital, 2 prospective studies), Düsseldorf (university hospital, 1 retrospective study, Stuttgart (academic teaching hospital, 1 prospective study), and Mönchengladbach (academic teaching hospital, 1 retrospective study). Similarly, all adult patients (≥18 years) with the highest triage level on arrival (red level in DEPT triage) between January 2016 and March2018 were included from all five EDs in the Region of Southern Denmark (population 1.2 million). Patients with red triage are most often managed in the resuscitation room in the Danish Region.
Results:
We found that 1.5% (5929/408,673 ED visits) at the Danish centres and 1.2% (2016/174,306 ED visits) in the German sites had resuscitation room managed NTCI. This ranged from 0.7% (575/82,803) to 2.0% (1556/77,142) in the Danish sites and 0.5% (213/40,346) to 1.6% (532/34,303) in the German sites. At all sites, NTCI patients mean age ranged between 65±16 and 70±16, and between 51% and 60% were male. Most of the patients presented with a life-threatening B (breathing) problem, range 21.7-45.8 %, a C (circulation) problem, range 31.2%-47.4% or a D (disability) problem, range 11.3-41.2%.
At all nine EDs NTCI patients arrived at the resuscitation room 24/7 with a variety of 45-48 % during daytime (8.00- 16.00), 33-38% evening (16.00-24.00) and 14-21% night (00.00- and 8.00)
Thirty-day mortality ranged at the sites between 12.9% (66/621 NTCI visits) and 28.8% (61/213 NTCI visits) without patients with Out-of-hospital-cardiac arrest (OHCA) and between 18.5% (115/621 NTCI visits) and 39.9% (85/213 NTCI visits) including OHCA patients.
The admission rate to ICU or IMC was high in the German study centres (76-85.5%) but was lower in the Danish hospitals.
Conclusion
Among all ED patients, 1.4% arrive with a life-threatening non-traumatic critical condition and show mainly B-, C- and D-problems. The mortality rates vary but is higher than in trauma patients. Despite the retrospective, unselected cohort and the transnational setting, there is a close match in the overall results.
The findings emphasize the need for a 24/7 structured management in non-traumatic critically ill patients due to the high mortality and variety of different emergencies.
Stefan POSTH, Annmarie LASSEN, Christoph WASSER, Sebastian BERGRATH, Jana RÖDLER, Peter BIESENBACH, Lone MADSEN, Christian MOGENSEN, Michael BERNHARD, Michael MARK (Duesseldorf, Germany)
00:00 - 00:00
#42346 - Epidemiology, Risk Factors, and Management of Falls in Elderly Patients Attended in Emergency department Spanish teaching hospital.
Epidemiology, Risk Factors, and Management of Falls in Elderly Patients Attended in Emergency department Spanish teaching hospital.
Falls among the elderly pose a significant public health challenge, contributing to heightened morbidity, mortality, and healthcare utilization. Understanding the multifaceted nature of this issue is paramount for developing effective preventive strategies and optimizing clinical interventions to mitigate the negative outcomes associated with falls in this vulnerable demographic.
Metods.
A retrospective observational design, scrutinizing 5593 instances of elderly patients admitted to the emergency department due to falls spanning from January 2022 to November 2023. Inclusion criteria specified patients aged 65 and above with a discharge diagnosis indicative of a fall or its consequences.
The average age of the patients was 86 years, with women constituting the majority at 66% of the cohort. On average, patients were managing eight medications, suggesting potential polypharmacy complexities. Alarmingly, 597 individuals had experienced more than three falls, underscoring the recurrent and often preventable nature of this issue. Despite this, a mere 3.12% underwent geriatric assessment, representing a missed opportunity for comprehensive risk evaluation and intervention. Additionally, only 12.67% received follow-up care in primary care settings, highlighting a gap in continuity of care for fall prevention and management.
Furthermore, the consequences of falls were severe, with 6.3% of patients succumbing to their injuries post-fall. Disturbingly, only 1.75% of fall diagnoses were identified upon discharge from the emergency room, indicating potential underreporting or oversight of fall-related incidents in clinical documentation.
In conclusion, our findings underscore the urgent need for a concerted effort to address falls among older adults comprehensively. The high prevalence and associated adverse outcomes necessitate a proactive approach to fall prevention and management in healthcare settings. Strategies to enhance geriatric assessment utilization and promote follow-up care in primary care settings are imperative to mitigate the burden of falls on individuals and healthcare systems.
Moreover, interdisciplinary collaboration and education are vital to raising awareness among healthcare providers about the importance of fall risk assessment, early intervention, and ongoing management. By implementing evidence-based practices and fostering a culture of fall prevention, we can strive to reduce the incidence of falls, minimize their impact on the elderly population, and ultimately improve overall health outcomes and quality of life for older adults.
Yanelys Del Carmen GARCIA CARMENATE, Karla Lopez LOPEZ (Burgos, Spain), Elisa Maria FERNANDEZ RODRIGUEZ, Viviana MAROTO CARMENATE, Jorge A OLANO FELIPE, Leonardo NARANJO NEIRA, Chrismel Carolina LEGUISAMÓN REYES, Jesica OUTAMURO GONZALEZ, Eldymar GUTIERREZ MARTIN
00:00 - 00:00
#41797 - Episodes of consciousness among emergency clinically unconscious patients in the resuscitation room: preliminary findings of a prospective observational study.
Episodes of consciousness among emergency clinically unconscious patients in the resuscitation room: preliminary findings of a prospective observational study.
Background: Growing evidence suggests that some patients who appear to be clinically unconscious during emergency procedures can experience episodes of "connected consciousness" (CC; awareness of the external environment) or "disconnected consciousness" (DC; environmental stimulus-independent mental content), the latter including near-death experiences (NDEs).
Aims: This project aims to (1) prospectively investigate the prevalence and consequences of CC/DC among clinically unconscious patients admitted to the resuscitation room (RR) of our university hospital, (2) accurately characterize these episodes, and (3) pinpoint their underlying neurobiophysiological processes.
Methods: This prospective observational study will enroll a total of 201 clinically unconscious adult patients (i.e., ongoing sedation, intubation, cardiopulmonary resuscitation, Glasgow Coma Scale score=3). The patients are passively exposed to unexpected visual and auditory stimuli during their stay in the RR. An audio-visual system allows for objective environmental control. A wide range of medical parameters are collected, including partial pressure of carbon dioxide in arterial blood (PaCO2) and blood pH. Regional cerebral oxygen (rSO2) levels and a 6-channel electroencephalogram are recorded from the patient's admission. The prevalence and consequences of CC/DC are evaluated through semi-structured interviews (including freely expressed narratives, implicit memory tasks, and administration of standardized scales, such as the NDE-Content scale permitting to identify NDEs using a validated cut-off score) conducted within three days post-admission or awakening, and then at 2 and 6 months. For EEG analysis, data are arbitrarily divided into 10-time windows of the same length and analyzed in the time-frequency domain (using Continuous Wavelet Transform – CWT). Transient changes in brain signal complexity (using Lempel-Ziv Complexity index – LZC) are also sought.
Preliminary results: (1) We expect to find between 10% and 20% of patients reporting CC or DC, respectively. Out of seven unconscious patients included so far, six have survived. No CC was reported as no patient explicitly reported visual or auditory stimuli. However, two of them (33%) reported DC episodes. (2) These DC experiences have been identified as one positive and one negative NDE. (3) We here present the EEG results, the rSO2, the PaCO2, and the pH for the patient who experienced the negative NDE. The rSO2 values ranged from 61 to 90%, with an average value of 79 for both hemispheres. The patient showed high arterial PaCO2 (66 mmHg; normal range: 35-45 mmHg) with acidosis (pH = 7,20) on admission, suggesting acute episode of hypercapnia. We observed increased activity in beta and gamma frequency ranges and higher LZC values in two consecutive windows at the beginning of the recording compared to the rest of the recording. We hypothesize that, with this patient, hypercapnia contributed to the overall NDE experience while the transient increase in gamma activity may be a neural correlate of the DC episode.
Conclusion: Our project aims to identify and study CC/DC episodes in emergency patients, ultimately raising awareness of these episodes in the medical field and improving patient care. In addition, it is important to highlight that this is a feasible study with promising preliminary data, demonstrating the potential impact of our research.
Clinical Trial reference : NCT06362525
Funding :
-BIAL Foundation (Portugal)
-Conscience Sans Frontières
Pauline FRITZ (Liège, Belgium), Aurore ANCION, Nicolas LEJEUNE, Rourre ANAÏS, Pablo NÚÑEZ, Alexandre GHUYSEN, Olivia GOSSERIES, Charlotte MARTIAL
00:00 - 00:00
#40881 - Equity in the Provision of Helicopter Emergency Medical Services in the United Kingdom: A geospatial analysis.
Equity in the Provision of Helicopter Emergency Medical Services in the United Kingdom: A geospatial analysis.
Background
Helicopter Emergency Medical Services (HEMS) in the United Kingdom (UK) are provided in a mixed model, with the majority of services funded by charities alongside a small number of government-funded operations. More socially deprived communities are known to have greater need for critical care, such as that provided by HEMS in the UK. The inverse care law describes the tendency of healthcare provision to vary inversely with population need. It is not known to what extent the inverse care law applies to HEMS in the UK.
Methods
Every small unit geography in the United Kingdom was assigned to its closest HEMS operational base, to create modelled service areas. The total population, median decile on index of multiple deprivation, and geographic area for each modelled service area was determined from the most recently available national statistics. Linear regression was used to determine the association between social deprivation, geographic area, and total population served for each modelled service area.
Results
The provision of HEMS in the UK varied inversely to expected population need; with HEMS operations in more affluent areas serving smaller populations. The model estimated that population decreases by 18% (95% confidence interval; 1-32%) for each more affluent point in median decile of index of multiple deprivation (Figure 1). There was no significant association between geographic area and total population served.
Discussion
The provision of HEMS in the UK is consistent with the inverse care law. More deprived communities have less access to HEMS. Funding structures likely explain this variation; charities are more highly concentrated in more affluent areas. Further work is required to assess the delivery of enhanced care services that are delivered by ground assets. Policy should consider how to better distribute HEMS resource to better meet expected need.
Unfunded Research
Ryan MCHENRY (Glasgow, ), Alasdair CORFIELD
00:00 - 00:00
#41647 - Esophageal achalasia: unusual cause of chronic cough in adult.
Esophageal achalasia: unusual cause of chronic cough in adult.
Chronic cough is one of the most frequent complaints among outpatients and is mainly caused by cough variant asthma, posterior rhinorrhea, and gastroesophageal reflux disease. We experienced a Japanese man with chronic cough who eventually received a diagnosis of esophageal achalasia. Achalasia is not a common disease, with a prevalence of approximately 1.8-12.6 per 100 000 people; however, early diagnosis is desirable because it increases the risk of esophageal cancer, and to be impaired quality of life significantly.
A 53-year-old Japanese man presented to our hospital with a chronic cough that had persisted for more than one year and that aggravated during meals. He had a history of loss of appetite without weight loss for several years, dysphagia, and transient fever several times for a year that was treated with antimicrobials for suspected pneumonia. There was no history of smoking, medication use, or symptoms, such as heartburn or regurgitation. Upper gastrointestinal endoscopy performed for appetite loss two years ago showed no significant findings.
On examination, the patient had no acute distress. Vital signs were normal with a respiratory rate of 18 beats per minute. Late inspiratory crackles were observed in the right middle lung field. Laboratory data showed an elevated inflammatory response with a C-reactive protein 0.5 mg/dL. Infection or neoplasm, such as tuberculosis or lung cancer, was suspected, the patients was performed chest computed tomography (CT); it revealed stenosis at the esophagogastric junction, esophageal dilatation and fluid retention of the esophageal lumen. Ground-glass opacity was also observed in the right upper lobe. Based on the esophageal achalasia and aspiration pneumonia due to achalasia, the patient was referred to the gastroenterology department. The patient underwent upper gastrointestinal endoscopy and esophagography and was suspected to have esophageal achalasia. Drug treatment was initiated; however, the patient's symptoms did not improve, and esophageal manometry and elective endoscopic treatment or surgery were considered.
Esophageal achalasia is a primary esophageal motor disorder of unknown etiology that has a peak incidence between 30 and 60 years of age, with no difference in the prevalence of either sex or race. It can often lead to delayed diagnosis due to a variety of symptoms, such as heartburn, chest pain, and coughing, or the relatively low sensitivity of upper gastrointestinal endoscopy compared to the barium swallow test and chest CT scan5-7. To avoid a delayed diagnosis, when ‘middle-aged ’patients have specific symptoms such as dysphagia (86-94%) or regurgitation of undigested food or saliva (76-91%), esophageal achalasia should be considered as well as gastroesophageal reflux disease, and CT should be performed.
none
Shun MAEKAWA (Aizuwakamatsu, Japan)
00:00 - 00:00
#41489 - Ethylene Glycol Toxicity Due to Drinking Antifreeze for Suicide.
Ethylene Glycol Toxicity Due to Drinking Antifreeze for Suicide.
Introduction: Ethylene glycol toxicity is most commonly caused by drinking antifreeze. End-organ damage due to tissue damage occurs with the accumulation of glycolic acid and calcium oxalate crystals, which are toxic metabolites of ethylene glycol. There are 3 stages of intoxication clinic; neurological stage, cardiopulmonary stage and renal stage. The acute neurological phase occurs within 30 minutes to 12 hours after ingestion. Central nervous system depression, nystagmus, ataxia, and vomiting may occur. It causes neurological conditions such as hallucinations, convulsions and coma. The acute cardiopulmonary phase occurs within 12-24 hours after ingestion. Hypertension and tachycardia may occur. Tachypnea, metabolic acidosis, myositis, ARDS, cardiogenic pulmonary edema may occur. The renal phase occurs within 24-72 hours after ingestion. Acute tubular necrosis, hematuria, proteinuria, anuria may occur.
Case: A 28-year-old male patient admitted to the emergency department because he drank a glass of antifreeze 8 hours ago for suicide. The patient complained of blurred vision. He also had agitation, palpitations, nausea and vomiting. On physical examination, pupils were isochoric and bilateral light reflexes were decreased. Heart sounds were rhythmic and tachycardic and the patient had tachypnea, but other system examinations were normal. In laboratory study, blood gas pH: 7.11, pCO2: 10.2 mmHg, lactate: 26 mmol/L, HCO3: 7.7mmol/L, Base (Ecf)c: -25.3 mmol/L, K: 5.5 mmol/L. Cr: 1.67 mg/dL Urea: 37 mg/dL Hgb: 16.7 g/dL Ca: 10.53 mg/dL ethanol 0 mg/dL. The patient was intubated and transferred to the intensive care unit (ICU) due to the poor general condition. NaHCO3 and ethyl alcohol treatment was started due to severe metabolic acidosis. Hemodialysis treatment was given in the ICU. Despite daily hemodialysis, the patient's acidosis did not improve. Kidney functions gradually deteriorated in the patient who developed hypocalcemia and creatine kinase elevation. The patient developed renal failure and ARDS. The patient progressed to multiorgan failure and died on the 10th day of follow-up.
Conclusion: In our case, there were symptoms of the neurological and cardiopulmonary phase. Basic principles of treatment; providing cardiopulmonary support, treating acidosis, preventing the formation of toxic metabolites and increasing the clearance of the main component and toxic metabolites. Treatment includes alkalinization with NaHCO3, ethyl alcohol, fomepizole and hemodialysis. In our case, the patient died despite NaHCO3, ethyl alcohol treatment and hemodialysis. Ethylene glycol intoxication is a condition that can progress to multiorgan failure and be fatal. Therefore, early diagnosis and initiation of treatment will be lifesaving.
Songul COLAK (Alanya, Turkey), Onur GURKAN, Ismail Erkan AYDIN
00:00 - 00:00
#42317 - Etiological assessment and therapeutic management of acute abdominal pain in elderly patients.
Etiological assessment and therapeutic management of acute abdominal pain in elderly patients.
Introduction:
Abdominal pain is a frequent reason for consultation in the emergency room, the etiologies
are multiple medical and surgical and the initial treatment can affect the vital prognosis.
Objective:
Determine the etiological assessment and therapeutic management of acute abdominal pain in
elderly patients.
Materials and method:
Single-center prospective descriptive study which took place in the emergency department
over 6 months.
Inclusion criteria: elderly subject; two kinds
Non-inclusion criteria: patient in ACR, traumatic context
Results:
Fifty-two patients collected; gender ratio=1.2; mean age=74±8 years; ECBU positive
(23.1%); pathological abdominal ultrasound (21.2%); pathological uroscan (4%); Pathological
abdominal CT (40.4%); NHA (2%); pulmonary focus (4%); cholecystitis (2%); appendicitis
(2%); biliary peritonitis (2%); generalized peritonitis (2%); cholangitis (2%); urinary sepsis
(23%); mesenteric ischemia (2%); mesenteric infarction (2%); acute pancreatitis (6%);
obstructive stone (6%); OIA (6%); small bowel hematoma (4%); NSTEMI (2%); STEMI
(4%); ACD (2%); paralytic ileus (4%); filling (38.5%); norepinephrine (11.5%); antibiotic
therapy (25%); favorable development (38.5%); Septic EDC (19.2%); hemodynamic distress
(17.3%), death (15.4%).
Conclusion:
The etiologies of abdominal pain in elderly subjects were in the majority of cases surgical,
cardiac and metabolic causes can be manifested by abdominal symptoms.
Khaireddine JEMAI (Tunis, Tunisia), Dhekra HOSNI, Safia OTHMANI, Hana HEDHLI, Ismail SAHNOUN, Yessmine KARRAY, Oumaima NACEUR, Sarra JOUINI
00:00 - 00:00
#41486 - Euglycemic Diabetic Ketoacidosis in a patient presenting with acute abdominal pain.
Euglycemic Diabetic Ketoacidosis in a patient presenting with acute abdominal pain.
Introduction:
Diabetic Ketoacidosis (DKA) is a severe and life-threatening complication of both T1 and T2 Diabetes Mellitus (DB). The incidence of Euglycemic Diabetic Ketoacidosis (EDKA) has grown due to the use of SGLT2-inhibitors. However, the overall incidence of DKA due to SGLT2-inhibitors use is still very low, estimated at 0.1%. EDKA is characterized by euglycemia (Blood Glucose<250 mg/dL) in the presence of severe metabolic acidosis (pH<7.3, serum bicarbonate (HCO3)<18mEq/L) and ketonemia. EDKA patients can have a varied clinical presentation, similar to DKA.: nausea, shortness of breath/Kussmaul respiration, fruity breath odor, fatigue, loss of appetite, drowsiness, signs of total body fluid loss and/or abdominal pain. Nonspecific clinical manifestation, normal blood glucose levels and the fact that the majority of T2 DB patients have comorbidities pose a diagnostic challenge for the emergency physician.
Clinical case:
A 66 year-old woman was presented to the ED, because of abdominal pain, nausea, diarrhea and tachypnea. Abdominal pain started 2 weeks ago, mild at the beginning and located at the upper abdomen, but it gradually deteriorated. Pain was accompanied with gradual loss of appetite and no food intake the last 24 hours, nausea, vomiting and diarrhea for the last 12 hours. A few days before, she had visited a gastroenterologist, who prescribed a maximum dosage of omeprazole (80mg daily), a specific diet and she was scheduled for an esophagogastroduodenoscopy after 7 days.
Her medical history includesT2 DB, for which she takes an empagliflozin/metformin combination at 12.5mg/1000mg twice daily, 8IU of insulin degludec daily and injected semaglutide once a week, ischemic heart failure with reduced ejection fraction (EF 30%) and is scheduled for a CRTD implantation, triple CABG 4 years ago, arterial hypertension, Graves disease and thyroidectomy.
Patient was hemodynamically stable at arrival, but drowsy and tachypnoeic (“Kussmaul respiration” RR>30/min), with fruity breath odor. Clinical examination of the abdomen revealed diffuse tenderness at palpation and diminished bowel sounds. Complete blood count and biochemical tests panel were performed along with CTA of chest and abdomen. Thereafter, surgical consultation was asked. Arterial blood gases (ABGs) showed an arterial pH of 7.24, HCO3:8.2 mEq/l, paCO2:19.5 mmHg and Glucose at 113mg/dL. Blood ketones were 7,5mmol/L. The rest of the blood tests were within normal range. CT revealed a severe stenosis at the beginning of the superior mesenteric artery, but without signs of bowel ischemia.
Fluid resuscitation started at the ED, promptly followed by continuous infusion of insulin and dextrose solution. The SGLT2-inhibitor/metformin combination was discontinued. Patient was admitted and quickly recovered. While in hospital, an esophagogastroduodenoscopy was performed, which revealed pangastritis and duodenitis. Tests for helicobacter Pylori turned out negative. She was discharged with prescription of metformin and insulin degludec, maximum daily dosage of omeprazole and a specific diet.
Conclusion:
EDKA is a rare clinical entity with a varied and non-specific clinical presentation. Additionally, patient population most commonly affected by it, have comorbidities, which complicate and delay diagnosis further. Measurement of ABGs and blood ketones must not be omitted in patients with a suspicious clinical manifestation, even when they are euglycemic.
Sofia GKARMIRI, Adamantia NANO, Sofia-Chrysovalanto ZAGALIOTI, Ekaterini APOSTOLOPOULOU, Marianthi PERTSIKAPA, Vasileios GROSOMANIDIS, Varvara (Barbara) FYNTANIDOU (Thessaloniki, Greece)
00:00 - 00:00
#41886 - Euglycemic diabetic ketoacidosis in a type 2 diabetes mellitus patient not associated with sodium-glucose cotransporter-2 inhibitor use.
Euglycemic diabetic ketoacidosis in a type 2 diabetes mellitus patient not associated with sodium-glucose cotransporter-2 inhibitor use.
Brief clinical history:
A 58-year-old man presented to the emergency department (ED) complaining of generalized abdominal pain, diarrhea and decreased oral intake for two days duration. He had a history of type 2 diabetes mellitus (T2DM) on metformin, gliclazide and linagliptin. He denied alcohol use and reported compliance to his medications. He was noted to be tachypneic with respiratory rate 40/min. The rest of his vital signs were temperature 37.4 degree Celsius, heart rate 67/min, blood pressure 107/67mmHg, and oxygen saturation 100% on room air.
Misleading elements:
The patient was clinically dehydrated. Cardiorespiratory examination was unremarkable. His abdomen was soft to palpation with no localized tenderness. Capillary blood glucose level was normal at 4.8 mmol/L. Full blood count noted elevated white blood cells with neutrophil predominance. Kidney function tests noted acute kidney injury with raised creatinine levels and hyperkalemia. Liver function test was normal. Of note, a review of the patient’s medical records did not note previous prescription of sodium-glucose cotransporter-2 (SGLT-2) inhibitors.
Helpful details:
The patient’s hemodynamic status deteriorated rapidly in the ED to blood pressure 78/56mmHg, heart rate 109/min, oxygen saturation 88% on room air, and respiratory rate 38/min. He became increasingly drowsy and confused. He required stabilization with endotracheal intubation and vasopressor support. An arterial blood gas performed noted severe decompensated metabolic acidosis. The results were pH of 6.94, pCO2 22.5mmHg, pO2 213mmHg (FiO2 1), Bicarbonate 4.8mmol/L, Base Excess -27.
Differential and actual diagnosis:
In view of his clinical presentation of abdominal pain out of proportion to clinical examination, complicated by rapid clinical deterioration and severe metabolic acidosis, we initially suspected mesenteric ischemia as the primary diagnosis. However, an urgent mesenteric computed tomography angiogram performed did not note any vascular occlusion or stenosis of the mesenteric vasculature. Serum beta-hydroxybutyrate level was sent, which eventually returned elevated at 5.2 mmol/L. The patient was diagnosed with euglycemic DKA (euDKA), precipitated by gastrointestinal infection, complicated by acute kidney injury from hypovolemia. The patient was managed with intravenous insulin and dextrose infusion. He was admitted to the intensive care unit and eventually recovered completely with no deterioration of functional status.
What is the educational and/or clinical relevance of the case(s)?
EuDKA was first reported among insulin-dependent type 1 diabetic patients. Following the introduction of SGLT-2 inhibitors, euDKA has been sporadically reported in literature to be associated with SGLT-2 inhibitor use among T2DM patients. We report a case of euDKA in a T2DM patient treated with oral hypoglycemic agents apart from SGLT-2 inhibitors, an association not widely identified. We report this case to apprise the medical community that euDKA may arise in T2DM patients on oral hypoglycemic agents apart from SGLT-2 inhibitors. A diagnosis of DKA should be suspected in diabetic patients presenting with acute illness and metabolic acidosis, regardless of initial blood glucose level or class of pharmacologic therapy received. Clinical presentation of abdominal pain, decreased oral intake and use of multiple oral hypoglycemic agents may be important clues leading to a diagnosis of euDKA.
The author has no conflicting financial or non-financial interests to disclose.
Darius Shaw Teng PAN (Singapore, Singapore)
00:00 - 00:00
#41566 - Evaluating the effects of doctors’ Industrial Action in Accident and Emergency Department attendance at Oxford University Hospital (OUH): A comparative study.
Evaluating the effects of doctors’ Industrial Action in Accident and Emergency Department attendance at Oxford University Hospital (OUH): A comparative study.
Title:
Evaluating the effects of doctors’ Industrial Action in Accident and Emergency Department attendance at Oxford University Hospital (OUH): A comparative study.
According to NHS England, 2023 marks the 75th anniversary of the National Health Service, treating more than a million people per day. Whilst the NHS was celebrating its anniversary, it was also facing one of its gravest challenges in the form of Industrial Action (IA) taken by junior doctors.
Junior doctors decided to take IA in 2023 and 2024. According to the British Medical Association, this was to achieve full pay restoration, improving patient safety and staff retention.
As a result of the IA, OUH had to reschedule appointments, elective inpatient, and day case procedures across four sites prioritising urgent and emergency care.
A 2012 study by Milagros Ruiz et al, found that such IA led to 2.4% reduction in A&E attendance.
This study aims to understand doctor’s IA’s impact on A&E’s attendance at OUH and whether this reflects the national study conducted in 2012, which compares non-industrial action and IA days’ attendance.
Question:
How doctor’s IAs impact hospital attendances in the Emergency Department of the Oxford University Hospital (OUH)?
Methods:
OUH’s Discern Analytics reporting portal was used to collect the data from IA that OUH doctors participated in January, April and December 2023. The data comprised of the numbers of OUH A&E attendance the week before, during and the week after the doctor’s IA.
Results and Discussion:
The data showed that there were 15,691 attendances in A&E pre, during and post doctor’s IA. Pre-industrial action 4,840 (27%), during 6,333 (29%) and a week after 4,518 (44%) patients attended A&E. There was a 15% increase of A&E attendance post the doctor’s IA.
Interestingly, there was a 2% increase in attendance during the IA, which is in contrast with the 2012 national data where there was a 2% decrease in attendance. It is possible that the reason for the increase in attendance during the IA was due to people seeking emergency care as their elective appointments were cancelled, and other health services were disrupted. Additionally, the population has increased since 2012, which could also contribute to the rise in attendance.
After the IA, A&E attendances surged by 15%, which may be due to accumulated health issues and delayed care during the IA. It is important to consider these factors when analysing the data and drawing conclusions.
Conclusion:
The rise in A&E attendance both during and after the IA has highlighted the vital role of continuous healthcare provision and the impact of disruptions caused by IAs. It is worth noting that unlike the data from 2012, different IAs can have varying impacts on patient behaviour and healthcare service utilization. This may be due to the nature of the IA, the number of cancellations, and broader demographic changes. This analysis emphasizes the importance of robust planning and communication within healthcare settings to effectively manage patient flow during such disruptions.
This study received no funding
Alexis ESPINOSA (Oxford, ), Rufino Roger MAGALLANO, Martina IORIO, Domonique GEORGIOU, Tinelly SAMBO
00:00 - 00:00
#42369 - Evaluating the efficacy of short, opportunistic simulation based education in improving knowledge in emergency medicine staff.
Evaluating the efficacy of short, opportunistic simulation based education in improving knowledge in emergency medicine staff.
Introduction
Simulation is an effective way to teach both technical and non-technical skills. Often large scale multidisciplinary team simulation are time and resource consuming. Coordinating these sims is becoming increasingly difficulty due to the pressures on emergency departments and often, due to overcrowding and staff deficits, simulation based education sessions are cancelled. Our aim was to see if short, opportunist simulation based education training could be effective in developing both clinical and non-clinical skills for emergency medicine staff.
Methods
Over the course of one month we carried out seven simulation based education sessions each lasting approximately 5 minutes. These covered a range of skills and topics and were conducted at times when the activity in the emergency depart would allow, including during night shifts. Participants included emergency medicine non consultant hospital doctors and emergency medicine nurses.
Each participant was asked to complete a questionnaire, using a Likert scale, post simulation. The primary outcome of the study was to assess if the staff found the short simulations as beneficial to improving their knowledge, skills and teamwork as the longer simulation sessions (> 20 minutes in length).
Secondary outcomes assessed i) if staff felt the pressure to return to clinical duties effected their learning during the simulation based education sessions; ii) if staff preferred short five minute simulations over longer (twenty minute plus) simulation scenarios.
Results
All participants in the study fully completed the questionnaire. The primary outcome of the study assessed if the staff found the short simulation based education beneficial to improving their knowledge, skills and teamwork. All participants strongly agreed (90%) or agreed (10%) with this statement. In addition all participants agreed or strongly agreed that these simulation helped improve their communication skills.
When analysing the secondary outcomes of the study 80% of staff disagreed that they felt pressure to return to clinical duties during the simulation scenarios, while 20% reported feeling neutral. 70% of staff agreed or strongly agreed that they preferred the short 5 minute simulation scenarios to longer ones.
All participants agreed or strongly agreed that the simulation scenarios were relevant to their clinical practice.
Discussion
Short small group simulation based education is an effective way to deliver education to staff in an emergency department. Short simulation based education improves staffs knowledge, communication and teamwork. By using shorter scenarios staff feel less pressure to return to their clinical duties and still feel they benefits or working in a multidisciplinary team to increase their skills and ultimately improve patient outcomes.
Emma-May CURRAN (Dublin, Ireland), Robert EAGER
00:00 - 00:00
#41981 - Evaluating the Efficacy of Topical Tranexamic Acid Versus Standard First Aid in Prehospital Management of Epistaxis in Adults: A Literature Review.
Evaluating the Efficacy of Topical Tranexamic Acid Versus Standard First Aid in Prehospital Management of Epistaxis in Adults: A Literature Review.
Background
Epistaxis is a common emergency department presentation, particularly among the elderly—an increasingly large demographic. Despite its prevalence, optimal management strategies in prehospital settings remain underexplored. Introducing tranexamic acid for managing epistaxis in prehospital settings may reduce the number of patients referred to emergency departments. This literature review aims to evaluate topical tranexamic acid's effectiveness compared to standard epistaxis treatments in a prehospital setting.
Methods
Due to the scarcity of prehospital-focused research on the topic, this review turned to a detailed analysis of emergency department practices; recognising the absence of direct studies on prehospital tranexamic acid use for epistaxis, a literature review was conducted between 2010 and 2024 across PubMed, Medline, Clinal, and Scopus for studies involving the use of tranexamic acid in emergency department settings. The selection criteria included studies that used tranexamic acid as either a primary or an additional intervention for epistaxis. Trials' administration methods must be topical in the cavity of the nose to be included in the review. This review looks only at original research, including clinical trials. Critical appraisal was performed using the Joanna Briggs Institute (JBI) tools for assessing bias and quality.
Results
Nine studies met the inclusion criteria. Four studies evaluated tranexamic acid as a primary treatment, comparing it against standard first aid with the presence of other topical agents. These studies reported that tranexamic acid could reduce the need for further interventions, such as anterior nasal packing (nasal tampons) and decrease the discomfort associated with additional treatments. Four other studies assessed tranexamic acid as an adjunct treatment after the failure of initial management. The results were mixed, with some studies showing reduced rebleeding rates and length of hospital stay. In contrast, others found no significant difference compared to placebo or other treatments. Overall, tranexamic acid as a primary treatment showed promise in improving patient outcomes, whereas its effectiveness as an additional treatment was less conclusive.
Conclusion
Topical tranexamic acid shows potential as an effective primary treatment for epistaxis in prehospital care, possibly reducing the need for subsequent medical interventions and improving patient comfort. However, evidence for its use as an adjunct treatment is inconclusive. Given the current gaps in literature specifically addressing prehospital management of epistaxis with tranexamic acid, further prehospital research is needed to establish robust guidelines that can be applied in prehospital settings. This could significantly impact clinical practice, especially in a demographic with a high incidence of epistaxis.
Svend VITTINGHUS (Aarhus, Denmark)
00:00 - 00:00
#41685 - Evaluating the Impact of the URG Dijon App on Emergency Medicine Practices: A Quantitative and Qualitative Analysis.
Evaluating the Impact of the URG Dijon App on Emergency Medicine Practices: A Quantitative and Qualitative Analysis.
Background: The URG Dijon app, collaboratively developed at CHU Dijon, provides over 100 tailored emergency protocols and clinical calculators. This study investigates the app’s effectiveness and user satisfaction to ascertain its utility in emergency medical practices.
Importance: In emergency medicine, timely access to accurate protocols and calculators is essential for effective patient management and can significantly impact outcomes. The growing reliance on digital tools underscores the need for robust evaluations of such applications.
Study Design: An online survey was distributed among app users, encompassing a variety of healthcare professionals. The app is utilized by over 2000 professionals across more than 20 countries, primarily Francophone. The survey included both scaled questions and open-ended responses, allowing for a detailed assessment of user experiences.
Intervention/Exposure: Utilization of the URG Dijon app for accessing and implementing emergency medical protocols.
Outcome Variables: User ratings were collected on ease of use, protocol advice quality, confidence in decision-making, and overall efficacy. Comparisons were made with traditional paper and computer-based protocols, as well as emergency reference books.
Statistical Methods: Descriptive statistics summarized user ratings and an ANOVA was conducted to compare the app’s performance against traditional methods. The study utilized a 95% confidence interval to ascertain the significance of the findings.
Results:
Quantitative:
Ease of Use: Average rating of 4.08/5, with 75% of users rating it 4 or higher.
Confidence and satisfaction were highly rated, with a significant portion of users feeling more confident in decision-making using the app.
No significant differences were found in efficacy ratings between the app and traditional methods (p = 0.608), indicating comparable performance.
Comparative Efficacy:
41% found the app more effective than standard paper protocols.
42% noted faster access to information compared to standard computer protocols.
42% rated the app as much more effective than traditional emergency reference books.
Qualitative:
Feedback highlighted the app's rapid access to information and ease of use as major benefits.
Suggestions for improvement included updates to existing protocols and additional specialized calculators.
Conclusions: The URG Dijon app is highly regarded by its users, providing efficient and reliable support in emergency situations. It stands on equal footing with conventional methods in terms of effectiveness and surpasses them in user satisfaction and speed of information retrieval. Continuous updates and feature enhancements are recommended to sustain its effectiveness and relevance. The findings emphasize the critical role of digital tools in modern emergency medicine and suggest avenues for further development to enhance user engagement and clinical utility.
Ethical Approval and Informed Consent: Ethical guidelines were followed with informed consent obtained from all participants, in compliance with terms of service on both Google and Apple platforms.
Funding: Self-funded
Trial Registration: N/A
Ilinca ROMOCEA (Dijon), Cristian TEREC
00:00 - 00:00
#41855 - Evaluation and comparison of Normal Saline and Hypertonic Saline Nebulizers in treatment of Bronchiolitis. A non-randomized Controlled Clinical Trial.
Evaluation and comparison of Normal Saline and Hypertonic Saline Nebulizers in treatment of Bronchiolitis. A non-randomized Controlled Clinical Trial.
Introduction: This study was conducted to assess the response to treatment and compare the effects of nebulized normal saline 0.9% and hypertonic saline 3% in the management of acute bronchiolitis, a condition associated with multiple complications in pediatric patients.
Materials and Methods: In this clinical trial, a total of 60 children diagnosed with viral bronchiolitis in the autumn and winter of 2021 at Ali Asghar Children's Hospital's emergency department were enrolled. The cohort consisted of 30 children in the control group treated with normal saline 0.9% nebulization and 30 in the treatment group treated with 3% hypertonic saline nebulization. Demographic variables, symptom onset duration, and initial heart and respiratory rates were recorded. Disease severity was assessed using the Respiratory Distress Assessment Index (RDAI). Data were analyzed using SPSS software.
Results: Following treatment, both groups exhibited significant improvements in vital signs (respiratory rate, heart rate, oxygen saturation) and RDAI scores (P value < 0.001). However, there was no statistically significant difference in the degree of improvement in vital signs and RDAI scores between the two treatment groups (P value > 0.05). The mean hospital stay duration did not significantly differ between the groups (P value = 0.16).
Conclusion: Nebulized hypertonic saline and normal saline both effectively ameliorated symptoms in children with bronchiolitis. The absence of a significant difference between these treatments suggests that either can be recommended for use in the pediatric population experiencing acute bronchiolitis symptoms.
(IR/IUMS.FMD.REC.1397.123).
Seyedeh Mahsa MAHMOUDINEZHAD DEZFOULI, Samane Sadat KHOOBBIN KHOSHNAZAR, Kourosh JAVDANI ESFEHANI (Dubai, United Arab Emirates)
00:00 - 00:00
#41840 - Evaluation of a new score for the diagnosis of acute coronary syndrome based on the application of Geleijnse and TIMI score in patients with acute chest pain referred to the emergency department.
Evaluation of a new score for the diagnosis of acute coronary syndrome based on the application of Geleijnse and TIMI score in patients with acute chest pain referred to the emergency department.
Background. Acute coronary syndrome brings patients to the emergency department with a variety of features in the chest pain, but there is no definite criteria for diagnosing this syndrome.
Objectives. To evaluate acute coronary syndrome diagnostic score (ACSD) which combines Thrombolysis in Myocardial Infarction (TIMI) and patient’s pain scoring system (Geleijnse score) to obtain a new model for diagnosing ACS.
Methods. The data of 150 patients out of 350 patients who referred to the emergency department of two hospitals with chest pain were reviewed and two TIMI points and chest pain’s score in patients were calculated. The combined ASCD model score for patients was also evaluated. Mortality and morbidity of Patients who discharged from emergency department, were followed up by on days 7 and 28 after days.
Results. 10% of patients had ACS. The average ACSD scoring system is 12.47±2.295, which is 8.65±2.338 in patients with non-acute cardiac syndrome. The level below the ROC curve chart for the ACSD scoring system was 0.871 (95% CI= 0.865-0.976) compared to Gelenijse, 0.819 (95% CI 0.696-0.942) and TIMI, 0.616 (95% CI= 0.445-0.787) has a higher value. The best scoring cut-off in the ACSD scoring system is 9, which has a sensitivity of 93%, a specificity of 61%, a positive predictive value of 21% and a negative predictive value of 99%.
Conclusions. ACSD has a desirable sensitivity, specificity and negative predictive value for ACS diagnosis in patients with chest pain referred emergency department.
Kourosh JAVDANI ESFEHANI (Dubai, United Arab Emirates), Davood FARSI, Shahriar LAHOUTI, Fatemeh AFRASHTEH, Hamidreza KHOSHNEZHAD EBRAHIMI, Shabahang JAFARNEJAD
00:00 - 00:00
#41684 - Evaluation of CT-Scan prescriptions for Mild Brain Injuries Following the 2022 French Recommendations at Rouen University Hospital’s Emergency Department.
Evaluation of CT-Scan prescriptions for Mild Brain Injuries Following the 2022 French Recommendations at Rouen University Hospital’s Emergency Department.
Evaluation of CT-Scan prescriptions for Mild Brain Injuries Following the 2022 French Recommendations at Rouen University Hospital’s Emergency Department.
Introduction:
In 2022, the French Society of Emergency Medicine, in collaboration with the French Society of Anesthesiology and Critical Care Medicine, revised the guidelines for managing mild traumatic brain injury (mTBI). Notably, antiplatelet monotherapy is no longer considered an independent risk factor for intracranial injury. This update prompts the research question: How significantly have brain CT-scan prescriptions in emergency departments changed since the introduction of the new guidelines?
Methods: A retrospective observational study was conducted with adults admitted to Rouen University Hospital's ED within 24 hours post-mTBI. Patients with a Glasgow Coma Score under 13, prior CT-scans, or other indications were excluded. The study compared adherence to guidelines regarding brain CT-scan prescriptions for adult patients with mTBI over two distinct five-month periods: one before and another seven months post-guideline update. Subgroup analysis focused on patients receiving antiplatelet monotherapy. Instances of non-compliance with guidelines were categorized as either under-triage (CT-scan recommended but not performed) or over-triage (CT-scan not recommended but performed). Variables such as age, gender, history of neurocognitive disease, and criteria from the Guidelines for risk stratification of clinical worsening or intracranial lesions were gathered from the regional healthcare database (EDSaN) and analyzed using Chi2 or Fisher’s t-test. Populations were compared using the Student’s t-test or Wilcoxon test. Descriptive analysis aimed to identify potential risk factors for under- and over-triage.
Results: The study included 1,559 patients, with 796 from 2022 and 763 from 2023. Epidemiological data, trauma circumstances, and clinical information showed no significant differences between the two groups, except in gender distribution. Overall, 792 (50.8%) CT-scans were performed across both periods. Non-compliance with guidelines was observed in 195 patients (12.5%). Adherence to brain imaging recommendations significantly decreased after guideline updates (89.6% pre-update vs. 85.3% post-update, p=0.01), especially among patients on antiplatelet monotherapy (96% pre-update vs. 84.7% post-update, p=0.002). There were no significant differences in under-triage or over-triage rates between the groups. Patients who were treated contrary to the guidelines were more likely to present at night (58.5% vs. 46.8%, p=0.002, OR: 1.6, 95% CI [1.2; 2.2]). Intoxications deviated significantly from the guidelines (31.3% vs. 13.3%, p<0.0001, OR: 2.9, 95% CI [2.1; 4.2]) and were identified as a risk factor for under-triage (80.3% vs. 19.7%).
Discussion and Conclusion: While the methodology of the study limits the generalizability of the results, it underscores the challenges in swiftly incorporating new recommendations into existing practices. Efforts should be made to enhance adherence to guidelines, particularly following updates and in specific situations like night shift or post-intoxication scenarios.
Mathieu JAMET, Mélanie ROUSSEL, Mathieu BEN-HADDOUR (ROUEN)
00:00 - 00:00
#42200 - Evaluation of effectiveness of mechanical chest compression device (LUCAS) in intra hospital setting, using high fidelity simulation among Italian EM residents.
Evaluation of effectiveness of mechanical chest compression device (LUCAS) in intra hospital setting, using high fidelity simulation among Italian EM residents.
It is well known that simulation is a valid tool to teach, prove and maintain technical and non technical skills, especially in the EM schools. We decided to use different case scenario simulations among our EM residents to describe the effectiveness of managing the CPR following ACLS protocol with and without a mechanical chest compression device and with the presence of the CPR coach.
The EM residents were divided in 4 groups made up of 3 people, subdivided following background criteria (year of residency, previous experience in managing a cardiac arrest, ACLS provider).
Simulation case scenarios were all different and unique and were setted in the Simulation lab of Sapienza University of Rome. A high fidelity mannequin was used to perform every session. Three distinct facilitator doctors evaluated each single registered case using the Ottawa Crisis Resource Management global rating score.
Our results suggested that mechanical chest compression device is an effective implement but it doesn’t change the quality of the CPR management as compared to the coach. We focused our attention to soft skills and CRM, in order to implement our training on teamwork behaviors and resource utilization in critical settings. Our aim is also to rise the awareness on the importance of simulation for the specialty training in EM, as a learning and evaluation tool.
Marco COLANTONIO, Michela CASCIO (ROME, Italy)
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#42311 - Evaluation of GRACE score and sCAMI score in the NSTEMI.
Evaluation of GRACE score and sCAMI score in the NSTEMI.
*Introduction: Non-ST+ ACS are frequent reasons for hospitalization in the emergency room. The course is variable and fraught with the risk of acute complications. Early risk stratification plays a critical role in therapeutic strategy and risk of subsequent events. Different risk stratification scores were thus developed. the objective of this work is to determine the contribution of the sCAMI scores and GRACE score in the assessment of the progressive risk of NSTEMI.
*Materials and methods: Comparative study carried out over a period of 4 months. Patients hospitalized in the emergency room for NSTEMI were included. Identification of two groups in each score: Low risk group, and intermediate to high risk group. A univariate study was conducted identifying the factors associated with high intermediate sCAMI and GRACE scores.
*Results: Inclusion of 120 patients hospitalized for NSTEMI. The mean age was 61 ± 11 years with extremes ranging from 32 to 88 years. The main antecedents were: hypertension (69; 57.5%), diabetes (64; 53.3%), dyslipidemia (31; 36.5%), coronary insufficiency (52; 43.3%) with angioplasty in 23 patients. The main reasons for consultation were: chest pain (99; 82.5%) and dyspnea (16; 13.3%). Repolarization disorders: ST depression (57.5%), transient ST elevation (18.3%), negative T waves (24.2%), biphasic T waves (5.8%). The main territories affected were: the lower territory (36.7%), anterior (15.8%), apico-lateral (16.7%), infero-basal (14.2%). The evolution was marked by complications in 23 patients: OAP (14.2%), anginal recurrence (11.7%) and MI (6.7%). Two groups were identified: patients with intermediate to high GRACE scores (82.5%); Group with intermediate to high sCAMI score (40.83%). Factors associated with an intermediate to high sCAMI score were: cardiovascular history (p=0.023), SBP(p=0.000), PAD(p=0.031); basal territory (p=0.05); acute complications (p=0.002); SpO2 (p=0.042); Blood sugar (p=0.001); Hemoglobin (p=0.04). Factors associated with an intermediate to high GRACE score were: below ST shift (p=0.048); apical territory (p=0.032); inferobasal (p=0.041); PAD (p=0.003); SpO2 (p=0.017).
*Conclusion: NSTEMI risk stratification scores make it possible to adapt therapeutic management as well as revascularization times.
Sirine KHABOUCHI, Dhekra HOSNI, Khaireddine JEMAI (Tunis, Tunisia), Seif OUERGHI, Hana HEDHLI, Sarra JOUINI, Safia OTHMANI
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#42056 - Evaluation of Patients Admitted to Pediatric Emergency Departments Due to Suicide Attempts: A Multicenter Study from Türkiye.
Evaluation of Patients Admitted to Pediatric Emergency Departments Due to Suicide Attempts: A Multicenter Study from Türkiye.
Background
Suicide is one of the leading causes of morbidity and mortality in the adolescent age group. Particularly during late childhood and adolescence, it represents a significant public health concern that is progressively increasing. There are numerous studies conducted on pediatric emergency department visits related to suicide from both our country and worldwide. These studies have shown that self-poisoning is the leading method of suicide attempts, with analgesics and psychotropic drugs being the most frequently used medications.
The primary aim of this study is to examine whether there is a trend of change in suicide methods and to demonstrate the variations in medications used in suicide attempts involving poisoning over the 5-year period.
Methods
During a five-year period from July 1, 2017, to June 30, 2022, patients aged between 8 and 18 years who presented to 29 pediatric emergency departments in Türkiye due to suicide attempts were included in the study. The demographic characteristics, suicide methods, and clinical information of the patients were recorded. Patients with missing or inconsistent data were excluded.
Results
During the study period, a total of 9,736,825 visits to 29 pediatric emergency departments in Turkey were reviewed, resulting in the evaluation of 6,004 suicide attempt presentations over the 5-year period. Female/male ratio was 3.7/1 and the median age was 15 (14-16) years. Of the patients, 5580 (92.9%) were in the 13-18 age group, while the remaining 424 patients (7.1%) were in the 8-12 age group. Among all presentations, the frequency of admissions due to suicide attempt was 0.5 per 1000, with rates of 0.2 per 1000 in the 8-12 age group and 2.8 per 1000 in the 13-18 age group. The most commonly used method for suicide attempts was self-poisoning (95.4%). This was followed by self-injury by cutting, jumping off height, hanging, and firearm self-injury (3.4%, 1.5%, 0.4% and 0.1%, respectively). A total of 23.5% of self-poisonings involved the patient's own medication, with 76.2% of these being psychotropic drugs. One thousand eight hundred forty-eight patients (30.8%) had a known psychiatric disorder, and 13.2% of patients had a history of prior suicide attempt, and of those 63.6% have had a psychiatry consultation. The most commonly used medications in self-poisoning were NSAIDs, paracetamol, SSRIs, and atypical antipsychotics. There is an increasing trend observed over the years in the frequency of suicide attempts with patients' own medications among those diagnosed with psychiatric disorders. There was no significant trend observed in presentations due to suicide attempts using methods other than self-poisoning.
Conclusions
Suicide attempts represent a significant problem frequently encountered in pediatric emergency departments, with a predicted increase in prevalence in the future. Pediatric emergency departments serve as the initial point of contact for these patients seeking help. In addition to medical care, facilitating access to psychiatric and social services through a multidisciplinary approach would be appropriate.
This study did not receive any specific funding.
The study was approved by Hacettepe University Ethics Commission (GO 22/1243).
Hande YIGIT (ANKARA, Turkey), Ahmet Ziya BIRBILEN, Burcu AKBABA, Emel BERKSOY, Alper ÇIÇEK, Cansu DEMIREL, Göksel VATANSEVER, Berke MUTLU, Deniz TEKIN, Sevcan BILEN, Hayri Levent YILMAZ, Gamze GÖKULU, Ali TUNÇ, İlknur AKANSU, Emel ULUSOY, Durgül YILMAZ, Murat DUMAN, İlknur FIDANCI, Medine Ayşin TATAR, Aytaç GÖKTUĞ, Gülser Esen BESLI, Anıl ER, Hurşit APA, Şule SARI, Aykut ÇAĞLAR, İlknur BODUR, Nilden TUYGUN, Sinem SARI GÖKAY, Şener ÇINIÇEV, Ayla AKÇA ÇAĞLAR, Okşan DERINÖZ GÜLERYÜZ, Berker OKAY, Süleyman BAYRAKTAR, Zeliha YAVŞAN, İhsan ÖZDEMIR, Aysun TEKELI, Zeynep Gizem ERGÜN ÖZDEL, Çağlar ÖDEK, Öznur ESER, Şirin GÜVEN, Leman AKCAN YILDIZ, Funda KURT, Halise AKÇA, Can Demir KARACAN, Yunus Emre DOĞAN, Ahmet Kağan ÖZKAYA, Selcen BEDIR, Yılmaz SEÇILMIŞ, Özlem TOLU KENDIR, Nilgün ERKEK, Ayşe GÜLTEKINGIL, Ekin SOYDAN, Özlem DEMIREL, Azize ÖRENSOY ÇILINGIROĞLU, Nihan ŞIK, Ekin NURHAN, Sinem ORAL CEBECI, Özlem ÖZDEMIR BALCI, Gülşen AKTAŞ YALÇIN, Murat ANIL, Berfu TOKUÇ ÜLGEN, Emel EKSI ALP, Ozlem TEKSAM
00:00 - 00:00
#42374 - Evaluation of procedural simulation's impact on the quality of basic cardiopulmonary resuscitation in adults.
Evaluation of procedural simulation's impact on the quality of basic cardiopulmonary resuscitation in adults.
INTRODUCTION: The prognosis of cardiopulmonary arrest (CPR) is highly dependent on the quality of cardiopulmonary resuscitation (CPR) provided, as well as on the performance of responders in achieving external cardiac massage in accordance with international recommendations. Our study was interested to evaluate the impact of procedural simulation on the quality of basic adult CPR in the context of further medical training.
METHODS: Cross-sectional study, over 3 months, involving 14 doctors practicing in the emergency department. The assessment sessions were based on a pre-established grid. Each learner was assessed before (T0), immediately after (T1) and after 3 months (T2) of the simulation session program A satisfaction survey was conducted at the end of the session.
RESULTS: Our work showed a clear improvement in learners' technical and non-technical skills in basic cardiopulmonary resuscitation. The average overall CPR performance (score/20) rose from 9.6 at T0 to 20 at T1 and 16 at T2. There was an improvement in all three skill areas at T1 and T2, most markedly in the know-how area. A regression in average CPR performance was noted at 3 months compared with T1, However, it remained significantly higher than at T0. The observed improvement in the mean between T0 and T2 was 7.4 points, i.e. a gain of 66.67%. The subject matter covered during the sessions was considered very relevant and most learners were very satisfied with the simulation session program, the consolidation of their previous knowledge and the improvement of their skills.
CONCLUSIONS: Educational simulation is a learning tool for consolidating prior knowledge and improving technical and non-technical skills in the continuing medical education program on emergency medicine.
Fatma HEBAIEB, Saloua HOUIMLI (la Marsa, Tunisia), Mohamed ASSADI, Hajer HAMZAOUI, Amira TABKA, Wiem DERBALA, Sarra AKKARI
00:00 - 00:00
#41743 - EVALUATION OF QUALITY INDICATORS OF PATIENTS ADMITTING TO GERIATRIC EMERGENCY SERVICE FOR NON-TRAUMATIC REASONS.
EVALUATION OF QUALITY INDICATORS OF PATIENTS ADMITTING TO GERIATRIC EMERGENCY SERVICE FOR NON-TRAUMATIC REASONS.
Purpose: The World Health Organization (WHO) and the United Nations (UN) use the age of 65 and above chronologically when defining elderly individuals. According to UN reports, the elderly population, which is 10% of the world population in 2022, is expected to increase to 16% in 2050. Considering the increasing geriatric population, geriatric emergency models are being implemented in various countries to meet the needs of this population more accurately and in a short time. We made first geriatric emergency department in Turkey. The main purpose of this study is to evaluate the geriatric ED quality indicators established for the first time within the Erasmus project Safe And Friendly Emergency for Elderly (SAFE ME)
Method: Study data were analyzed with SPSS (Statistical Package for the Social Sciences) 23.0 and MedCalc 23.110 programs. Numerical data were expressed as median [interquartile range (IQR)], and frequency data were expressed as percentage. In comparing two independent groups, Mann Whitney U test was used for numerical data, and Pearson Chi-square and Fischer's Exact tests were used for frequency data. For frequency data, comparison of three or more independent groups was performed with the multi-well chi-square test.
Results: There are significant differences between the study conducted before the geriatric emergency and our study after the geriatric emergency. While the number of blood tests requested before geriatric emergency is 1087 (71.7%; p=0.00), in our study it was 761 (50.2%; p=0.00); While the number of imaging was 780 (51.5%; p=0.00), it was later determined to be 580 (38.3%; p=0.00). There was a significant decrease in the number of consultations compared to before the geriatric emergency (16.1 vs 6.6, p = 0:00). Waiting times after registration were 20 minutes (IQR: 7-55) before the geriatric emergency, and 7 minutes (IQR: 0-21) after the geriatric emergency opened. The length of stay in the emergency department also stands out with a significant decrease compared to before (150 vs 70; p=0.00). The cost of patients applying to the emergency department was calculated based on the dollar exchange rate at which the studies were conducted, and in our study, we found a significant difference compared to the geriatric emergency period (9.6 USD (IQR: 2.6-17.6; p=0.00) vs 5 .9 USD (IQR:3.07-12.53; p=0.00))
Conclusion: The results of our work are extremely positive. It was implemented with the project supported by Geriatric ED within the scope and financing of the Erasmus+ project. Providing training to doctors, nurses, staff and even security guards working in the ED, including the 112 team that transfers elderly patients to the ED, creating a separate area for the geriatric ED, rearranging the created areas according to the needs of the elderly, and accordingly, the service we provide. has led to an increase in the quality of operation.
Bora BALTACIOGLU (Nigde, Turkey), Mustafa KESAPLI, Yavuz Fatih YAVUZ, Deniz KILIC, Gizem AKCIN, Iffet TIFTIKCI, Mehmet AY
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#41668 - Evaluation of shared vigilance practices in emergency departments.
Evaluation of shared vigilance practices in emergency departments.
Introduction
Shared vigilance is a safety practice which consists of encouraging all members of an organisation to be attentive to the safety of their environment. The aim of our study is to assess the current situation and the application of this practice in emergency departments (EDs).
Method
An observational study was carried out among nurses in EDs in France, in public, university hospital, semi-private and private establishments. An anonymous questionnaire was sent out with closed, multiple choice and open questions.
Results
Of the 24 establishments, 114 nurses responded. 58% worked in adult emergency departments, 36% in paediatrics and 6% in both. 29% of nurses were familiar with the term "shared vigilance". It was used in 97% of cases for identity vigilance, 88% for material vigilance, pharmacovigilance (including 83% for emergency situations and 81% for dose calculations) and haemovigilance (76%). Shared vigilance was applied both during the day and at night (84%). A majority (75%) of departments encouraged staff to apply shared vigilance. Some departments have pre-existing protocols (identity vigilance 61%, haemovigilance 50%, material vigilance 45%, pharmacovigilance 44%).
The obstacles mentioned to shared vigilance were: interruption of tasks (81%), lack of time (70%), lack of specific training (36%), lack of risk culture (25%), unsuitable premises (19%) and lack of willingness on the part of management to practice shared vigilance (7%).
The benefits identified were: a reduction in errors (100%), mutual support and team cohesion (78%), support for new arrivals (60%), professional reassurance (57%) and reassurance for patients (36%).
Discussion
Shared vigilance is widely used in current practice, mainly in identity and material vigilance, but more informally. Although obstacles to its application have been identified, there are many advantages for healthcare professionals, such as team cohesion and a feeling of safety at work.
Conclusion
Shared vigilance could be extended to emergency medicine and protocolised, with an impact on patients to be assessed in terms of safety of care and benefits for carers.
not applicable
Sabine PERRET (Pierre-Bénite), Serieys LAETITIA, Cindy HERNANDEZ, Goeffrey SAGNOL, Sebastien BEROUD, Julien DURAND, Sophie BRONDEX, Sophie VESCO, Marion DOUPLAT
00:00 - 00:00
#41926 - Evaluation of teamwork by high fidelity simulation in severe trauma patients.
Evaluation of teamwork by high fidelity simulation in severe trauma patients.
Background: Learning through simulation is not mainly about technical skills. Non-technical skills, which are part of the prerequisite competencies for professionals working in emergency care, can be worked on through simulation as well. They are complement to technical skills and contribute to the quality and safety of care.
The aims of this study were to evaluate the learning of non-technical skills in the care of a severe trauma patient and to study the retention of these non-technical skills after one month of simulation sessions.
Methods: We conducted a prospective, observational, descriptive and single-centered study carried out at the North East SAMU01 Emergency Care Teaching Center (CESU01) over a period of one year from january to december 2021.
The use of a hetero-evaluation score of non-technical skills by the Anesthesist's Non-Technical Skills (ANTS score) was carried out by an observing instructor for all participants during the simulation session and one month later.
Results: We included 30 residents. The average age was 28 years old with a sex ratio of 4. Twenty one residents (70%) had already benefited from simulation training.
Participants significantly improved their situational awareness skill (3.6 vs 3.95 with p=0.026); decision-making (3.41 vs 3.52 with p=0.043) and teamwork (1.72 vs 1.19 with p=0.003) between the first session and one month later.
The comparison of the evolution of different non-technical skills in the two groups” prior to training by simulation” and “no prior to training by simulation” showed a significant difference concerning the means at 01 month in the group “prior to training by simulation” (3.42 vs 3.92 with P= 0.002).
Conclusion : Health simulation is therefore a major educational tool in the learning of non-technical skills in emergency medicine
Amina JEBALI, Hanene MOUSSI (Tunis, Tunisia), May ZNATI, Wejdene ZAIRI, Soumaya BADRI
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#41816 - Evaluation of the contribution of a cognitive aid to the learning of level 1 echocardiography five views : prospective experimental study of a cognitive aid for emergency medicine residents from Rouen.
Evaluation of the contribution of a cognitive aid to the learning of level 1 echocardiography five views : prospective experimental study of a cognitive aid for emergency medicine residents from Rouen.
Introduction: Point of care ultrasound (POCUS) in emergency medicine is a mainstay to the skills of emergency physicians. Level 1 echocardiography is part of the emergency medicine internship curriculum. The aim of this study was to evaluate the contribution of a cognitive aid to learning how to perform level 1 cardiac ultrasound views.
Method: A prospective, single-centre, randomised, before-and-after study was carried out at Rouen University Hospital from March 2023 to September 2023. The population studied was all emergency medicine residents in Rouen. Students were divided into 2 groups: with and without cognitive aid. The allocation of cognitive aid was randomised according to experience of cardiology department internship, year of residence and place of current internship. The primary endpoint was the evaluation score of the examination quantified by the RACEr score at T1 (first evaluation before any cognitive aid) and at T2 (3 months after the first evaluation). The secondary endpoints were the time taken to perform the five focused cardiac ultrasound views and the number of echocardiographies performed in the interval between the two assessments. A descriptive and comparative statistical analysis was performed.
Results: Of the 56 DESMU students in Rouen, 40 (71%) took part in the first evaluation and 36 (64%) in both evaluations. After randomisation, 21 students (52.5%) were in the cognitive aid group and 19 (47.5%) without cognitive aid. The median score at T2 for the cognitive aid group was 16 [IIQ 13-19] and 18 [IIQ 14-20] for the group without cognitive aid (p=0.48). In the cognitive support group, the median score at T1 was 11 [IIQ 9-15] and the median score at T2 was 16 [IIQ 13-19] (p=0.04). The number of ultrasounds performed between T1 and T2 was 11 [IIQ 8-17] in the cognitive support group and 5 [IIQ 2-10] in the group without cognitive support (p=0.002).
Conclusion: In the population of emergency medicine interns in Rouen, the presence of a cognitive aid in learning level 1 cardiac ultrasound views did not improve significantly the students' grade assessed by the RACEr score. However, the cognitive aid seemed to encourage students to carry out additional ultrasound examinations.
Mehdi TAALBA (Rouen), Hugo DHENAIN, Alix DELAMARE FAUVEL, Mathieu BEN HADDOUR, Luc-Marie JOLY, Mélanie ROUSSEL
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#42225 - Evaluation of the effect of diastolic failure on mortality in patients diagnosed with sepsis and septic shock in the emergency department.
Evaluation of the effect of diastolic failure on mortality in patients diagnosed with sepsis and septic shock in the emergency department.
Objectives:
In this study, we aimed to investigate the effects of sepsis mortality and morbidity by defining diastolic dysfunction by bedside cardiac ultrasonography in patients followed up in the emergency department with the diagnosis of sepsis and septic shock.
Methods:
The study was designed as a single-center, prospective study. Patients with a pre-diagnosis of sepsis and septic shock in the emergency department for 12 months will be identified and their demographic data, vital values, and blood gas and biochemistry parameters decided to be performed by the prime physician will be evaluated. Cardiac ultrasonography will be performed with the Vivid S60 USG device in the emergency room; Echocardiographic findings showing systolic and diastolic function will be recorded. The final diagnosis and outcome of the patients in the emergency department will be evaluated and the mortality and survival of the patients will be recorded at the end of 28 days after their hospitalization or discharge.
Conclusions
A total of 270 patients were included in the study. 116 patients were excluded according to the study's exclusion criteria and 154 patients were included. The patients included in the study were classified as insufficiency according to their echocardiographic findings; The rate of patients with systolic and diastolic failure is 45.5% (n=70), the rate of patients with isolated systolic failure is 19.5% (n=30), the rate of patients with isolated diastolic failure is 17.5% (n=27) and the rate of patients with no signs of failure It was 17.5% (n=27).The survival rate of the patients on the 28th day was 35.1% (n=54), and the rate of exitus was 64.9% (n=100).
When the relationship between patients with systolic and diastolic failure and 28th-day mortality was evaluated, the rate of patients with both systolic and diastolic failure was found to be 45.5% (n = 70) and the exitus rate was 34.4% (n = 53). The mortality relationship of patients with systolic and diastolic failure was found to be statistically significant. The effect of this patient group on mortality (Cramer's V:0.34 p=0.000) was found to be 34%.
The rate of patients with systolic failure was 64.9% (n=100), and 48.7% (n=75) of the patients with systolic failure exited. A statistically significant relationship was found between systolic insufficiency findings and mortality in these patients, and the effect of systolic insufficiency on mortality (Cramer's V: 0.29 p=0.000) was found to be 29%.
The rate of patients with diastolic failure was 63% (n=97). When the relationship between patients with diastolic failure and 28th-day mortality was evaluated, the exitus rate was found to be 44.8% (n = 69), and the relationship between patients with diastolic failure and mortality was found to be statistically significant. The effect of this patient group on mortality (Cramer's V:0.17 p=0.0035) was found to be 17%.
Results
Diastolic dysfunction is a condition marked by abnormal function of one or both ventricles and increased resistance to diastolic filling. Diastolic failure, combined with the systemic inflammatory response and circulatory problems caused by sepsis, is associated with an increased risk of mortality in patients.
Ferdi OGET, Funda KARBEK AKARCA (Izmir, Turkey), Burcu YAGMUR
00:00 - 00:00
#42314 - Evaluation of the effectiveness and tolerance of two NSAIDs by intravenous injection in the PEC of patients admitted to the emergency department for renal colic.
Evaluation of the effectiveness and tolerance of two NSAIDs by intravenous injection in the PEC of patients admitted to the emergency department for renal colic.
Introduction: The aim of this study is to evaluate the effectiveness and safety of two intramuscular NSAIDs (Dexketoprofen versus Ketoprofen) in patients admitted to the emergency department (ED) admitted for renal colic.
Materials and methods: This is a prospective, randomized, double-blind study. We included all patients consulting the emergency room for renal colic, aged > 18 years, with a pain score > 3 (VAS from 0 to 10). We excluded patients who refused to participate in the protocol or who had a contraindication to NSAIDs, and patients unable to assess the intensity of pain according to the EVN. Patients are randomized into one of the study groups: Dexketoprofen group and Ketoprofen group. Patients received 1 intravenous (IV) injection upon arrival. The primary objective of our study is to evaluate the variation in VAS post-injection. Tolerance is assessed by the occurrence of adverse effects linked to the drug, their timing and the degree of attributability.
Results: 99 patients were included in the study: 56 in the Dexketoprofen group and 43 in the Ketoprofen group. The average age of the study population is 41.3±7.6 years with a sex ratio (M/F) of 1.08. The two groups are comparable in terms of age, sex ratio and background. The 50% reduction in pain VAS was observed in an average of 5.4 ± 1.9 minutes in the Dexketoprofen group versus 5.1 ± 1.1 minutes in the Ketoprofen group, no statistical difference. was noted between the two groups (p=0.912). No adverse effects were noted in both groups.
Conclusion: The effectiveness of Dexketoprofen and Ketoprofen administered IV is comparable in the management of pain in patients admitted for renal colic.
Lobna MHJOUB, Rahma JABALLAH (Sousse, Tunisia), Hajer YAAKOUBI, Rym YOUSSEF, Fadi CHOUCHENE, Arij BAKIR, Imen TRABELSI, Houda BEN SALAH, Asma ZORGATI, Lotfi BOUKADIDA, Riadh BOUKEF
00:00 - 00:00
#41630 - Evaluation of the Knowledge Level of Pediatric Emergency Physicians about E-CPR.
Evaluation of the Knowledge Level of Pediatric Emergency Physicians about E-CPR.
BACKGROUND
Extracorporeal membrane oxygenation (ECMO) is a life support system for life-threatening illnesses that affect the function of the heart or lungs. The method of emergency application of ECMO in cases where there is no response to cardiopulmonary resuscitation is called E-CPR. Although it’s recommended to perform E-CPR on children, there is no previous data in the literature about the knowledge level of physicians regarding the application of E-CPR in children. In this study, we aim to evaluate the knowledge level of physicians working in pediatric emergency departments regarding E-CPR.
METHODS
A Google survey form was prepared. The survey consists of 25 questions about E-CPR application in children (twelve questions including the demographic characteristics of the participants and the institution they work in, eight questions regarding the knowledge levels of the participants about E-CPR, and five questions of pediatric arrest sample cases). The survey was shared with the e-mail group of physicians working in the Pediatric Emergency Department in Turkey on 15.01.2024, and physicians who agreed to participate could answer the survey within one month. The obtained Google form data was evaluated using the SPSS version 22 program, and descriptive statistics were used.
RESULTS
One hundred and six physicians (68 Females, 38 Males) with a mean age of 35.93±7.11 years participated in the study. 94.3% of the participants worked in the Pediatric Emergency Department of a tertiary hospital. 51.9% of the participants were pediatric emergency physicians, 37.7% were specialists, and 36.8% had more than 11 years of experience in pediatrics. 90.6% of the participants had no previous E-CPR experience, 89.6% had not received any training on E-CPR, and 22.6% had never heard of E-CPR. 76.4% of the participants answered that E-CPR could be applied in all age groups in children, 58.5% in cases of cardiac arrest due to treatable diseases, and 54.7% in cases of witnessed arrest and if CPR was started at the time of the arrest. 30.2% of the participants answered that E-CPR could be applied if spontaneous circulation did not return at the 10th minute of CPR; the other 30.2% answered that E-CPR could be applied if spontaneous circulation did not return at any time, regardless of the CPR duration. The percentage of those who responded that there was an indication of E-CPR for five sample cases were 44.3%, 75%, 58.9%, 49.1%, and 36.6% for cases 1-5, respectively. The percentage of those who answered "I have no idea" was 20.8%, 17.9%, 24.5%, 34% and 24.5%, respectively.
CONCLUSION
E-CPR serves as a life-saving bridge in cases of reversible causes of cardiac arrest. While there are more precise data and application guidelines regarding E-CPR indications and contraindications in adults, unfortunately, there is no accurate data for children. Also, there is a lack of guidelines about when to apply E-CPR in children. This survey clearly shows that there is apparent confusion about E-CPR among pediatric emergency physicians. Education programs and guidelines regarding E-CPR in children are needed.
The study was not registered because no patients involved.
This study did not receive any specific funding
Ayla AKCA CAGLAR (ANKARA, Turkey), Oksan DERINOZ GULERYUZ
00:00 - 00:00
#42048 - Evaluation of the pain level felt by patients during intramuscular injection in the emergency department and the pain-drug relationship.
Evaluation of the pain level felt by patients during intramuscular injection in the emergency department and the pain-drug relationship.
Background: Intramuscular injection may cause pain, fear and agitation in patients. In the literature, it has been determined that techniques such as breath holding and providing local anesthesia before the procedure are used in the adult age group to reduce these complaints. We aim to evaluate the level of pain felt by patients coming to the green area and injection room in the emergency department during intramuscular injection and the pain-drug relationship with the Visual Pain Score.
Material and Methods: This prospective observational study was conducted at the University Hospital of Alanya Alaaddin Keykubat ED (March-June 2023). All stable patients who were admitted to outpatients who received an injection, agreed to participate in the study were included in the study. The pain was marked by the patient on the Visual Pain Scale after the application. Patients were monitored in the waiting room for 30 minutes for possible complications.
Results: 287 patients were included in the study, 164 patients were injected with breath holding, 122 patients were injected without breath holding. The mean age of the patients was 36.4 ± 13.7 (95% CI: 34.8 – 38.0) and the mean pain score was 21.3 ± 24.3 (95% CI: 18.4 – 24.1) mm. When we divided the patients into two groups: IM injection with breath holding and IM injection without breath holding, the median age in the breath holding group was 34 (IQR; 23.3, min-max: 14 – 81) and the median pain score was 17 (IQR; 35, min-max: 0). – 100) mm. In the non-breath holding group, the median age was 38 (IQR; 19.8, min-max: 13 – 70) and the median pain score was 10 (IQR; 30, min-max: 0 – 100) mm. When the two groups were compared in terms of age and pain score, no statistically significant difference was detected between the groups (p: 0.233, p: 0.284).
The most common drug administrations to the patients participating were diclofenac sodium 221 (77%), dexketoprofen 35 (12.2%), pheniramine maleate 24 (8.4%) and others 7 (2.4%). When the pain scores of the patients were compared according to the types of drugs administered, a statistically significant difference was detected between the groups (p: 0.008) and the difference was detected between diclofenac and dexketoprofen (median pain scores of diclofenac 10, dexketoprofen 35, respectively) (p 0.038).
When the pain scores of the patients were compared according to gender, the median pain score was found to be 17 (IQR 37, min-max 0-92) in women and 10 (IQR 30, min-max 0-100) in men, and no significant difference was found between the groups in terms of pain score (p 0.150).
Conclusions: When the relationship between diclofenac and dexketoprofen active substance agents, which are frequently preferred in the treatment of pain by intramuscular injection in our country's emergency departments, and pain, we found that patients who received dexketoprofen felt more pain. We determined that the patient's breath holding during the im injection application had no effect on the pain score.
Banu KARAKUS YILMAZ, Ismail Erkan AYDIN, Hasan PAKIR (Antalya, Turkey), Erdem CEVIK
00:00 - 00:00
#42372 - Evolution of mortality over 7 years in a European level 1 trauma centre: a retrospective single centre study.
Evolution of mortality over 7 years in a European level 1 trauma centre: a retrospective single centre study.
Objectives: Improved trauma management in trauma centres and organising trauma networks resulted in a significant decrease of mortality. In the Antwerp University Hospital (UZA) in Belgium, structured trauma care was implemented in 2016. This retrospective analysis was undertaken to analyse the evolution of the mortality of the major trauma population from 2016 to 2022.
Materials and methods: In this descriptive, retrospective, monocentric study, all major trauma patients admitted to UZA from 2016 until 2022 were included. Only trauma patients with a Maximum Abbreviated Injury Score (MAIS) = 2 with the need for intensive care or a MAIS of ≥ 3 were included. Patients who were transferred in from another hospital or were transferred out within 48 hours were excluded. Data were collected from the trauma registry. The cause of death (COD) of patients that died in the hospital was classified into four groups: “traumatic brain injury” (TBI), “haemorrhagic shock” (HEM), “organ failure” and “other”. The RISC II was calculated for each patient to calculate an excess mortality defined as the difference between the observed and the predicted mortality.
Results : A total of 1639 trauma patients were admitted from 2016-2022. After exclusion, 1291 patients were further analysed. No significant differences were noted for the type of injury or mechanism of injury during this period. The median age was 49 (IQR 31-62) and 74.2% was male. The most prevalent mechanisms of injury were traffic accidents and falls from height. The predicted mortality was 15.8% based on RISC II and the observed mortality was 18.7%. This excess mortality of 3% was observed each year. TBI remained the major COD over the years (54.8%), although only 73% of TBI patients deceased due to their brain injury. The median survival length varied among the different COD groups, ranging from 1 day (interquartile range [IQR] 0-6) in TBI and 0 days (IQR 0-0) in HEM, compared to 12 days (IQR 1-22) in cases of organ failure and 7 days (IQR 1-17) due to other causes. A withdrawal of care was noted in 68.9% of deaths, with an increase from 2016 (52.4%) to 2022 (82.8%), with near significance (p = 0.08).
Conclusion: Although previous studies have demonstrated a significant decrease in mortality following the implementation of structured trauma care, our data did not reflect a similar trend. Nonetheless, this study underscores several important considerations when assessing the progress of trauma centres. Reducing mortality is multifactorial and can be influenced by evolving ideas across different hospital departments (e.g., ICU protocols regarding care withdrawal). The limited number of deceased patients in our centre restricted our ability to derive significant conclusions. Uniformity of trauma registration in an trauma network is needed to to facilitate advancements in trauma care. Additionally, it's worth noting that we only analysed the evolution over the past seven years, whereas substantial improvements often manifest after a minimum of ten years, as time is required to observe the effects of newly implemented care protocols.
Approval by the Ethics Committee of the Antwerp University Hospital was not necessarily due to the retrospective design of the study.
Financial support and sponsorship: The corresponding authors are not recipients of any research scholarship, grant or funding for this work.
Matthew PETERS, Tom STROOBANTS (Antwerp, Belgium), Eva JANSSENS, Sebastian SCHNAUBELT, Joo-Ree MELIS, Philip VERDONCK
00:00 - 00:00
#41809 - Examining ten years of emergency call utilization among citizens in Region Zealand, Denmark: An observational study of data from 2013-2022.
Examining ten years of emergency call utilization among citizens in Region Zealand, Denmark: An observational study of data from 2013-2022.
Background: Improving prehospital care requires a comprehensive understanding of the efficiency of emergency medical services and the fluctuations in demand. The medical emergency call serves as the primary contact between a citizen and the emergency medical dispatch center, playing a critical role as the gateway to accessing emergency assistance. This study aimed to characterize the emergency call population and analyze the temporal development of emergency call utilization among citizens in Region Zealand over a decade-long period, from 2013 to 2022.
Methods: The study was an observational retrospective register-based study of administrative data from the emergency medical dispatch center in Region Zealand linked with national register data. Descriptive and Poisson regression analyses were used to characterize the data. Temporal trends were analyzed both overall and stratified by four geographical areas corresponding to the catchment areas of the region's four hospitals with emergency departments.
Results: The study included a total of 641,518 emergency calls. Among these, 517,647 calls involved a patient with a valid personal identification number. Male patients accounted for 52.3% of the cases. Children aged 0 to 14 constituted 5.1% of the patients, while patients aged 15-24 accounted for 8.6%, those aged 25-64 for 38.1%, and patients aged 65 and older for 48.2% of the cases. Regarding comorbidity, 48.7% of individuals had no comorbidities, while 7.6% had mild comorbidities, and 43.6% had severe comorbidities, as assessed by the Charlson’s Comorbidity Index. This distribution showed geographic variations, particularly in the southern region where 47.4% of individuals had severe comorbidities. The absolute number of emergency calls rose from 58,456 in 2013 to 80,838 in 2022 (138%). The incidence rate of emergency calls increased from 71.1 (95% CI = 70.6;71.7) per 1000 citizens in 2013 to 95.2 (95 % CI = 94.5;95.9) per 1000 citizens in 2022, corresponding to an incidence rate ratio (IRR) of 1.35 (95% CI = 1.33;1.36). The southern part of the region had significantly more emergency calls during the study period compared to the northern part of the region (IRR 1.64 (95% CI = 1.63;1.65).
Discussion & Conclusions: The study revealed a notable increase in emergency calls throughout the study period, both in absolute numbers and per 1000 citizens. These results suggest a heightened demand for emergency care among citizens, along with a corresponding surge in workload at the region's dispatch center. Additionally, the identification of regional disparities underscores the potential necessity for tailored developmental approaches over time.
Registered in Region Zealand’s Research Registry, REG-145-2023. Ethical approcal was not necessary.
Funded by The Danish Health Authority.
Thea Palsgaard MØLLER (Vaerloese, Denmark), Josefine Tangen JENSEN, Stig Nikolaj Fasmer BLOMBERG, Annette Kjær ERSBØLL, Helle Collatz CHRISTENSEN
00:00 - 00:00
#41842 - Examining the frequency of simultaneous infection of the central nervous system (meningitis and encephalitis) in patients admitted to the emergency department with a diagnosis of urinary tract infection.
Examining the frequency of simultaneous infection of the central nervous system (meningitis and encephalitis) in patients admitted to the emergency department with a diagnosis of urinary tract infection.
ABSTRACT
Introduction: Considering the importance of central nervous system diseases such as meningitis and encephalitis and the high prevalence of urinary tract infections, this study was designed and carried out with the aim of investigating the frequency of simultaneous central nervous system infections in patients admitted to the emergency department with a diagnosis of urinary tract infection.
Materials and methods: In this cross-sectional-analytical study, 81 patients with a definitive diagnosis of urinary tract infection who visited the emergency department of Firoozgar Hospital from the beginning of 2014 to the end of 2016 and underwent a lumbar puncture were examined and the percentage of simultaneous infection of the system was examined. The central nervous system (meningitis and encephalitis) was investigated with the diagnosis of urinary tract infection. The required information was collected using the information checklist. Data were analyzed using SPSS version 23 software.
Findings: In this study, among these 81 patients with a definitive diagnosis of urinary tract infection, 28.4% (23 people) of them, in addition to urinary tract infection, had a simultaneous infection of the central nervous system, of which 52.20% were men (12 people) and 80/8 47% were women (11 people) and their average age was 75.04 ± 9.75 years. The results of blood culture in the simultaneous infection group were negative in 87.00% (20 people) and 8.70% (2 people) were positive, and in the other group that did not have central nervous system infection, 87.93% (51 people) were negative and 8.62% (5 people) were positive, (p=1.00). The result of urine culture in the infection group was negative in 39.13% (9 people) and positive in 60.87% (14 people), and in the other group, 20.69% (12 people) were negative and 75.86% (44 people) ) was positive, (p=0.160). In the simultaneous infection group, 17.40% (4 people) had redar symptoms and 82.60% (19 people) had no symptoms. And in the other group, 1.72% (1 person) had Redor's sign, 1.72% (1 person) had Kernig's sign, and 91.38% (53 people) had no symptoms, which was a significant difference between the two groups (032 /0=p).
Conclusion: Timely and quick diagnosis of the disease as well as the initiation of appropriate treatment is very important, so that the delay in each leads to high mortality and serious and permanent complications for the patient. Sometimes, due to unnecessary and misplaced diagnostic measures, the diagnosis of a disease is delayed, which in addition to the financial cost to the patient, also leads to irreparable physical complications.
Reza MOSADDEGH, Sogand DAEI, Kourosh JAVDANI ESFEHANI (Dubai, United Arab Emirates), Hamidreza MOVAHEDI, Mahdi REZAI
00:00 - 00:00
#41751 - Exertional Rhabdomyolysis – Admit or Discharge?
Exertional Rhabdomyolysis – Admit or Discharge?
Exertional Rhabdomyolysis – Admit or Discharge?
Introduction: Rhabdomyolysis is a condition characterised by the breakdown of skeletal muscle tissues, often leading to the release of intracellular contents into the bloodstream1. Patients classically present with muscle pain, weakness or dark-coloured urine2. Treatment usually requires hospitalisation for intravenous hydration3 (this is the current practice in most hospitals in Singapore) with monitoring of hepatic and renal failure1,4. We studied a cohort of patients with exertional rhabdomyolysis presenting to an emergency department (ED) of a tertiary hospital in Singapore who were admitted to an acute short stay ward (24-hour) in the same hospital. This descriptive work would allow for optimisation of healthcare protocols and practice, especially given current limited healthcare resources4.
Method: We conducted a retrospective descriptive cohort study from 2020 to 2022 using administrative data for all exertional rhabdomyolysis patients who were admitted to an acute short stay ward through the ED. Data included the presence of risk factors, symptoms and laboratory values at presentation. We made a point to track the diagnostic symptoms and levels of laboratory investigations from the day of the triggering events. Outcomes included time to creatine kinase (CK) downtrend and the level of CK at which a patient is more likely to develop acute renal impairment (AKI).
Results: We followed-up a cohort of 103 patients. The majority were young (mean 27 years) and male (66%). 5% of cases had underlying risk factors (presence of previous rhabdomyolysis, diabetes mellitus, thyroid disorders). The majority presented within 2 to 4 days from the triggering event (mean 3, SD 1.1). Muscle pain was the earliest and most common symptom (97/103). At presentation, the majority had CK levels of >20,000 U/L (84%), abnormal liver function (94/95, 99%) or renal impairment (1/103, 1%). In this cohort, CK was noted to peak from day 4 to 6 of the triggering events. Average time for CK levels to downtrend was 7 days. 1 patient with AKI had CK of 48,000 U/L (day 2 from triggering event) and discharged well on day 4 (CK level of 45,000 U/L). The second patient developed new onset AKI during the admission in the acute short ward and was transferred to a general medical ward and discharged well 4 days later.
Conclusion: CK levels peaked within day 4 to 6 (from the triggering events), and on average started to trend downwards from day 7. It is important for ED physicians to document the time interval from the triggering exertion to first CK level on ED presentation as this may guide the disposition. We postulate that patients under the age of 50 with exertional rhabdomyolysis who do not have risk factors and present to the ED on day 2 (from their triggering event) onwards with CK levels <45,000 U/L and are able to drink a minimum of 5L of fluids per day, can be managed in an ambulatory setting with regular medical reviews.
Trial registration: Not required because the study does not involve interventions.
Funding: No funding.
Wey Ting LEE (Singapore, Singapore), Hann Yee TAN, Alethea Qiping CHEW, Aidan Lyanzhiang TAN, Adamjee THOFIQUE, Eillyne SEOW
00:00 - 00:00
#40931 - Experiences and perceptions of acute testicular pain, with a focus on delayed reasons for presentation to hospital: a qualitative evidence synthesis.
Experiences and perceptions of acute testicular pain, with a focus on delayed reasons for presentation to hospital: a qualitative evidence synthesis.
Introduction
The annual incidence of testicular torsion is approximately 1 in 4000 males under the age of 25. Despite the 97% testicular salvage rate when surgical intervention is within 6 hours of onset, orchidectomy is required in 40% of cases. These comparatively poor outcomes are driven by delays to intervention, the majority of which take place prior to presentation to healthcare. This study synthesises existing evidence to understand factors leading to delayed presentation to hospital in individuals with acute scrotal pain.
Methods
A comprehensive literature search was performed with support from an information scientist. Two authors performed article screening, data extraction, and inductive thematic synthesis independently, with disagreements resolved by discussion at each stage. An assessment of confidence in the review findings was performed using the ConQual approach.
Results
The search identified 1251 unique articles for screening, with 5 eligible for inclusion all were publications developed from two PhD theses. Synthesis of these articles revealed 5 descriptive themes with 5 subthemes and 1 analytical theme. Communication was an overarching factor connecting the descriptive themes, with lack of knowledge and education about testicular health, embarrassment, and reliance on others for access to healthcare being major factors leading to delays in presentation to healthcare.
Discussion
A lack of knowledge about testicular anatomy and health among both adults and children is amenable to improvement through education, and would likely impact many of the factors identified as contributory to delays.
Registration not required.
Funded by the Derby and Burton Hospitals Charity, approval number TI240764
Elizabeth ANDERSON, Wendy J CHAPLIN, Chloe TURNER, Graham JOHNSON, Holly BLAKE, Andrew TABNER (Derby, )
00:00 - 00:00
#41385 - Experiences of healthcare staff in an acute hospital-nursing home collaboration: a qualitative study.
Experiences of healthcare staff in an acute hospital-nursing home collaboration: a qualitative study.
Introduction: Many countries are facing an ageing population, and this is also evident in Singapore. To alleviate this matter and to cope with the increasing number of older persons today, nursing homes are also expanding. Residents of nursing homes are often frail and are at higher risk of multiple hospital admissions. On many occasions, the benefit of conveying the frail residents to acute hospitals is unclear and may even cause more harm. We implemented an acute hospital-nursing home collaborative pilot in two nursing homes with an objective to reduce emergency department visit and inpatient hospitalization among nursing home residents. We aim to study the experiences of the healthcare staffs from the two nursing homes.
Methods: Explorative qualitative interviews were conducted on 26 nursing home staffs who have had experience in using the collaboration intervention. The interview transcripts were thematically analyzed.
Results: Five main domains were explored - knowledge and understanding; service satisfaction; challenges; enablers; and service improvements. Most of the ground staffs had incomplete grasp of the purpose and logic of the collaboration. However, the consensus obtained were that they felt reassured knowing they could consult hospital providers easily without activating emergency services immediately. Nursing home staff also acknowledged having equipped themselves with skills to identify residents who required escalation of care through this collaboration. Interventions used such as NEWS assessment tool, hospital transfer forms and teleconsultation portal were found to be easy to use. Among the challenges faced on the ground were pressure by next-of-kins on treatments in acute hospitals than nursing homes and lack of on-site resources. Some of the enablers identified in this collaboration include a good support system, nursing home staff competency and motivation to improve residents’ care, which facilitated the collaboration. There are some suggestions for further improvement of the service which were highlighted. These include training opportunities and skills development amongst the nursing staff as well as workforce enhancement to promote adherence to the collaboration.
Conclusion: Expanding emergency care beyond the four walls of hospital to NHs, has shown promising effect in reducing transfers and admissions to acute hospitals. Further efforts and studies could be done in order to better align the expectations of different stakeholders to ensure an effective and sustainable collaboration. In the light of an ageing population globally, this highlights the importance to explore alternatives to providing medical care to this group of patients in the comfort of a familiar setting without compromising quality of care.
Yee Har LIEW (Singapore, Singapore), Yingjia YANG, Xin Yi Sheryl LIM, Mui Hua Jean LEE, Chong Yau ONG
00:00 - 00:00
#41938 - Exploring Acute Osteomyelitis in Children: Bacteriology Insights.
Exploring Acute Osteomyelitis in Children: Bacteriology Insights.
Aim: Acute osteomyelitis (OMA) is a common condition in children, often presented with febrile bone pain, the most common reason for consultation in our country. Due to the increased prescription of antibiotics, the epidemiological profile of pathogens and therapeutic approaches can vary. It is crucial to recognize that OMA represents a therapeutic emergency due to the risk of destruction of growing bone and cartilage structures. Our aim is to describe the bacteriological profile of OMA in children treated at our Orthopedic Surgery Department.
Methods: This is a retrospective study including all patient records hospitalized in our orthopedic service for OMA over an 8-year period [January 1, 2015 - December 31, 2022]. All patients underwent a clinical examination, biological assessment, and radiological diagnostic evaluation. All data were collected on a predefined form.
Results: 50 patients were included in our study. The mean age of patients was 8 years and 4 months, with a male-to-female ratio of 2.12. The main reason for consultation was bone pain, often accompanied by fever in 84% of cases. The preferential infectious site was the lower limbs in 82% of situations. The most frequent symptomatology was functional impairment in 74% of cases. A portal of entry was identified in only 30% of patients, with skin lesions in 33.3% and hematogenous routes, notably septicemia, in 33.3%. Microorganisms were noted in half of the cases (n=25), primarily identified by intraoperative sampling (n=14). Staphylococci represented 92% of the isolated microorganisms (n=23), including methicillin-sensitive Staphylococcus aureus (MSSA) (n=16), methicillin-resistant Staphylococcus aureus (MRSA) (n=6), and coagulase-negative Staphylococci (n=1). Salmonella and Streptococcus A were identified in a single case, constituting 4% of the isolated microorganisms. The average duration of antibiotic therapy was 48 days, ranging from 2 to 183 days. Complications observed were mainly the transition to chronicity in 10% of cases.
Conclusion: This study emphasizes the importance of understanding the bacteriological profile of OMA in children to adapt better management strategies and adequate antibiotic therapy.
This study did not involve a trial registration. No external funding was received for this study.
Jacem SAADANA, Khouloud KHEMILI (Tunisia, Tunisia), Firas CHAOUECH, Bilel FAIZI, Hatem BELGACEM, Ahmed MDAOUKHI, Iheb NTICHA, Amine SIOUD, Moez JELLALI, Habib HADJ TAIEB, Insaf BEN MESSAOUD, Aymen FEKIH, Abderrazek ABID
00:00 - 00:00
#42132 - Exploring Copetti's Sign: an innovative approach to diagnosing Renal Colic via Ultrasound.
Exploring Copetti's Sign: an innovative approach to diagnosing Renal Colic via Ultrasound.
In two patients presenting to the emergency department with renal colic, the Copetti's Sign was observed during point-of-care ultrasound (POCUS) evaluation. Renal ultrasound revealed Copetti's sign with low-grade hydronephrosis in one case and without hydronephrosis in the second case. Abdominal CT confirmed a 10 mm stone lodged in the lumbar ureter in the first case and a 7 mm stone located in the pelvic ureter in the second case.
Copetti's sign, also known as the swinging sign, was first described by Dr. Roberto Copetti in 2022 and serves as an indirect marker of ureteral calculi in the distal (most commonly juxtavesical) tract. This diagnostic sign manifests as an undulating movement of the kidney, resembling oscillations. Unlike the typical cranial-caudal movement seen during respiration, this oscillatory motion along the major axis of the affected kidney is akin to a boat swaying on waves. This phenomenon is attributed to the pronounced aortic pulse at the upper pole of the kidney, possibly facilitated by the presence of a urinoma. The urinoma, often formed due to increased ureteral pressure from impacted stones, may result in micro-lacerations of the renal fornices, leading to urine extravasation and subsequent retroperitoneal accumulation.
Copetti's sign holds significant diagnostic value for identifying distal ureteral calculi, particularly in the juxtavesical region, which is challenging to visualize with ultrasound alone. Additionally, it appears to be associated with smaller stone sizes (<10 mm), allowing for initial attempts at conservative expulsive therapy. Awareness of this sign during suspected acute renal colic could enhance patient management strategies.
The identification of the Copetti's sign on ultrasound may aid in the diagnosis of distal ureteral stones in patients with acute renal colic. Its association with smaller stone sizes and juxtavesical localization adds to the armamentarium of diagnostic sonographic signs. Further prospective studies are warranted to ascertain the diagnostic accuracy and clinical utility of this novel finding.
Carmine Cristiano DI GIOIA (Modena, Italy)
00:00 - 00:00
#41108 - Exploring the Impact of Physical, Psychological, and Social Frailty on Post-Discharge Outcomes in Elderly ED Patients: A Prospective Cohort Study.
Exploring the Impact of Physical, Psychological, and Social Frailty on Post-Discharge Outcomes in Elderly ED Patients: A Prospective Cohort Study.
Introduction:
This research examines the relationship between various types of frailties and the likelihood of one-month revisits, readmissions, and mortality among elderly emergency department (ED) patients. With a focus on enhancing triage and care for this high-risk group, the study aims to improve our understanding of how physical, psychological, and social frailties affect patient prognosis in the ED setting.
Methods:
Conducted at the Emergency Department of National Taiwan University BioMedical Park Hospital, this prospective observational cohort study enrolled older adult patients over a three-month period. Frailty assessments included the Study of Osteoporotic Fractures scale for physical frailty, the Tilburg Frailty Indicator for psychological frailty, and the Makizako Social Frailty Index for social frailty. Data analysis involved a multivariable logistic model to determine the the link between multifaceted frailty and subsequent outcomes.
Of the 991 older adults seeking medical care, 207 participated in the study. Physical frailty was identified in 46.38%, psychological in 41.06%, and social in 48.79%. One-month follow-ups revealed a 22.22% ED revisit rate, a 17.39% readmission rate, and a 5.8% mortality rate. Physical frailty significantly elevated the odds of ED revisits and readmissions. In contrast, psychological frailty predominantly influenced revisit rates, and social frailty demonstrated a non-significant yet suggestive trend toward affecting readmissions and mortality.
Conclusion:
The study concludes that identifying frailty early in the ED visit could be critical for reducing revisits and readmissions for elderly patients. While social frailty’s role requires further investigation, it may be more impactful than currently quantified, hinting at the value of comprehensive frailty assessments for elderly ED patients to inform better resource allocation and potentially improve short-term outcomes.
Ethics approval:
The study protocol has been reviewed and approved by the Research Ethics Committee of the Hsinchu Branch of National Taiwan University (# 111-115-E) within which the work was undertaken and conforms to the provisions of the Declaration of Helsinki.
Funding
This project was sponsored by a research grant from the National Taiwan University Hospital Hsin-Chu Branch, grant no. 112-BIH027.
Yu-Chieh TSAI (Taipei, Taiwan), Edward Pei-Chuan HUANG, Chien-Hua HUANG, Ya-Mei CHEN
00:00 - 00:00
#41558 - Exploring the journeys of patients who end their calls prior to triage by the English National Health Service 111 telephone service: The EXPECT cohort study.
Exploring the journeys of patients who end their calls prior to triage by the English National Health Service 111 telephone service: The EXPECT cohort study.
Background
The English National Health Service (NHS) 111 telephone service aims to assist members of the public with urgent medical care needs. However, each year nearly 18% of the 20.6 million calls to 111 are ended prior to speaking to a health advisor. There are concerns that callers who are not triaged may not appropriately seek the correct level of care for their needs.
The aim of this study was to explore the patient journey for callers who contact 111 but end the call prior to speaking to a health advisor. The primary objective was to determine whether callers to NHS 111 who end the call prior to triage are delayed in attending an ED with a non-avoidable cause compared to those who are triaged by a 111 health advisor.
Methods
For this cohort study, we obtained a convenience sample of all 111 calls made by adult patients registered with a General Practitioner (GP) in the Bradford region of Yorkshire, UK, between the 1st January 2022 and 30th June 2023. Subsequent healthcare access in the following 72 hours following the first (index) call (whether triaged or not) was identified using the Connected Yorkshire research database, which provides linked healthcare data for approximately 1.4 million citizens across the region.
We conducted a time-to-event analysis comparing the two cohorts (those triaged by a NHS 111 health advisor vs callers who ended the call prior to triage). The 'event' was defined as an ED attendance within 72 hours for a non-avoidable cause.
We utilised Kaplan–Meier (KM) curves and log-rank tests to compare the time to first non-avoidable ED attendance between groups for each cohort. In addition, a Cox proportional hazards model was used to adjust for baseline characteristics. From this, we calculated the adjusted hazard ratio (aHR) of attending an ED with a non-avoidable cause.
Results
134,816 index calls to 111 (115,058 triaged calls and 19,758 non-triaged calls) were included in the study, of which 20,307 (17.6%) triaged callers and 1,293 (6.5%) non-triaged callers subsequently attended an ED. The median time to attend ED was 1 hour for triaged calls and 3 hours for non-triaged calls (p<0.0001 by log rank test). The aHR for triaged vs non-triaged calls was 1.41 (95%CI 1.35–1.49, p=0.0003).
Discussion and Conclusion
The time-to-event analysis found that callers to NHS111 who do not wait to be triaged, attend ED with a non-avoidable cause more slowly than those who are triaged. This suggests that triaging of patients with a serious health problem that would be considered non-avoidable at ED by NHS111, supports those patients to seek appropriate help more quickly. In turn, patients with such health conditions who abandon the call before triage, may delay seeking appropriate levels of healthcare. NHS 111 calls should be triaged promptly to ensure patients are directed to the appropriate level of care in a timely manner.
Funding statement
This abstract presents independent research by the NIHR Applied Research Collaboration Yorkshire and Humber (ARC YH). This work was supported by the National Institute for Health Research Applied Research Collaboration Yorkshire and Humber. The views expressed in this publication are those of the author(s) and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care.
Richard PILBERY (Sheffield, ), Jen LEWIS, Rebecca SIMPSON, Colin O'KEEFFE
00:00 - 00:00
#42352 - Exploring the reality of a pediatric emergency department: A retrospective analysis of workload, peak hours, waiting times, and length of stay.
Exploring the reality of a pediatric emergency department: A retrospective analysis of workload, peak hours, waiting times, and length of stay.
Background:
Optimal operation of Pediatric Emergency Departments (PED) is essential for ensuring high-quality care. To date, only a sparse number of reports have been published. Implementing data-driven interventions,sourced from large datasets, can enhance effectivity and effectiveness PEDs by facilitating a more optimal allocation of staff and material resources.
Methods:
A comprehensive analysis was conducted on anonymized electronic medical records from a tertiary-level 24/7 operating PED, that exclusively manages internal medical, neurological, and psychiatric cases. All cases were included between 01/01/2020 and 12/31/2023. Our analysis covered patient flow, waiting times, and length of stay in the PED, considering age groups, triage categories, days of the week, and four-hour intervals throughout each day. The data analysis was performed in the R programming language, then non-parametric tests were applied (Kruskal-Wallis, Chi-square, Fisher's exact, and Wilcoxon rank-sum test).
Results:
A total of 39,409 patient presentations were analyzed, demonstrating an overall increase in patient counts across all categories, particularly in triage category V [2020: 38.8%(n=2,338) vs. 2023: 48.8%(n=6,067); p<10x10-5). Median age was 3.21 years [IQR:40 days - 16 years]. Significant differences were observed between age groups (p<2.2x10-16), with the highest number of cases in the 1-3 year old age group (n=7,900), followed by the 3-6 year old age group (n=9,709), whilst newborns (0-28 days old) had the fewest presentations (n=1,331). No gender variation was observed across age groups. The prevalence of severe triage categories was found to be significantly lower [I:0.18% (n=72); II:3.59% (n=1,416); III:19.7% (n=7,768); V:28.501% (n=11,232); V:48.012% (n=18,921)].
No difference in admissions by day was seen overall. However, in certain years, e.g. 2022 and 2023, statistically more admissions are presented on weekends and Mondays (p=0.02 for both).
As it was expected, higher triage levels received faster attention (I:18 min [IQR:10-25]; II:17 min [11-26]; III:22 min [24-39]; IV:38 min [20-75]; V:51 min [22-109];p<0.001]).
Analyzing the week in 4-hour intervals, we identified significant (p<1x10-10) peaks with longer median waiting times. Specifically, 4-8 pm, Saturdays (66 min), Sundays (62 min), and Fridays (41 min) recorded the highest activity, compared to other days' median 34 minutes.
The length of stay varied significantly across the time periods observed, with a median of 87 to 135 minutes (p<0.001).The shortest time was observed in triage category II, with a median of 87 [IQR 57-159] minutes and the longest in categories IV and V, with medians of 131 [79-219] and 135 [77-218] minutes, respectively.
Discussion and Conclusion:
Our retrospective study uncovered significant insights. Despite acknowledging limitations (e.g: erroneous or missing information), we devised a robust data analysis approach for sustained use. Utilizing peak period identification, already adjustments were made in our human resource allocation. Encouragingly, our findings demonstrated consistent management of treatment and waiting times across triage categories amid rising workloads. Future investigations, particularly those focusing on diagnosis-specific analyses, are planned to enhance operational efficiency and ensure optimal patient outcomes in pediatric emergency care.
Trial registration: No trial registration was required for this retrospective analysis.
Funding: This study did not receive any specific funding.
Dániel SEIDL (Budapest, Hungary), Anna VÉGH, J. Attila SZABÓ, Péter KRIVÁCSY
00:00 - 00:00
#41439 - Exploring variation in Emergency Department Attendances and Acute Hospital Admissions for Ambulatory Care Sensitive Conditions: A Federated Data Analysis.
Exploring variation in Emergency Department Attendances and Acute Hospital Admissions for Ambulatory Care Sensitive Conditions: A Federated Data Analysis.
Background:
Emergency Department (ED) demand in England has risen consistently since 2003. In 2019 there were 25.6 million ED attendances, 20% more than in 2011. Emergency admissions also grew by 28% over the same time period to 6.5 million/year. Ambulatory care sensitive conditions (ACSCs) are conditions where effective management, treatment and interventions can prevent the need for hospital admission. The aim of this study was to identify potentially avoidable admissions focussing on ACSCs and to understand variation across the country in ED attendances and acute hospital admissions.
Methods:
Using a cross-sectional design and federated multi-regional approach, data were collected and analysed internally within seven different regions. ED and inpatient data were included for the period 01/11/2021-31/10/2022. ED data included adult (18+) unplanned first emergency care attendances at a type 1 ED. Inpatient data included adults (18+) who had a completed acute emergency admission. The outcomes were the proportion of attendances/admissions with an ACSC, proportion of attendances resulting in an admission, proportion of admissions with a length of stay less than two days. Each region produced pre-specified aggregate-level tables of patient demographics, attendance/admission characteristics and outcomes, by those who attended with an ACSC and those who did not. The lead site combined aggregate level data to produce overall summary statistics and to make comparisons between hospitals.
The study was classified as a service evaluation with patient level data accessed with the approval of local Research Ethics Committees and Caldicott Guardians.
Results:
The study population included data from 21 hospitals with 1,513,445 first time ED attendances (median: 73,125, range: 32,880-114,190) and 660,105 admissions (median: 30,425, range: 10,625-51,905).
Overall, 29.6% of ED attendances were for ACSCs, varying between hospitals (13.8%-54.2%). The most common diagnoses were ‘condition unspecified’ (25%) and low-risk chest pain (9.0%). 32.7% (range: 4.1%-54.2%) of attendances for an ACSC resulted in an admission to hospital compared to 23.2% (range: 6.7%-40.5%) of attendances for other conditions.
The overall percentage of admissions with ACSCs was 40.8%, varying between hospitals (27%-50.9%). The most common condition was low-risk chest pain (13.2%). 49.3% (range: 17.4%-72%) of admissions for an ACSC had a length of stay less than two days compared to 52.1% (range: 13.7%-72.8%) of admissions for other conditions.
Discussion & Conclusions:
The results suggest that there are a high proportion of patients attending ED and being admitted to hospital avoidably with ACSCs. There is also large variation by hospital in decisions to admit patients with ACSC. This may indicate a lack of alternatives to admission within trusts (e.g. access to Same Day Emergency Care, ambulatory care facilities), in the pre-hospital environment, and wider healthcare system (i.e. primary and community care). The study highlights that robust management of ACSCs (e.g. low risk chest pain) could be an important way to reduce demand for acute beds. This study has significance policy, service, and patient relevance as reducing hospital admissions is a key priority for government and NHS England. However, further study is needed to understand what is driving variation to identify ways of reducing potentially avoidable admissions.
This study was funded by Health Data Research UK.
Richard JACQUES (Sheffield, Afghanistan), Rebecca SIMPSON, Madina HASAN, Susan CROFT, Simone CROFT, Suzanne MASON
00:00 - 00:00
#41730 - Extensive facial subcutaneous emphysema: a case of iatrogenic tracheal rupture.
Extensive facial subcutaneous emphysema: a case of iatrogenic tracheal rupture.
Introduction
Tracheal rupture is a life-threatening complication that results from either a blunt or a penetrating trauma to the neck and chest. However, iatrogenic tracheal rupture is extremely rare and occurs with endotracheal intubation, bronchoscopy or oesophagectomy.
We describe the case of a patient with facial swelling following tracheal rupture.
Case Report
A 41-year-old female underwent an elective day-case laparoscopic cholecystectomy under general anaesthetic (GA) and was discharged 4 hours after an uneventful post-operative recovery.
Two hours post discharge, she presented to the emergency department (ED) with progressive submandibular and facial swelling, along with chest erythema.
Although haemodynamically stable, her facial swelling rapidly worsened without any airway compromise.
On initial investigations, a chest X-ray (CXR) showed a pneumoperitoneum associated with subcutaneous (SC) emphysema across the upper chest and neck. Subsequent imaging with a CT scan revealed a widespread thoracic SC emphysema extending to the orbits along with a significant pneumomediastinum and a 3.8cm posterior tracheal wall defect in keeping with a tracheal rupture.
The patient was urgently transferred to the regional cardiothoracic unit for further management.
Discussion
Tracheal rupture is a rare condition and carries a high morbidity and mortality. This condition is mostly seen in elderly women with a higher mortality rate in men.
Multiple risk factors contribute to tracheal rupture following endotracheal intubation, such as overinflation of the endotracheal tube cuff, sudden movement of the tube or direct tear by the tube itself.
Clinical manifestations include SC emphysema, pneumomediastinum, pneumothorax, respiratory distress, and haemoptysis. Generally, these signs are identifiable intra-operatively or in the immediate postoperative period but can be delayed for hours or even days.
Majority of cases will require surgical intervention. However, conservative management is an option reserved for short tracheal ruptures (less than 4cm) that are associated with minimal, non-progressive symptoms and for those occurring after non-thoracic procedures.
Conclusion
Tracheal rupture is a very rare presentation to the ED. Crucially, it is important to maintain a high index of clinical suspicion in the presence of a rapidly developing SC facial emphysema and recent GA surgery.
Mohamed ABUOBAIDA, Fahad ABDUL, Abdo SATTOUT (Liverpool, )
00:00 - 00:00
#41092 - External Validation of a Decision Rule for Rapid Electrocardiogram at Triage.
External Validation of a Decision Rule for Rapid Electrocardiogram at Triage.
External Validation of a Decision Rule for Rapid Electrocardiogram at Triage
Aim
To validate the Glickman rule and determine its sensitivity in picking up STEMI in our local population.
Background
Prompt diagnosis of ST Elevation Myocardial Infarction (STEMI) cases is essential, as early reperfusion therapy results in better outcomes. For this purpose, American Heart Association (AHA) guidelines recommend a rapid electrocardiogram (ECG) within 10 minutes of the patient’s arrival at the emergency department.
As a number of STEMI patients may present with symptoms other than chest pain, various decision rules have been derived to help select patients with possible symptoms of Acute Coronary Syndrome (ACS) for rapid ECG at triage. One such rule is the Glickman rule, which recommends triage ECG for age ≥ 30 with chest pain, age ≥ 50 with dyspnea, altered mental status, upper extremity pain, syncope or weakness, and age ≥ 80 with abdominal pain or nausea/vomiting. The aim of this study was to determine its performance in our local population.
Methodology
We carried out a retrospective review of STEMI cases in an acute care, tertiary hospital over a 10-month period. Submission was made to our Institutional Review Board, who determined that this study did not require ethical review as the data would be de-identified. The list of patients with a final diagnosis of STEMI (Acute Transmural Myocardial Infarction) from January to October 2023 was generated from the hospital database, and relevant data fields such as patient demographics and presenting complaints extracted. The Glickman rule was then applied to all the cases based on their age and symptoms.
Sensitivity of the Glickman rule for STEMI and the corresponding 95% confidence intervals (CIs) were calculated. We also calculated the sensitivity of a modified rule where the age cut-off for abdominal pain and nausea/vomiting was changed to 50, and compared the two using McNemar’s Exact Test.
Results
A total of 426 STEMI patients were treated at our centre during the study period, and after cases with incomplete data were excluded, 270 patients were included in the study analysis. The mean age was 61.0±14.6 years and 20.7% (56/270) were female patients. Chest pain was the most frequent complaint, occurring in 72.6% of visits.
The Glickman rule had an overall sensitivity of 90% (95% CI 85.8 to 93.4). By modifying the age for abdominal pain and nausea/vomiting to 50, an additional 13 cases were picked up, resulting in improved sensitivity of 94.8% (CI 91.5 to 97.1). The superior sensitivity of the modified rule was statistically significant (McNemar’s exact test P<0.001).
Conclusion
Our findings suggest that the Glickman rule has lower sensitivity in our Asian population than in previous validation studies, but modifying the age cut-off for abdominal pain and nausea/vomiting may improve its performance.
Applied for research grant under the Singhealth Emergency Medicine Academic Clinical Program (EMACP) - outcome still pending
Shieh Mei LAI (Singapore, Singapore), Abhay KANT, Ting Wen YEOW, Pravin THIRUCHELVAM, Xuan Han KOH, Yi Liang TEO, Qamarul Arifin MD MEKEH, Shu Woan LEE
00:00 - 00:00
#41653 - External validation of the HEART, HEAR- and HET-scores for prediction of major adverse cardiac events in adult patients with acute chest pain.
External validation of the HEART, HEAR- and HET-scores for prediction of major adverse cardiac events in adult patients with acute chest pain.
BACKGROUND: In the cohort of patients presenting to the emergency department with acute chest pain differentiating between those at high risk of Major Adverse Cardiac Event (MACE), and those who can safely be discharged, remains a challenge. The HEART- (history, ECG, age, risk factors, troponin) score, as well as several abridged versions (HEAR, HET) are commonly used for this purpose. As with many clinical risk scores, they might be useful, but often lack proper validation. We aimed to externally validate the HEART-, HEAR- and HET-scores in the setting of a high-volume tertiary care emergency department in a healthcare system without gatekeeping functions and thus a low-risk population. We further aimed to compare the prognostic performance (discrimination and calibration) of the scores to each other.
METHODS: Based on a-priori sample size calculations, we included adult patients presenting to the ED with acute chest pain. We assessed overall model performance, discrimination, and calibration of all scores, analysed reclassification from the HEART-score and performed decision curve analysis.
RESULTS: A total of 3,273 patients were included, 383 (12%) suffered MACE within 30 days. Classification differed significantly between scores (HEART: 810; 25% low risk; HET: 55; 2%; HEAR: 195; 6%), as did overall performance (AUC 0.85, 0.80, and 0.79, respectively; p<0.001). HEART-score misclassified 7/810 patients (0.9%; 95% CI 0.4-1.8%) with MACE as low-risk, HET 2/55 (3.6%, 0.9-13.8%), and HEAR 0/195, whereas 2087 (72%), 2837 (98%), and 2695 (93%) patients without MACE were erroneously not classified as low risk.
CONCLUSION: The abridged scores fell short of their results in derivation studies, identifying only very few low-risk patients, and showing inferior model performance compared to the original HEART-score. Instead of developing new scores, existing scores should be recalibrated to local population characteristics, as needed.
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Maximilian NIEDERER (Scheibbs, Austria), Karina TAPINOVA, Bernert LARISSA, Behringer WILHELM, Dominik ROTH
00:00 - 00:00
#41412 - Extracellular vesicles derived from human umbilical cord mesenchymal stem cells attenuate septic acute kidney injury by delivering miR-125a-5p and miR-125b-5p to inhibit inflammation and glycolysis.
Extracellular vesicles derived from human umbilical cord mesenchymal stem cells attenuate septic acute kidney injury by delivering miR-125a-5p and miR-125b-5p to inhibit inflammation and glycolysis.
Introduction: Sepsis is a fatal disease with high morbidity and mortality, and acute kidney injury is a common complication. Recent studies have shown that excessive inflammatory response is a key mechanism for sepsis-induced acute kidney injury (SAKI). Extracellular vesicles derived from human umbilical cord mesenchymal stem cells (hucMSC-sEV) have the capacity for intercellular signaling communication, making them a novel therapeutic strategy for various diseases. Our previous study found that hucMSC-sEV has a protective effect on ischemia reperfusion induced AKI. However, the use of hucMSC-sEV in SAKI has been rarely reported.
Objective: To investigate the protective effect of hucMSC-sEV against SAKI and its potential mechanism.
Methods: hucMSC were extracted for culture and identification, and hucMSC-sEV were collected and characterized. SAKI model was established by cecal ligation and puncture in vivo and HK-2 cells induced by LPS in vitro, and hucMSC-sEV was given. The weight change and survival rate of mice were counted daily. IVIS imaging systems assess the relationship between organ damage and sEV distribution. Serum levels of Scr, BUN, Cys-C and NGAL were measured to reflect renal function. The mRNA levels of Kim-1 and inflammatory markers (IL-1β, IL-6, TNF-a, MCP-1 and F4/80) were measured by qRT-PCR. HE and immunohistochemical/fluorescent staining were performed to assess tissue damage. RNA sequencing was used to explore the key effector molecules of SAKI. Analysis of protective molecules in sEV cargoes by exosome miRNA sequencing.
Results: We successfully isolated and characterized hucMSC-sEVs. hucMSC-sEV converge heavily on CLP-induced injury to the kidney, attenuate AKI by delivering miR-125a-5p and miR-125b-5p, miRNAs that are highly enriched in hucMSC-sEVs, and reduce mortality. miR-125a-5p and miR -125b-5p co-target to inhibit TNFR2 expression, which in turn inhibited the activation of NF-κB signaling pathway, reduced the level of inflammatory factors, and ameliorated kidney injury. Furthermore, hucMSC-sEV also significantly attenuated LPS-induced HK-2 cells injury in vitro. However, when miR-125a-5p and miR-125b-5p were knocked down in hucMSC, the protective effect of mucMSC-sEV against SAKI was reduced.
Conclusion: In SAKI, hucMSC-sEV may inhibit the inflammatory response and ameliorate renal injury by delivering miR-125a-5p and miR-125b-5p to co-regulate the TNFR2/NF-κB signaling pathway, thereby improving survival.
Feng CHEN (Beijing, China), Tang TAO-TAO, Chen ZHI-QING, Liu BI-CHENG, Wang ZHONG
00:00 - 00:00
#41701 - Extremely rare but lethal primary aorto-duodenal fistula.
Extremely rare but lethal primary aorto-duodenal fistula.
Brief clinical history
A 61-year-old man with a history of alcoholic drinks presented to the emergency department(ED) with hematemesis. He denied any analgesic use or other medical history. Laboratory study revealed a Hemoglobin of 5.2 g/dL. Under the suspicion of upper gastrointestinal bleeding (UGIB), he was treated with blood transfusion(BT), proton-pump inhibitors (PPIs), and transferred for panendoscopy.
Two hours later at the receiving ED, his blood pressure was 145/83 mmHg, with a pulse rate of 64 bpm. One hour later, the patient started profound hematemesis and became pulseless. Emergent cardio-pulmonary-cerebral resuscitation(CPCR) was started. After 15 minutes of CPCR, the patient regained a pulse.
Despite aggressive resuscitation, the patient was hemodynamically unstable and had CPCR twice at ED. Meanwhile, panendoscopy was performed, showing enormous bloody material in the stomach and the second portion of duodenum. Then computed tomography angiography (CTA) was performed, revealing irregular dilatation of the infra-renal abdominal aorta and active contrast extravasation into the third portion of duodenum, which is compatible with an aorto-duodenal fistula(ADF). The stomach and small bowel loops were filled with high-density content suggesting blood clots. (Fig 1,2)
The patient expired after CTA.
Misleading elements
Without known medical history or analgesic use, hematemesis combined with a history of alcoholic drinks is often caused by esophageal variceal(EV) bleeding.
Helpful details
The patient had a “herald GI bleeding” first, followed by massive bleeding six hours later. Endoscopy was done immediately, showing absence of EV or ulcer bleeding.
Differential and actual diagnosis
For UGIB, peptic ulcer disease accounts for 40% to 50% of the cases, followed by erosive esophagitis (11%), duodenitis (10%), Varices (5% to 30%), Mallory-Weiss (5% to 15%), and vascular malformations(5%).
The actual diagnosis of this case is primary ADF, which is extremely rare, with an annual incidence of 0.007 per million.
What is the educational and/or clinical relevance of the case(s)
Aortoenteric fistula (AEF) is extremely rare but lethal, and is classified into primary and secondary types. Primary AEFs are mostly associated with spontaneous rupture of an abdominal aortic aneurysm (AAA) into the GI tract, typically at the third portion of the duodenum; secondary AEFs are related to previous aortic prosthetic reconstruction and are 10 times more frequent than primary AEFs.
The diagnosis of AEF is difficult because of its nonspecific and subtle clinical presentation. Typical symptoms are characterized by “herald GI bleeding”, followed by massive exsanguination, which often occurs within the next six hours in one-third of cases.
The mortality of untreated AEF is nearly 100%. Prompt diagnosis and surgical repair could reduce the mortality to 18–63%.
Guidelines suggest that UGIB patients should first receive endoscopy within 12-24 hours. CT is indicated only when endoscopy shows negative findings and/or the patient is contraindicated for endoscopy. However, with AEF in mind, clinicians should determine whether concomitant AAA presents in UGIB patients (either by history taking or bedside sonography); if AAA exists, clinicians should raise the suspicion of AEF and prioritize CT for confirmation.
Hsu-Cheng HUANG (Taipei, Taiwan), Pei-Chen LIN, Yu-Chan CHIEN
00:00 - 00:00
#41688 - Eye – brain – heart syndrome case presented in our ED.
Eye – brain – heart syndrome case presented in our ED.
A 57-year-old woman was presented to our Emergency department ED for headache, dizziness and right eye floaters for 3 days. She is diabetic and hypertensive and had a kidney transplant with normal creatinine level since 10 years ago. The patient is seen and examined by an ophthalmologist. The examination was normal, and the fundus examination showed mild non-proliferative diabetic retinopathy. The brain CT done was unremarkable. The patient got admission for MRI . The MRI showed : Tiny bilateral temporo-occipital, occipitoparietal, high right frontal cortical and juxtacortical as well as left parietal white matter spots of diffusion restriction with T2/FLAIR bright signal suggestive of tiny acute/early subacute infarcts. Trop T was mild elevated at about 43 , the creatinine was normal, about 72. ECG , echo were unremarkable . The patient got anti-coagulant, antiplatelet , statin , the eye scotoma improved, then discharged . One month after she came with loss of vision in her right eye and black spots, she got a right central retinal arterial occlusion. The CT head done again. There were no new changes. Fundus examination showed Normal Disc, Superior branch retinal artery occlusion Embolus seen along the superior arcade Flat retina . Ultrasound Doppler carotid and ECHO were normal with no stenosis or thrombus. Patient got admission for anti-ischemic treatment, statin and neurology, ophthalmology and cardiology follow-up.
Eye – brain-heart syndrome is a syndrome presented by emergency finding [blurred of vision or scotoma ] , acute brain symptoms like dizziness or headache because of acute brain infarction and heart incident as chest pain or high trop t . We suggested examining and investigating the heart, brain and eye if we get signs of emergency finding for one or two of them.
Dr Islam ELROBAA (Al wakra, Qatar), Aftab MOHAMMAD UMAR, Eslam MOHAMED
00:00 - 00:00
#42214 - Factor influencing the severity of myelopathy in NO abuse in an Emergency Department : a single-center retrospective study.
Factor influencing the severity of myelopathy in NO abuse in an Emergency Department : a single-center retrospective study.
Introduction : In the 21st century, nitrous oxide (NO) recreational use has grown in the young population. Cases of neurological, thrombo-embolic and psychiatric complications cases increasingly described in the literature. Complication of NO abuse are explained by a disturbance of cobalamin metabolism with increase of homocysteine (HCY) and methylmalonic acid (MMA). The aim of the study is to describe patients admitted in an emergency department for NO abuse according to the severity of myelopathy and investigate its risk factors. We also study factors influencing IRM abnormalities.
Method : We realized a single-center retrospective observational study between October 2021 and October 2023. All adults for whom HCY or MMA measurement were performed, are included. Demographic variables, clinical symptoms, examination data, biological data, MRI and Nerve Conduction Study (NCS) results were collected. We use peripheral neuropathy disability (PND) score to determine severity of myelopathy : mild for score 0 to 2 and severe for score 3a to 4. Due to the retrospective nature of the study, local ethics committee or institutional review board approval was not necessary.
Results : 56 patients including 34 women (61%) aged 23 ± 5 years were enrolled. 43 patients (76.8%) presented a definite mild form and 13 (23.2%) a severe form. The median consumption of patients was 4305g of N2O per week IQR[1538, 13761] for 13 ±12.6 months. The main reason for emergency use was paresthesias in 72% of cases. Patients have paresthesia predominantly in the lower limbs, gait disturbance and a positive Romberg in more than 50% of cases. The progression of symptoms is longer in severe forms compared to mild forms (median respectively at 1 month [0.42,3.5] for 0.25 months [0.1]; p=0.026) . Serul vitamin B9 and B12 were normal regardless of severity.
Serum HCY and MMA were high, respectively 115 ±51 μmol/L (N<14 μmol/L) and 5 ±3 μmol/L (N<0.21 μmol/L) without significant difference depending on severity. The only risk factor for severe form in our study was female gender with an OR of 15.6, CI 95% [1.3, 188.3] (p=0.031). 30 patients underwent MRI, 14 of whom (46.7%) had a spinal cord lesion compatible with posterior cord syndrome without correlation to severity. 23 patients underwent NCS, 18 (78.3%) of whom had axonal lesions and 6 (26.1%) associated demyelinating lesions.
Conclusion: Our study does not highlight any biological or paraclinical element to predict the severity of myelopathy. Hospitalization is necessary for severe forms to consider early rehabilitation. All subjects with N2O abuse were B12 replete, suggesting a functional B12 deficiency as a cause for toxicity or self-medication. HCY and MMA are systematically increased and are therefore sensitive biomarkers while MRI and ENMG can remain normal. Studies are still necessary to determine the benefit of markers in the treatment and monitoring of patients.
Rémy DIESNIS (Roubaix), Anas BENNIS, Guillaume GRZYCH
00:00 - 00:00
#41802 - Factors affecting the poor prognosis of ischemic stroke patients with posterior circulation involvement who present to the Emergency Department.
Factors affecting the poor prognosis of ischemic stroke patients with posterior circulation involvement who present to the Emergency Department.
Introduction
Posterior circulation ischemic strokes (PCIS) account for 20% of all ischemic strokes. These strokes can be difficult to diagnose and manage in the emergency department (ED). The aim of our study is to analyze the demographics of PCIS patients and identify factors that increase morbidity.
Methods
A total of 606 PCIS patients who were admitted to the Emergency Department, Eskisehir Osmangazi University, Turkey between January 2019 and December 2022 were included. The demographics, symptoms, laboratory, risk factors, ED time management, NIHSS and imaging findings were collected from ED and hospital data-base, and factors affecting poor prognosis were further analyzed. Modified rankin score > 2 was considered as poor prognosis.
Results
A total of 391 (64.5%) of the cases were male. The median age of the cases was 69 [Q1-Q3:60-78] years. In 114 (18.8%) of the patients had AF. The most common complaints were speech disorder (58.3%), motor deficit (55.8%) and dizziness (55.7%). CTA results showed basilary artery occlusion in 80 (13.2%), PSA occlusion in 77 (12.7%), and VA occlusion in 67 (11.1%). In MRI findings, cerebellar infarction was detected in 177 (29.2%) and pontine infarction was detected in 164 (27.1%). IV rtPA treatment was applied to 79 (13%) of the cases and EVT was applied to 47 (7.8%). Good outcome at discharge was 48.2%, in-hospital mortality was 14.5%.
Conclusion
PD strokes, which have an important place among ischemic strokes; It requires special attention for ED physicians due to the diversity of clinical presentations compared to anterior circulation strokes, difficulties encountered in diagnosis, and differences in treatment strategies.
Irem AYDOGDU, Engin OZAKIN (Eskişehir, Turkey), Atilla Ozcan OZDEMIR, Ozlem AYKAC, Mustafa Emin CANAKCI, Nurdan ACAR, Filiz B KAYA, Evvah KARAKILIC
00:00 - 00:00
#41762 - Factors associated with 30-day mortality in patients with acute heart failure who visited the emergency department.
Factors associated with 30-day mortality in patients with acute heart failure who visited the emergency department.
Background: Acute heart failure is a common condition encountered in emergency departments, particularly with the advancement of medical technology leading to an increased average age of the population. However, despite improvements in medical care, there are still no clear criteria for making discharge or admission decisions for patients after emergency room management.
Objective: To identify factors associated with 30-day mortality in patients with acute heart failure who visited the emergency department.
Method: This study was a retrospective cohort study conducted in Maharaj Nakorn Chiang Mai Hospital from 2011 to 2018. All patients diagnosed with acute heart failure and presenting to the emergency department were divided into two groups: those who died within 30 days and those who survived beyond 30 days. Various factors obtained from medical history taking, physical examination, and laboratory investigation results were compared between the two groups. Cox’s proportional hazard was done and reported hazard ratio (HR)
Result: This study analyzed data from 1,951 patients diagnosed with acute heart failure. The overall 30-day mortality rate was 12.4%. Multivariable analysis identified 6 factors significantly associated with increased 30-day mortality: respiratory rate > 30/min; HR = 1.61 (1.03-2.53), systolic blood pressure < 90 mmHg; HR = 2.25 (1.13-4.45), creatinine levels > 2 mg/dL; HR = 1.61 (1.08-2.39), serum sodium levels < 135 mEq/L; HR = 1.70 (1.24-2.34), potassium levels > 5.0 mEq/L; HR = 1.59 (1.02-2.49), and the use of inotropic drugs; HR = 2.89 (1.50-5.56). Dyslipidemia was found to reduce the 30-day mortality rate; HR = 0.54 (0.36-0.81), indicating a protective effect (maybe from the statin effect).
Conclusion: This study concludes that in patients presenting with acute heart failure in the emergency department, several factors should be considered for hospital admission, including elevated respiratory rate, low systolic blood pressure, high creatinine, low sodium, high potassium levels, and the use of inotropic drugs, all of which are associated with increased 30-day mortality rates.
The study was approved by the Research Ethics Committee, Faculty of Medicine, Chiang Mai University (STUDY CODE: EME-2564-08511).
This research was funded by the Faculty of Medicine, Chiang Mai University Hospital.
Chanon CHANGRATANAKORN (Chiang Mai, Thailand)
00:00 - 00:00
#41418 - Factors causing emergency medical care overload during heatwaves: A Delphi Study.
Factors causing emergency medical care overload during heatwaves: A Delphi Study.
Background: Climate change and global warming are increasing disasters triggered by natural hazards. Among these, heatwaves pose a critical risk to population health and are associated with a higher demand for emergency care. Unfortunately, this topic has been scarcely studied in emergency medicine, only with retrospective studies. In the era of emergency medical care crisis and ED overcrowding, this study aimed to find the factors causing an overload of emergency care during heatwaves, pursuing the United Nations’ Sustainable Development Goal No. 13th: Climate Action.
Methods: This study was an expert opinion study based on the Delphi methodology, modified to be delivered and conducted online. After local ethics committee approval (No. 160 – 18/02/2022), experts in emergency medicine, disaster medicine, or public health were recruited. Authors of literature on heatwaves and overload of healthcare or emergency medical care systems, retrieved through recent reviews, were contacted via email. A last recruitment round was held during the EUSEM congress in October 2022 to ensure sufficient experts to conclude the study after possible dropouts. Anonymity among panel members was ensured throughout the study, with only two researchers having access to personal details. The first round posed one open-ended question: “What are the factors causing emergency medical care overload during heatwaves?”. After content analysis, the obtained statements were sent to the experts in two rounds to be rated on a 7-point linear scale. Consensus was defined as a standard deviation ≤ 1.0.
Results: Fifteen experts participated, mainly with a combined emergency medicine/disaster medicine background (n=10) and from high-income countries. Thirty-one statements were obtained after content analysis of the 79 provided answers. The experts agreed on 18 statements after two rounds, with a response rate of 100%. The majority of the statements achieving consensus, and the only three statements with a mean score > 6 (Important), focused on the input part of patient processing, indicating a proactive approach to prevent the surge rather than solely expanding the capacity of an emergency system. For instance, solutions to enhance stakeholder and policymaker awareness, community information campaigns, and strengthening primary care (by identifying fragile population strata, preventing the activation of chronic conditions, and implementing telemedicine) were deemed crucial. The experts also advocated for implementing staff and stuff, adapting structures, providing dedicated training, and expanding hospital bed capacity to better prepare for a forecasted heatwave and improve patient throughput and output.
Discussion and conclusions: The 18 statements derived from this Delphi study provide the first evidence for targeted and systematic interventions to alleviate emergency care strain during heatwaves. Most experts came from high-income countries, mirroring the need for published research on the health impact of heatwaves from developing countries, thus limiting the generalizability of the results. Anyway, these findings identified significant gaps and have the potential to inform and improve heat-health action plans. They should also be prospectively tested in emergency departments and prehospital emergency medicine to fill current gaps in the literature.
No registration needed; no funding to disclose
Matteo PAGANINI (Padova, Italy), Hamdi LAMINE, Francesco DELLA CORTE, Ives HUBLOUE, Luca RAGAZZONI, Francesco BARONE-ADESI
00:00 - 00:00
#41995 - Family Witnessed Resuscitation Survey.
Family Witnessed Resuscitation Survey.
Family presence during resuscitation is a crucial topic that is regularly covered in the literature for both adult and pediatric populations. There is a lack of clear evidence-based ways for implementing this technique. If it is decided that it is safe, low-level evidence recommendations favor having a medical professional assist the family member. Including the family in the process could help them feel as though the necessary steps have been taken and that their grieving process is healthier as a result
Aim
To explore experiences of cardiac arrest in-hospital and the impact on life for the patient who suffered the arrest and the family member who witnessed the resuscitation.
Background
Guidelines advocate that the family should be offered the option to be present during resuscitation, but little is known about family-witnessed cardiopulmonary resuscitation in hospital and the impact on the patient and their family.
Design
A qualitative design consisting of joint in-depth interviews with patients and family members.
Methods
This prospective cross-sectional survey study was approved on May 24, 2023, by the Ankara Bilkent City Hospital No. 1 Ethics Committee, and it was carried out over a period of three months. The poll was carried out in a busy hour, such as after work, in a conveniently placed shopping mall in Ankara. Random selection was used to choose people who were exiting the shopping center's escalators, and in-person surveys were conducted. The topics assessed in the survey include demographic information about age, gender, education level, first aid training, and propensity to see resuscitation.
In our survey,average age was 34.8±12.5, 61.1% male, 56.0% university graduate total 1305 samples were included in the study.(Table 1)
Family members' presence during CPR is a complicated matter that presents a wide range of viewpoints regarding the nature and morality of medical intervention. This study is significant because it sheds light on the general opinions and degree of knowledge held by society about the topic, which can serve as a useful foundation for decisions made in this area.
Taking into account the suggestions from earlier research, we believe it is important to stress that this application can be chosen in certain patient or patient relative profiles and that information and support staff are required.
Cagrı AY, Kadir YENAL (Yenimahalle, Turkey), Alp SENER
00:00 - 00:00
#42137 - Fast Diagnosis of Deep Vein Thrombosis in the Emergency Department: Point-of-Care Ultrasound.
Fast Diagnosis of Deep Vein Thrombosis in the Emergency Department: Point-of-Care Ultrasound.
Deep vein thrombosis (DVT) is a significant medical condition requiring prompt diagnosis to prevent serious complications. This case report presents a 60-year-old female patient with a recent bladder cancer diagnosis, scheduled for surgery, who presented to the emergency department with left lower limb swelling for three days, without accompanying pain or dyspnea.
Utilizing point-of-care ultrasound (POCUS) in the ED, the two-point compression technique was employed to diagnose DVT. By assessing the common femoral vein and popliteal vein for compressibility, thrombosis was identified. Doppler imaging was used to evaluate blood flow. The two-point compression technique demonstrated a sensitivity of 91% and specificity of 98% for DVT diagnosis.
While false negatives can occur in certain cases, such as partial compression of small non-occlusive DVTs, the two-point compression technique remains a valuable initial diagnostic tool. In cases with high clinical suspicion and inconclusive results, additional imaging modalities, such as venography or magnetic resonance imaging (MRI), may be considered.
This case underscores the effectiveness of POCUS in rapidly diagnosing DVT in the ED.
By promptly identifying DVT through the two-point compression technique, healthcare providers can initiate appropriate interventions and prevent potential complications.
Lam IAN-SENG (Macao, China), Leong HOI-IP
00:00 - 00:00
#41025 - Fatal Superwarfarin Poisoning.
Fatal Superwarfarin Poisoning.
A 41-year-old lady with history of depression was brought to the emergency department for suicide attempt. She was not forthcoming but ultimately admitted to have ingested multiple sachets of rodenticide bought from an online store on 2 occasions- 10 days and 4 days ago. On arrival, patient was alert with GCS 15, with no obvious toxidrome. Patient denied any bleeding diathesis apart from easy bruising although her INR was >10 and PT >180s. She was treated with IV Vitamin K 10mg stat and admitted. It was later found out that the rodenticide contained Brodifacoum (BDF) through translation of the ingredient. She was treated with IV Vitamin K 10mg OM for 3 weeks with normalisation of PT/ INR when patient decided to discharge against medical advice. She defaulted all her hematology clinic follow up and oral vitamin K.
3 weeks after the discharge, patient was brought to the emergency department in pulseless electrical activity cardiac arrest. She had been feeling unwell 3 days prior with per vaginal (PV) bleeding, giddiness and multiple falls with head injury. Her venous blood gas point-of-care-test showed severe metabolic acidosis with pH 6.5, HCO3- <3mmol/L, pCO2 35mmHg, K 5.8mmol/L and undetectable Hb level. There were multiple large ecchymoses throughout her body with PV bleeding. She was resuscitated as per ACLS protocol along with blood transfusion. Bedside ultrasound was negative for pericardial effusion or intraperitoneal free fluid. Lab results came back later showed Hb 4, PT>180s, aPTT>180s, INR>10, acute kidney injury and transaminitis. Patient unfortunately demised despite resuscitation efforts.
Brodifacoum, also known as superwarfarin, is a 4-hydroxycoumarin anticoagulant which is 100x more potent and has significantly longer half life of 16-62 days compared to warfarin. It inhibits Vitamin K epoxide reductase, resulting in reduced level of active Vitamin K required for the production of coagulation factors II, VII, IX, and X. This leads to uncontrolled bleeding and ultimately death due to internal hemorrhage, although case series by Yu et al reported zero mortality. Treatment for BDF is aimed at replacing Vitamin K and fresh frozen plasma until INR normalizes to reduce bleeding.
Emergency physicians should be cognizant about the use of BDF as an active ingredient in rodenticide and its mechanism of action and unique pharmacokinetics requiring prolonged treatment. Early identification and treatment is potentially life saving for the patient after BDF poisoning.
Daniel Weei Jang TAN (SINGAPORE, Singapore)
00:00 - 00:00
#41540 - Features and 30-day outcomes of patients under 40 years of age visiting the Emergency Department with acute chest pain: a monocentric cohort study.
Features and 30-day outcomes of patients under 40 years of age visiting the Emergency Department with acute chest pain: a monocentric cohort study.
Background: Acute chest pain is a frequent complaint in the Emergency Departments (ED), affecting 14% of patients under 40 years of age. The aim of this study was to investigate the features, care pathways and 30-day outcomes of patients under 40 years of age visiting the ED with acute chest pain.
Methods: This retrospective study was conducted between August 6th, 2022, and March 16th, 2023, at the Rouen University Hospital (academic tertiary hospital), and included all consecutive patients aged from 18 to 40 who visited the ED for acute non-traumatic chest pain. Demographic data, tests performed, diagnoses and referrals were collected. Patients were phone called 30-day after their ED admission to find out whether they had visited an ED for the same complaint (primary outcome), outpatient examinations, outpatient consultation and new diagnosis made (secondary outcomes). After describing the population, a comparative analysis was performed stratified by the presence or absence of a new visit within 30 days of follow-up.
Results: Of 1,041 patients initially screened, 847 met the inclusion criteria and 504 (59.5%) had an available 30-day follow-up and were included. Among them, 230 (45.6%) were male and 119 (38.4%) were active smokers. Among the tests performed, 451 (96.8%) patients had an electrocardiogram, 364 (72.2%) a chest X-ray and 411 (81.7%) a blood test, that were interpreted as normal by physicians in 87.7%, 92.3% and 81.7% of cases, respectively. At discharge, 238 patients (47.2%) had no established diagnosis. There was no difference in the 30-day follow-up for patients without any diagnosis compared with patients with an established diagnosis, except for the number of new diagnoses made after the discharge (10.5% in the group with a diagnosis vs. 60.9% in the group without any diagnosis, p<0.001). At 30-days, 36 patients (7.2%) had a new visit to the ED, with no difference in demographics or in the number of tests performed in the ED compared with those who did not have a new visit in an ED. The recurrence of chest pain was associated with a new visit within 30 days (OR 10.1 IC95% 2.39-42.54).
Discussion & Conclusions: Although many tests were performed on patients under 40 years of age visiting the ED with acute chest pain, only few patients had a new visit in the ED one month after their initial visit, and almost half of them were discharged without any established diagnosis. A recurrence of chest pain makes 10 times more likely a new visit in an ED.
Trial Registration: This study was registered in the local institutional review board (CERDE n°E2022-47).
Funding: This study did not receive any specific funding.
Ethical approval and informed consent: The non-interventional research ethics committee at Charles Nicolle Rouen University Hospital approved the study without the need for informed consent signed by the patients included.
Alix DELAMARE FAUVEL (Rouen), Bastien GUERNION, Mélanie ROUSSEL, Cedric DAMM, Luc-Marie JOLY
00:00 - 00:00
#41548 - Federated data collection and analysis approach for routinely collected hospital data.
Federated data collection and analysis approach for routinely collected hospital data.
Background
There is currently a lack of access to routinely collected data on emergency department attendances and hospital admissions in near real time. This is due to lags in reporting data to central registries and the time to get approval to access data. The aim of this work was to fill this data gap and to test and critique a federated data collection and analysis approach to routine NHS data across multiple regions. This addresses an important policy-related question. Filling this gap would be beneficial for future healthcare system threats.
Methods
Two test projects were used to pilot the federated data collection and analysis methods; one project which was led by the University of Sheffield focused on patients attending Emergency Departments (ED) with Ambulatory Care Sensitive Conditions (ACSC). There were eight regions that were involved in both projects which were invited to provide data.
The lead site developed a data processing document, an analysis plan and analysis tables which were shared with the 7 remaining regions. The data processing document contained details on what datasets were required (Emergency Care Data Set (ECDS) and Admitted Patient Care (APC)) and what variables would need to be extracted from those datasets. It also contained information on how the variables should be categorised using SNOMED codes, APC codes and ICD10 codes. This enabled other sites to extract the correct data and have all the data mapped and harmonised consistently across all regions. The analysis plan contained descriptions on how to filter the data to identify the correct population and the types of analyses which would be used. The analysis tables document included all the output the regions were to produce.
Each region applied for access to their data through their own research governance processes. Each region followed the data processing document and analysis plan and sent aggregate data tables to the lead site. The lead site could then collate the results and produce overall results.
Results
Following a development period of 6 months, two separate data sets, one for ED attendance and one for hospital admissions data were successfully extracted, harmonised and analysed for seven regional centres covering 12 hospital trusts, 22 EDs and 23 acute hospitals for the period 01/11/2021 to 31/10/2022. Two projects were able to use the data produced from this method, the original ACSC project (led by Dr Richard Jacques) and an additional winter pressures project (led by Dr Jen Lewis).
Discussions & Conclusion
This approach was successful in aggregating real world hospital data for analysis. However, there were several challenges faced with this data collection approach, including complex local ethics and information governance processes, time delays meant the 3-month estimated turnaround was not feasible and having no control over data extraction and analysis from external regions. These challenges will be described in detail in the presentation alongside recommendations for the future.
Ethics
It was classified as a service evaluation with patient level data accessed with the approval of local Research Ethics Committees and Caldicott Guardians.
The study was funded by Health Data Research UK.
Rebecca SIMPSON (Sheffield, ), Richard JACQUES, Jen LEWIS, Madina HASAN, Richard CAMPBELL, Susan CROFT, Simone CROFT, Ross MCMURRAY, Suzanne MASON, Hrduk REGIONAL LINKED DATA CONSORTIUM
00:00 - 00:00
#41658 - First 72 hour diffuculties after the Kahramanmaras Earthquake in Turkey.
First 72 hour diffuculties after the Kahramanmaras Earthquake in Turkey.
The two major earthquakes that occurred in Kahramanmaraş on February 6, 2023 and affected 11 provinces were one of the most devastating disasters experienced by the Republic of Türkiye. The first 72 hours of the eathquake were of critical importance for saving lives, search and rescue efforts and meeting the basic needs of the survivors. Many difficulties were experienced during this process, and these difficulties caused the loss of life to increase and the grievances to grow.
Major Challenges:
• Lack of Coordination: During the first hours of the earthquake, there was a lack of coordination in triage, first aid, search and rescue efforts and aid distribution. The flow of information between different institutions and non-governmental organizations was inadequate, leading to delays, chaos and anger.
• Transportation Problems: Roads and infrastructure were damaged in many regions affected by the earthquake. This situation made it difficult for search and rescue teams and aid trucks to reach the area.
• Communication Disruption: After the earthquake, there were power and internet outages in many regions. This situation prevented earthquake victims from communicating with their families and relatives and made coordination difficult.
• Inadequate Shelter and Hygiene: Millions of people who survived the earthquake faced the need for shelter. Although tent cities and container cities were established, the capacity of these areas was insufficient and many people had to shelter in difficult conditions. There were also serious problems in ensuring hygiene conditions.
• Inadequate Aid: In the first days of the earthquake, it was very difficult to access food, water, medicine and other basic needs. There were delays in aid distribution and many earthquake victims were unable to meet their needs.
• Winter Time: The fact that the earthquake occurred in the winter season made search and rescue efforts and the living conditions of the survivors even more difficult. Freezing temperatures caused delays in transportation to the region and aid distribution.
Promising Efforts Despite Challenges:
Despite all these difficulties, search and rescue teams, non-governmental organizations and volunteers worked with great devotion in the first 72 hours of the earthquake and saved many lives. State institutions also accelerated aid distribution by ensuring coordination over time. Food, water, medicine, blankets, heaters, tents for shelter and other basic needs were delivered to earthquake victims.
Conclusion:
The February 6, 2023 Kahramanmaraş Earthquake was one of the most devastating disasters in the history of the Republic of Turkey.expand_more The first 72 hours of the disaster passed with many difficulties such as lack of coordination, transportation problems, communication breakdown, inadequate shelter and hygiene, insufficient aid and the winter season. Despite these difficulties, search and rescue teams, non-governmental organizations, volunteers and government institutions worked with great devotion, saving many lives and providing aid to earthquake victims. The lessons learned after this earthquake can serve for future disaster preparedness.
Busranur BERRAK, Ulkumen RODOPLU (Izmir, Turkey)
00:00 - 00:00
#40832 - First aid and basic life support training in wilderness.
First aid and basic life support training in wilderness.
Introduction: French Guiana is a territory of South America covered by 90% of tropical forest. Despite regular first aid standards training, some of the problems encountered by workers in isolated areas remain untrained and unsolved. We present here the knowledge assessment of this workers concerning first aid and a new training program meeting their needs.
Methods: 32 workers working in remote areas attended a one-day training. The program covered infectious diseases, wildlife envenomations, first aid and basic life support specialized in wilderness. Questionnaires assessing learners' knowledge and their satisfaction were deployed.
Results: The learners were 78% (n=25) male and of intermediate age (26-55 years). The most common profession was forester (n=17, 53%). Professionals had been working in remote areas for 12 (4;19) years. 91% had already received first aid training. The main vital emergencies weren’t well known: 6 (19%) knew how to recognize a cardiac arrest, 23 (72%) performed maneuvers not recommended in cases of upper airways partial obstruction, 7 (22%) recognized symptoms of severe anaphylaxis. The training met the expectations (100%). However, 24 (92%) would like further training, and 25 (96%) requested regular renewal.
Conclusion: This training was the first step towards the creation of a specialized training of first aid in wilderness. This work supports the need to reinforce training for non-medical personnel, by integrating the specificities of a region. This experience permitted the rise of a working group which will shortly propose a medical kit and first aid protocols for workers in isolated areas.
None
Alexis FREMERY (Cayenne, French Guyana), Rémi MUTRICY, Florian NEGRELLO, Jean PUJO, Thomas LABROUSSE, Loïc EPELBOIN
00:00 - 00:00
#41661 - First aid training for the visualy impaired people.
First aid training for the visualy impaired people.
First-aid training for the visualy impaired people is Turkish Emergency Medicine Association for ALL (TEMA) Project, that is planned for the whole Country of Turkiye.
The goal of this Project is to teach first-aid for visually impaired people.
It is important for visually impaired people to be informed about situations where they may encounter emergencies and save the lives of others or themselves. First aid training teaches visually impaired people how to react in emergency situations.
The following features were taken into account when planning first aid training for the visually impaired:
One of the most important characteristics of visually impaired people is that they have strong touch, hearing and senses.
1. Instructions and techniques used in training were conveyed by explaining and demonstrating aloud.
2. Educational materials were all easy to understand and recognise by touch. First aid supplies were introduced by touch.
3. The educational area was accessible. It is important to provide a safe environment.
4. Learned topics were repeated and reinforced with practical exercises.
5. Cooperation and support was provided in education according to the needs of the visually impaired.
6. Participants were given confidence. Their achievements were highlighted and supported.
TEMA organised 8 training Course in less than a year, for 29 Visualy Impaired People (VIP)
During these Courses the following subjects were taught:
1. How to react in emergency situations.
2. Basic first aid skills such as stopping bleeding, first aid for burns how to intervene in cases of fracture.
3. CPR.
5. Poisoning.
6. Anaphylaxis.
7. Sunstroke.
8. Natural Disasters: How to stay safe and how to help in natural disasters such as earthquakes, floods and wild fires.
TEMA has started first aid training courses for the VIP after one year of research. It was clear during this research that only a few Organisation could succeed to make it an ongoing training.
First aid training planned for the visually impaired may not be sustainable because:
i) Specialized educational materials and application tools may be required and it may be difficult to provide these resources continuously.
ii) Instructors may need to be trained in methods suitable for the visually impaired and this training may need to be constantly updated.
iii) It is important that trainings are accessible for the visually impaired, and this should be constantly ensured.
iv) Customized training and materials can be costly and require ongoing funding.
v) The continued participation and interest of visually impaired people in training should be ensured, which may face certain challenges.
As conclusion, in order to organise sustainable first-aid training courses for the visualy impaired people, the challenges require sustained effort and resources. As TEMA, we decided to train visualy impaired volunteers as first aid instructors.
Ulkumen RODOPLU (Izmir, Turkey), Nick DORALP, Busranur BERRAK
00:00 - 00:00
#42283 - Flight to Recovery: Impact of a rooftop Helipad Air Ambulance service at the Emergency University Hospital of Bucharest-A Caseload analysis of the first 3 years after its implementation.
Flight to Recovery: Impact of a rooftop Helipad Air Ambulance service at the Emergency University Hospital of Bucharest-A Caseload analysis of the first 3 years after its implementation.
Background:
The helipad, established in April 2019, is the only rooftop medical helipad in Bucharest authorised for day and night flights. By significantly reducing transportation time and facilitating timely medical assistance, the helipad has enhanced patient care and treatment outcomes. Its influence extends beyond the local region, enabling the hospital to receive patients from various cities across Romania.The helipad has particularly strengthened the hospital’s capabilities in cardiology, neurovascular emergencies, and neonatal care. Patients with acute myocardial infarctions or strokes can now be swiftly transported to the hospital for immediate intervention, while critically ill newborns can receive specialised care at the earliest stages of their lives. This paper aims to provide a comprehensive historical timeline of the helipad's implementation and demonstrate its transformative role in improving patient transportation, enhancing medical interventions, and elevating the overall efficiency of the healthcare facility.
Method:
The study is a retrospective regional, population-based caseload analysis based on data gathered from the Emergency Department of the University Emergency Hospital of Bucharest database. We included all air-transfer missions registered between December 2019, till December 2022, exactly 3 years apart at the beginning of the program.
Results:
The data revealed that the mean age of patients treated at the hospital was 55.9 years, with a higher representation of males (156) than females (59). The average
duration of hospitalisation was 10.68 days. The study also examined transportation statistics, showing a decrease in the average number of transports per month over the years. Cardiological cases accounted for the highest frequency (62.8%) among the analysed categories, followed by neurosurgery (8.8%) and neurological cases (8.4%).
The findings provide valuable insights into patient demographics, case distribution, and trends, highlighting the importance of specialised medical interventions at the Bucharest Emergency University Hospital.
Conclusion:
The analysis provides important insights into patient demographics, case distribution, and trends. The findings highlight the significance of specialised medical interventions, particularly in cardiology and neurosurgery, which accounted for a substantial portion of the cases. The implementation of the helipad has greatly improved patient transportation, reducing travel time and facilitating timely medical assistance.
The study was not registred because there was no appropriate register.
This study did not receive any specific funding.
The study was approved by the Ethics Council of the Bucharest Emergency University Hospital.
Dimitrios KONIARIS, Constantin SUCIU (Bucharest, Romania), Silvia NICA
00:00 - 00:00
#42331 - Floor of mouth hemorrhage following guided bone regeneration (GBR) and dental implants placement in the atrophic interforaminal mandible: a report of two cases.
Floor of mouth hemorrhage following guided bone regeneration (GBR) and dental implants placement in the atrophic interforaminal mandible: a report of two cases.
The authors present two cases of mouth floor hemorrhage consequences of implant placement and GBR technique within the atrophic anterior mandible In this well vascularized area the vessels run very close to the bone and can be injured during surgical maneuvers. In both patients the hematoma rapidly spread in the loose tissues of the mouth floor, displacing the tongue posteriorly and cranially, with airway compromise. Hemorrhage control required hospitalization and intubation to maintain the airway. Literature reports the main cause of bleeding as an injury of sublingual artery or less frequently submental artery, due to the lingual cortical plate perforation during bone drilling.
In the first patient presented this surgical error was observed on CT although in the second case no signs of inner cortical perforation was noted: a different cause of bleeding was identified and firstly, the mouth floor hemorrhage caused by an injury of a vestibular soft tissue artery during GBR surgery is reported.
The ascending mental artery was injured during periosteal release incision and hematoma spread in the mouth floor through the similar incision done on the lingual flap.
Strategies to avoiding them and recommendations for complications managing are provided, based on the literature review and the author's experience.
Domenico SFONDRINI, Dr Stefano MARELLI (PAVIA, Italy), Rachele PATRIARCA, Giorgio NOVELLI, Alessandro BARDAZZI, Abdelouahab BELLOU, Boudi ZOUBIR, Dr Gabriele SAVIOLI
00:00 - 00:00
#42266 - Focal cellulitis in a context of Cocaïne sniffing mimicking resistant face allergic oedema.
Focal cellulitis in a context of Cocaïne sniffing mimicking resistant face allergic oedema.
Introduction
Localized face oedema is widespread clinical feature and has multiple etiologies which could be allergic, septic or systemic diseases. Clinical diagnosis making in such situations remains a challenge and must be organized . Emergency physician must be aware furthermore by the emergence of some new clinical situations correlated to new habits such as addictive substances use. Cocaïn sniffing is rapidly evolving in European young population with unconfessed use and can expose to misidagnosed urgent presentations needing rapid specific management.
Case report
We report the case of a young female patient aged 34 years with no medical history who presented to the emergency department addressed for management of resistant ongoing localized allergic face oedema. Symptoms were described persisting despite use of corticoids and antihistaminic agents a fewer days ago with repeated visits to other emergency wards. On admission, patient was conscious, afebrile. Physical examination noticed a localized erythema of the nose with bilateral swallowing of palpebral regions. On biological markers we objective CRP elevation with hyperleukocytosis. First therapeutic attitude was to initiate salbutamol nebulization and oral corticoid continuing. Rapid evolution was marked by fever reaching 39°C. Computed tomography Imaging showed face cellulitis with nasal epicenter, nasal septum cartilage necrosis with bilateral palpebral extension and maxillary sinusitis. Intra venous antibiotics with large spectrum was initiated. Further screening of medical history and patient’s finally objectives cocaine sniffing habits. Patient was referred to a specialized Ortho rhino pharyngeal surgical ward for further management.
Discussion and conclusion
Cocaine Induced Midline Destructive Lesions (CIMDL) are destructive lesions involving due to cocaine consuming by sniffing. Positive diagnosis remains a challenge in the emergency department especially when cocaine use is unconfessed by the patient. Real incidence is unknown but is meant to evolve with the wide spread of sniffing addictive substances use. Even if the clinical presentation may be not specific diagnosis must be suspected when clinical features associate cellulitis central face oedema with necrotic lesions in the context of sniffing habits.
Rym HAMED (Tunisie), Houda NASRI, Imen MEKKI, Khaoula RAMMEH, Adel WALHA, Marion GUERRIER, Akim SADDAR
00:00 - 00:00
#41103 - Foley Uropathy: A Rare Obstructive Complication of Foley Catheter.
Foley Uropathy: A Rare Obstructive Complication of Foley Catheter.
A 69-year-old man with a history of putaminal hemorrhage was admitted to the emergency department with a high fever for two hours. The patient had undergone craniectomy and hematoma evacuation and had impaired cognition, left hemiplegia, and facial palsy. He lived in a nursing home and depended on a Foley catheter for better quality of life. Although he denied any discomfort, his vital signs showed high temperature (40℃), rapid heart rate (160 beats per minute), and increased respiratory rate (22 breaths per minute). The nursing home staff reported that he had no upper respiratory tract symptoms, vomiting, complaints of chest or abdominal pain, hematuria, or diarrhea. However, the facial expression seemed more asymmetric than usual. Physical examinations showed clear breath sounds and a soft abdomen without tenderness. The urine in the Foley catheter was mildly turbid. The patient was too weak to receive a thorough neurologic examination.
The patient was suspected to have a new cerebrovascular event, CNS infection, or other sites of infection resulting in decreased cerebral perfusion. Blood tests, fluid resuscitation, and a whole-body CT scan were arranged. Blood-brain barrier penetrating antibiotics were given as soon as possible. Non-sustained ventricular tachycardia developed and was treated with Amiodarone. After a shared decision-making process with the family, the patient underwent procedural sedation for the CT scan due to agitation, and the cerebrospinal fluid exam was denied due to comfort considerations.
Laboratory values demonstrated leukocytosis (15 x 109 /L), elevated C-reactive protein (10.6 mg/dL), and impaired renal function (Creatinine: 1.6 mg/dL). Urine analysis revealed pyuria. Brain CT showed no evidence of intracranial hemorrhage or abscess formation other than old insults; abdominal CT revealed right hydronephrosis and, surprisingly, the Foley catheter tip obstructing the right ureteric orifice. The catheter was replaced immediately and checked with an ultrasound. The patient soon stabilized afterward. Finally, the blood and urine cultures yielded E. coli with the same susceptibilities.
This case demonstrated a rare complication of Foley catheters, which obstructed the ureteric orifice with the catheter tip and caused obstructive uropathy and sepsis. In 2022, Qin KR et al. reported that a catheter balloon obstructed bilateral ureteric orifices in a post-TURP patient. The same year, Al-Zubi M et al. reported a case of unintended Foley catheter placement into the ureter. However, there was no history of recent exchange or manipulation of the Foley catheter in our case. Thus, we suggest considering catheter-related complications in patients with Foley catheters developing rapidly progressing urinary tract infections, even without a history of catheter exchange. Proper image studies should be used to rule out any form of obstructive uropathy.
Chung-Shiung WEN (Taipei, Taiwan), Chen WEI-LUN, Hung TZU-YAO
00:00 - 00:00
#41149 - Following the trail of Calcium in the Emergency Department.
Following the trail of Calcium in the Emergency Department.
No drug allergies. No HTN, no DM, no dyslipidemia. Colon cancer treated with right hemicolectomy and chemotherapy in 2005. L4-L5 lumbar canal stenosis, refused surgery. Generalized osteoarthritis. Myofascial syndrome and right low back pain.
75-year-old woman who comes to the emergency room due to general deterioration. A month ago he began with pain in the right inguinal region, which has limited his life, preventing him from walking. Previously independent, he currently requires a walker to walk and help with grooming and dressing. It associates unquantified weight loss in the last month with significant anorexia and asthenia. He reports nausea and vomiting for 3 days and a tendency toward constipation. He also reports generalized pain. Repeated visits to the emergency department for right inguinal pain in the last month.
At phisical exams BP: 121/73, HR: 89, Sat O2: 96%, Tª: 36.3º bilateral cervical lymphadenopathy with inflammatory characteristics, no supraclavicular lymphadenopathy. non-painful abdomen, without peritoneal irritation, slight tympany on percussion. No inguinal lymphadenopathy. No edema in legs, femoral pulses present. No inguinal lymphadenopathy. Pain in the right inguinal region, with painful but preserved right hip mobility, without bone deformity.
Blood count with Hemoglobin 10.6,hematocrit 30,lymphocytes 900,platelets 127,000;coagulation without alterations; biochemistry:urea 101,creatinine 1.67,filtrate 30,sodium 125,calcium 16.6, corrected calcium 16.8,LDH 1174,GOT 45,C-reactive protein 221,pro-BNP 4800,rest without alterations, including magnesium.Venous gasometry pH 7.43 bicarbonate 32.6,ionic calcium 1.84, rest normal. Normal urine.Chest x-ray:mediastinal widening,without infiltrates.
Admitted to Internal Medicine for study of right inguinal pain, hypercalcemia,acute renal failure, and constitutional syndrome.
CT NECK-THORAX-ABDOMEN: 6 mm lung nodule in right upper lobe. In right iliac blade, lytic lesion with cortical rupture and associated soft tissue mass, compatible with a tumor lesion.
PELVIS MRI WITH CONTRAST: Multiple bone metastases in the pelvis, the largest of them in the right iliac blade with cortical destruction and muscle invasion.
PET-CT: Extensive bone infiltration, including iliac bone, lumbar and sacral vertebrae and both femurs. Metabolically negative lung nodules.
BONE BIOPSY: high-grade B lymphoma.
Trauma requested said pathological subcapital fracture of the right femur three weeks after admission, partial hip prosthesis implantation was performed.
Haemathology requested compatible with high-grade B lymphoproliferative process, with intermediate cell morphology and activated immunophenotype. Start of treatment with R-CHOP.
CLINICAL JUDGMENT: Symptomatic hypercalcemia. Acute kidney failure. Anemia in transfusion range. High-grade bone lymphoma with multiple bone metastases in the pelvis and pathological fracture of the femur.
Correction of hypercalcemia with hydration and bisphosphonates, treatment with corticosteroids and opiates to control pain, heparins to prevent thromboembolic disease.
The usual symptoms of hypercalcemia are actually non-specific: loss of appetite, nausea and vomiting, constipation and abdominal pain, need to drink more fluids and urinate more, tiredness, muscle weakness or pain, confusion, disorientation and difficulty thinking, headaches, depression. It is necessary to be aware of this pathology in the emergency room to request blood calcium levels in the face of such non-specific symptoms. Once hypercalcemia is found, different tests are required to find the origin, with hypercalcemia of tumor origin being very common, in addition to correcting hypercalcemia with medical treatment.
Álvaro MARTÍN PÉREZ (Badajoz, Spain), Vanesa YAÑEZ BERMEJO, Esther HERNANDEZ LOPEZ
00:00 - 00:00
#41927 - Food-borne botulisme: not to be forgotten.
Food-borne botulisme: not to be forgotten.
INTRODUCTION : Botulism is an infectious disease secondary to a neurotoxin produced by Clostridium Botulinum. It is rare, and can be fatal sometimes.
We report a case of familial food−borne botulism in a coupe with their 15 yo son, due to ingestion of canned food.
CASES
The first patient, a 69-year-old woman with a history of arterial hypertension, presented with neurological symptoms after consuming poorly preserved canned turkey meat. These symptoms included bilateral ptosis, visual blurring, dry mouth, and total dysphagia to solids and liquids, along with speech disorder. Within 12 hours, her condition deteriorated, showing decreased muscle strength, respiratory distress, but no facial paralysis. Food-borne botulism was confirmed via serology, supported by electromyogram findings of motor axonal polyneuropathy. Treatment involved IV fluids, gastric tube nutrition, proton pump inhibitors, and thromboprophylaxis.
In the second case, the 67-year-old husband of the previous patient developed symptoms 24 hours post-ingestion of the contaminated meal. He experienced dry mouth, vomiting, blurred vision, constipation, and muscle weakness. Initial clinical assessment revealed normal vital signs and neurological deficits, including ptosis and diplopia. Brain MRI and electromyogram results were consistent with the diagnosis of food-borne botulism, confirmed by serology. Symptomatic treatment led to a positive outcome.
DISCUSSION
Botulism, a rare yet grave illness, manifests through paralysis and secretory inhibition, often culminating in respiratory distress and fatality. Its etiology lies in the potent neurotoxin produced by Clostridium botulinum, instigating acute bilateral cranial neuropathies and symmetric descending weakness. Initially presenting with gastrointestinal discomfort, dysarthria, dysphonia, and dysphagia, patients subsequently experience neurological deficits like diplopia, blurred vision, and ptosis. Despite its infrequency, food-borne botulism poses a significant public health concern due to its propensity for swift progression to respiratory failure, mandating mechanical ventilation for management. Recognizing and addressing this perilous condition promptly is paramount for favorable outcomes.
Yasser AFIF (Casablanca, Morocco), Mohamed Anass FEHDI, Asmae DAFIR, Mohamed MOUSSAOUI, Mohammed MOUHAOUI
00:00 - 00:00
#41996 - Forecasting emergency department demand: integrating environmental data for enhanced resource allocation. A retrospective cohort study.
Forecasting emergency department demand: integrating environmental data for enhanced resource allocation. A retrospective cohort study.
Background: Efforts have been made to construct and continuously update a database of Emergency Department (ED) utilisation to characterise and potentially predict ED arrivals. Observing trends and patterns in ED visits is crucial for better resource allocation both at the ED and the hospital level. Coupling this data with weather and environmental pollution conditions can help develop a tool to adapt medical services by predicting the peak and acuity of ED visits.
Methods: This retrospective cohort study, conducted at the Department of Emergency Medicine of Semmelweis University, analysed ED utilisation data from June 2016 to July 2023. The study included all patients presenting to the ED during this period. Data on patient demographics, arrival times, triage level, discharge or admission decision, diagnosis and length of stay were collected. The Hungarian Meteorological Service provided data on various weather conditions and environmental pollution levels. Statistical analysis, including descriptive statistics, trend analysis, and regression modelling, was conducted to identify associations between environmental factors and ED visits.
Results: A total of 194,191 Emergency Department (ED) visits were recorded (53.1% female). Notably, there has been a continuously increasing trend in the number of ED visits year by year, with visits peaking during the winter and spring seasons. Most patients presenting with respiratory issues were triaged as category I or II. Furthermore, it was observed that heat waves, regardless of whether they occurred during the day or night, were associated with an increase in patient presentations. Though the statistical analysis is still being finalised, we anticipate the results will provide valuable insights into the trends and patterns related to ED visits at the Department of Emergency Medicine, Semmelweis University.
Discussion & Conclusions: The study highlights the importance of integrating environmental data with ED utilisation patterns to enhance predictive modelling and resource allocation. Understanding the impact of weather and pollution on the number and acuity of ED visits can aid in proactive planning and better resource allocation strategies. conducting a more in-depth analysis could potentially reveal additional underlying factors contributing to the issue of ED crowding. Additionally, segmenting the data into specific disease groups may provide greater clarity and precision in comprehending the diverse patient population commonly encountered in the ED setting.
Funding: This study received funding from RRF-2.3.1-21-2022-00014 Éghajlatváltozás Multidiszciplináris Nemzeti Laboratórium / National Multidisciplinary Laboratory for Climate Change.
Ethical Approval: SE RKEB 198-1/2021
Informed Consent: not applicable
Szabolcs GAAL (Budapest, Hungary), Dora MELICHER, Bence SIPOS, Dorottya GAAL, Bank FENYVES, Brigitta SZILAGYI, Csaba VARGA
00:00 - 00:00
#42134 - Frailty prevalence in emergency department short stay unit .
Frailty prevalence in emergency department short stay unit .
Frailty Prevalence in the Emergency Department Short Stay Unit.
Introduction:
Frailty, characterized by a vulnerable state in older adults, significantly heightens the risk for adverse health outcomes. Older patients visiting the Emergency Department (ED) often experience functional declines, institutionalization, and even mortality, regardless of their initial presenting conditions. Understanding the complexities of aging, geriatric emergency medicine can develop personalized care plans tailored to the specific needs and goals of older patients. This approach involves coordination with other healthcare professionals to provide holistic care.
Short stay units (SSUs) have emerged as integral components of modern healthcare facilities. Designed to offer efficient and effective care for patients requiring brief medical interventions or observation periods, SSUs provide numerous advantages.
Methods:
To address this gap, our SSU initiated comprehensive geriatric assessments led by our geriatric emergency group, composed of geriatricians. We conducted a prospective observational study in our unit between April 2023 and November 2023 to determine the prevalence of frailty. Utilizing a comprehensive geriatric assessment, including tools such as the Barthel Index, Lawton Index, Short Physical Performance Battery, Rockwood Clinical Frailty Scale, SARC-F, and Frailty Index, we assessed all patients over 75 years old. Inclusion criteria were Barthel Index scores exceeding 90 points. This paper aims to quantitatively assess the prevalence of frailty within our SSU and the outcomes following a care plan focused on a holistic approach to patient care.
Results:
Out of 102 patients included during this period, 54% were men and 46% were women, with a mean age of 87 +/- 6 years. The prevalence of frailty, as measured by the Clinical Frailty Scale (CFS), was 76% among patients admitted to the short-stay unit, with 96% having a CFS score of 4. Following intervention by the Geriatric team, patients received discharge plans focused on frailty, nutrition, and physical activity. T
Conclusion:
The geriatric approach may have contributed to decreased iatrogenic disabilities without increasing the risk of readmission. Implementing a geriatric approach in SSUs can enhance the care of frail older adult patients, potentially preventing readmissions and adverse outcomes associated with emergency visits.
Karla LOPEZ LOPEZ, Veronica Andreina CASTRO JIMENEZ, Monica DE DIEGO ARNAIZ (Burgos, Spain), Elisa Maria FERNANDEZ RODRIGUEZ, Amanda IBISATE CUBILLAS, Monika D OLIVEIRA MILLAN, Marta IBARRONDO CUESTA, Karla LOPEZ
00:00 - 00:00
#41094 - Frequency of serious bacterial infections in infants presenting with fever to emergency department by applying rochester criteria.
Frequency of serious bacterial infections in infants presenting with fever to emergency department by applying rochester criteria.
Infants younger than 60 days may have variable critical illness. Delaying treatment until signs and symptoms emerge may increase the risk of morbidity and mortality that can be preventable. The aim of our study is to determine the frequency of infants at risk of having SBI by applying the Rochester criteria based on clinical and basic lab assessment. Further aim is to see the outcome and trends of antibiotic use in patients initially diagnosed to have SBI so that resource utilization can be done and risk of iatrogenic infection be minimized. Considering the rapid dynamics of emergency department(ED), by knowing the frequency of infants actually confirmed to have SBI with the help of lab parameters and relating them to initial presentation can help us to know the expected outcomes of patient and manage them accordingly. The study is crossectional and conducted in tertiary care hospital in emergency department settings. Infants presenting with fever were enrolled and culture results were followed and then rochester score was applied to see the infants to have serious infections. Positive culture results was the main outcome. Total 135 were enrolled male were predominant population and under 28 days of life infants were more. The no of patients were more 98/135.The positive culture was one of the outcome criteria in infants to have SBI and constituted 33%. 66% of the infants were classified to be high risk as per RC. Maternal history of genitourinary infection was not a risk factor. The optimal cut-off value for the Rochester score was found to be a score of ≥2, at which sensitivity of 72.7 (55.5 -85), specificity 55.9 (46.2 to 65.1), PPV was 34.8%, NPV of 86.4% and accuracy of 60% was observed. The total number of true positives and true negatives was 60%. The sensitivity and specificity at a score of >2 was 68%.Though for our study we have set the in our operational definition with score of more than 3 to be at high risk for SBI as we shown from our analysis as the score increases the no of true positive increases making it a reliable score for ruling in SBI. Considering Pakistan being the developing country and resource limitation of our population this prediction rules should be applied to strengthen the clinical diagnosis.
Non funded project
Erum SHAKEEL (Karachi, Pakistan), Ghazala KAZI
00:00 - 00:00
#41879 - From headache to heartache, Kounis syndrome case report.
From headache to heartache, Kounis syndrome case report.
Background:
Kounis Syndrome is characterized by the concurrence of acute coronary syndrome with mast cell activation induced by inflammatory mediators released during an allergic reaction.
Matherial and method:
We report a case of a 61-year-old patient presents to the emergency care unit on Valentine's Day for 'headache' (paroxysmal right hemicrania). Personal medical history: hypertension in treatment with indapamide, nebivolol, prestarium. No known drug allergies documented. When we evaluated the patient, his vital signs were in normal parameters and the first ECG had no pathological findings. A symptomatic treatment with Metamizole was administered intravenous. After 30 minutes, the patient experienced a general rash reaction so anti allergic agents were given. After just another 15 minutes an acute chest pain was resented, irradiating to his shoulders leading to collapse and elevated ST-T segment in the inferior leads and negative T waves in the anterior ones. Monitoring the patient, we noticed different patterns on the ECG concordant with his angina. At this moment we took under consideration an acute coronary syndrome due to vasospasm.
Differential diagnosis; acute coronary syndrome- STEMI, myocarditis, cocaine-associated chest pain, aortic dissection, Takotsubo cardiomyopathy, anaphylactic shock
With a high range of Troponin T (27,48 pg/ml), emergency angiography was performed. The result indicates an amount of 50 percent stenotic plaque on the circumflex artery and 40 percent on the right coronary artery.
The patient was admitted to the coronary care unit and the case was managed as allergic myocardial infarction (Kounis syndrome).
Conclusions:
Kounis syndrome can be life-threatening, being frequently underdiagnosed. Treatment of one component of this syndrome may aggravate the other, and therefore it is extremely important to re-evaluate the patient on an ongoing basis. It is important always to ask if the patient is known to have allergies to medication.
Cristina Ramona TASE (Constanta, Romania), Camer SALIM, Andreea URECHE
00:00 - 00:00
#41419 - Fulminant hepatitis due to HSV infection.
Fulminant hepatitis due to HSV infection.
Fulminant hepatitis is a very severe condition with general poor outcome. Herpes Virus is a very rare cause of fulminant hepatitis, the clinical presentation can be very variable and for this reason is frequently underdiagnosed. Herpes virus fulminant hepatitis occurs especially in immunodeficient patients and very few cases have been reported in immunocompetent patients. We report a case of an immunocompetent female of 69years presenting to the ED with an association of fatigue and confusion. She had a medical history of diabetes under oral antidiabetic drugs and well balanced. Blood samples have shown elevated liver enzymes at 40 times the normal range for AST and ALT, a blood sodium of 128mEq/l, a leukopenia at 2.8*10/L, and a CRP of 90mg/dl. The initial tests imagistic tests (Brain, Thoracic and Abdominal Tomography) and the lumbar puncture were normal. In the following days the liver parameters continued to increase confirming the diagnosis of fulminant hepatitis. The leukopenia persisted and a thrombopenia appeared at 95 000 without coagulation abnormalities. The patient was admitted to the Intensive care unit. She undergone a liver biopsy and extensive PCR multi-virus tests. The first viral test did not include the Herpes Virus and the diagnostic was made only after 1week. The viral PCR came positive at HSV at the same time as the liver biopsy. Once the HSV infection was confirmed a treatment with intravenous Acyclovir was started and pursued for two months until the viral PCR came out negative. The liver parameters began to normalize after 5 weeks. The classic association in fulminant hepatitis with HSV is fever- leukopenia- transaminase elevation. This unusual presentation without fever and in and immunocompetent patient lead to an important delay in the etiologic diagnosis.
Fulminant hepatitis is a very severe condition with very high mortality and its rapid diagnosis and rapid start of proper antivirals significantly improves the outcomes of these patients.
Oana Maria DAN, Sebastian MAYOR (Paris)
00:00 - 00:00
#41921 - Gastric volvulus: a rare etiology of epigastralgia in adults.
Gastric volvulus: a rare etiology of epigastralgia in adults.
Acute gastric volvulus is a rare condition, complicating 4% of hiatal hernias. Diagnosis is often delayed due to a frequently non-specific symptomatology. We report the case of a 64-year-old patient with no pathological history who consulted us for epigastralgia associated with vomiting for 3 days, unimproved by symptomatic treatment. Examination revealed a contracture of the supra-umbilical region with a retro-cardiac hydroaeric level on the unprepared abdominal Xray. The diagnosis of gastric volvulus was confirmed on CT scan, and treatment was surgical.
An unprepared abdomen Xray: revealed 2 hydroaeric levels in the left hypochondrium, giving the appearance of a double gastric air sac, an elevation of the left diaphragmatic dome, digestive clarity in the retrocardiac region and an absence of digestive gas in the rest of the abdomen.
generally, the unprepared abdomen Xray is usually of little help, but its easy performance in the emergency department can show gaz distension of the upper abdomen, retro-cardiac hydroaeric levels in the case of associated hiatal hernia, and sometimes emphysema of the gastric wall.
Amina JEBALI, Soumaya BADRI, May ZNATI (Béja, Tunisia), Amal ZOUAGHI, Souhayla RIGHI
00:00 - 00:00
#41562 - Gastrocutaneous fistula due to median arcuate ligament syndrome two years after open gastroenteroanastomosis.
Gastrocutaneous fistula due to median arcuate ligament syndrome two years after open gastroenteroanastomosis.
This case report describes a rare occurrence of a gastrocutaneous fistula (GCF) in a 70-year-old female patient who developed the condition two years after open gastroenteroanastomosis to treat duodenal stenosis.
GCFs increase morbidity and mortality of patients and usually result from gastric surgery complications. In this case, a GCF in an already fragile abdominal wall was attributed to Median Arcuate Ligament Syndrome (MALS), which compromised gastric tissue perfusion due to compression of the celiac trunk. The patient presented with a discharging abdominal wound and was diagnosed with a GCF through a CT-scan. Corrective surgery was performed, and the arcuate ligament was resected. The patient's outcome was successful, with no complications observed at follow-up. This is one of the rare case reports in literature documenting the association of the two entities, GCF and MALS, and the first documented case of a GCF resulting from iatrogenic and vascular gastric wall weakening due to MALS. It contributes to the understanding of GCF formation and highlights the importance of preoperative radiological evaluation to identify potential risk factors like MALS and reduce the incidence of GCF.
Martina DELL'ERBA, Eugenia MORELLO, Roberta PETRINO, Davide DEMAGISTRI, Ilenia MASCHERONA (Switzerland, Switzerland)
00:00 - 00:00
#41387 - Gastroenteritis with severe dehydration in infants, other causes that could lead to a fatal outcome: case report of an energy disorder.
Gastroenteritis with severe dehydration in infants, other causes that could lead to a fatal outcome: case report of an energy disorder.
Why is this case interesting?
This case of a dehydrated infant with fever and diarrhea is particularly critical in an emergency setting. Despite initial suspicion of infection and treatment with antibiotics, the lack of response underscored the need for further investigation. Genetic testing revealed a rare metabolic disorder, carnitine palmitoyltransferase II deficiency, which can be life-threatening if undiagnosed. This case highlights the value of genetic testing in urgent situations with unexplained symptoms. Early diagnosis allows for prompt intervention with specific treatment plans, potentially preventing serious complications like muscle weakness, heart problems, and liver failure.
Clinical History:
Male patient, two months old, without pathological history, non-consanguineous parents, who enters pediatric emergency care for a clinical picture of less than 12 hours of evolution characterized by fever peaks quantified at 38°C concomitant with hyporexia, loose stools without mucus or blood number three abundant and irritability; physical examination, hypoactive, with poor sucking, tachypneic, tachycardic, with signs of grade II dehydration, without fever; Therefore, probable sepsis is suspected, dual antibiotic coverage is started prior to taking cultures and paraclinics, and dehydration correction is started with 5% dextrose. Despite this, twelve hours later he presents nine loose stools that show evidence of rapidly progressive deterioration to severe dehydration, hypoglycemia, neurological deterioration due to somnolence and depression of the anterior fontanelle, and with difficulty accessing peripheral vascular access, he is transferred to resuscitation rooms where an intraosseous catheter is placed, in addition he had metabolic acidosis with hyperlactatemia, elevated anion gap, therefore, he is transferred to the ICU, in the context of hypovolemic shock secondary to dehydration by gastroenteritis, it is striking that the hemogram showed anemia, without leukocytosis or neutrophilia, platelets without alteration, slightly elevated PCR not significant, negative cultures, renal function and electrolytes preserved, urinalysis not suggestive of infection, normal coproscopy, but elevated transaminases, additionally adequate fluid correction was performed with an increase in dextrose concentration to 10% presented clinical improvement but metabolic acidosis with hyperlactatemia persisted, which is why an inborn error of metabolism was suspected, mainly a non-ketotic hyperglycinemia disorder, since among the amino acids requested, an elevation of it was found, a molecular genetic study was requested to confirm or rule out the disease, a clinical exome report is received where the probably pathogenic variant in heterozygosity was documented: c.680C>T; p.Pro227Leu in the carnitine palmitoyltransferase II gene, defects in this gene are associated with mitochondrial long-chain fatty acid oxidation disorders including infantile carnitine palmitoyltransferase II deficiency.
Educational and Clinical relevance:
carnitine palmitoyltransferase II deficiency is a rare genetic disorder that can cause a variety of clinical presentations, including dehydration, fever, diarrhea, and neurological symptoms. Carnitine palmitoyltransferase II deficiency should be considered in the differential diagnosis of infants and children with unexplained dehydration, fever, diarrhea, or neurological symptoms. Early diagnosis and treatment of this deficiency are important to prevent complications, such as muscle weakness, cardiomyopathy, and liver failure. Treatment options include dietary modifications, carnitine supplementation, and exercise restriction. Genetic counseling is recommended for families with a history of carnitine palmitoyltransferase II deficiency.
Michael Alexander VALLEJO, Valentina VILLARREAL (, Colombia), Oscar GOMEZ, Stephany RAMIREZ, Cabrera ANDRES
00:00 - 00:00
#41690 - Generalized body patient result of hypothyroidism, myopathy and acute kidney injury presented in our ED.
Generalized body patient result of hypothyroidism, myopathy and acute kidney injury presented in our ED.
A 46-year-old male patient presented to our ED because of all body ache tired since one month . The patient has no co-morbidity. He denied any fever, cough, vomiting or loose motion. He denied any polyuria, or polydipsia. He works as a laborer . Vital signs were stable. The blood work-up showed high creatinine , uric acid , liver enzyme and a lot of increase in myoglobin . White blood cells and C reactive protein were at normal levels. Thyroid function showed a lot of elevation in thyroid stimulating hormone and low T3 that reflected severe hypothyroidism. The patient has a normal physical exam , no neck selling or goiter too. The patient received aggressive IV fluid with levothyroxine oral. Then the lab showed much improvement in kidney function, myoglobin . After 2 months, thyroid function became acceptable on oral levothyroxine 100mcg daily.
Learning points : severe hypothyroidism is usually presented with severe myopathy or rhabdomyolysis. In our ED we get cases of severe hypothyroidism guided by severe myopathy and acute kidney injury. Thyroid function test should be investigated in cases of rhabdomyolysis. Myopathy and muscle injury should be investigated in severe hypothyroid cases . Hypothyroidism may be suspected in rhabdomyolysis cases . Non-explained body weakness or muscle pain should be investigated by kidney , thyroid function and myoglobin , to rule out myopathy or hypothyroidism symptoms .
Dr Islam ELROBAA (Al wakra, Qatar), Mohamed BAUMY
00:00 - 00:00
#42348 - Geriatric population triage: the risk of real-life over and under triage in an overcrowded ED. 4- and 5-level triage systems compared: The CREONTE (Crowding and R E Organization National TriagE) study.
Geriatric population triage: the risk of real-life over and under triage in an overcrowded ED. 4- and 5-level triage systems compared: The CREONTE (Crowding and R E Organization National TriagE) study.
Objectives: We sought to determine the effects of introducing a 5LT on wait times in general and geriatric (>75 years old) populations. The secondary aim was to evaluate the impact of introducing a 5LT on UT, and OT in the general and geriatric (> 75 years old) populations. Other outcomes included the impact of crowding on triage. Crowding indices considered were the length of ED stay, total access block time, and rate of access block. . Methods: We examined geriatric ED access both in the context of 4-level (4LT) and 5-level triage systems (5LT), from January 1, 2014, to December 31, 2020. Results: We evaluated OVER 500-000 ED presentations. Visits to the ED by geriatric, more fragile and seriously ill individuals increased, with progressive increases in crowding. Older (>75 years) patients represented more abut 25% of the tested population. During the same period, the number of ambulatory arrivals decreased significantly in favour of ambulance ones. A progressive increase in patients requiring higher triage codes was also reported. There were a little statistically significant differences between geriatric (> 75 years of age) and younger patients within the subdivision of triage priority codes for medical examination and care intensity. Geriatric patients are at little increased risk of UT compared to the general population (OR>2; p<0.001). The geriatric subjects are however also more frequently subjected to over-triage than the younger subjects, this phenomenon persists both in the period of 4LT and in that of 5LT and remains in both areas of intensity of care
The rise in the length of stay (LOS), exit block, boarding, and processing times showed a net increase in throughput and output factors, with a consequent lengthening of wait times.. The increased risk of over-triage in young people is lower in 5LT, while the reduction in the risk of OT in the elderly is greater in 5LT. The presence of access blocks, intended as a crowding measure, always greatly increases the risk of under triage in the elderly, or rather: in the elderly more than in the young. During access block the risk of over triage is significantly reduced.
The reduction is more evident in the 5LT period
Conclusions: geriatric patients are more frequently subject to undertriage. In crowding situations, the risk of under triage increases and the risk of over triage is reduced, especially in the elderly population. Crowding causes extension of waiting times. From these data it seems clear that rehabilitation for the elderly has further improved
Dr Gabriele SAVIOLI, Maria Antonietta BRESSAN (, Italy), Iride Francesca CERESA, Giovanni RICEVUTI, Boudi ZOUBIR, Abdelouahab BELLOU
00:00 - 00:00
#41849 - GET IT ON TIME – A PARKINSON’S DISEASE QUALITY IMPROVEMENT PROJECT.
GET IT ON TIME – A PARKINSON’S DISEASE QUALITY IMPROVEMENT PROJECT.
INTRODUCTION
The incidence of Parkinson’s Disease (PD) is 2:1000 of the general population. Ireland has approximately 12000 PD patients and is expected to double in the next 40 years. There is no cure for PD but symptom management is possible. Unfortunately, the medication regimes can range in complexity. A small delay of 30 minutes in medication administration can contribute to serious health consequences and prolong hospital stays. The mainstay of symptom management is carbidopa-levodopa. The omission of levodopa is recognised by NICE and RCEM as an area of quality improvement. The Parkinson’s UK Get-It-on-Time Campaign was adopted in Ireland in 2022 and University Hospital Limerick (UHL) was the first Emergency Department (ED) to introduce it in Ireland.
The objectives of this quality improvement project (QIP) are to minimise any delay in the time to administration of time critical medication to less than 30 minutes, raise awareness of PD, and how to improve their quality of care.
METHODS
Baseline audit in March 2023 included demographic data, medication prescription and administration time, presenting complaint and disposition data. A multimodal intervention includes stickers at triage, stakeholder engagement, frequent training sessions, ED zone restructuring, posters, and feedback. A repeat audit in February 2024 was performed as part of the Plan Do Study Act (PDSA) cycle to compare progress since the baseline audit.
RESULTS
A total of 29 patients with PD presented to the ED in February 2024 compared to 27 in the baseline audit. The majority were male (2023: 18(67%) vs 2024: 17(59%)). The median age in 2024 was 80 years (minimum 68, maximum 90) compared to 78 years (minimum 61, maximum 90) in 2023. Get-it-on-time sticker use increased by 20% to 22(76%). There was a 5% increase in medication prescription and a 16% increase in medication administration. When medication was prescribed, 94% of patients received their medication and 83% (increased by 33%) received it in less than 30 minutes. Most patients were admitted to medicine (76%) and 10% were admitted to surgical disciplines.
CONCLUSION
Early identification of patients with Parkinson's Disease in the ED has improved medication administration times by 33%, which improves patient’s quality of care, and in turn can reduce hospital length of stay. Further improvements are needed. With regular training, memory aids, stakeholder engagement, and feedback, patients with PD can receive good quality care.
Gideon-Phil MEYER (Dublin, Ireland), Cormac MEHIGAN
00:00 - 00:00
#42059 - Gluteal abscess that hurts in the neck?
Gluteal abscess that hurts in the neck?
INTRODUCTION
Spinal epidural abscess (ESA) is a severe infection of the epidural space and a rare condition, accounting for 0,2-1,2 per 10 000 hospital admissions. To the best of our knowledge, the present case is the third reported of ESA as a result of hematogenous spread from gluteal abscess.
Nowadays, EAS has a high mortality rate that can reach 31%. Therefore, suspicion and early diagnosis are vital because the delay can cause neurologic compromise and even death.
CASE REPORT
A 47-year-old man was admitted to the ED because of gluteal and neckache, fever and chills. His past medical history included alcoholism, asthma, and atopic dermatitis. Nine days before he started with cervical pain and received intramuscular injections of diclofenac and diazepam. On arrival, vital signs were stable. He was pale, sweaty, and lethargic. Physical examination revealed right gluteal hyperemia and localized warmth, as well as an indurated area at the greater trochanter. No other neurological deficits were found.
Laboratory findings showed a WBC count of 22,750 per mm3, C-Reactive Protein of 249mg/mL and procalcitonin was 6,08ng/mL. Biochemically, urea was 69 mg/dL, creatinine 1,28 mg/dL, ALT was 60 and sodium was 122mEq/L. INR was 1,7. Blood cultures were collected. Thoracoabdominal CT was performed showing an abscess in the right gluteus maximus muscle, extending to the trochanteric region and chronic liver disease with portal hypertension. Piperacillin-tazobactam and linezolid was administered intravenously, and he underwent urgent surgery to drain the gluteal abscess. Then, he was hospitalized in the infectious diseases service. The next day, blood cultures were positive to methicillin-susceptible Staphylococcus aureus as well as the pus culture, so they changed to cloxacillin. Due to persistence of neckache, contrast enhanced MRI was performed. It demonstrated a cervical epidural abscess extending from the 2nd to the 3rd cervical vertebra (Figure 1), causing spinal canal stenosis, and discitis at the C4-5 level (Figure 2). Echocardiography was negative for endocarditis. He was treated conservatively, completing 3 weeks of intravenous antibiotic followed by oral therapy. He was recovered with no neurological dysfunction.
DISCUSSION
EAS is a disease of men over age 30. Risk factors include diabetes mellitus, alcoholism, venous drugs abuse, AIDS, chronic renal failure, cancer, and spinal procedures.
The classical triad of SEA is pain, fever, and neurologic deficit, but clinical course can be highly variable. Back pain is the most common symptom. The most frequent site affected is lumbar spine; cervical area is the least compromised. S. aureus is by far the most common pathogen related to ESA.
The differential diagnosis includes meningitis, epidural hematoma, osteomyelitis, spinal tumors, and spinal artery syndromes.
MRI is the imaging modality of choice. Treatment options include nonoperative (immobilization and 4 to 6 weeks of parenteral antibiotics) or operative management, consisting of surgical decompression.
CLINICAL RELEVANCE
In a patient with acute onset of back pain, risk factors, and elevated inflammatory markers, emergency physician should consider EAS given that it can result in very rapid deterioration to neurologic compromise. Early diagnosis and immediate treatment are the cornerstones in improving the outcomes.
Erika Y. CÉSPEDES-SUZUKI (Bilbao, Spain), Patricia MARTÍNEZ-OLAIZOLA, María Isabel SIERRA-TORRIJOS, Itxaso LOMBIDE-AGUIRRE, Martín SAENZ-AGUIRRE, Mercedes VARONA-PEINADOR
00:00 - 00:00
#41467 - GLYCEMIC CONTROL IN HYPERGLYCEMIC CONTROL IN HYPERGLYCEMIC PATIENTS IN AN EMERGENCY DEPARTMENT.
GLYCEMIC CONTROL IN HYPERGLYCEMIC CONTROL IN HYPERGLYCEMIC PATIENTS IN AN EMERGENCY DEPARTMENT.
-Introduction: Diabetes Mellitus is a chronic metabolic disorder with a high prevalence worldwide, not free of complications. One of the most frequent acute complications is hyperglycemia, which, due to its potential severity, requires urgent medical attention in some patients.
The appropriate treatment consists of insulin administration, which requires intensive monitoring of blood glucose values in the emergency department until the patient is stabilized.
The aim of this study was to describe the characteristics and the care received by patients with hyperglycemia in the Emergency Department of the Hospital Universitario de La Ribera, with emphasis on the study of glycemic control.
-Material and methods: Observational, descriptive and retrospective study carried out on a sample of patients in whom hyperglycemia with a diagnosis associated with diabetic disease was recorded as a reason for consultation during triage in 2023. The variables under study described the sociodemographic characteristics, the determination of glucose in triage, blood tests and blood gases, the glycemic control performed, the time spent in the emergency department, the discharge destination and the rate of exitus.
-Results: A total of 241 patients were studied, 54.8% male, half of them over 64 years of age, classified with a priority level of P3.
A digital glycemia was performed in triage in 99.2% of the patients, 9 out of 10 were asked for an analysis and 8 out of 10 were asked for a blood gas analysis to also know the pH value.
On average, 5 glycemic control determinations were made per patient, with glycemic control being correct in 80% of the cases, taking into account the time the patient spent in the emergency room. The exit rate during hospital stay was 10.8%.
-Conclusions: It is necessary, in the Emergency Department of the Hospital Universitario de la Ribera, to implement strategies that allow the correct performance of glycemic control in 100% of patients, since the literature has shown that better glycemic control results in better outcomes.
María CUENCA TORRES (alzira, Spain), Carmen LOPEZ-BERGUES BUSTOS, Immaculada TORMOS MIÑANA, Ricardo MUÑOZ ALBERT, Luis MANCLÚS MONTOYA
00:00 - 00:00
#41409 - Going beyond the hospital report: The value of learning conversations in prehospital feedback.
Going beyond the hospital report: The value of learning conversations in prehospital feedback.
Background
Prehospital feedback systems allow ambulance staff to follow up their patients. This provides opportunities to maintain good practice and identify areas for development. Many prehospital feedback systems have feedback delivered directly to prehospital clinicians by the hospital. Others have this feedback mediated by a senior clinician (‘facilitators’) from the same ambulance service and delivered in learning conversations to explore the case with the prehospital clinician. This latter method (used for ‘PHEM Feedback’) is more resource intensive. Comparisons to determine which approach is more effective have not been done.
Method
After each learning conversation, surveys based on the ‘Student Assessment of Learning Gains’ tool were completed by prehospital clinicians and their facilitators, measuring the gains made across different developmental domains. These questions were ‘Likert-type scales’. Some questions measured the value of the hospital report and learning conversations on the prehospital clinicians’ learning.
Results
Of the 145 learning conversations completed at the time of this snapshot, interim analysis taken at 2 years, 72.4% (n=105) surveys were returned by clinicians and 84.8% (n=123) were returned by facilitators.
When comparing the value of the clinicians 1) reading the hospital report, 2) interacting with the facilitator and 3) reading further sources on the topic, the greatest proportion of responses were the most positive option (‘Great Help’) for all questions (61.9%, 73.3% and 49.5% respectively).
Facilitators rated the hospital report as of greater value for preparing learning conversations than reading further sources which they or the hospital had identified.
Conclusion
Hospital reports are an important component of the learning process. Prehospital clinicians collectively rate the value of the learning conversation around the case even more highly suggesting that there is greater learning to be had beyond just what is revealed by a hospital about a case and the combination with learning conversations can achieve this.
Udara WICKRAMANAYAKE (Cambridge, Sri Lanka), Matthew SNOWSILL, Sinead Keane KEANE
00:00 - 00:00
#41859 - Harmonizing Pain Management: The Impact of Classical Music Therapy on Pain Reduction and Patient Satisfaction During Suturing in the Emergency Department.
Harmonizing Pain Management: The Impact of Classical Music Therapy on Pain Reduction and Patient Satisfaction During Suturing in the Emergency Department.
Introduction: This study evaluates the efficacy of classical music therapy in reducing pain and anxiety during suturing in an emergency setting, aiming to provide a low-risk, cost-effective alternative to conventional pain management strategies.
Methods: This randomized clinical trial involved 200 adult patients with lacerations requiring suturing at Haftome-Tir Hospital. Participants were randomly assigned to either a control group, receiving no music during suturing, or an experimental group, where soothing classical music from composers like Beethoven, Bach, and Mozart was played through headphones. Pain levels were assessed using a numeric scale (0-10), and patient satisfaction was measured with a five-point Likert scale before and after the procedure.
Results: Initial pain scores were closely matched between the two groups, with the control group averaging 4.5 ± 1.2 and the music group averaging 4.6 ± 1.1. After the procedure, both groups experienced a minor decrease in pain scores: the control group’s average decreased to 4.3 ± 1.2 and the music group’s to 4.2 ± 1.0, which was not statistically significant (p=0.45). In terms of patient satisfaction, there was a noticeable but not statistically significant difference; the music group reported higher satisfaction (3.5 ± 0.7) compared to the control group (3.0 ± 0.8), with a p-value of 0.07.
Conclusion: While classical music did not significantly decrease pain during suturing, it may enhance patient satisfaction, indicating potential benefits in patient experience.
Peyman HAFEZIMOGHADAM, Kourosh JAVDANI ESFEHANI (Dubai, United Arab Emirates), Amirmohammad SALEHI, Naghshbandi MOBIN, Mahdi REZAI, Neda ASHAYERI
00:00 - 00:00
#41717 - Have a look in the ear as well. An unusual case of herpes zoster oticus (Ramsay Hunt syndrome) in a nonagenarian woman complicated with coma due to viral encephalitis, with review of the literature.
Have a look in the ear as well. An unusual case of herpes zoster oticus (Ramsay Hunt syndrome) in a nonagenarian woman complicated with coma due to viral encephalitis, with review of the literature.
Brief clinical history:
We present the case of a 92-year-old woman who was brought to the Emergency Department with a low level of consciousness. Ten days prior to her admission, she had developed severe right peripheral facial palsy, for which her physician had started oral prednisone at a dose of 1 mg/kg/day. After a week, the facial palsy had not improved, and the level of consciousness began to deteriorate, with stupor progressing to hyporesponsive coma.
Misleading elements:
Out-of-hospital care detected a capillary glycemia of more than 500 mg/dl, started intravenous rehydration together with insulin, and referred the patient to the ED with the suspicion of steroid-induced hyperosmolar coma.
Helpful details:
However, on arrival at the ED, blood glucose and osmolarity were easily and rapidly corrected without improvement in the level of consciousness, and crusty lesions suggestive of herpes zoster oticus were discovered in the Ramsay Hunt area of the right ear. A lumbar puncture showed hyperproteinorrachia and detection by polymerase chain reaction (PCR) of Varicella Zoster virus (VZV) genome in cerebrospinal fluid.
Differential and actual diagnosis:
As VZV encephalitis was suspected, intravenous acyclovir was started at a dose of 10 mg/kg every 8 hours, with progressive improvement of the level of consciousness over the first 48 hours.
Educational and/or clinical relevance:
This case emphasizes the need to systematically assess the auricular region for herpetic lesions in all cases of facial palsy, as well as to consider initiating empirical antiviral treatment even in the absence of lesions, especially when facial palsy is severe (grades IV to VI of the House-Brackmann Classification). Together with the case report, a review of the literature is added, summarizing the main characteristics of the few cases of herpes zoster oticus complicated with encephalitis published in the main medical databases.
Informed Consent Statement:
The patient gave consent to submit her case details; and correct anonymization of the case has been verified.
Álvarez Freire LUCÍA, Figueiras González MARÍA (A Coruña, Spain), Roca Paz SABELA, Souto Suárez BEATRIZ, Montero González ROMÁN, Fernández Robelo UXIA, Íñigo GREDILLA- ZUBIRÍA
00:00 - 00:00
#41365 - HEADSTRONG: Twelve month follow-up of a program to characterize and promote sustained bicycle helmet use.
HEADSTRONG: Twelve month follow-up of a program to characterize and promote sustained bicycle helmet use.
Introduction: Bicycling in Canada is widely used for transportation, recreational activity, and sport. While beneficial for individual and population health, cycling injuries are common and can result in significant morbidity or death, with head injury as a frequent preventable cause. We sought to characterize unhelmeted injured cyclists presenting to the emergency department (ED), and to assess an intervention using principles of behavioural economics to increase sustained helmet use.
Methods: Prospective cohort study (consecutive, convenience sample) in a downtown teaching hospital in Toronto, Canada. Injured cyclists presenting to the ED were recruited if unhelmeted at time of injury and over age 18. Exclusion criteria included inability to consent (language barrier, cognitive impairment) or admission to hospital. The HEADSTRONG protocol aimed to promote sustained helmet use by providing: 1) Education in ED 2) Free bicycle helmet 3) Four email follow-ups (f/u) over 12 months 4) social media engagement 5) Peer nomination of a colleague for enrolment at one year month f/u. A standardized survey and f/u questions were administered by a research coordinator (D.P.). Patients were randomized to HEADSTRONG protocol or control group (baseline survey and 12 month f/u).
Results: We enrolled 72 UICs (unhelmeted injured cyclists) with mean age of 34.3 years (range 18–68, median 30, IQR 15.8 years) in 27 months of recruitment. Almost all (98.6%, n = 71) had planned to cycle when departing home that day. UICs reported rarely (11.1%, n = 8) or never (65.3%, n = 47) wearing a helmet. Reported factors discouraging helmet use included inconvenience (31.9%, n = 23) and lack of ownership (33.3%, n = 24), but few characterized helmets as unnecessary (11.1%, n = 7) or ineffective (1.4%, n = 1). Of the 26 (36.1%) cyclists randomized to HEADSTRONG protocol, 16 (62.6 %) responded to at least one email follow-up, half (50%, n=13) redeemed their helmet voucher, 13 (50%) replied at 2-week f/u, 9 (34.6%) at 2-month f/u, 10 (38.5%) at 6-month f/u, and 8 (30.8%) at one year f/u. Fewer controls (n=9/46, 19.6%) responded at one year. At one year f/u most (6/8, 75%) HEADSTRONG respondents reported always wearing a helmet, compared with few (2/9, 22.2%) of controls.
Discussion and Conclusions: Unhelmeted injured cyclists were frequent commuter cyclists who chose not to wear helmets for reasons largely related to convenience. There is a need for effective approaches to improve voluntary helmet use by adult cyclists. Interventions employing principles of adult education and behavioural economics may be effective to achieve sustained helmet use in adult cyclists, warranting larger studies.
This study was supported by a grant from The Dr. Tom Pashby Sports Safety Fund.
Steven Marc FRIEDMAN (Toronto, Canada), Brenda VARRIANO, Danielle PORPLYCIA
00:00 - 00:00
#42165 - Health vulnerabilities of participants to a Christian religious mass gathering event, a retrospective analyses.
Health vulnerabilities of participants to a Christian religious mass gathering event, a retrospective analyses.
Introduction: In the 21st century, mass-gathering medicine has emerged as a new field of study. Religious mass-gathering events are repeated occurrences characterized by a large convergence of populations in a specific location. These events challenge local administration and infrastructure and pose several health risks for participants. However, there is limited data about how these events impact local health systems and about participants' health risks. One such event is Sf. Parascheva, a 9-day religious event with an attendance of 300.000 participants in 2023. This study provides a demographic description of participants requesting healthcare services during the above event and aims to identify risks associated with attending. Material and methods A retrospective study was performed on data registries from the on-site care facilities. Descriptive statistics were used to describe baseline characteristics and distribution. Continuous variables were compared using an independent-sample student t-test. Chi2 or Fisher exact test was used to assess differences between categorical variable groups. Univariate analyses and a multivariate logarithmic model were developed considering two primary outcomes related to disease severity: the need for on-site treatment and the need for further hospital care. Results: 547 events were recorded during the religious gathering, with an incidence of 1.8/1000 participants. People originated from all the geographic regions of the country. However, 21.3% of cases were local residents. There were 2.2 times more participants presenting during the night shifts than during the day (395 vs. 179, p<0.001). The highest concentration of cases was during the day of the event and the day before (days 7 and 8), which summed up to 58.54% of cases. Most presentations were related to non-communicable diseases, with neurologic (21.7%), neuro-vegetative disorders (18.82%), and cardiac (17.94%) symptoms being the most frequent. Infectious diseases were reported in 6.27% of cases, with viral upper respiratory tract infections being the most frequent. Women needed medical attention 2.15 times more often than men (392 vs. 182, p=0.001). However, in univariate analyses, men presented higher odds of needing further hospital care (OR 1.81, 95% CI:1.05-3.13, P= 0.038). Three age cohorts were identified with individual risks. Young participants age<25 (25.96%) had a higher risk of presenting for allergic reactions due to insect bites (OR 8.87, P=0.005), infectious (OR 5.79, p<001), digestive (OR- 2.39, p<0.001), and gynecologic conditions (OR 5.02, P=0.002). The adult cohort (ages 25 to 59) was the largest population (45.64%) and had a higher risk of presenting with neurologic symptoms. The elderly demographic (28.40%) exhibited higher risks for cardiovascular disease exacerbation during the event (OR 4.99, P<0.001) and had a higher risk of needing further hospital care (OR 1.86, P=0.03), while the need for on-site treatment reached marginal significance (OR 1.55, p = 0.053). However, these variables did not remain statistically significant in our logarithmic model. Conclusion: Our study highlights gender disparities in healthcare needs beyond the initial presentation and the vulnerability of the elderly population. This warrants tailored healthcare intervention and surveillance during the aforementioned event.
Alexandra HAUTA, Radu-Alexandru IACOBESCU, Paul-Lucian NEDELEA, Mihaela CORLADE-ANDREI, Carmen Diana CIMPOESU (IASI, Romania)
00:00 - 00:00
#42239 - Heart, cerebellum, and alcohol under scrutiny.
Heart, cerebellum, and alcohol under scrutiny.
Brief clinical history: 47-year-old female smoker (1 pack/day) with no other relevant medical history. Presents with progressive dyspnea and oppressive chest pain improving with sitting and increasing in intensity over the last two days, along with dry cough and intense fatigue. She also reports episodes of profuse sweating and feeling hot, suggestive of fever although not measured. Denies palpitations, dizziness, or syncope. Presented to the Emergency Department 48 hours prior with clinical signs consistent with acute alcohol intoxication.
Misleading elements: Physical examination: Conscious, oriented, cooperative. (BP 95/70 HR 108 SpO2 93% T 37.9°C) Mild dysarthria and ataxia with increased base of support with no other neurological abnormalities. Mild tachypnea at rest. Carotid pulses with normal morphology and no murmurs. Cardiac auscultation: tachycardic without audible rub. Pulmonary auscultation: scattered crackles in left base. Abdomen: soft, depressible, non-tender, no palpable masses, no abdominal bruits, normal bowel sounds. Lower extremities: no edema, no signs of DVT, symmetric distal pulses
Helpful details:
-Chest X-ray: Consolidation in anterior segment of left lung.
-Laboratory tests: Chemistry: glucose 102; urea 76; uric acid 10.9; Cr 1.01; AST 514; ALT 133; GGT 9; total proteins 6.7; Ca 8.8; phosphorus 3.4; LDH 2611; total bilirubin 0.58; Mg 2.71; Na 134; K 4.4; CRP 93.1; PCT 0.21. Troponin I 4200 ng/mL. Hemogram: Leukocytes 25.1, Hematocrit 4.6, Hemoglobin 15, Platelets 292, and normal coagulation with D-dimer 1849 ng/mL.
-ECG: Sinus rhythm at 110 bpm, axis within normal range, PR 160 ms, wide QRS, incomplete right bundle branch block; QS in lead I and aVL; Q wave in lead V2. ST elevation in leads V3-V5; negative T wave in anterolateral leads.
-CT pulmonary embolism protocol: No signs of pulmonary embolism. Pulmonary trunk at upper limit of normal. Consolidations in left lung and areas of ground-glass opacities predominantly in left lung, suggestive of infectious pathology, pulmonary edema... (Differential diagnosis with pneumonitis). Bilateral pleural effusions.
-Echocardiogram: Non-dilated left ventricle; EF 30%; global hypokinesia except for hyperdynamic apical septum, grade 2 MR; normal sized and functioning right ventricle. Moderate tricuspid regurgitation. No pericardial effusion.
Initial diagnosis:
Myocarditis with severe systolic dysfunction and signs of pulmonary congestion in the context of pneumonia.
Final diagnosis:
1. Evolved anterior myocardial infarction Killip III. Severe LV dysfunction EF 21%. Severe TR with significant PH at rest
2. Cerebellar stroke.
3. Left upper lobe pneumonia.
4. Epistenocardiac pericarditis.
5. Paroxysmal atrial fibrillation CHADSVASC 5. 6. Heart failure with refractory pulmonary congestion.
What is the educational and/or clinical relevance of the case?
1. The differential diagnosis between myocarditis and acute myocardial infarction (AMI) became complex in the emergency room due to the presence of pneumonia. Electrocardiographic signs in patients with myocarditis can resemble those of an infarction, including alterations in the T wave and ST segment. Clinically, both conditions may present with chest pain, dyspnea, tachycardia, dizziness, as well as elevated cardiac enzymes.
2. Presence of concomitant myocardial infarction and cerebellar stroke.
3. Excessive alcohol intake contributed to delay in diagnosis.
María Teresa AMPUDIA GARCÍA (yes, Spain), Maria Nuria ALVAREZ DIEZ, Gregorio Enrique FERNÁNDEZ FERNÁNDEZ, Saul ESCUDERO ALVAREZ, Miriam MARTINEZ FERNANDEZ, Carlos REHBERGER GARCIA, Michael DAWS GÓMEZ-LANDERO, Raquel GARCÍA GONZÁLEZ, Alberto ALVAREZ MADRIGAL, Rubén LÓPEZ GONZÁLEZ, Luis Miguel MAESTRO GILMARTIN, Paula FERNANDEZ DE LA MATA
00:00 - 00:00
#42276 - Heat related pathologies in elderly patients.
Heat related pathologies in elderly patients.
Backgrounds:
Exposure to high heat can be responsible for serious clinico-biological abnormalities, particularly if the terrain is fragile, as in the case of elderly patients, who may require more appropriate management.
Objectives:
To determine the clinico-biological and evolutionary particularities of heat-related pathologies in elderly patients admitted to emergency departments.
Methods:
This was a descriptive, analytical, prospective, monocentric study conducted in the emergency department over a two-month period.
Inclusion criteria: both sexes, patients admitted for heat-related illness.
Exclusion criteria: patients seen on an outpatient basis.
elderly patients :age >65 years.
Results :
51 patients were enrolled; mean age=68.4±11.1 years; gender (p=0.009); history (0.026); arterial hypertension (p=0.003); diabetes (p=0.003); previous antihypertensive treatment (p=0.012); clinical examination showed no significant difference; mean PAS(p=0.888); mean HR(p=0.616) : mean temperature (p=0.255); biologically, greater cytolysis was objective, with mean ALT (p=0.016); evolution: complications (p=0.668); unfavorable evolution (p=0.351); death (p=0.796)
Conclusion:
Heat-related pathologies were significantly present in elderly male patients with a medico-surgical history, mainly diabetes and arterial hypertension, whereas there was no significant difference in clinical or evolutionary terms.
Sirine KHABOUCHI, Khaireddine JEMAI (Tunis, Tunisia), Dhekra HOSNI, Hana HEDHLI
00:00 - 00:00
#41795 - Hemoptysis Reveals Aortic Dissection: A Case Report.
Hemoptysis Reveals Aortic Dissection: A Case Report.
Introduction:
Massive hemoptysis is a relatively infrequent occurrence and can be ascribed to a myriad of etiological factors, encompassing infections, malignancies, traumatic events, iatrogenic sources (such as pulmonary artery catheterization), and cardiovascular pathologies. It is noteworthy that aortic dissection has not previously been documented as a causative factor for hemoptysis. In the absence of prompt and comprehensive therapeutic intervention, the mortality rate associated with this presentation can reach an alarming 80%. In this report, we present a case of a painless aortic dissection manifesting as hemoptysis in a patient with no discernible medical history.
Case report
A 65-year-old man with no previous medical history, 15 PPY smoking, presented with 2 episodes of hemoptysis over the past two weeks. He denied fever, night sweat, weight loss, chronic cough, wheezing, chest pain, or chest trauma. The first episode of a quarter cup was preceded by throat irritation and hoarseness, with admixture of mucous and blood. The second episode 2 weeks later was mostly blood. The patient sought consultation with a pulmonologist at our hospital, who subsequently requisitioned a chest X-ray that revealed an enlarged mediastinum, there for he was referred to our emergency department to rule out a cardiovascular emergency, particularly aortic dissection.
Upon examination, the patient appeared in a normal state. Vital signs were within normal. Auscultation of the lungs revealed rare bilateral basal crackles. The blood pressure was 120/90mmHg and symmetric, respiratory rate was 18 breaths/minute and oxygen saturation was 99% on room air. The abdominal exam was unremarkable. The patient's neck was supple, and there was no jugular venous distention or tracheal deviation. His electrocardiogram was normal. Initial laboratory evaluation was normal.
Soon after his admission, the patient underwent CT-chest which findings suggestive of an extended Stanford type A aortic dissection involving the aortic arch, supra-aortic trunks, and abdominal aorta. A region of ground-glass opacification hyper-density, indicative of intravascular hemorrhage, was observed in this context.
Consequently, the patient was transferred to a cardiovascular surgery department.
Conclusion
Hemoptysis is an exceptionally uncommon alarming symptom of aortic dissection. When aortic dissection occurs without the typical presentation of pain, there is a risk of delayed diagnosis and treatment. This case underscores the importance of considering aortic dissection as part of the differential diagnosis when evaluating patients with hemoptysis.
Khouloud KHEMILI (Tunisia, Tunisia), Chaima MANAI, Bouhamed CHAFIAA, Sarra SOUA, Imen KETATA, Mariam FAYALA
00:00 - 00:00
#42235 - Hemorrhagic stroke and spontaneous hemoperitoneum in patients on vitamin K antagonists: case reports and review.
Hemorrhagic stroke and spontaneous hemoperitoneum in patients on vitamin K antagonists: case reports and review.
Introduction: Vitamin K antagonists (VKAs) are widely used therapeutics and have been the go-to means of anticoagulation therapy for over 50 years. Acenocoumarol remains the most prescribed VKA in Morocco (Warfarin worldwide). VKAs usage is limited by their numerous drug-food and drug-drug interactions and their especially narrow therapeutic window. Nevertheless, they still benefit from a wide range of indications including supraventricular arrhythmias and treatment and/or prevention of deep vein thrombosis.
Cases: We report the cases of a 28 years old female and a 58 years old male. The first patient had a history of valvular replacement due to acute rheumatic fever at the age of 8 on 2mg of Acenocoumarol daily. The second patient had a history of mitral valve stenosis on 4mg of Acenocoumarol daily. Both patients had no recent control INRs. The first patient had a notion of increase in dosage up to 6mg 2 days prior to her admission. The female patient was admitted to the ER with an altered mental status following an episode of severe headaches and loss of consciousness. The second patient presented with severe abdominal pain and rapid onset pallor and fatigue. No physical trauma was reported in both cases. On admission, the 28 years old patient was comatose and showed signs of hemodynamic distress. The 58 years old patient showed signs of shock. Physical examination found a mydriasis of the right eye and diffuse coarse crackles in both lungs in the first case and abdominal tenderness and dullness in percussion over the flanks in the second case. The initial treatment included rapid sequence intubation and large bore venous access to start isotonic serum perfusion. Laboratory findings contained INRs of 9.6 and 10, hemoglobin levels of 10.2 g/dL and 9.2 g/dL and a prothrombin time of 68.3 seconds (15% prothrombin time ratio) and prothrombin time of 82 seconds respectively. CT scans were performed and showed a cerebellar hemorrhage in the former and a high abundance hemoperitoneum in the latter. Both patients received vitamin K, prothrombin complex concentrate (4F-PCC) and packed red blood cells. They both had unfavorable outcomes and passed away shortly after admission.
Discussion: Bleedings in patients on anticoagulants are frequent and potentially fatal situations. For that, the treatment options should obey a unified and universal approach. Care for VKA overdose must include, in all cases, interruption of VKAs, followed by a fast administration of vitamin K and prothrombin complex concentrate (4F-PCC). Vitamin K and 4F-PCC work in harmony as antagonists of VKAs. Acenocoumarol has a short half-life of 10 to 24 hours. 4F-PCC (the half-life of FII is 60–72 h, the half-life of other factors is 6–24 h. FVII has the shortest half-life of approximately 6 h) and Vitamin K (half-life of 24.7 hours) adjudication allows the restoration of Vitamin K dependent coagulation factors until VKAs are eliminated.
Our case reports are particularly interesting due to the spontaneity of the hemorrhages and the rarity and fatality of such clinical presentations.
Othman LMEJJATI (Casablanca, Morocco), Mohamed Anas FAHDI, Badria AGGOUG, Asmae DAFIR, Mohamed MOUSSAOUI, Mohamed MOUHAOUI
00:00 - 00:00
#42025 - HEMS presentations to tallaght university hospital emergency department: a 6 year review.
HEMS presentations to tallaght university hospital emergency department: a 6 year review.
Introduction
Helicopter Emergency Medical Services (HEMS) plays a vital role in the implementation of the National Trauma System in Ireland. Tallaght University Hospital (TUH) Emergency Department (ED) has been receiving patients via HEMS since 2012 and has been a regional trauma receiving centre since 2019. The aim of the study was to establish the demographics, management and outcomes of patients presenting to TUH ED via HEMS.
Method
This study was a retrospective descriptive study of all presentations to TUH ED via HEMS between January 2016 to December 2021. Patients, aged sixteen years and older, were identified using the local emergency department information system (Symphony) and the Trauma Audit and Research Network (TARN) database.
Results
192 cases were identified as having presented within the 6 year study period. The mean age of the cohort was 46.8 years (standard deviation 17.579) and the patients’ age ranged from 16 to 91. There was 41 females and 151 males. 7 patients in the cohort died. Patients were transferred to TUH emergency department from 17 out of the 26 counties in the Republic of Ireland. The majority were traumatic presentations (177/192, 92%). The most common presenting complaint was ‘road traffic accident’ (62/192, 32%) followed by ‘fall from height’ (54/192, 28%). The majority of patients required admission (81%, 152/192) and 14 (7.2%) patients required transfer to another unit to receive further specialised care that was not available at TUH. A third (33%, 65/195) required surgical intervention and 19% (37/192) required critical care admission. The mean time spent in the emergency department was 10.66 hours (standard deviation 7.41) and the mean total hospital stay was 10.04 days. The mean length hospital of stay was shorter in the patients under 65 years of age compared with patients 65 years and older (9.6 days versus 12 days, p< 0.01).
Conclusion
TUH is a trauma receiving hospital for a wide geographical area. Whilst HEMS presentations represents a low proportion of overall attendances, they typically represent a high acuity and high resource burden. A minority of patients required secondary transfer to another unit as TUH does not have neurosurgical or cardiothoracic specialties. Case suitability could be considered as the HEMS and Irish trauma system evolves.
Lushavia GOVENDER, Lushavia GOVENDER (Dublin, Ireland), Adrian KOOPMAN, Tracy-Lee SPLINTER, Aidan GRUFFERTY, Aileen MCCABE
00:00 - 00:00
#41226 - HEPATIC HYDATID CYST IN THE STUDY OF REPEATED SYNCOPE.
HEPATIC HYDATID CYST IN THE STUDY OF REPEATED SYNCOPE.
50-year-old woman comes to the clinic for 3 syncopal episodes, unrelated to exertion, spaced over a few months, with complete loss of consciousness, lasting minutes, without premonitory symptoms or convulsive movements or sphincter relaxation. Personal history: allergy to streptomycin and kanamycin, and anemia due to menstrual loss under treatment with iron therapy and pending evaluation by Gynecology. Family history: no interest. Physical examination: alert, oriented, cooperative, good general condition, tolerates recumbency, normally hydrated and perfused, normally colored. Normal PCA, abdomen without findings, normal LS and normal basic neurological examination. Complementary tests: normal complete analysis; normal ECG; Cranial CT: no alterations of pathological significance are observed; EEG fundamental activity of normal values; echocardiography: hepatic cyst. Abdominal ultrasound: polycystic lesion in right hepatic lobe with thick hyperechoic septa, intracystic fluid with internal echoes, lesion close to the cava and adjacent to the right suprahepatic vein, which appears to displace medially. Abdominal echo-Doppler: no significant Doppler signal is identified. Abdominal CT: Right hepatic libe shows a rounded cystic image Differential diagnosis: syncope of cardiovascular, neurogenic, psychogenic, metabolic and compressive etiology due to mass effect. Clinical judgment: recurrent syncope of vascular compressive etiology due to hepatic hydatid cyst. Due to the sex and age of the patient, there is a tendency to think of a vasovagal cause of syncope, but we must not forget the rest of the etiologies if we do not want to be surprised. It is worth highlighting the importance of ultrasound in Primary Care to diagnose some other pathologies.
Álvaro MARTÍN PÉREZ (Badajoz, Spain), Vanesa YAÑEZ BERMEJO, Ignacio SIERRA MAYNAR, Luis CADAVAL LOPEZ
00:00 - 00:00
#41783 - HEPATITIS C VIRUS (HCV) SCREENING IN AN EMERGENCY DEPARTMENT (ED), AN EFFECTIVE STRATEGY TO HEPATITIS C ELIMINATION.
HEPATITIS C VIRUS (HCV) SCREENING IN AN EMERGENCY DEPARTMENT (ED), AN EFFECTIVE STRATEGY TO HEPATITIS C ELIMINATION.
Background and Aims:
Spain may be one of the first countries to achieve the World Health Organization's goal of eliminating viral hepatitis C by 2030. A serosurvey by the Spanish Ministry of Health 2017-2018 estimated a 0.22% hepatitis C virus (HCV) active infection prevalence among the general population, but a large number of people are unaware of their infection status. Increasing HCV screening is a priority. Emergency Departments (ED) often act as safety nets due to health equity issues for key populations affected by viral hepatitis, as they often lack optimal links with their primary care providers.
We aimed to evaluate HCV screening efficacy in the ED of Torrecárdenas University Hospital, in Almería, Spain.
Methods
We implemented opportunistic HCV screening in the ED (FOCUS Program), using existing infrastructure and staff. Patients ages 18 to 69 were eligible for testing if they did not have a known diagnosis or test performed in the previous year and required blood tests at the current ED visit. We used the LIAISON®X- Diasorin assay for HCV antibodies (anti-HCV) and the Roche Cobas® 6800 for viral RNA (HCV RNA) in the same specimen. Appropriate follow-up or discharge was given regardless of test results. We contacted positive patients to ensure linkage to care.
Results
We screened 20,394 patients from August 2021 to March 2024, finding 332 anti-HCV positive patients (average age 56 y.o, 75% male) and 75 HCV RNA positive patients (83% males).
With these data, the seroprevalence rate in the population that comes to our hospital ED is 1.63%, and the active infection rate is 0.37%. Of the total number of patients with active infection, 62 (83%) have been linked to care. A large percentage of viremic patients had stage F3-F4 liver cirrhosis, indicating a late diagnosis in the course of their HCV infection.
Conclusions
Undocumented HCV infection among our population is higher that estimated in the Spanish population. Hepatitis C screening in EDs is an effective strategy to increase the rate of diagnosis of HCV infection and should be considered in more hospitals.
Gilead Sciences’ FOCUS Program funding supports screening & linkage to a first appointment after diagnosis regardless of how organizations handle subsequent patient care and treatment
Anny CAMELO CASTILLO (Almería, Spain), Antonio DUARTE CARAZO, Teresa JORDÁN MADRID, Manuel RODRÍGUEZ MARESCA, Teresa CABEZAS FERNANDEZ, Alba CARRODEGUAS, José Luis GONZALEZ, Jose VEGA SAENZ, Marta CASADO MARTIN
00:00 - 00:00
#41150 - Hepatitis C virus screening program in an emergency department and results of the first ten months of implementation.
Hepatitis C virus screening program in an emergency department and results of the first ten months of implementation.
Introduction:
Following the worldwide healthcare strategies against viral hepatitis for 2022-2030, the World Health Organization (WHO) has set the global goal to eradicate hepatitis C virus (HCV) infection by 2030.
It is estimated that the prevalence of active HCV infection in Spain is 0.2%, but there is a considerable number of patients with silent infection who are unaware of their status, so their detection through screening strategies is indispensable.
Emergency departments (ED) represent an opportunity to improve HCV screening.
Objectives:
The main objective of this project is to develop a multidisciplinary HCV screening program in the ED of our hospital, in order to detect the maximum number of patients and achieve future automation.
Methods:
The screening program is carried out in the ED of our University hospital that visited 123,471 people in 2023 and is a community reference for a population of more than 200,000 inhabitants and a reference center for processes that require high technology for more than 2 million inhabitants.
Continuous training is provided to the entire medical and nursing team of our ED with the aim of raising awareness of the importance of screening, both for patients and for the community, and requesting serology.
A pre-configured application for HCV serology has been developed and information campaigns are carried out periodically.
Target population: patients aged 30-70 years who consult the ED and for whom an analysis is requested according to routine clinical practice.
Circuit: Project staff inform patients of the positive results and will refer them to a Gastroenterology consultation, who will decide on subsequent care.
Results:
The screening program started on June 1, 2023. Within the first ten months (June 2023-March 2024), 3262 serologies were requested (average of 11 per day) of the total of 12,500 that constituted our target population, achieving 26% of the objective. Of these, 93 (2.85%) resulted positive, and 10 (0.31%) presented positive viral load (PVL). All patients with a PVL (100%) were linked to a first Gastroenterology consultation.
Conclusions:
The prevalence of patients with active HCV infection in our ED is greater than 50% of the global prevalence recorded in Spain, which demonstrates the importance of screening in EDs.
The opportunistic screening program in the ED has achieved full linkage to Gastroenterology consultations for 100% of patients with HCV PVL.
Automating the process will help to increase the number of patients screened, link those with PVL and thus converge with the WHO objective of being able to eradicate HCV by 2030.
Ferran LLOPIS (Barcelona, Spain), Ana SUÁREZ-LLEDÓ, Alexis REBOLLO, Laura CALATAYUD, María Jesús URDÁNIZ, José CASTELLOTE, Alba CARRODEGUAS, José Luis GONZÁLEZ, Pierre MALCHAIR
00:00 - 00:00
#41297 - Hidden in Plain Sight: Resolving Paradoxical Embolism as a Stroke Trigger in a Young Athlete.
Hidden in Plain Sight: Resolving Paradoxical Embolism as a Stroke Trigger in a Young Athlete.
Brief Clinical History:
A 22-year-old competitive runner presented to the emergency department with sudden onset of confusion and right-sided weakness. The symptoms appeared abruptly during a routine training session. The patient was previously healthy, with no history of smoking, drug use, or significant family history of cardiovascular disease.
Misleading Elements:
The patient's young age and healthy lifestyle initially led clinicians to consider more benign causes such as dehydration or electrolyte imbalances common in athletes. His vigorous physical activity level and lack of traditional stroke risk factors also diverted attention from more serious neurological conditions.
Helpful Details:
Upon detailed questioning, the patient mentioned a recent long-haul flight two weeks prior, where he experienced mild shortness of breath and leg cramps, which he had attributed to muscle soreness from sitting. A thorough neurological examination revealed aphasia and right-sided hemiplegia, which heightened the concern for a cerebrovascular event.
Differential and Actual Diagnosis:
The differential diagnosis included transient ischemic attack (TIA), migraine with aura, and seizure. However, given the abrupt onset of symptoms and focal neurological deficits, a CT scan followed by an MRI was performed, revealing an ischemic stroke in the left cerebral hemisphere. Further investigations with a echocardiogram confirmed the presence of a patent foramen ovale (PFO), suggesting a paradoxical embolism as the stroke's cause.
Educational and/or Clinical Relevance:
This case underscores the importance of considering paradoxical embolism in young patients presenting with ischemic stroke, especially those with recent potential for venous thromboembolism, such as prolonged immobility during travel. It highlights the need for a thorough assessment and consideration of all potential risk factors, regardless of patient age or perceived health status. This case also emphasises the role of echocardiography in the diagnosis of PFO in stroke patients, which can significantly impact the management and secondary prevention strategies, including the potential closure of the PFO.
Dr Firas ABOU-AUDA (London, )
00:00 - 00:00
#42353 - Hidden intramural aortic hematoma.
Hidden intramural aortic hematoma.
Traumatic intramural aortic hematoma (IMH) is a potentially life-threatening condition, with a mortality rate of 30%. Krukenberg first described IMH as an aortic dissection without initial intimal tear, often referred to in the literature as atypical aortic dissection.
Although the imaging findings of intramural aortic hematoma are distinct from those of aortic dissection and are easily recognizable, the clinical presentations can be indistinguishable, as both conditions are part of the acute aortic syndrome. Ninety-four percent of intramural hematomas have a non-traumatic cause. Among hematomas of traumatic cause, 75% occurred in a traffic accident. Eighty percent of patients reported chest pain, back pain, or both. The presence or absence of ulceration in imaging tests has important prognostic implications with a high probability of progression if only medical treatment is performed.
Brief clinical history: A 75-year-old woman with a history of non-valvular atrial fibrillation and arteriosclerosis, anticoagulated with Apixaban 5 mg, presents to the emergency department after a casual fall from her own height with trauma to the left shoulder and hemithorax. After an X-ray, she is diagnosed with a non-displaced fracture of the proximal humerus and thoracic contusion, which are managed conservatively with analgesia and immobilization using a sling.
Two days after the fall, she returns to the emergency department presenting dyspnoea, central chest pain radiating to the back, and sweating.
Misleading elements: Physical examination reveals the patient is conscious, oriented, cooperative, and sweaty. She is eupneic at rest without oxygen. Temperature is 36.7°C. Blood pressure is 105/61 mmHg. Oxygen saturation: 93%. Cardiac auscultation reveals an irregular rhythm at 90 beats per minute. Pulmonary auscultation shows preserved vesicular murmur. Abdomen is non-tender with negative bilateral percussion.
Helpful details:
ECG shows sinus rhythm at 75 bpm. Normal axis. Normal PR interval. Narrow QRS complex. T-wave flattening in leads I, aVL, V4-V6. Laboratory analysis reveals a hemoglobin level of 9.9 g/dL with no abnormalities in coagulation or biochemistry.
Chest X-ray shows mediastinal widening, prompting a decision to perform a thoracic CT scan, which reports thickening of the wall affecting the ascending, descending thoracic aorta, and aortic arch with a crescent-shaped morphology consistent with an intramural hematoma measuring 1.6 cm in thickness. A small contrast extravasation is identified in the aortic arch, 6 mm cranial to the origin of the left subclavian artery, suggesting a small aortic ulcer with active leakage.
Differential diagnosis: thoracic contusion / traumatic intramural aortic hematoma.
The case was discussed with cardiac surgery. The patient undergoes intervention with thoracic endoprosthesis placement and occlusion of the left subclavian artery, showing good postoperative evolution and being discharged asymptomatic ten days after the surgery.
What is the educational and/or clinical relevance of the case?
Elderly patients with multiple comorbidities may present with atypical injuries following a trivial fall. A high index of suspicion is necessary to identify potentially life-threatening lesions in patients with traumatic histories who initially do not show symptoms. A combination of atherosclerosis and oral anticoagulation may have contributed to the development of this unusual intramural aortic hematoma.
María Teresa AMPUDIA GARCÍA (yes, Spain), Rubén LÓPEZ GONZÁLEZ, Gregorio Enrique FERNÁNDEZ FERNÁNDEZ, Michael DAWS GÓMEZ-LANDERO, Raquel GARCÍA GONZÁLEZ, Saul ESCUDERO ALVAREZ, Miriam MARTINEZ FERNANDEZ, Carlos REHBERGER GARCIA, Alberto ALVAREZ MADRIGAL, Maria Anunciacion LAMUEDRA GIL DE GOMEZ, Juan Manuel SANTOS ESCUDERO, Humera SAFIR JABEEN
00:00 - 00:00
#42177 - History of a conquest: the otitis media from another point of view.
History of a conquest: the otitis media from another point of view.
We are presenting a 20 years old female with previous history of chronic suppurative otitis media in her youngest age without any targeted therapy, that arrives at the primary care (general medicine) with a clinical presentation of fever, otalgia and otorrhea diagnosed with acute otitis media and starting a therapy with Amoxycilin 500 mg. After three days of treatment the patient was still with pain so she reconsulted switching the antibiotic to Amoxycilin-Clavulanate 875/125 mg. Four days after, the patient came to the hospital for persistent otalgia without fever.
The clinical examination showed a perforated tympanic membrane with abundant otorrhea. The patient spoke a different language and only had local symptoms. However she had difficulty understanding commands and a tendency to drowsiness.
While under observation, she had a decreased level of consciousness requiring orotracheal intubation and an emergency tomography that revealed an otomastoiditis with an image suggestive of collection with probable areas of cerebritis with vasogenig oedema at the right temporal level. Consequently the team began a treatment with Cefotaxime, Ampicilin, Metronidazole and Dexamethasone and the patient was referred to the intensive care unit where remained until she underwent surgery and regained clinical stability. As differential diagnosis we had a brain tumor, an epileptic seizure or a brain abscess, which was the final diagnosis.
This is an interesting case from a medical point of view due to the fact that this is a rare complication of the otitis media. In fact, the literature explains that brain abscess is a dreaded complication of otitis media and it still can result in mortality in about 10% of cases. The most frequent location is the temporal lobe and cerebellum by infecting directly from the middle ear. Furthermore, it is more frequent in people with medical records of chronic otitis media (just like our patient) and cholesteatoma. The early sings and symptoms are fever, headache, bad-smelling otorrhea and drowsiness. It may cause a deadly meningitis if the abscess ruptures into the ventricle or subarachnoid area. The previous use of corticosteroids or antibiotics could lead to an abscess encapsulation. The best diagnostic approach is by using MRI better than with CT scan; however, CT scan may identify the abscess earlier.
This case emphasizes the importance of a thorough anamnesis and physical examination besides a good teamwork.
Teresa CASTELLÓ IVARS, Teresa CASTELLÓ IVARS (Jávea, Spain), Nilieska CANO SANTANA
00:00 - 00:00
#41526 - HIV detection in the Emergency Department.
HIV detection in the Emergency Department.
Introduction
The fight against underdiagnosis and late diagnosis of HIV belongs to the entire health system, including emergency departments.
According to some published studies, the prevalence in the Spanish Emergency Department is higher compared with other departments within the healthcare system.
The Spanish Ministry of Health requires a prevalence of 0.1% to perform HIV screening.
Method
From the Spanish Society of Urgencies and Emergencies (SEMES) it was raised the procedure of testing for HIV at the Emergency Department in patients with Pneumonia, Mononucleosis Syndrome, Herpes Zoster, Drug abuse- Chemsex, Sexually transmitted Infections (STIs), Post-exposure prophylaxis to risky sexual relations and Hepatitis.
In our hospital we established the automatization of the petition for HIV test by creating profiles in our laboratory management system to ease the procedure for the doctors that solicitated the test. To achieve this, we added a HIV serology to the microbiologic test for patients belonging to the groups detailed previously. During the last trimester from 2021 a pilot study was carried with the new procedure and shortly after it was implemented to the training to the doctors and nurses from our service. Subsequently this model was exported to the rest of hospitals in our autonomous community.
Results
In 2021 the results for the pilot study during the last trimester of 2021 had a total of 168 serologies with 4 positives test, in 2022 VIH serologies 477 with 17 positive test and in 2023 VIH serologies 634 with 7 positive test.
Since the implementation of this new procedure the total of VIH serologies performed amount to 1279 with 28 positive cases (2.18%)
The distribution by processes was as follows: Pneumonia, VIH serologies 164, positive test 3 (1.82%); Mononucleosis Syndrome, VIH serologies 354, positive test 3 (0.84%); Herpes Zoster, VIH serologies 30, positive test 1 (3.33%); Drug abuse, VIH serologies 69, positive 0; STIs, VIH serologies 547, positive test 19 (3.47%); Post-exposure prophylaxis to risky sexual relations, VIH serologies 28, positive 1 (3.57%); Hepatitis ,serologies 65 positive 1 ( 1.53%)
Conclusions
The selective screening of these 6 selected processes is cost effective given that from the 1279 serologies performed a total of 28 new HIV cases have been diagnosticated, this amounts to a 2.18% of positive cases with post-exposure prophylaxis to risky sexual relations, STIs, herpes Zoster and pneumonia having the higher percentage of incidents.
Maria Carmen NAVARRO BUSTOS (BARCELONA, Spain), Antonio BARCO SÁNCHEZ, Jose Manuel GARRIDO CASTILLA, Fernando OLTRA HOSTALET, Isabel Maria MORALES BARROSO
00:00 - 00:00
#40773 - Hourglass appearance: A POCUS finding of Gastric Obstruction passing through a Diaphragmatic Hernia (Case Report).
Hourglass appearance: A POCUS finding of Gastric Obstruction passing through a Diaphragmatic Hernia (Case Report).
77 years old male patient, presented to ED due to 3 days of progressive abdominal distention and pain. Associated with intermittent non bloody vomiting. Review of other systems was negative. His past medical illness included Hypertension and Dyslipidemia. He also reports a severe blunt abdominal trauma due to car accident, more than 20 years ago. On examination, his vital signs were normal, he had significant abdominal distention, and mild tenderness to palpation all over the abdomen, but no guarding or rigidity. Immediately POCUS was done and showed a huge (>20 cm) fluid filled structure, mostly the stomach which was seen on all quadrants of the abdomen. But specifically, the left upper quadrant view showed this distended stomach having an hourglass appearance as it is passing through a hiatus hernia.
[I will include XRs, POCUS images and Coronal CT scan images, if possible, also GIF images or videos]
Learning Objectives:
1) To report the appearance of gastric obstruction passing through diaphragmatic hernia
2) To related remote history of trauma to acute presentation to ED
3) To briefly discuss the management steps of such cases
** If the EUSEM congress settings allows I would like to present it as a short oral presentation (but it would be better if I can attach videos or clips of the POCUS findings or the CT scan, rather than a still images)
Thank you.
Dr Basel ELMEGABAR, Dr Basel ELMEGABAR (Doha, Qatar)
00:00 - 00:00
#41085 - How Green Are You? Assessing Awareness, Practices, and Barriers to Environmental Sustainability in the Emergency Department.
How Green Are You? Assessing Awareness, Practices, and Barriers to Environmental Sustainability in the Emergency Department.
How Green Are You? Assessing Awareness, Practices, and Barriers to Environmental Sustainability in the Emergency Department
Introduction:
Climate change and ecological crises pose escalating threat to global health. Emergency Departments (EDs) at the frontlines play a critical role in caring for our vulnerable patients affected by extreme environmental events. The healthcare industry itself contributes 5% of global greenhouse gas (GHG) emissions. Therefore, every effort to reduce our carbon footprint in our workplace has a domino effect on our sustainability journey, for the betterment of our patients, ED staff, and the planet. While there have been limited data available from EDs internationally, it is important to understand the current practices, awareness and attitude towards environmental sustainability and identify the barriers before any recycling and other low carbon footprint initiatives can achieve meaningful success.
Objectives:
This study aims to find out the awareness, current practices, and attitudes of healthcare workers in the ED of Singapore General Hospital towards environmental sustainability together with the potential barriers that they may face at the workplace.
Method/Description:
With Singhealth Centralised Institutional Review Board approval, an anonymous questionnaire created by the secured national survey platform form.sg was sent to the nurses, and the physicians of all grades via E-mail, WhatsApp chat group, daily nursing rollcall, and flyers. The survey consists of 16 questions assessing existing knowledge, awareness, current practices, and potential barriers to recycling efforts in the department. It also explores possible plans on strengthening the awareness and increasing the recycling efforts both personally and within the department.
Results/Outcomes:
Eighty-one participants responded to the survey. Although most of the participants (75/81, 92.6%) acknowledge the importance of the awareness of environmental impact of ED related products and procedures, only half (42/82, 51.9%) are confident in their knowledge to guide their everyday practice. This could be attributed to lack of formal training and education. Despite habits of recycling at home and a strong willingness to do so at work, only 47/81 (58%) are aware of current recycling efforts in the department. The 3 most reported barriers to recycling practices in the ED included unwillingness to recycling due to time constrains, staff being unaware of current departmental initiatives, and lack of recycling facilities. Among the methods to increase the awareness and the practices of recycling in the department, formal curriculum during residency training (24/81, 29.6%), workshop and conferences (23/81, 28.4%), and e-learning module (17/81, 21%) are the most reported by the participants. Other valuable thoughts are also highlighted. Some examples are working out a win-win recycling solution which supports clinical practices and incorporates with current workflows, making downstream recycling processes more visible, and starting an initiative to reduce printouts in the department as a low-hanging fruit.
Conclusion:
There appears strong willingness from our ED staff to start recycling at work. These efforts are however dampened by limited knowledge, poor awareness, and significant barriers. This survey demonstrates high need in continued education on sustainability, strengthening recycling infrastructure, and ideally implementing win-win solutions which benefit both the environment and clinical practices.
Not applicable
Jeevan Raaj THANGAYAH (Singapore, Singapore)
00:00 - 00:00
#40867 - How much medicine and utensils are needed for acute, basic End-Of-Life palliation? An observational cohort study.
How much medicine and utensils are needed for acute, basic End-Of-Life palliation? An observational cohort study.
Background: End-of-life (EOL) care, also known as terminal care, is essential for alleviating patient suffering in the last days. The Acute, Basic Palliation Concept (ABPC) in this study included instructions for doctors and nurses, patient information, a medication box, and a decision tool. It was developed to support patients, relatives, and healthcare professionals in relieving suffering in patients who preferred to die at home. The aim of this study was to investigate the amount of medication and utensils used for EOL care in the ABPC study of patients without specialized palliative needs and a life expectancy of days.
Methods: This observational study was conducted in the North Denmark Region. Forty dying patients were discharged from the hospital using the ABPC, which included a box of medicine and utensils for EOL care. When the patient had passed away, the boxes were collected, the remaining medication and utensils counted, and the used medicine calculated.
Results: Of the 40 patients, boxes were picked up from 32 patients, whereas the rest had been sent for destruction by healthcare staff before we could retrieve them. Median time to death was 2.0 (1;3) days, mean age was 85 (standard deviation 9.4) years, and 69% were women. To cover 95% of the patient’s needs for EOL care the following were used: 20 vials of Morphine (10 mg/mL), 18 vials of Midazolam (5 mg/mL), four vials of Haloperidol (2.5 mg/mL), six vials of Glycopyrronium (0.1 mg/mL), and six suppositories of Bisacodyle (10 mg).
Conclusions: The number of medication vials needed for EOL palliative care in 95% of patients without special needs was documented in this study of 32 patients dying within a median of 2.0 days.
Mike ASTORP (Aalborg, Denmark), Dorte MELGAARD, Amanda Agnes Østervig Buus BUUS, Joschka Martin BAUER, Cecilie MØLLER, Caroline Rebbe KJELLERUP, Lisa ROUTHE, Anne Lund KRARUP
00:00 - 00:00
#42227 - How to detect upcoming emergencies in elderly patients at an early stage at home: The research project PAge@Home – A digital Patient Agent in the home environment.
How to detect upcoming emergencies in elderly patients at an early stage at home: The research project PAge@Home – A digital Patient Agent in the home environment.
Background:
During the next years there will be a rise in geriatric patients in many countries. Living at home, many of these patients need nursing care by family members. To support quality of life, strategies are needed to identify upcoming emergencies at an early stage, thus, some of these patients could be treated at home, e.g. by their GPs. and admissions to emergency departments (ED) could be avoided.
Here we describe a research project combining clinical information, e.g. vital signs collected by approved medical devices (MDs) and information of mobility and falls, collected by non-MD devices such as wearables, smart watches etc., focusing on evaluation of data quality and plausibility, thus, getting even more continuous information on patient’s health status. By combining these data with existing health data, health status could be monitored and deterioration detected at an early stage at home.
Methods:
Starting in February 2023 a “digital Patient Agent” for monitoring geriatric patients in their home environment (PAge@Home) is being developed. The PAge collects health relevant parameters using different MD and non-MD and combine them with existing health data (diagnoses, medication, laboratory values etc.). A rule-based AI-approach is used to assess patient’s health status and to detect deterioration on an individual basis. A prototype will be evaluated under controlled conditions in an emergency department as an addition to standard monitoring and treatment.
Results:
Up to date heart rate, blood pressure, oxygen saturation, body temperature, weight and fall events were identified as possible parameters, which can be monitored using non-MDs and MDs. A hardware-software system was developed to collect the raw data from various non-MDs and MDs, to check for plausibility and transfer it to a data repository for further processing. These data will be enriched with additional health data (diagnoses, medication plan, laboratory values etc.) and a rule-based AI-approach will generate a decision support for patients and medical staff. To prove the functionality, we identified the two symptom complexes: dyspnea and fever. Case vignettes have been developed to train the rule-based AI. Next steps are training of the rule-based AI, development of a graphical user interface for patients and medical staff to display AI-based decision support, followed by the laboratory- and field testings as described above.
Discussion & Conclusion:
In future, the PAge may assist outpatient care of geriatric patients. The user-friendly presentation of measured data and its interpretation may empower patients in their health perceptions and behaviors. By “pre”-preparing the data and supporting analysis, the PAge may enable medical staff to monitor even a larger number of patients without safety concerns. Early intervention could reduce further health deterioration as well as emergency admissions and in-hospital treatment. Furthermore, the PAge's outpatient monitoring options after hospitalization could enable earlier discharge and reduce readmission rates. Finally, in addition to improving quality of care, the PAge could contribute to reduce the economic burden on the healthcare system.
The project “PAge@Home” is funded by the German Federal Ministry of Education and Research for a three-year period (02/2023-01/2026).
Robert ARNDT (Berlin, Germany), Haink MICHELE, Naumann BJÖRN, Stahl MARIA, Schröer CHRIS, Simon KÖNIG, Kuner EDGAR, Andre SANDER, Durkovic MARCO, Soaz CHRISTINA, Reinhard GILLES, Wolfgang FRIESDORF, Nils LAHMANN, Rajan SOMASUNDARAM
00:00 - 00:00
#41786 - How to get Excellence in Geriatric Care in Emergency Departments? Adapting to the older is adapting to the new times.
How to get Excellence in Geriatric Care in Emergency Departments? Adapting to the older is adapting to the new times.
Introduction:
The General University Hospital of Villalba has responded to the increasing demand for care from elderly patients by implementing a comprehensive geriatric care program in its emergency department. This initiative aims to enhance the quality of care for this patient group. The accreditation received from the American College of Emergency Physicians (ACEP), the John A. Hartford Foundation, and the West Health Institute, known as GEDA, validates the hospital's ability to meet or exceed the standards and requirements for addressing older adults in the Emergency Department.
Methods:
The implementation process of the geriatric care program at the General University Hospital of Villalba's Emergency Department involved a multidisciplinary approach, with collaboration between the Emergency and Geriatric departments. Key actions taken included:
1. Adaptation of the physical environment: Modifications were made to the emergency department area to enhance mobility, autonomy, orientation, communication, and safety for elderly patients. This included providing specialized equipment such as warming blankets, suitable mattresses, and mobility aids like walkers or canes. Lighting and flooring were also adjusted to ensure a safe and comfortable environment for geriatric patients.
2. Staff training: A comprehensive training program was developed for emergency department staff, focusing on the clinical and social characteristics of elderly patients. Emphasis was placed on the importance of comprehensive care, including the early detection of geriatric syndromes, and involving elderly individuals in decision-making processes.
3. Implementation of protocols and procedures: Specific protocols and procedures were established for the care of older patients in the emergency department. The goal was to expedite the discharge process and ensure smooth transitions between different healthcare resources. Multidisciplinary care was promoted, involving various specialties and services to provide comprehensive and personalized care for elderly patients.
These efforts were aligned with the criteria established by the Geriatric Emergency Department Accreditation (GEDA), which is based on objective and measurable items to ensure quality care for elderly patients in emergency departments.
Results:
The implementation of the geriatric care program has significantly improved the efficiency and quality of care in the Emergency Department of the General University Hospital of Villalba. Key benefits include the early detection of geriatric syndromes, expedited discharge of elderly patients, and overall improvement in the experience of geriatric patients in the emergency department.
Conclusions:
The GEDA accreditation achieved by the General University Hospital of Villalba validates its commitment to providing comprehensive, specialized, and high-quality care for elderly patients in its Emergency Department. This accreditation recognizes excellence in the care of aging patients, with specific geriatric initiatives aimed at optimizing care in various areas. Objective and measurable criteria ensure quality care for elderly patients in emergency departments, promoting comprehensive, safe, and personalized care that meets the specific needs of this population group.
Alfredo PIRIS VILLAESPESA (MADRID, Spain), Lourdes DERISIO, Juan ANDUJAR TAVERAS, Maria Teresa CERDAN CARBONERO, Teresa NUÑEZ GOMEZ ALVAREZ, Borja HERNANDEZ MORENO, Daniel ROMERO PALACIAN, Maria MESTRE LUCAS
00:00 - 00:00
#41991 - HUMAN : AI INTERACTION.
HUMAN : AI INTERACTION.
Background:
Artificial Intelligence (AI) is the use of digital technology to create systems capable of performing tasks commonly thought to require human intelligence.
The use of AI in health and care is at an early stage. Currently AI based technologies are used for augmented decision making for health and care treatment decisions.
clinicians’ trust in AI remains a barrier to implementation (Markus, Kors and Rijnbeek, 2021)
Statistical accuracy in AI refers to how often the AI system’s predictions match the truth, potential problem of automation bias also occurs when humans overvalue information produced by an automated, usually computerised, system (Pot, Kieusseyan and Prainsack, 2021).
Aims & Objectives:
The aim of this project is to assess MSK AI Solution performance and benefits within the emergency/ acute setting.
The objective is to:
• Identify whether the AI solution is being used within emergency/ acute setting.
• Assess the staffs’ experience of working with the AI.
• To ascertain if there are any benefits of the MSK AI image report within the emergency/ acute setting, such as increased accuracy.
• Does the AI help the team to save time when dealing with patients or does it slow down the workflow.
Methodology:
• Retrospective staff user questionnaire
• Online performa to gather the data.
Results:
In total 50 questionnaires were completed, and these were from a range of different clinicians, including Advance and Emergency Nurse Practitioners, Junior and senior Doctors including Consultants.
38% always use AI, 35% use it often.
Question regarding if it impacts clinical decision making, 32% said it doesn’t impact their decision making.
68% Clinician feels it helps them gain confidence.
56% feels it save time in assessment. This could be researched further to assess if this is due to the AI system being new and therefore takes time to get used to or if AI makes the responders re consider an image. If this results in highlighting a missed fracture, then having no time gain is positive.
60% thinks AI has helped diagnose a fracture that was not detected.
84%finds AI reports helpful.
Despite the positive answers to the questions above, 84% (n=21) of responders would feel confident in overruling AI, which is important.
Some comments made responders are about the correlation with clinical findings, such as
“AI may assist in some cases however there are times when AI fracture diagnosis has no correlation with clinical signs and symptoms”.
Other comments on how AI cannot differentiate between anomalies or previous fractures, such as “Sometimes it highlights irregularities like bunion surgery or previous #”.
There are positive comments about the use of AI such as
“I do like to know it’s there as it’s good to see what they have picked up.
Conclusion:
Whilst AI holds immense potential to enhance the performance of clinicians as a technical supplement, it is not a replacement, but rather an augmentation of clinicians’ knowledge. Collaborative efforts between AI systems statistical accuracy and healthcare professionals have the potential to significantly improve diagnostic accuracy and patient outcomes.
Asim HABIB (Wigan, UK, ), Muhammad Saleem NASIR, Sana SIDDIQ
00:00 - 00:00
#42202 - Human Leptospirosis: A Case Report.
Human Leptospirosis: A Case Report.
Introduction: Leptospirosis, commonly known as "rat fever," is a bacterial disease transmitted to humans by certain mammals, especially rats and rodents. We report a case of leptospirosis with rapidly unfavorable progression.
Case Report: A 62-year-old man, hypertensive and diabetic, presented to the emergency department with asthenia, fever, and myalgia evolving for 4 days without a history of viral exposure. On examination, the patient was febrile at 40°C, conscious, well-oriented, without any signs of neurological deficit or meningeal syndrome. He was stable hemodynamically, eupneic, with pulse oxygen saturation at ambient air of 98%. Abdominal examination was strictly normal. He also had an isolated ecchymosis on the right calf without signs of purpura. Laboratory tests showed an inflammatory syndrome with CRP at 194 mg/l without leukocytosis or coagulation abnormalities. The rest of the workup was unremarkable. Chest X-ray did not reveal any pulmonary focus, and urine cytobacteriological examination was negative. Further questioning revealed a history of ingestion of dirty water a week prior, and the patient reported a rat and rodent infestation at home, suggesting leptospirosis as the cause of calf swelling. Initial management included administration of rabies vaccine and initiation of combination therapy with Amoxicillin-Clavulanic Acid (Augmentin) and Levofloxacin (Tavanic) without significant improvement. The patient developed an acute coronary syndrome without ST-segment elevation with positive troponins, for which he received anti-ischemic treatment. On day 3, the patient remained febrile at a plateau of 39°C with the onset of bilateral pneumonia, and he was transferred to the intensive care unit with escalation of antibiotic therapy to Piperacillin-Tazobactam in combination with Doxycycline and Teicoplanin. On day 4, he developed acute respiratory distress and septic shock. On day 6, the patient succumbed to multi-organ failure.
Conclusion: Leptospirosis is widespread worldwide, especially in precarious living conditions. Our case underscores the importance of recognizing this potentially deadly disease to establish an early diagnosis and improve patient prognosis.
Saloua HOUIMLI (la Marsa, Tunisia), Sarra AKKARI, Syrine TROJETTE, Kaouther BOUKADIDA, Amira TABKA, Nour El Houda MAATOUG, Fatma HEBAIEB
00:00 - 00:00
#40970 - Human umbilical cord mesenchymal stem cell-derived small extracellular vesicles ameliorate sepsis-associated acute kidney injury by suppressing inflammatory responses and glycolysis through the let-7a-5p/TLR4/NF-kB axis.
Human umbilical cord mesenchymal stem cell-derived small extracellular vesicles ameliorate sepsis-associated acute kidney injury by suppressing inflammatory responses and glycolysis through the let-7a-5p/TLR4/NF-kB axis.
Objective: To investigate the role and molecular mechanisms of human umbilical cord mesenchymal stem cell-derived small extracellular vesicles (hucMSC-sEVs) in sepsis-associated acute kidney injury (SA-AKI).
Methods: hucMSC-sEVs were obtained through ultracentrifugation combined with size exclusion chromatography, and characterized by transmission electron microscopy, nanoparticle tracking analysis, and western blotting. SA-AKI was induced by cecal ligation and puncture (CLP) in mice and lipopolysaccharide (LPS)-induced HK2 cell model, followed by intervention with hucMSC-sEVs. The biodistribution of hucMSC-sEVs in the SA-AKI mouse model was imaged using the IVIS spectrum imaging system. Serum creatinine, urea nitrogen and cystatin C were measured to evaluate kidney function. Histopathological changes of kidney tissues in mice were detected by H&E staining. The mRNA levels of renal injury molecules, inflammatory cytokines and key enzymes of glycolysis in kidney tissues of mice and HK-2 cells were determined by qPCR. The miRNA expression profile of hucMSC-sEVs was analyzed through small RNA sequencing.
Results: We found that hucMSC-sEVs exhibited significant improvements in SA-AKI both in vitro and in vivo. In vitro, hucMSC-sEVs inhibited inflammation and glycolysis in LPS-stimulated HK-2 cells. In vivo, administration of the hucMSC-sEVs improved the extent of weight loss, enhanced survival rate, reduced serum levels of creatinine, urea nitrogen, and cystatin C, ameliorated the pathological injury of kidney tissues in mice, and decreased mRNA expression levels of KIM-1, NGAL as well as IL-1β, IL-6, TNF-α, MCP-1, HK2, PKM2, LDHA, PDK1, and showing dose-dependent protective. Mechanistically, exosomal small RNA sequencing and qPCR analysis demonstrated that let-7a-5p, which is highly enriched in hucMSC-sEVs, has the ability to reduce inflammation and glycolysis by targeting TLR4/NF-κB pathway. Conversely, downregulation of let-7a-5p in hucMSCs attenuated the protective effects of hucMSC-EVs on SA-AKI in mice.
Conclusion: We have unveiled a novel potential therapeutic mechanism whereby let-7a-5p in hucMSC-EVs may ameliorate SA-AKI by modulating TLR4/NF-κB pathway to reduce inflammation and glycolysis, which may benefit patients with SA-AKI in future clinical applications.
Zhi-Qing CHEN (Jiangsu, China), Tang TAO-TAO, Chen FENG, Liu BI-CHENG, Tang RI-NING
00:00 - 00:00
#41835 - Hydatid vomiting in a 9-year-old child.
Hydatid vomiting in a 9-year-old child.
A 9-year-old child presented with a complicated hydatid cyst of the lung, which was diagnosed following an acute onset of dyspnea, skin rash, and vomiting. The patient had a favorable outcome after resuscitation and surgical treatment.
A 9-year-old girl from a rural environment with no previous pathological history presented to the emergency department with acute dyspnea associated with a cutaneous rash and one episode of vomiting. This followed a flu-like illness that had been evolving for a week and was improving, with only a residual cough. Her weight was 25 kg.
Upon admission, the patient's respiratory status on room air was 40 breaths per minute, with a Spo2 of 86% and no abnormalities noted upon pulmonary auscultation.
The patient's blood pressure was 90/55 mmHg, heart rate was 130 beats per minute, and there were no signs of peripheral hypoperfusion.
The patient's neurological examination was normal.
Palpation of the abdomen revealed tenderness in the right hypochondrium, with an estimated subcutaneous hepatic overhang of 3 cm.
- A generalized erythematous papular rash, pruritic but fleeting.
- An episode of vomiting of a salty liquid (poorly described by the girl).
- Apyretic at 36.8°C.
Chest X-ray: appearance of an excavated image with a hydroaeric level in the right lower lobe.
A hydatid cyst of the vomited right lung was first suspected, followed by a lung abscess.
In our case, the patient was stabilized and transferred to the pediatric surgery department for surgical intervention the following day. After five days of hospitalization, the patient was discharged and kept on respiratory physiotherapy and albendazole.
CONCLUSIONS:
Hydatid disease is a worldwide health problem. Children are frequently infested by the cyst in endemic countries. Surgery is the treatment of choice. However, prophylactic measures are essential to interrupt the parasite's life cycle.
Chebbi NABIL (Tunisie-Sousse, Tunisia), Rabeb MBAREK, Haifa BRADAI, Sondes LAAJIMI, Dorra LOGHMARI, Naoufel CHEBILI
00:00 - 00:00
#41506 - Hydronephrosis with Renal Pelvis Rupture Secondary to Endometriosis.
Hydronephrosis with Renal Pelvis Rupture Secondary to Endometriosis.
Compulsory Question: What are the key clinical and radiological findings suggestive of ureteral obstruction?
Answer: Key clinical findings suggestive of ureteral obstruction include severe left flank pain with left costovertebral angle (CVA) tenderness, radiating to the inguinal area, and associated nausea and vomiting. CT imaging reveal dilation of the renal collecting system with ureter, indicative of urinary obstruction with hydronephrosis.
Brief Clinical History: A 30-year-old female with a history of endometriosis, including excision, left ureterolysis, and ovarian cystectomy, presented to the Emergency Department (ED) with severe left-sided flank pain radiating to the left inguinal area. She exhibited left costovertebral angle (CVA) tenderness, and the pain progressed gradually to sharp severity, accompanied by nausea and vomiting. This episode of pain was distinct from her typical endometriosis-related abdominal pain. Despite the severity of symptoms, the patient did not manifest infectious or urinary symptoms, fever, or frank hematuria. Vital signs were within normal limits except for left CVA tenderness and left-sided flank tenderness.
Misleading Elements: Absence of typical infectious or urinary symptoms may initially lead to underestimation of the severity of the condition. Gradual onset of pain progressing to sharp severity may initially suggest a non-urgent etiology.
Helpful Details: History of endometriosis-related surgeries provides context for potential complications. Presence of left CVA tenderness indicates a potential obstructive uropathy. Radiating pain to the groin is classic for nephrolithiasis but was not confirmed on imaging. Lack of urinary symptoms and normal urinalysis help rule out infectious etiologies. Imaging findings of left renal collecting system dilation and ureteral obstruction support the diagnosis.
Differential Diagnosis: Ureteral obstruction secondary to nephrolithiasis, Urinary tract infection, Pyelonephritis, and Renal pelvis rupture.
Actual Diagnosis: Ureteral obstruction secondary to endometriosis causing renal pelvis rupture.
Educational and/or Clinical Relevance: This case highlights the importance of considering endometriosis-related complications in the differential diagnosis of acute flank pain, especially in patients with a history of endometriosis. It underscores the value of a thorough history and examination, including recognition of atypical symptoms, in guiding diagnostic workup and management decisions. The case emphasizes the need for appropriate imaging modalities to confirm the diagnosis and assess the extent of complications. Understanding the varied and complex presentations of endometriosis-related complications is crucial for timely intervention and optimal patient outcomes.
Wayne MARTINI (Scottsdale, USA), Shari BRAND, Marcie TORRES, Andrej URUMOV, Matthew VAN LIGTEN, Nicole HODGSON
00:00 - 00:00
#41201 - Hypertensive encephalopathy in the Emergency Department, a case of Posterior Reversible Encephalopathy Syndrome (PRES).
Hypertensive encephalopathy in the Emergency Department, a case of Posterior Reversible Encephalopathy Syndrome (PRES).
Hypertension is commonly encountered in the Emergency Department. While Emergency physicians are understandably concerned about hypertensive emergencies, such occurrences are rare. Here, we present a case report of hypertensive encephalopathy causing posterior reversible encephalopathy syndrome (PRES), manifesting in a patient with altered mental status and seizures. We discuss also the risk factors for PRES, common symptoms and signs, investigation, management, and PRES as a crucial consideration for patients with hypertension and altered mental status in view of the differences in subsequent management as compared to other differential diagnoses. With timely recognition and treatment, most patients with PRES exhibit a complete recovery in several days. In summary, our patient is a 65 year old lady with a background of diabetes mellitus, hypertension, and hyperlipidemia who was found semiconscious in her cabin with fecal incontinence. She was drowsy, had a blood pressure of 227/105mmHg, and a capillary blood glucose count of 27mmol/L. Computer Tomographic (CT) scan of the brain noted small hypodensities in the right frontal lobe representing age indeterminate and possibly chronic lacunar infarcts. While still in the Emergency Department, she had a witnessed generalised tonic-clonic seizure, which was swiftly aborted with intravenous diazepam. Systolic blood pressure for the patient was by now trending consistently above 220mmHg. Clinical impression was that of altered mental status possibly secondary to PRES. Titrated insulin infusion therapy was started for the hyperglycemia, levetiracetam for seizure control, and a nicardipine infusion started for blood pressure control. Subsequently, the patient appeared more alert as blood pressure started to trend downward, though she remained slightly confused with a GCS of 14 (E4, V4, M6). However, there was a dichotomous thought process to treat her as having an ishchemic stroke based on the CT findings versus posterior reversible encephalopathy syndrome(PRES). This is a very important point of distinction as one would involve reduction in blood pressure (PRES) whereas the other would allow permissive hypertension (stroke). In the ED, we had initiated BP lowering medications which was discontinued in the ward initially. However, after an MRI brain was performed that revealed the classic findings of PRES, BP target was lowered and anti-hypertensive medications were started with good clinical effect. The patient had a repeat MRI brain performed 2 weeks later that showed near-resolution of areas of cortical and subcortical white matter signal changes associated with swelling, predominantly in the posterior distribution involving both occipital lobes, classical for PRES. This is an important case as the management of PRES differs from that that of ischemic stroke, which is another common cause of altered mental status in the Emergency Department. In the former, we aim for a reduction of blood pressure, where in the later permissive hypertension is allowed. This presents a clinical conundrum that can affect patient outcomes, hence, the diagnostic accuracy of the Emergency Physician and index of suspicion has to be high for detecting PRES in high-risk patients.
Jeevan Raaj THANGAYAH (Singapore, Singapore)
00:00 - 00:00
#42324 - Hypnosis during lumbar puncture in the emergency department: a prospective study on pain.
Hypnosis during lumbar puncture in the emergency department: a prospective study on pain.
introduction: Hypnosis is a recognised adjuvant analgesic technique suitable for many situations, but is still being developed in emergency medicine.
Lumbar puncture (LP) is one of the most painful procedures commonly performed in emergency departments.
The main objective of our study is to compare the pain felt according to the use or non-use of hypnosis for the performance of LP in the emergencie department.
Method: Prospective multicentre study of patients >18 years of age who underwent LP with or without hypnosis between May and October 2023. The contribution of hypnosis was evaluated according to the maximum pain felt, patient anxiety, duration of the procedure and satisfaction of the operator.
Results: 30 patients included: 10 patients benefited of hypnosis The median VAS was 2.5 [1.25; 5] with hypnosis compared with 4 [4; 6] in the control group (p = 0.04). Median anxiety was 0 [0; 1] with hypnosis vs 1 [0.5; 3] in the control group (p=0.05). Hypnosis did not significantly increase the duration of the procedure: 10 [5 ; 15] minutes vs 15 [7.5 ; 20] minutes in the control group (p =0.16). Operator satisfaction was not significantly different: 9/10 [8.75 ; 9] in the hypnosis group vs 8 [8 ; 9] for the controls (p= 0.24). Multivariate analysis showed that membership of the hypnosis group was the only factor independently associated with VAS.
Conclusion: The use of hypnosis is associated with a significantly lower VAS and anxiety level without modifying the duration of the procedure or the satisfaction of the operator. It would be interesting to study the feasibility of democratising hypnosis in the emergency environment.
Hamza TOBI (RABAT, Morocco), Aziz BERTUL, Naoufel CHOUAIB, Tahir NEBHANI, Ahmed BELKOUCH, Saad ZIDOUH, Lahcen BELYAMANI
00:00 - 00:00
#41609 - Hypokalaemia Induced Arrhythmia - ECG Features and Management.
Hypokalaemia Induced Arrhythmia - ECG Features and Management.
The electrocardiogram features of severe hypokalaemia can masquerade as myocardial ischemia. Clinical suspicion for hypokalaemia must remain high given the vast difference to approach and management of these disparate conditions. Severe hypokalaemia is a medical emergency, and must be recognised and promptly treated to minimise risk of degeneration into malignant arrhythmias, alongside other undesirable outcomes.
We describe a case of a 29-year-old woman presenting with multiple episodes of non-exertional presyncope culminating in a seizure at home, with alarming ECG changes on arrival in our ED. She did not have a background of cardiovascular risk factors, nor a history of angina. Her cardiovascular and neurological exam was normal on physical examination. Her initial electrocardiogram (ECG) showed a prolonged QT interval at 510ms with multiple ventricular ectopics, with widespread ST depressions, T wave inversions and U waves.
Suspicion of electrolyte abnormalities causing ECG changes were entertained, which was confirmed by point of care testing showing profound hypokalaemia. Careful history taking revealed diuretic use in the form of weight loss supplements procured online as the likely aetiology of her hypokalaemia. She was kept on continuous electrocardiogram monitoring with initiation of aggressive potassium replacement via both oral and intravenous routes. After a period of observation within the Emergency Department, during which she remained alert with stable vitals, she was sent up to the General Ward on continuous telemetry. At the point of transfer, the ventricular ectopics, inverted T waves and U waves present on her initial ECG had resolved. She unfortunately then suffered cardiac arrest on the General Ward, with initial Torsade-de-pointe morphology on telemetry which degenerated into pulseless ventricular tachycardia. This event was detected immediately by telemetry monitoring and she had return of spontaneous circulation after 10 chest compressions, with return of consciousness to baseline. She was transferred to the Medical High Dependency where she underwent central line insertion for more concentrated potassium replacement. She made a full recovery and was discharged shortly after with resolution of her hypokalaemia and correspondingly, her electrocardiogram changes.
This case report aims to serve as a revision on the characteristic ECG features of hypokalaemia, as well as elucidate the emergent management of hypokalaemia and its associated arrhythmias. The ECG features of severe hypokalaemia may be easily confused with ischemic changes. It is an important differential to be cognisant of, with high mortality and morbidity if missed. This case also serves to highlight how the rising consumption of supplements and alternative medications make them an important aetiology to consider.
Dawn TAN (Singapore, Singapore), Wei Ling TAY
00:00 - 00:00
#41328 - Hypokalemic hypochloremic severe metabolic alkalosis due to duodenal stenosis.
Hypokalemic hypochloremic severe metabolic alkalosis due to duodenal stenosis.
Introduction: Metabolic alkalosis (MA) is a common acid-base disorder in hospitals. pH > 7.45 in blood gas is defined as alkalosis, pH > 7.60 is defined as severe alkalosis. Mortality rate is directly related to the severity of acid-base disorders. Mortality increases to 80% when serum pH exceeds 7.60. The most common causes of saline-responsive MA are extracellular volume depletion, high doses of antacids, gastrointestinal fluid losses, and diuretics.
Case: A 30-year-old male patient was admitted to the emergency department with a complaint of vomiting. In the patient's story, it was learned that he came from Syria and was injured in his abdomen during the war and had surgery. He stated that the patient had been vomiting for a long time, but it had increased significantly for a few days. The patient's general condition was moderate, he was conscious, cachectic and had involuntary contractions in his fingers. There was no tenderness in the abdomen. Other system examinations and rectal examination were normal. Blood pressure: 100/60mmHg, respiratory rate: 14/min, SO2: 98%, pulse: 110 beats/min, body temperature: 37.0 C. In venous blood gas, pH: 7.87, pCO2: 37mmHg, HCO3: 74.9mmol/L, BE: 43.1, lactate: 1.3mmol/L, K: 2.4mmol/L, Ca++: 0.81mmol/L. Blood gases were repeated to confirm severe MA. There was sinus tachycardia on the ECG and QTc: 497ms. In the laboratory, K: 2.6mmol/L, Na: 135mmol/L, Cl: 51mmol/L, Ca: 11.35mg/dL, Urea: 82mg/dL, creatinine: 1.9mg/dL, hGFR:45ml/min/1.73m2. On bedside ultrasound, there was no free fluid in the abdomen, there was grade 1 echogenicity in bilateral kidneys, and there was no urine in the bladder. Saline and potassium replacement was started. Urine output was observed at the end of the 1st hour. At the 6th hour of the treatment, the ECG showed heart rate: 79 beats/min, QTc: 448ms and pH: 7.60, pCO2: 40mmHg, HCO3: 64.6 mmol/L, BE: 40.9. Abdominal non-contrast CT was imaged. The stomach and duodenum were observed to be distended (Figure 1). The patient was transferred to the intensive care unit and his blood gas on the 3rd day was pH: 7.48, pCO2: 40mmHg, HCO3: 35mmol/L, BE: 12.5. Endoscopy was performed after the patient's clinical findings were stable. Endoscopy revealed reflux esophagitis grade B, pangastritis, deformity and dysfunction in the pylorus, ulcer (Forrest III) and stenosis in the duodenum bulbus. The endoscope is forced and gently pushed II. segment was passed. The lumen and mucosa in the second segment of the duodenum were normal.
Conclusion: In our case there was deformity and stenosis in the duodenal bulbus. Severe MA due to duodenal stenosis is commonly reported, especially in newborns, but is very rare in adults. Among the causes of duedonal stenosis, peptic ulceration, inflammatory strictures and malignancy (primary or secondary) are more common in adults. However, our case was injured in the abdomen in the war and had surgery. QTc was 497ms on ECG. As a result of early diagnosis and treatment, QTc improved to 448ms in the emergency department. Severe MA is a fatal condition. Early diagnosis and timely treatment reduce mortality.
Nalan KOZACI, Ismail Erkan AYDIN, Tugce ERSAHIN (, Turkey)
00:00 - 00:00
#42084 - Hyponatremia requires high resource level in the Emergency Department: a prospective cohort study.
Hyponatremia requires high resource level in the Emergency Department: a prospective cohort study.
Background:
Hyponatremia is the most common electrolyte disorder in clinical practice and is frequently encountered in the emergency department (ED). Symptoms are heterogenous and nonspecific and its severity can range from mild to severe and life-threatening. At the same time its symptoms can mimic a broad range of different acute conditions. This often requires the emergency physician to assess multiple possible differential diagnoses. To quantify the amount of resources required for these assessments and to evaluate the resource utilization specific to hyponatremic-patients in the ED, we conducted a prospective cohort study.
Methods: This monocentric prospective cohort study consecutively enrolled adult patients presenting with and without hyponatremia to the ED of a tertiary care center between February 2022 and January 2023. Hyponatremia was defined as serum sodium of 134mmol/l or below. Patient characteristics, presentation, required care, diagnostic and treatment received in the ED, length of hospital stay and level of care and mortality after 30 and 90 days were collected for each patient. Nominal characteristics were analyzed using the Chi-square test, ordinal and metric variables using the Mann-Whitney U test.
Results: 410 patients were included, 221 with hyponatremia (35.7% mild, 33.5% moderate, 30.8% severe) and 189 without. Patients with hyponatremia were more frequently hospitalized (77.4% vs. 60.3%, p<0.001) and directly admitted to the ICU (12.7% vs. 4.8%, p=0.037) despite similar age, sex, Charlson Comorbidity Index and triage category. In the ED, rates of fluid and medication administration were higher among patients with hyponatremia (76.0% vs. 47.1%, p<0.001 and 63.8% vs. 52.4%, p=0.023, respectively).
Patients who presented with severe hyponatremia had a longer mean hospital stay (12.9 (SD 12.7) vs. 9.96 (SD 9.89) days (p=0.044)). There was no significant difference in in-hospital mortality, 30-day mortality or 90-day mortality between hyponatremic and non-hyponatremic patients in our cohort. However, hyponatremia did result in a higher number of requests for a higher level of care at 30-day follow-up (25.3% vs. 17.5%, p=0.037).
Discussion & Conclusion: The management of patients with hyponatremia consumes a considerable amount of resources, both in the emergency department and overall. The higher rates of hospitalization and ICU admission are consistent with the findings of previous studies. Previously reported increased risk of mortality from hyponatremia in larger cohorts was not found in our cohort. However, our findings indicate possible negative long-term effects in patients presenting with hyponatremia to the ED.
The study was founded by the Senate Department of Berlin for Urban Mobility, Transport, Climate Action and the Environment (Senatsverwaltung für Mobilität, Verkehr, Klimaschutz und Umwelt Berlin). The Ethics Committee of the Charité – University Medicine Berlin approved the study (EA1/132/21). Informed consent of each participant was obtained.
Eva DIEHL-WIESENECKER (Berlin, Germany), Sandra PFLOCK, Mona MAINERT, Prpic MONIKA, Kai KAPPERT, Wolfgang BAUER
00:00 - 00:00
#41771 - Hypovolemic shock due to central diabetes insipidus (arginine vasopressin deficiency) in the elderly.
Hypovolemic shock due to central diabetes insipidus (arginine vasopressin deficiency) in the elderly.
Hypovolemic shock is a critical reduction in the effective circulating blood volume with systemic hypoperfusion, which leads to ischemic damage to vital organs, resulting in multiorgan failure and death if untreated1. We report the case of an elderly Japanese woman with treatment-resistant hypovolemic shock due to central diabetes insipidus who eventually received a diagnosis of pituitary tumor. Central diabetes insipidus with hypovolemic shock is a rare condition because patients feel thirsty and consume water by themselves; however, the elderly, infants, patients with altered mental status, and intubated patients are known to be in the risk group2.
A 71-year-old Japanese woman was transferred by ambulance because of gradual development of fatigue over one month and difficulty in moving. She reported that she had visited another hospital one month ago for vomiting, appetite loss, and watery diarrhea, and had undergone upper gastrointestinal endoscopy and abdominal computed tomography (CT) with no significant findings. The patient had a history of dyslipidemia and total hysterectomy for uterine myoma.
On arrival, she was alert, and her Glasgow Coma Scale was E4V5M6. Blood pressure was 60/54 mmHg, pulse rate was 120 beats per minute and regular, respiration rate was 27 breaths per minute, SpO2 was 98% with a mask of 5L O2 per minute, and temperature was 39.7°C. On examination, pallor, dry mouth, collapsed jugular veins, and dry axilla without decreased skin turgor were observed. The patient presented with a normal auscultation of the lungs and heart. Laboratory data revealed elevated white blood cell count and creatine kinase level. It also indicated hypernatremia with a serum sodium level of 155 mmol/L. Computed tomography was performed to determine the cause of the shock; however, no significant findings were revealed with collapse of the inferior vena cava.
The patient received an extracellular fluid infusion 1500mL, but the shock persisted. For treatment-resistant hypovolemic shock, a urine examination was performed, which showed high urine osmolality at 263 mOsm/kg H2O. Magnetic resonance imaging revealed a pituitary tumor, and high signal intensity in the posterior lobe was absent on T1-weighted images. Panhypopituitarism was also observed in endocrine stress response tests, but the renin-angiotensin-aldosterone system maintained homeostasis. Thus, severe hypovolemic shock due to central diabetes insipidus and panhypopituitarism was diagnosed, and the patient was treated with desmopressin and hydrocortisone. The patient was discharged 32 days after admission and followed up for elective surgery.
Central diabetes insipidus, characterized by polyuria and polydipsia, is caused by a deficiency of arginine vasopressin. Diagnosis is often delayed because of several differential etiologies and difficulties in measuring polydipsia and polyuria. Thus, urinary tests including osmolality, which are convenient and inexpensive, should be considered when patients show treatment-resistant dehydration and hypernatremia. Furthermore, it is a rare condition in which central diabetes insipidus develops into a hypovolemic shock. However, we should be careful to see specific groups, such as the elderly, infants, patients with altered mental status, and intubated patients. They are at high risk of hypovolemic shock because they cannot compensate for themselves.
Tetsuya EGAWA (Aizuwakamatsu-shi, Japan), Kazuhiro KAMATA, Motoyuki MUNAKATA
00:00 - 00:00
#41913 - I am confused.
I am confused.
We were called to give medical care to a 40 years-old woman with confusion. At 17:30 h she went to take a nap and when she woke, she was confused. She didn´t recognized her childs and she didn´t even know her name.
When we arrive, the patient was aware but confused with a Glasgow Coma Score of 14. Her language was repetitive and obeyed order erratically. She couldn´t nominate objects. There were no dysarthria, hypoesthesia, palsy, or other focal signs on the neurological examination. She had no fever and no symptoms or signs of infections. EKG and her vital signs were normal. The physical examination was also normal.
We transferred her to the hospital where an urgent CT scan was performed excluding an acute cerebrovascular accident (ACVA) or other structural lesions. Blood and urine tests were normal, and toxicology screen was negative. Magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) were normal. Electroencephalogram (EEG) showed a left temporal epileptiform activity, so the diagnosis of non-convulsive status epilepticus (NCSE) confirmed. She was treated with Lacosamida with good response and was discharged with antiepileptic treatment.
The differential diagnosis of a confusional syndrome is wide. The most important in our case are ACVA, NCSE, encephalitis, and metabolic/toxic encephalopathy.
ACVA can present with isolated findings, such as language deficit or confusion. That’s why, in a patient with sudden onset of confusion, a Stroke should be ruled out. In this case, ACVA was discarded with a normal neuroimaging.
Encephalitis was another differential diagnosis in our patient. Encephalitis is an inflammation of the brain parenchyma that can be caused by infection or autoimmunity. The presentation of encephalitis usually consists of symptoms or signs of neurologic dysfunction (headache, decreased level of consciousness, seizures, focal deficits, papilledema, behavioral changes). At this case, encephalitis was ruled out by normal CT and MRI, and with a normal CSF.
Another differential diagnosis was acute toxic-metabolic encephalopathy (TME). TME is an acute global cerebral dysfunction manifested by altered consciousness, behavior changes, and/or seizures occurring as a consequence of systemic disorders in the absence of primary structural brain disease. The etiology of TME is diverse including organ dysfunction such as renal or hepatic failure, electrolyte/metabolic imbalances, infection, endocrine disorders, and drugs/toxins. To do the diagnosis of TME, neuroimaging test (such as CT or MRI), blood/urine test and toxicology screen should be performed. EEG is also necessary to confirm the diagnosis and to do the differential diagnosis with NCSE. In our patient, normal laboratory test ruled out TME, and EEG confirmed the diagnosis of epilepsy.
NCSE is defined as an ongoing state of seizures without convulsions for at least 30 minutes. The clinical manifestations of NCSE are highly variable and they include change in mental status, speech arrest, subtle movements, head/eye deviation, autonomic signs, automatisms, and bizarre behaviors. These features can challenge diagnosis, as such symptoms may arise from other conditions. Assessment includes laboratory evaluation, neuroimaging, and EEG. In our case EEG was essential to confirm the diagnosis.
Vanesa Natalia ISAAC, Cristina BARREIRO MARTÍNEZ, Blanca GUERRERO MOÑUS, Noemi SOTO TOSTADO, Marta HUEDO JIMENEZ, María REDONDO LOZANO, Pilar VARELA GARCÍA, Miriam UZURIAGA MARTÍN (Madrid, Spain)
00:00 - 00:00
#41612 - Imagine where it bleeds.
Imagine where it bleeds.
A 56-year-old woman with no history of interest, came to the emergency department due to abdominal pain in the right hypochondrium of sudden onset and partial improvement with conventional analgesia, associated in recent days with asthenia and intolerance to exercise.
On examination, she was afebrile, hemodynamically stable, with marked cutaneous and mucosal pallor. Abdominal examination revealed a painful mass in the hypochondrium and right flank on palpation without peritonism.
Laboraty tests showed normocytic anemia not present in previous studies (Hb 6.7 gr/dl) and slightly abnormal liver enzymes.
Given the suspicion of intraadominal bleeding, an urgent computerised axial tomography (CT) scan was requested, which showed an extensive hematoma in the right perirenal space with mass effect on the kidney, as well as a fatty lesion dependent on the lower pole with a major axis of 12 cm and a 2 cm pseudoaneurysm, with no evidence of active bleeding.
Transfusion of red blood cell concentrates was started and assessment by urology and vascular radiology was requested.
Finally, embolization of the pseudoaneurysm was performed due to the possibility of rebleeding and the patient was admitted to the urology department.
The patient had a good recovery, and was discharged ten days after admission.
FINAL DIAGNOSIS: PERIRENAL HAEMATOMA IN RELATION TO BLEEDING FROM RENAL ANGIOMYOLIPOMA.
DISCUSSION:
Angiomyolipomas are rare benign renal tumours (1-3%), consisting of fatty tissue, aberrant blood vessels and smooth muscle cells.
They can occur sporadically (80%) or in association with tuberous sclerosis and lymphangioleiomyomatosis (in these cases they are usually bilateral, multiple, larger and with a higher risk of bleeding).
Sporadic angiomyolipomas are more common in middle-aged women due to the hormonal role in their growth.
The vast majority are asymptomatic and are diagnosed incidentally when an abdominal imaging test is performed for another reason.
Patients may present abdominal pain, hematuria, an abdominal mass, anemia, and kidney failure.
Diagnosis is made by imaging studies, preferably an MRI with gadolinium, but computed tomography (CT) is also used. Ultrasound is not enough to completely define the diagnosis.
The most serious and feared complication is spontaneous rupture of a vessel, which may occur in up to 10% of patients, leading to Wünderlich syndrome, consisting of lumboabdominal pain, palpable mass and hypovolemic shock.
In these cases, an urgent CT scan and urological assessment should be requested, as the patient's life is at risk. In addition, patient stabilization must be carried out and possible therapeutic options evaluated.
Embolization is the procedure of choice in patients with acute bleeding, as it helps stabilize the patient and can avoid the need for more aggressive treatments.
It is minimally invasive, safer and has fewer complications than surgery. In patients where surgery is not possible, partial or total nephrectomy is indicated.
Isabel FERNÁNDEZ-MARÍN, Ana Belén CARLAVILLA MARTINEZ (MADRID, Spain), María CUADRADO FERNÁNDEZ, Luz Tamara VAZQUEZ RODRIGUEZ, Juan VILA SANTOS, Elena MARTÍNEZ CHAMORRO, Laín IBÁÑEZ SANZ
00:00 - 00:00
#41499 - Imaging in a Pandemic: How Lack of Intravenous Contrast for Computed Tomography Affects Emergency Department Throughput.
Imaging in a Pandemic: How Lack of Intravenous Contrast for Computed Tomography Affects Emergency Department Throughput.
Introduction: During the coronavirus 2019 pandemic, hospitals in the United States experienced a shortage of contrast agent, much of which is manufactured in China. As a result, there was a significantly decreased amount of intravenous (IV) contrast available. We sought to determine the effect of restricting the use of IV contrast on emergency department (ED) length of stay (LOS).
Methods: We conducted a single-institution, retrospective cohort study on adult patients presenting with abdominal pain to the ED from March 7–July 5, 2022. Of 26,122 patient encounters reviewed, 3,028 (11.6%) included abdominopelvic CT with a complaint including “abdominal pain.” We excluded patients with outside imaging and non-ED scans. Routine IV contrast agent was administered to approximately 74.6% of patients between March 7–May 6, 2022, when we altered usage guidelines due to a nationwide shortage. Between May 6–July 5, 2022, 32.8% of patients received IV contrast after institutional recommendations were made to limit contrast use. We compared patient demographics and clinical characteristics between groups with chi-square test for frequency data. We analyzed ED LOS with nonparametric Wilcoxon rank-sum test for continuous measures with focus before and after new ED protocols. We also used statistical process control charts and plotted the 1, 2 and 3 sigma control limits to visualize the variation in ED LOS over time. The charts include the average (mean) of the data and upper and lower control limits, corresponding to the number of standard deviations away from the mean.
Results: After use of routine IV contrast was discontinued, ED LOS (229.0 vs 212.5 minutes,
P =<0.001) declined by 16.5 minutes (95% confidence interval −10, −22).
Conclusion: Intravenous contrast adds significantly to ED LOS. Decreased use of routine IV contrast in the ED accelerates time to CT completion. A policy change to limit IV contrast during a national shortage significantly decreased ED LOS.
None.
Wayne MARTINI (Scottsdale, USA), Marcie TORRES, Andrej URUMOV, Shari BRAND, Nicole HODGSON
00:00 - 00:00
#41229 - Imapct the measures introduced in Life Support during the COVID-19 pandemic.
Imapct the measures introduced in Life Support during the COVID-19 pandemic.
Purpose of the study: To analyze wheter the preventive measures introduced in Life Support during the COVID-19 pandemic have had a negative impact on the quality and survival parameters of the Intrahospital Cardiac arrest (IHCA) management team.
Material and methods: Retrospective observational comparative study of CA activations of the IHCA team in a tertiary hospital between 2018-19 (G18/19: non-pandemic group) and 2020-21 (G20/21: pandemic group). It was approved by the ERB of the Hospital Clínic de Barcelona (HCB/2021/1075). Epidemiological and demographic data, return of spontaneous circulation (ROSC), survival and Glasglow outcome score (GOS) at hospital discharge were collected. Statistical analysis of the results was performed with IBM SPSS Statistics version 27.0
Results and Discussion: 395 patients (Prepandemic 189 vs Pandemic 206) were included in the study. Demographic data did not differ significantly between groups. IHCA team activations for CA were higher in the pandemic group (G18/19=30 % vs G20/21=37.9%, p=0.1). Onset times (G 18/19 =1.52 min vs G20/2 =1.45 min; p=0.55), duration of manoeuvres (G 18/19 = 21.61 min vs G20/21=22.84 min; p = 0.81), ROSC (G18/19=56.3% vs G20/21=53.5%; p=0.69) and survival at discharge (G18/19=28.2% vs G20/21=26,7.3%; p=0.79) showed no significant differences. 3 patients in G19 suffered a neurovegetative status at discharge and 4 patients in G20 a severe disability.
Conclusion: The changes to the IHCA protocols during the COVID19 pandemic have not led to a significant increase in resuscitation times and neither had a negative impact on ROSC or survival at hospital discharge in our institution. These data contradict those recently published.
References Gupta K et al. Resuscitation. 2022;170: 134–140
It was approved by the ERB of the Hospital Clínic de Barcelona (HCB/2021/1075)
Jaime FONTANALS (BARCELONA, Spain), Tio MONTSERRAT, Carrero ENRIQUE, Ramis BARTOMEU, Magaldi MARTA, Tercero FRANCISCO JAVIER, . COMMISSION FOR CARE FOR IN-HOSPITAL CARDIO-RESPIRA
00:00 - 00:00
#42204 - Impact of AI-Assisted Diagnostic Information on Medical Decision-Making in Emergency Medicine.
Impact of AI-Assisted Diagnostic Information on Medical Decision-Making in Emergency Medicine.
Background and Objectives: The integration of artificial intelligence (AI) in healthcare has profound implications for medical diagnostics and decision-making. This study evaluates the impact of AI-driven diagnostic information on the decision-making processes in emergency medicine, focusing on how AI influences physician approaches to diagnosis and treatment planning.
Methods: The study engaged 100 physicians, including interns, residents, and specialists, to evaluate the effects of AI assistance using the MedAssistAI application by AssistAI. Participants used the AI tool to diagnose patient cases and make treatment decisions. The study tracked the frequency and types of queries submitted to the AI application, analyzing its influence on diagnostic choices and treatment planning.
Results: The use of AI-assisted diagnostic tools significantly affected medical decision-making, enhancing diagnostic speed and accuracy. Physicians reported increased confidence in their decisions with AI support, noting a variation in reliance across different medical specialties. The application’s impact on clinical outcomes highlighted both its potential benefits and limitations in emergency settings. Our study is in its final data collection phase. Specific results will be presented in the final publication. Present conclusions are based on preliminary analysis and feedback obtained during the ongoing research period.
Conclusion: AI applications in emergency departments can improve diagnostic efficiency and accuracy, supporting complex decision-making processes. This study underlines the importance of further research to assess the long-term implications of AI in clinical practice and its transformative potential in emergency medicine.
No funding
Robert KRION (Gdańśk, Poland), Aleksandra SZYMCZYK, Klaudia KRZYZANIAK, Anna WSCISLAK, Mariusz SIEMINSKI
00:00 - 00:00
#42098 - Impact of Air Particulate Matter on Emergency Department Care for Elderly Patients at a Metropolitan Area.
Impact of Air Particulate Matter on Emergency Department Care for Elderly Patients at a Metropolitan Area.
World Health Organization (WHO) describes air pollution as a major environmental risk to health and suggests that reducing air pollution can reduce emergency department (ED) burden of chronic illnesses such as stroke, heart diseases and multiple respiratory illnesses including asthma. Outdoor air pollution was estimated to cause 3.7 million premature deaths in 2012 worldwide. Sources of air pollution are considered beyond the control of individuals and air quality guidelines were prepared by WHO and Environmental Protection Agency (EPA) for global standardization. People are encouraged to plan their daily outdoor activities based on these guidelines. A group of common air pollutants are regulated by EPA. These are ozone, nitrogen oxides, carbon monoxide, sulfur dioxide, particulate matter and lead. Other than serious carcinogenic effects outdoor air pollution can present with the symptoms like burning eyes, aching lungs, difficulty breathing, wheezing, coughing, headache, irritated throat and nose. These symptoms have been experienced by most of the urban population and described as an important factor for ED care. Geriatric patients are at higher risk due to heart disease, congestive heart failure, asthma, emphysema and bronchitis. Main aim of this paper is to examine air pollutants and its effects on ED care for elderly patients. Patients over 65 years old admitted to two major emergency departments at a metropolitan area with a population of 4 million people were evaluated. Air pollutant level data was publicly available online by the responsible government agency. ED admission rates for elderly patients and air pollutant levels were compared for the time period of January 2018 to January 2019. Patients over 65 years old were evaluated for fınal diagnosis, hospital admission rates, length of stay and mortality. Exclusion criteria were multitrauma patients and insufficient data. Patients were followed up from the hospital information system and by phone for final diagnosis. There were 278654 patient admissons to our ED and 2.4% (n=6697) of these were admitted to hospital wards. Average PM10, NO2, and CO levels were 58.4µg/m³, 65.1µg/m³ and 912.6µg/m³ respectively. Admission rates for over 65 year old patients were corraleted with elevated levels of air pollutants. Air pollutants are important factors for ED care of the elderly population. Patients and health workers should be informed about side effects of these pollutants and appropriate public health preventions should be implemented by the authotrities. EDs and hospitals should be prepared for increased admission rates during high levels of these air pollutants.
Erkan GUNAY, MD MPH (Istanbul, Turkey)
00:00 - 00:00
#42102 - Impact of COVID-19 restriction policies on road traffic injuries and related mortality in Turkey.
Impact of COVID-19 restriction policies on road traffic injuries and related mortality in Turkey.
Background and Objectives
According to a 2018 report by WHO road traffic injuries (RTI) are the leading reason of mortality for 5-29 age group worldwide. RTI and related mortality is important for Turkey with more than 1.1 million annual accidents and 5473 deaths in 2019.
First case of the COVID-19 was reported in March 2020 in Turkey. Following the Turkish National Scientific Board risk assessment meetings, various preventive measures were implemented including land border closures and national travel restrictions.
We aimed to investigate the impact of COVID-19 restrictions on RTI in Turkey and our facility.
Methods
Data from hospital information system retrospectively analyzed for the injured patients due to motor vehicle crashes or pedestrian strikes admitted to a level one trauma center in Istanbul. Patient demographic data such as age and gender, emergency department outcomes, and hospital admission rates were also recorded. Publicly available national data was obtained from the Turkish Statistical Institute website.
Results
RTI and related mortality at our facility significantly dropped during 2020 COVID-19 restrictions. Despite the decrease of total number of RTI the hospital admission rate was increased. National data analysis revealed that for the same time period RTI and related mortality decreased around 10%. But mortality rate increased from 0.46% in 2019 to 0.49% in 2020. In comparison to the data from previous years RTI were significantly dropped during April 2020 when traffic restrictions were implemented nationwide.
Conclusion
We found a significant drop in the total number of RTI and related mortality in our facility and Turkey. Contrarily admission rates for RTI at our facility and nationwide RTI related mortality rates were increased.
This study contributes to the understanding of the significance of COVID-19 travel restriction policies on RTI, and provides important data for the future implementations. Additional research is needed to understand overall impact of restriction policies on healthcare.
Erkan GUNAY, MD MPH (Istanbul, Turkey), Serkan GUNAY, PHD
00:00 - 00:00
#42019 - Impact of hypovitaminosis D on the outcome of severely burned patients.
Impact of hypovitaminosis D on the outcome of severely burned patients.
Introduction: Vitamin D deficiency is common in critically ill patients with severe infection and is associated with a worsened clinical outcome, especially in burn patients1.
The aim of our study was to assess the impact of hypovitaminosis D in burn patients.
Methods: Prospective, observational single-center study was conducted in intensive Burn Care Department in Tunisia over a period of 6 months (April-September 2023). Admitted burns with a presumed length of stay greater than 48 hours and those with hypovitaminosis D were included. Vitamin D levels were measured upon admission (25+1-25 OH vitamin D) using automated ELFA technique on VIDAS. Normal vitamin D levels range from 30-100 ng/ml. Hypovitaminosis D was defined as levels below 30 ng/ml, insufficiency between 10-30 ng/ml, and deficiency as <10 ng/ml. Pregnant women, children, patients with chronic renal failure and those admitted for burn sequelae management were excluded.
Results: During the study period, 91 patients were included. 87 had hypovitaminosis D (incidence of 95.6%). 53 patients (61%) had insufficiency and 34 patients (39%) had deficiency. The mean age was 33±12 years, with a sex ratio of 2.1. Total body surface area (TBSA) was 28 ± 9,8%. The average vitamin D level was 14.4 ± 6 ng/ml.
Patients with vitamin D deficiency (n= 34) were compared to those with insufficiency (n=53). Patients of 2 groups were comparable in terms of age (31.7±11.2 years for G1 vs. 33±9 years for G2; p=0.15) and burn extent TBSC (29.5±12.7% for G1 vs 26.6±8.4% for G2; p=0.84). Comparative study of two groups revealed that vitamin D deficiency was associated with an earlier onset of sepsis (days) (3,1±1,7 for G1 vs 5,8±2,4 for G2; p=0.04), a longer duration of sepsis(days) (19±7 for G1 vs 8,5±5.4 for G2; p=0.02), and a higher number of septic episodes( 4,2±1.7 for G1 vs 2,1±1,1 for G2; p=0.05) without impact on mortality (7 (20%) for G1 vs 11(20%) for G2; p=0.6)
Conclusion:
the severity of Hypovitaminosis D in burn patients is associated with an earlier onset of sepsis , a longer duration of sepsis and a higher number of septic episodes.
Hana FREDJ (Ben Arous, Tunisia), Amal ALOUI, Nour MARZOUKI, Abdelkader MELLEK, Mariem CHIEKHROUHOU, Lilia DEBICHE, Amenne ALOUINI, Bahija GASRI, Imen JAMI, Sarra DHRAEIF, Lamia THABET, Amel MOKLINE, Amen Allah MESSAADI
00:00 - 00:00
#42163 - Impact of Hypoxia on In-Hospital Mortality in Traumatic Brain Injury Patients.
Impact of Hypoxia on In-Hospital Mortality in Traumatic Brain Injury Patients.
Introduction:
Traumatic brain injury (TBI) remains a leading cause of morbidity and mortality worldwide. Hypoxia, characterized by inadequate oxygen supply to tissues, is a common complication following TBI and has been associated with poor outcomes. This study aims to investigate the association between hypoxia and in-hospital mortality among TBI patients.
Methods:
It was a prospective study. Patients admitted with TBI to the emergency department were prospectively enrolled in the study over a defined period (From January 2022 to December 2023). Continuous monitoring of oxygen saturation levels was conducted upon admission and throughout the hospital stay. Hypoxia was defined as oxygen saturation below a predefined threshold of 90%. Demographic data, pre-existing comorbidities and clinical characteristics were collected. The primary outcome measure was in-hospital mortality. The impact of hypoxia on in-hospital mortality was analyzed using the appropriate statistical methods.
Results:
In total, 273 patients with TBI were included in our study, with a mean age of 39 ± 17,6 years, and a sex ratio equal to 4.3. Most patients (70.7%) suffered a TBI due to a car accident. The in-hospital mortality rate was 18.3% due to TBI. Twenty-three patients (8.4%) had hypoxia upon admission with an oxygen saturation <90%. Twenty-nine patients (10.6%) were intubated immediately, while 44 (16.1%) required oxygenation ranging from nasal cannula to high-concentration mask.
Results suggest a significant association between hypoxia and in-hospital mortality among TBI patients. Those with SaO2<90% showed an increased risk of in-hospital death compared to those without (73.9% vs 13.2%, p<10-3).
Conclusion:
Our study underscores the critical role of hypoxia as a prognostic indicator in TBI patients. Early detection and prompt management of hypoxia may improve clinical outcomes and reduce in-hospital mortality rates.
Kais CHEOUR, Wiem DEMNI, Wided BAHRIA, Khaireddine JEMAI (Tunis, Tunisia), Faten SBEI, Dhekra HAMDI, Khaoula GHATTASSI, Nour Elhouda NOUIRA
00:00 - 00:00
#41689 - Impact of Integration of Point-of-Care Ultrasound in Triaging Patients in the Emergency Department.
Impact of Integration of Point-of-Care Ultrasound in Triaging Patients in the Emergency Department.
Introduction
The AIIMS Triage Protocol (ATP) is a commonly used three-tiered triage system in India which segregates emergency department (ED) patients into ATP Red (requiring immediate management), Yellow (moderately sick patients), and Green patients (having minor illness that are managed at triage and sent home). The ATP Yellow category patients wait for hours before seen by an ED physician and this leads to many untoward events in the waiting area. This study was conducted with an aim to investigate the role of point-of-care ultrasound (POCUS) in restratifying these heterogenous group of ATP Yellow patients.
Methods
This was a single center observational study conducted in a tertiary care center in India. We included 308 adult patients. Within the first 15 minutes of getting triaged by conventional ATP, the Yellow category patients were assessed by trained emergency physicians at triage using POCUS. These patients were examined using a newly developed POCUS protocol called ACLO (acronym for Abdomen, Cardiac, Lungs, Limbs, and Optic nerve). The POCUS examination was a brief (< 5 minutes) and restratified the ATP Yellow patients into POCUS Red and POCUS Yellow on the basis of evidence of infection with impending shock, fluid overload, cardiovascular pathologies requiring immediate interventions, and raised intracranial pressure. The objectives were to find out the proportion of ATP Yellow patients getting re-triaged using POCUS, to follow these patients at 6 and 12 hours intervals regarding their critical ED management, and impact of POCUS based triage on ED disposition.
Results
In this prospective observational study of 308 patients, 228 were classified as yellow. The median age was 41.5 years and 53.5% were male. Of these patients, 21.5% were re-triaged as POCUS Red using ACLO. Within 15 minutes of re-triage by POCUS, 39% of these patients received immediate intervention. It was found that at 6 hours of ED admission, 44 out of 49 POCUS red patients (89.8%) remained in the red area requiring close monitoring and care. Whereas 176 out of 179 POCUS yellow patients (98.3%) remained as yellow category patients. Similar results were observed at 12 hours of ED admission. The proportion of POCUS red category patients who got admitted was 38.8%, and it was significantly higher (p < 0.001) as compared to that in POCUS yellow category patients (16.8%).
Conclusion
It was shown that incorporating the POCUS in re-triaging heterogenous Yellow patients can lead to significant improvement in patient care in terms of early identification of impending serious issues and can improve ED disposition.
It was started after the approval of the Institute Ethics Committee (IECPG-52/27.01.2021).
CONFLICTS OF INTEREST
The authors did not have any conflicts of interest.
FUNDING
The authors did not receive any financial support from any source.
Dr Anand Kumar DAS (, India), Dr Sanjeev Bhoi PROFESSOR
00:00 - 00:00
#41808 - Impact of the COVID-19 Pandemic on Outcomes of Out-of-Hospital Cardiac Arrests in China: Insights from the BASIC-OHCA Registry.
Impact of the COVID-19 Pandemic on Outcomes of Out-of-Hospital Cardiac Arrests in China: Insights from the BASIC-OHCA Registry.
Background
The COVID-19 pandemic has had a significant impact on global public health, and multiple studies have demonstrated COVID-19 related changes in outcomes of out-of-hospital cardiac arrest (OHCA). China implemented a series of proactive containment strategies and effectively controlled the epidemic of COVID-19 in a relatively short period of time, and it remains unclear whether COVID-19 has affected OHCA outcomes nationwide.
Methods
Using data from the multicenter, population-based Baseline Investigation of Out-of-Hospital Cardiac Arrest (BASIC-OHCA) Utstein registry in China, we conducted an analysis to investigate the associations between the COVID-19 pandemic and the outcomes of OHCA across three different periods: the pre-COVID-19 period (September 1 to November 30, 2019), the outbreak period (February 1 to April 30,2020), and the regular prevention and control period (September 1 to November 30, 2020). Data from 18 participating emergency medical services (EMS) agencies which covered these 3 periods were included to analysis. Multilevel logistic regressions were used to compare patient outcomes across these periods. Primary outcomes were survival, and favorable neurological outcome at discharge or 30 days, and second outcome was return of spontaneous circulation (ROSC).
Results
A total of 16,595 OHCA cases were analyzed, with 3,890 cases in the pre-COVID-19 period (median age, 68 years; 1,231 women [31.6%]), 5,939 cases during the COVID-19 outbreak (median age, 69 years; 1,964 men [33.1%]) and 6,766 cases in the regular prevention and control period (median age, 68 years; 2,194 men [32.4%]). Compared with the pre-COVID-19 period, the rates of ROSC were lower in both the outbreak period (3.59% vs 5.27%; adjusted odds ratios (OR) 0.80 [95% confidence interval (CI): 0.64-0.99]; P＜0.05) and the regular prevention and control period(3.51% vs 5.27%; adjusted OR 0.80 [95%CI: 0.65-0.99]; P＜0.05). However, there were no significant differences in survival to discharge or 30 days in the COVID-19 pandemic period (0.54% vs 0.93%, adjusted OR 0.84 [95%CI: 0.50-1.42], P > 0.05), and the regular prevention and control period (0.65% vs 0.93%, adjusted OR 1.08 [95%CI: 0.66-1.75], P > 0.05). The same holds true for the favorable neurological outcomes in the COVID-19 pandemic period (0.30% vs 0.51%, adjusted OR 0.82 [95%CI: 0.41-1.64], P > 0.05) and the regular prevention and control period (0.44% vs 0.51%, adjusted OR 1.31 [95%CI: 0.70-2.45], P > 0.05).
Conclusions
The EMS service system in China was disrupted by the COVID-19 pandemic, resulting in a decline in the rate of ROSC. However, despite these challenges, there was no deterioration observed in survival and neurological outcomes of OHCA during this period.
The study was registered at ClinicalTrials.gov (NCT03926325). /None
Feng XU (Jinan, China), Yuguo CHEN, Yaping HOU, Wentao SANG, Jiaqi ZHENG, Wen ZHENG
00:00 - 00:00
#42042 - Impact of the Macintosh® blade size on the success rate of orotracheal intubation in pre-hospital and intra-hospital settings.
Impact of the Macintosh® blade size on the success rate of orotracheal intubation in pre-hospital and intra-hospital settings.
Background Direct laryngoscopy remains frequently performed in emergency and pre-hospital settings. In the absence of a clear recommendation regarding the size of the Macintosh® blade, the decision is left to the discretion of the operator and depends on their experience, habits and patient characteristics. To date, two studies have studied the impact of Macintosh® blade size on the success rate of the first intubation attempt by direct laryngoscopy (DL) on patients in critical conditions, in intensive care or in the hospital emergency ward, as well as the rates of associated complications.
Aim This study aims to assess the impact of the Macintosh® blade size used during the first DL on the success rate of oro-tracheal intubation in intra- and pre-hospital emergency medicine. The hypothesis made is a higher success rate when using size 3 blades compared to size 4.
Methods We conducted a prospective multicenter observational study using data from 4 hospital centers. Information collected after each intubation included patient and operator characteristics, Macintosh® blade size, results of the first DL, alternative techniques employed, and the need for a second operator. Intubation-related complication rates were also analyzed. The primary endpoint was the success rate of the 1st DL attempt with the Macintosh® blade choose.
RESULTATS Over 184 oro-tracheal intubations, 76 (41%) were performed with a Macintosh® blade size 3 and 108 (59%) with a blade 4. The intubation success rate during the first DL was significantly higher with the Macintosh® 3 blade than the 4 (respectively, 84.2% versus 70.4%, p = 0.03), for comparable levels of glottal visualization (Cormack-Lehane score, p = 0.13). Complication rates were lower with the Macintosh® 3 blade than the 4 (respectively, 48.7% versus 77.8%, p = 0.0001).
CONCLUSION This study indicates that the use of the Macintosh® 3 blade is associated with an improvement in the success of the first DL in intra- and pre-hospital emergency medicine. However, to confirm these conclusions, it is necessary to conduct a larger multicenter prospective randomized trial.
NCT05059067
Camelia EL GHISSASSI, Thomas GODET, Marine LORIDON, Marie DUPUY, Romain DURIF, Daniel ROUX-BONIFACE, Jeannot SCHMIDT, Dorian TEISSANDIER, Farès MOUSTAFA (Clermont-Ferrand)
00:00 - 00:00
#40416 - Implementation of a Scaphoid Fracture Assessment Pathway in the Emergency Department.
Implementation of a Scaphoid Fracture Assessment Pathway in the Emergency Department.
Introduction
Wrist injuries are a very common presentation to the ED. Scaphoid fractures comprise approximately 50-70% of carpal bone fractures but can be difficult to detect on initial plain film. Delayed diagnosis can lead to a high-rate of non-union, AVN and CRPS. As such, NICE Guidelines for 'suspected scaphoid fractures' advise "early" imaging with "early" in this context being requested from the first clinical encounter. CT Cone Beam (CTCB) has been shown in the literature to be an effective method for diagnosing scaphoid fractures with a sensitivity of 100% and specificity of 97% in some studies. The previous pathway in our institution involved referral for assessment +/- CTCB in our Orthopaedic Fracture Clinic. This project is a service evaluation which included the development a new EM-led ambulatory scaphoid pathway where outpatient CTCB was ordered at initial assessment and onward referrals to orthopaedics made depending on the results. Understanding resource limitations, we sought to determine if this EM ambulatory scaphoid pathway could expedite imaging, management decisions and subsequent appropriate care in suspected scaphoid fractures
Methods
We designed a clinical management pathway for suspected scaphoid fractures within the ED. An initial three-month service evaluation of current management of these patients was performed between 1st August 2022 and 31st October 2022 (Cycle 1) and reviewed from 1st March 2023 to 31st May 2023. Implementation of the pathway took place in February 2023. A list of patients who underwent CT Cone Beam Wrist/ Scaphoid/ Hand performed for the indication “suspected scaphoid fracture or carpal bone fracture” in the hospital ordered by either Emergency Medicine or Orthopaedics was obtained and patient records screened.
Results
There was a decrease in average (mean) time from presentation to CTCB from about 17 to 4.5 days after the implementation of our EM - radiology direct ordering.
90% of the CTCBs were ordered by orthopaedics through Fracture Clinic in the first cycle whereas only 4% were in the second cycle (96% by ED via the pathway). This meant that in the first cycle, 50 (92%) were seen in fracture clinics versus 25 (23%) and 6 of those patients had slipped through the cracks usually via locum EM staff who were unaware of the pathway. 42% of patients had incidental pathology found on CTCB which may have been otherwise missed if only plain film.
Conclusion
We successfully implemented a clinical pathway that reduced waiting times for patients with suspected scaphoid fractures for further dedicated imaging. This also reduced financial and personnel burden for fracture clinic and reduced waiting times for other orthopaedic patients in this department. CTCB also proved an effective method of diagnosing other commonly missed carpal bone or ligamentous injuries that may require alternative treatments that may have been otherwise missed by standard plain film repeat for suspected scaphoid fractures.
N/A
Leah FLANAGAN (Dublin, Ireland), Vinny RAMIAH, Sinead LOUGHRAN, Michael MARA, Grainne COLGAN, Brian GIBNEY, Mealla BARRY, Cora O'CONNOR CLARKE, Julie O'DRISCOLL, Oliver ALLEN, Aoife O'GRADY
00:00 - 00:00
#42006 - Improving Sepsis Screening at Triage – A Quality Improvement Project in the ED.
Improving Sepsis Screening at Triage – A Quality Improvement Project in the ED.
Infection prevention and control (IPC) is a key element of high quality and safe care and has been one of the key QI efforts the RCEM has focussed on nationally since the COVID pandemic. Having identified key areas for improvement, the RCEM published suggested national standards for screening and isolation of both, patients likely to have infectious disease, as well as patients with vulnerabilities such as immunocompromise with the aims to stop spread disease and protect vulnerable patients.
A baseline audit in our department focused on screening vulnerable patients at triage. The departmental audit data entered into the RCEM audit platform which compares performance nationally against set standards. This identified potential departmental shortcomings in triage documentation with regards to safe and effective identification and streaming of vulnerable adults. After stakeholder meetings and root-cause analyses, focal points for intervention were chosen. The chosen QI methodology for this project was ‘Plan-Do-Study-Act (PDSA)’.
‘Think Sepsis’ posters were displayed on all triage cubicles as the part of intervention, and they proved to be of critical value in prompting during the triaging process. Other interventions included targeted teaching for triaging nursing staff, as well as raising departmental awareness for medical staff during handovers and inclusion of infection control handover proformas used in the department.
During this project, data collected for year 2022-23, a total of 369 patients were taken into consideration in our department. Results showed an improved performance compared to our own historical data and compared to other Emergency Departments nationally with regards to identifying adults who need protective measures with regards to infection control at triage.
This project has contributed to an improved performance of identification of adults that are vulnerable to infectious disease resulting in appropriate protective measures such as timely isolation and departmental awareness.
The Royal College of Emergency Medicine, UK approved Quality Improvement Project.
Runal SHAH (London, ), Dr. Julia BURKERT
00:00 - 00:00
#41198 - Improving the quality of care in the emergency department in an Italian region through the evaluation of shared performance indicators.
Improving the quality of care in the emergency department in an Italian region through the evaluation of shared performance indicators.
BACKGROUND
Continuously assessing and improving the quality of care in the Emergency Department (ED) is crucial.
OBJECTIVE OF THE PROJECT
To establish a programme to monitor and improve ED performance indicators in Piemonte, an Italian region.
METHODS
The Fenice network (Italian Group for Clinical Research in Emergency Medicine, fenicenetwork.marionegri.it) is coordinating a professional-driven multiannual programme to improving the quality of care of EDs in Piemonte.
First, a panel of ED physicians, ED nurses, health policymakers, epidemiologists, and statisticians agreed on a list of performance indicators to be monitored at the ED level. These are classified into four macro-categories: (I) integration with other care services, (II) organisational appropriateness, (III) clinical appropriateness at triage, and (IV) clinical appropriateness at the medical visit. For each indicator, criteria defining desirable thresholds for improvement were also developed.
The programme is organised in the following steps:
1. Planning: at the beginning of the year, each hospital receives a customised report containing, for all the identified indicators, the value calculated on its own data for the past year. Each centre chooses two indicators on which to focus improvement efforts for the coming year.
2. Improvement interventions: each centre implements specific interventions to improve the two chosen indicators and achieve the established objectives. This requires specific data and context analysis and operational skills that will be made available to participating centres by the Fenice group.
3. Evaluation: a re-evaluation of the results achieved by each centre on the two indicators chosen as improvement targets is conducted. In addition to feedback on whether the target has been achieved, each hospital also receives a newly updated report on the entire panel of indicators, from which to choose the two on which to focus improvement efforts for the following year.
CONCLUSIONS
ED is one of the most important points of contact between the health service and the health needs of citizens and the first gateway to the hospital. It is therefore crucial to ensure proper evaluation and continuous improvement of the quality of care. To be convincing, however, such an initiative requires a constructive alliance among all leading professionals in the field. This study demonstrates the feasibility of such a program.
Vicky RUBINI (BERGAMO, Italy), Fabiola SIGNORINI, Giovanni NATTINO, Gianluca GHISELLI, Daniela ZATELLI, Guido BERTOLINI
00:00 - 00:00
#41396 - Improving the success rate of occipital nerve blocks in headaches.
Improving the success rate of occipital nerve blocks in headaches.
Introduction: non-traumatic headache is a common complaint in acute settings with a high care burden for service users and providers alike. Blocking the greater occipital nerve with local anesthetic (GONB) is becoming an increasingly popular treatment modality in the Emergency Department when caring for patients with recurrent, otherwise therapy resistant headaches . It is a safe and cost-effective intervention, the technique is easy to learn. However, the success rate is highly variable (42%-95%) regardless if GONB is performed either using a landmark technique or ultrasound guided infiltration. In both cases a small volume of local anesthetic (LA) is injected somewhere lateral to the occipital protuberance as an epi/perineural block. Recent studies highlighted the importance of the Cruvhelier plexus [1], an accessory neural shunt connecting the C2-3 segments with C4-5 which may not exist in every person (45% of the cases). This anastomotic conduction may explain the failure of GONB even if performed under ultrasound guidance. However nowadays, emergency physicians prefer fascia-plane infiltrations when appropriate instead of epi/perineurinal blocks, as the first provides multiple nerve conduction blockade and more sustained pain relief [2].
Objective: We aimed to identify one nuchal fascia compartments where the course of all branches of the occipital nerve AND the Cruvhelier (if available) can be blocked with preferably one single puncture.
Methods: Using a formaldehyde prepared human cadaver we have the above region dissected to better understand the course of the occipital nerves and identify the nuchal compartment.
Results: We learned that no single fascia compartment exists which encapsulates all three branches at the same time [Figure1], however the two dorsal branches (major and the third occipital nerve) are accessible just above the semispinalis muscle while the ventral branch (minor occipital nerve) is accessible when piercing through the rectus capitis muscle [Figure 2]. Unfortunately in our cadaver the Cruvhelier was non-existent. Based on the anatomy books however, when available it would run through the longissimus capitis muscle.
Discussion: As the three branches of the occipital nerve and the potential accessory pathway of Cruvhelier does not run in one single fascia compartment this may explain the considerable variability of the success rate of GONB. Considering the fascia relations, it seems logical to block each of the three nuchal fascia compartments separately with either a volume block or an intramuscular injection, rather than infiltrating one isolated nerve with a peri/epineurinal block. Intramuscularly administered LA – an alternative to fascia plane blockade - may probably sufficiently block the nerves, as all branches piercing through one nuchal muscle. In terms of the minor occipital nerve a potential fascia plane block may be administered using either a „pop” technique or US guidance to infiltrate the most superficial compartment as the ventral branch ascends from underneath the obliquus capitis inferior muscle and runs under the trapezius. Cruvhelier - when it exists - can theoretically be blocked in the second compartment.
Conclusion: Further anatomical and clinical studies are needed to better understand the nuchal anatomy and to improve the success rate of GONB.
N/A
Gabor Zoltan XANTUS (Pecs, Hungary)
00:00 - 00:00
#41922 - Improving times to ECG recording and interpretation in a busy Central London Accident & Emergency Department - our experience at University College London Hospital.
Improving times to ECG recording and interpretation in a busy Central London Accident & Emergency Department - our experience at University College London Hospital.
Background: The Royal College of Emergency Medicine recommends prompt electrocardiogram (ECG) performance for all patients presenting with chest pain, ideally within 15 minutes of arrival at the emergency department. Subsequent interpretation and reporting of ECG findings are crucial, with endorsement for review by physicians of all hierarchical levels, yet requiring co-signature by a consultant or registrar. Our study aimed to assess adherence to these guidelines within our department.
Methods: A retrospective analysis was conducted on fifty patient records at three distinct time points: early November 2023, late November 2023 post-intervention, and January 2024. Selection criteria encompassed adult patients presenting with chest pain, who underwent ECG assessment in the emergency department under the care of an emergency physician. Exclusion criteria comprised paediatric cases, self-discharges, and direct admissions.
Results and Interventions: The initial audit in early November 2023 revealed an average ECG initiation time of 45.04 minutes, with subsequent reporting occurring on average after 41 minutes, demonstrating only 18% compliance in timely reporting. Interventions were implemented, including educational initiatives such as circulating instructional videos, sending reminder emails, displaying posters, and providing verbal prompts. The subsequent audit in late November 2023 demonstrated an enhanced reporting compliance of 58%, with an average reporting time reduced to 39.5 minutes; however, the average ECG initiation time increased to 58 minutes. The final audit in January 2024 exhibited a regression in compliance, with only 24% adherence to reporting guidelines and an average reporting time of 60 minutes, coupled with an average ECG initiation time of 66 minutes.
Conclusion: The transient improvement in ECG reporting compliance was not sustained, deteriorating significantly within a mere two-month period. Enhanced strategies are imperative, including the establishment of new policies and structured training programs for medical personnel. Given the demanding nature of a central London teaching hospital, we recommend the implementation of dedicated ECG technicians, senior sign-off clinicians and facilities to facilitate meeting ECG performance targets.
N/A
Ahmad EL-MAHMOUD, Yuri KAWASHIMA, Sergio B SAWH (London, )
00:00 - 00:00
#41283 - In case of dermal lesions, how to suspect Crohn's disease in the emergency department?
In case of dermal lesions, how to suspect Crohn's disease in the emergency department?
A 25-year-old male patient came to the clinic complaining of abdominal pain in the right iliac fossa of colic type of 2 days of evolution, accompanied by febrile fever, nausea and a softer stool than usual.
Personal history: pulmonary TB 5 years ago.
Physical examination: soft abdomen, depressible, without masses or megaliths, painful on palpation in FID. No blood test done.
Clinical judgment is a probable gastroenteritis with treatment with diet and paracetamol.
After 6 days, the patient paid a secon visit to the Emergency Deparment due to persistent abdominal pain; he also presented pain in the anterolateral aspect of both legs, with skin lesions of different sizes, palpable, erythematous-echemotic and painful without previous trauma. The rest of the examination was unremarkable.
Differential diagnosis: tibial-pretibial contusion, systemic vasculitis, cellulitis, panniculitis (most likely erythema nodosum).
On suspicion, the patient was referred to the rheumatology department, where a colonoscopy was performed in the ileocecal region, which showed images compatible with inflammatory bowel disease.
The colon biopsy showed evidence of Crohn's disease.
It is a pluriethiologic syndrome characterized by outbreaks of painful, inflammatory skin nodules, predominantly affecting the pretibial surface of the lower extremities, and less frequently located on the thighs and forearms. Remission of the lesions occurs in 1-6 weeks without scarring or residual atrophy.
This pathology is related to various situations and diseases. Generally, digestive symptomatology in these patients is very scarce, as in our case. Up to 35% of patients present extraintestinal manifestations, which makes diagnosis very complicated.
Álvaro MARTÍN PÉREZ (Badajoz, Spain), Vanesa YAÑEZ BERMEJO, Rafael ROLDÁN JIMÉNEZ, Luis CADAVAL LOPEZ
00:00 - 00:00
#42022 - Incidence and geographical predominance of drowning in Kingdom of Saudi Arabia: A Cross- Sectional Study.
Incidence and geographical predominance of drowning in Kingdom of Saudi Arabia: A Cross- Sectional Study.
Background
Drowning is a significant public health issue and is considered to be one of the most avoidable yet underappreciated causes of mortality worldwide. Drowning likely presents a significant public health burden in Saudi Arabia especially in children. To our knowledge only three studies have been conducted investigating drowning in Saudi Arabia, all of which were single center hospital-based studies. This is the first national study to assess drowning in Saudi Arabia,with the largest MENA (middle east and north africa) region dataset and the first to utilize first responder data.
Aims
This study's main objectives are to quantify the burden of drowning in Saudi Arabia, and describe the epidemiological profile and geographic distribution of drowning cases across the Kingdom.
Methods
A cross-sectional study using electronic data from the Saudi Red Crescent Authority (SRCA) on drowning incidents, which acts as the primary national pre-hospital emergency medical service (EMS) responding to all community medical emergency incidents in Saudi Arabia. The studied time period was between January 2019 to November 2021 in a total of 1643 reported incidents of drowning in all 13 regions of the Kingdom. Variables reported in the dataset included patient demographics, region, time of reporting to EMS, incident location, methods of communication with the EMS services , time to arrival of EMS, whether CPR was performed by the EMS team, and the final disposition of the patient. Incident location was reported via geotagging and described with regards to city boundaries where “in city” referred to incidents within the main cities, and “out city” referred to incidents occurring outside of the city in surrounding rural areas or on highways, and agricultural roads, based on the Ministry of Interior’s classification.
The statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS), software for Windows (version 23.0). Descriptive statistics such as frequencies and percentages were calculated and a p-value of <0.05 is considered statistically significant.
Results
The annual national incidence of drowning in our dataset ranged from 15.8 to 18.4 per million and varied by region and demographic group. Men and children under 4 had the highest incidence of drowning. Although the most densely populated regions made up the largest proportion of drowning cases the highest incidence of drowning was see in smaller regions
Conclusion
This study is of high significance because drowning is a leading cause of morbidity and mortality worldwide. By identifying the local burden of drowning in Saudi Arabia, the epidemiological characteristics, and prehospital interventions, concerned authorities and health care professionals will be able to identify potential interventions to prevent drowning deaths, in addition to increasing public awareness.
Reema ALHUSSEIN (Saudi Arabia, Saudi Arabia)
00:00 - 00:00
#42199 - Incidence and Impact of Workplace Violence on Healthcare Personnel in Polish Emergency Departments.
Incidence and Impact of Workplace Violence on Healthcare Personnel in Polish Emergency Departments.
Objective: Workplace violence in emergency departments is an increasing concern impacting both healthcare delivery and personnel well-being. This study aims to evaluate the prevalence and impact of violence faced by healthcare workers in Polish emergency departments and assess the readiness of these units to address such challenges.
Methods: A comprehensive survey was distributed among healthcare professionals across several Polish emergency departments, gathering data on experiences of violence, types of incidents, and the effectiveness of existing measures to prevent and respond to these incidents. The study includes participants from diverse roles within the emergency services, reflecting a broad perspective on the issue. Additionally, live ongoing incident reporting is integrated into the study, allowing real-time data collection and analysis of violence as it occurs, providing an up-to-date overview of the situation.
Results: Preliminary results indicate a high incidence of both physical and verbal violence against emergency department staff, with significant variations in the type and frequency of incidents reported. Many respondents highlighted a lack of sufficient training and preparedness for handling violent situations. Feedback suggests an urgent need for strategic improvements in safety protocols and staff training programs. Detailed findings from the ongoing study will be shared in the final publication.
Conclusion: The study identifies critical gaps in the current approaches to managing workplace violence in Polish emergency departments. It underscores the necessity for comprehensive strategies that include enhanced training, better security measures, and improved support systems for affected healthcare workers. The findings advocate for a systematic approach to foster a safer working environment, thereby improving the overall quality of emergency healthcare services.
no funding
Robert KRION (Gdańśk, Poland), Aleksandra SZYMCZYK, Andrzej LUBIEWSKI, Natalia GLANER, Mariusz SIEMINSKI
00:00 - 00:00
#41796 - Incidence, process of care, and outcomes of in-hospital cardiac arrest in China: insights from a nationwide, prospective registry.
Incidence, process of care, and outcomes of in-hospital cardiac arrest in China: insights from a nationwide, prospective registry.
Background
In-hospital cardiac arrest (IHCA) poses a serious threat to hospitalized patients and presents a significant challenge to healthcare systems worldwide. However, there is currently a scarcity of data on IHCA from low- and middle-income countries. We aim to comprehensively describe the incidence, process of care, and outcomes of IHCA in China.
Methods
Baseline Investigation of In-hospital Cardiac Arrest (BASIC-IHCA) is the first nationwide, multicenter, prospective registry of IHCA in China. Monitoring sites are hospitals from both urban and rural areas, covering 29 of the 31 provinces in mainland China and ensuring that there is at least one rural monitoring site in each of the seven geographic regions. Case enrollment began in July 2019, and all cardiac arrests at participating hospitals were registered. Variables were determined based on the Utstein Template, which included baseline characteristics (patient and event information), processes of care (chest compressions, defibrillation, ventilation, drugs, etc.), and outcomes. Outcomes encompass return of spontaneous circulation (ROSC), sustained ROSC, 30-day survival or survival to hospital discharge, 6-month survival, and 1-year survival, along with corresponding neurological prognosis. Data of all cases that received cardiopulmonary resuscitation (CPR) from 39 hospitals (31 urban and 8 rural) were included for analysis.
Results
From July 1, 2019, to December 31, 2020, 33,722 patients were enrolled, with 18,647 (55.3%) receiving CPR. The annual incidence of resuscitated IHCA for 2020 was 7.8 per 1,000 admissions in China. The median age of IHCAs was 65 years (IQR 51-76), with 65.0% being male. Non-cardiac etiologies accounted for the majority of cases (63.5%), and the primary event locations were ICU (40.4%), general ward (32.2%), and emergency department (20.9%). At the time of the event, 17,796 (95.5%) patients were under monitoring. A total of 2,433 (13.1%) were documented with an initial shockable rhythm, of which 2,041 (83.9%) received at least one shock. The vast majority (95.9%) initiated CPR or defibrillation within 1 minute of cardiac arrest, and most (86.5%) received epinephrine injections. Advanced airway was emergency established or already in place at the time of the event in 13,167 (70.6%) cases. Extracorporeal cardiopulmonary resuscitation was performed in 61 (0.3%) cases. Additionally, standard targeted temperature management was utilized in only 85 cases (0.5%). A total of 7,762 (41.6%) IHCAs achieved ROSC, and 6723(36.1%) sustained for at least 20 minutes. Furthermore, 1,804 (9.7%) survived to 30 days/hospital discharge, with 1,410 (7.6%) having favorable neurological outcomes (CPC-1/2, PCPC-1/2/3). Patients with initial shockable rhythm demonstrated significantly higher rates of survival (33.9% Vs. 6.0%, P＜0.001) and good neurologic function (30.9% Vs. 4.0%, P＜0.001) compared to those with initial non-shockable rhythm. In our study, only 3 out of the 39 hospitals had established hospital-level rapid response teams.
Conclusion
Our study provides the first comprehensive depiction of the current status of incidence, treatment, and outcomes of IHCA in China. Compared to high-income countries, the prognosis of IHCA in China is less satisfactory. Further evaluation of care is needed for targeted quality improvement to improve outcomes.
ClinicalTrials.gov number, NCT03926325.
The Key Research & Development Program of Shandong Province (2021ZLGX02).
The National Science & Technology Fundamental Resources Investigation Program of China (2018FY100600 and 2018FY100602).
Feng XU (Jinan, China), Chunyi WANG, Jiaqi ZHENG, Wen ZHENG
00:00 - 00:00
#41619 - Incomplete Spontaneous Abortion and Right Ovarian Vein Thrombosis.
Incomplete Spontaneous Abortion and Right Ovarian Vein Thrombosis.
Background
Incomplete abortion is a form of spontaneous abortion that manifests itself in the partial loss of the products of conception before the 20th week of pregnancy. OVT is a rare disorder associated with postpartum, malignancy, abdominal and pelvic surgery and pelvic inflammatory disease. The diagnosis can be made with the help of ultrasound or computer tomography. The treatment of ovarian vein thrombosis is essential post-partum. The recommended treatment is to use anticoagulants.
Case report
A 37-year-old (gravida 1, para 1) patient presents to the Emergency Department for fever (during the day), severe abdominal pain, and vaginal bleeding (with sudden onset of one day).
The patient is not a smoker and has no personal pathological history. The date of the last menstrual period was ten weeks before the presentation.
The patient presented with a fever (38.3 degrees Celsius), leukocytosis (13.000 μL, reference values: 4-10.000 μL ), and severe microcytic hypochromic anemia with a hemoglobin of 6.2 g/dL. Clinically and paraclinical, the diagnosis of incomplete spontaneous abortion is decided.
Abdominal and pelvic ultrasound was normal.
The patient’s anemia was partially corrected post-transfusion. The following day, the patient continued to complain of pain in the epigastric area and the right and left iliac fossa. It is decided to perform transvaginal ultrasound: minimal to moderate vaginal bleeding, area of retrouterine and anteuterine fluid in moderate quantities and placental and embryonic remains are visualized. A hemostatic and bioptic evacuation uterine curettage is performed. The sample is sent for histopathology. At the level of the left appendix, which is painful at the time of examination, an ectopic pregnancy is not suspected.
It has been decided to perform a CT of the abdomen and pelvis with contrast. The CT scan result is as follows: thrombosis in the right ovarian vein and moderate abdominopelvic ascites fluid.
It has been decided that treatment should be started with low molecular weight heparin. The evolution of the patient is favorable, and the patient is discharged after ten days.
Upon one-year follow-up, she remained free from the recurrence of her symptoms while receiving therapeutic anticoagulation.
Conclusion
Thrombosis of the ovarian vein is rare. For patients with severe abdominal pain postpartum, it should be a diagnosis of exclusion. This condition can have a fatal outcome. Complications such as pulmonary embolism, sepsis, and thrombus extension may occur frequently. The use of anticoagulants can prevent these deadly complications.
Carmen WILLIAMS (Timisoara, Romania), Florina BULEU, Raluca RADBEA, Popa DAIAN, Sutoi DUMITRU, Ovidiu MEDERLE
00:00 - 00:00
#41122 - Increasing the use of Ultrasound guided technique for Fascia Iliaca nerve blocks in the Emergency Department.
Increasing the use of Ultrasound guided technique for Fascia Iliaca nerve blocks in the Emergency Department.
Aim:
To carry out 75% of Fascia Iliaca blocks (FIB) by Ultrasound guided technique for patients with X-ray confirmed fractured neck of femur attending the Emergency Department (ED)
Background:
Fractured neck of femur is a common presentation to Emergency Departments, particularly Trauma Units/Major Trauma Centres. In 2018 the Scottish Government published the “Scottish Standards of Care for Hip Fracture Patients 2018” which is endorsed by the following organisations: Scottish Committee for Orthopaedics and Trauma (SCOT) Royal College of Emergency Medicine National Board for Scotland (RCEM) and the British Geriatrics Society (BGS)
This report emphasised the importance of the “Big Six” bundle in the ED, specifically “The use of a nerve block is the recommendation of the Advisory group”. Delivery of “Big Six” treatment is commonly an ED Key Performance Indicator.
Landmark FIB was the established technique prior to the widespread use of US, however the new RCEM 2021 curriculum includes only US guided FIB as a core competency. There are numerous advantages to using US technique including direct visualisation of needle tip at all times, visual confirmation of infiltration of local anaesthetic below the fascia iliaca and it is safe to use in anti-coagulated patients (previously relatively contra-indicated in landmark technique).
Method:
Using Plan, Do, Study, Act (PDSA) Quality Improvement methodology we circulated a staff survey to establish current practice, barriers to US technique and then performed two separate 7 day periods of data collection on all FIB performed. This data was collected by staff logging any FIB done via a QR code.
We created a Process Map for both US guided and landmarked FIB and used this to create a Driver Diagram. This identified multiple potential intervention points primarily around education and skillset deficit amongst junior doctors as well as traditional departmental practice and equipment issues.
We delivered training sessions to the foundation and junior trainees as well as circulating the RCEM learning module on FIB.
Results:
Initial staff survey had 26 responses of which 11 said that US guided was their first line technique.
Over the two x 7 day periods of data collection pre-intervention there were 27 FIB performed of which 11 (37%) US guided.
Post intervention we analysed two further 7 day periods in which 22 FIB blocks were performed with 19 (86%) US guided technique. This was a significant improvement and achieved our initial target of 75% FIB performed using US guided technique.
Further interventions are planned including a consultant delivered session to the consultant cohort on US technique using demonstration equipment, updating the departmental policy to specify US guided technique as first choice and changing the procurement order to stock specific US compatible equipment. We will continue the QI cycle by doing further analysis of practice after these interventions.
Conclusion:
This project increased the use of US guided technique for FIB in patients requiring regional anaesthesia within our ED over a sustained period and helped change departmental practice to a technique with superior levels of efficacy and patients safety in line with RCEM guidance.
N/A
Dr Sean KELLY (Glasgow, ), Rebecca THOMAS
00:00 - 00:00
#41944 - Inflammation Biomarkers: Assessing Role and Performance in Acute Osteomyelitis.
Inflammation Biomarkers: Assessing Role and Performance in Acute Osteomyelitis.
Aim: Osteomyelitis, pathologically defined as an infection of bone and bone marrow caused by microbial agent. It is a significant consideration in cases of febrile limping in children. While mastery of clinical presentations is crucial, our study focuses on analyzing the diagnostic performance of inflammatory markers to guide diagnostic orientation and management strategies. Our aim is the Analysis of the sensitivity and specificity of inflammatory markers in the diagnosis of acute osteomyelitis in children.
Methods: This retrospective study includes all patient records admitted to our Orthopedic Department for acute osteomyelitis over an 8-year period (January 1, 2015, to December 31, 2022). All patients underwent clinical examination, laboratory tests, and diagnostic radiological assessment. Data was collected using a predefined form.
Results: The study involved 50 children hospitalized for osteomyelitis. The mean age was 8.48 ± 3.864 years, ranging from 1 to 20 years. There was a male predominance with 34 boys (68%) and 16 girls (32%). Ten patients had relevant medical and/or surgical histories (20%). Twenty-one patients (42%) received some form of medical treatment before admission, including analgesics (n=16; 32%), anti-inflammatories (n=5; 10%), and oral antibiotics (n=8; 16%). The general condition was preserved in 43 cases (86%) and altered in 7 cases (14%) upon admission. Fever was present in 42 patients (84%) at admission. The sensitivity and specificity for leukocytosis (≥11,000 cells/ml), CRP (≥20 mg/l), and erythrocyte sedimentation rate (ESR) (≥20 mm at the 1st hour) were 53.3%, 84.4%, and 97.78%, and 40%, 20%, and 20%, respectively. At admission, standard radiography revealed abnormalities in 40% of cases, while ultrasound detected abscesses in 38% of cases.
Conclusion: Although inflammatory markers, especially C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), are useful tools to support the diagnosis of osteomyelitis, they should not be considered definitive indicators due to variations in sensitivity and specificity. Diagnosis primarily relies on clinical elements, considering that different pathogens can lead to varying levels of inflammation.
This study did not involve a trial registration. No external funding was received for this study.
Jacem SAADANA, Khouloud KHEMILI (Tunisia, Tunisia), Bilel FAIZI, Firas CHAOUECH, Insaf BEN MESSAOUD, Said ABID, Ahmed MDAOUKHI, Amine SIOUD, Kais KHARROUBI, Moez JELLALI, Aymen FEKIH, Abderrazek ABID
00:00 - 00:00
#42127 - Inflammatory myopathy in patient with dysphagia lusoria and incomplete aortic ring.
Inflammatory myopathy in patient with dysphagia lusoria and incomplete aortic ring.
Idiopathic inflammatory myopathies (IIMs), often collectively known as “myositis,” are rare diseases characterized by inflammation and weakness of the skeletal muscles which can also involve internal organs such as the lungs, heart, and esophagus. In clinical practice the most common myopathies are polymyositis (PM) and dermatomyositis (DM). In recent years, the classification of such diseases has broadened beyond PM and DM. The currently accepted diagnostic categories are PM, DM, necrotizing autoimmune myopathy (NAM), antisynthetase syndrome, overlap myositis, inclusion body myositis, and juvenile myositis. The incidence of IIM is estimated to range from 0.2 to 2 per 100,000 person-years, with prevalence from 2 to 25 per 100,000 people.
A 60 years old female patient came to the ED because of dyspnea after dinner and subsequent desaturation. She neurologically good, tachycardic and apiretic. A POCUS was performed and showed a subpleuric consolidation and a chest x-ray showed a pleuroparenchimal hypodiafania at the left lower pulmonary field, witha thickening of the right lower field of the parenchyma. She was brought to the internal medicine department where labs showed increased white blood cells, o musclular enzymes (CK, LDH and AST), the RF, B2-microglobulin and IgM. This patient suffered from rheumatoid arthritis, lumbar bulging, right positioned aortic branch with abnormal anatomic origin of the epyaortic vessels and an incomplete aortic ring, which caused in October 2023 an hospitalization due to a dysphagia lusoria. She also had a hypertrophic cardiomyopathy. Since she had a worsening of the expiratory exchange and a Sars-Cov- 2 positivity was found, the patient has been transferred to the subintensive care unit where she was treated with NIV and HFNC because of her hypercapnia. She underwent an electromyography which concluded for an axonal sensitive and motor polyneuropathy and inflammatory autoimmune myopathy, with following infusion of 160 mg of intravenous immunoglobulin over 12 days. In meanwhile the Sars-Cov-2 test was negative. The patient moved to the internal medicine department where she had hypertention, controlled with clonidine patch. She also underwent an esophagogastroduodenoscopy in order to assess the an extrinsic compression on the esophagus, but it was negative and showed hyperemic erosive gastropathy. So she was evaluated by the rheumatologist who diagnosed a systemic autoimmune myositis with lung involvement and secondary pulmonary hypertension. A treatment with corticosteroids was started. During the hospitalization the patients had positive blood culture to S. hominis and S. epidermidis, while the urine culture was positive to E. coli and K. pneumonieae. So the patient was treated with piperacillin\tazobactam then switched to ceftriaxone, and ultimately substituted with vancomicine. Since she had also a positive blood culture for Candida parapsilosis it was introduced also anidulafungin. After that, the patient was transferred to a new hospital to complete the diagnostic pathway. Treated the infection she was treated by rheumatologists. Finally, this case reminds us we need to pay attention to dysphagia which is a common condition but it can be due to very critical and hard to find conditions.
Lorenzo BONGIORNO, Elena FAMIGLIETTI, Lucio BRUGIONI, Giovanni PINELLI, Francesco RENZO, Luca RONCUCCI, Nicolini ALBERTO, Riccardo ROGANTI (Modena, Italy)
00:00 - 00:00
#41805 - Influence of particulate matter on visits to an emergency department due to exacerbation of bronchial asthma.
Influence of particulate matter on visits to an emergency department due to exacerbation of bronchial asthma.
Background
Environmental pollution is a major health problem, especially in relation to respiratory diseases. The implications of various pollutants on bronchial asthma exacerbations are widely accepted, although in the case of particulate matter the existing results are contradictory.
Aim
to analyze the relationship between the number of visits to the emergency room for exacerbated asthma and the average daily concentration of particulate matter (PM) with a diameter equal to or less than 5 microns (PM2.5) and 10 microns (PM10) in a low pollution area.
Methods
Retrospective ecological study of visits to the emergency department of the Río Hortega Hospital in Valladolid due to an episode of asthma exacerbation in the period between 2010 and 2018.
The association between PM concentration and the number of emergency room visits for exacerbated asthma was studied using a generalized linear model with Poisson regression. The model is adjusted by meteorological variables (temperature, barometric pressure, precipitation and hours of sunshine) and seasonality, taking into account various lags or delays (from lag(0) days to lag(-7) days). The data were analyzed using the SPSS stats 24 statistical package. A descriptive analysis of each variable was carried out using the non-parametric Kolmogorov test, the chi square test for qualitative variables and the compensation coefficient was assessed using the Spearman coefficient. Significance threshold was demonstrated at p<0.05.
Results
1588 patients are included who caused 2557 visits to the emergency room during the study period. The average age was 51 years. 70% were women. The average number of visits per patient was 1.59, 78.5% of them attended only once. The average daily value of PM2.5 in the study period was 11.5 ± 6.7 µg/m3 and 17.4.5 ± 9.8 µg/m3 for PM10. Visits to the emergency room for asthma had a clear seasonal pattern. The increase in PM2.5 concentration showed a statistically significant positive association with the increase in visits to the emergency room, both for lag(-1) OR 1.06 (0.007-1.129, p=0.02) and lag(-3) OR 1.08( 0.02-1.14 p=007), although after adjusting for temperature and month this association was not maintained: lag(-1) OR 1.03 (0.97-1.09,p=0.251) and lag(-3) OR 1.03 (0.97-1.09, p=0.269). With respect to PM10, a significant association was found in all the lags evaluated, although after adjusting for temperature and season, no significant association was found.
Conclusions
The increase in environmental levels of particulate matter (PM2.5 and PM10) did not show an association with a greater number of visits to the emergency room for asthma in our environment
Dr Raul LOPEZ IZQUIERDO, Carlos DEL POZO VEGAS (Valladolor, Spain), Daniel ALVAREZ, Moreno FERNANDO, Sánchez HORNERO, Tomas RUIZ ALBI, Antonio DEL REY VIEIRA, Laura FADRIQUE MILLAN, Sobradillo Castrodeza NIEVES, Mario RODIL MUÑOZ, Regina PRIETO CARBALLO, Castellanos Florez ROSA, Francisco MARTÍN RODRIGUEZ, Del Campo FELIX
00:00 - 00:00
#40941 - Initiating clinical frailty scale assessment in emergency department.
Initiating clinical frailty scale assessment in emergency department.
Clinical Frailty Scale (CFS) assessment in the emergency department (ED) is a new initiative aimed at identifying frailty early in the older patients journey for proactive management with frailty interventions. It can help ED providers identify patients who may be at higher risk for adverse outcomes and tailor their treatment plans to address the patient's needs to achieve better outcomes. CFS assessment will be done at the point of triage and used to trigger a Comprehensive Geriatric Assessment (CGA) in ED. To address the knowledge deficit on CFS, a comprehensive training course needs to be developed and delivered to a large group of ED nurses within a limited time frame. A user-friendly interface enhancement to current triage process was needed. This project describes the process and challenges of implementing CFS in the ED, enhancing the Electronic Medical Record system's Triage Clinical Document for seamless integration of the CFS, and providing comprehensive training for ED nurses.
Activity mapping in ED was done on how CFS will be assessed during ED patient journey and how information flow within ED and onwards to inpatient and community partners. Progress was actively communicated with the ED nurses and invited for feedbacks. The feedbacks guided the user interface development and the nurses' learning needs. With the feedbacks, a pictorial algorithm was also created as a visual guide for quick CFS assessment. PDSA cycles were used to improve the pictorial algorithm, focusing factors important to the nurses. This team collaborated with the Information Technology (IT) team on the interface development, and the completed enhancement was tested prior to going live, and was well received by nurses. An e-learning training course consisting of 2 modules was developed. Module 1 on understanding frailty to raise awareness and knowledge of frailty, and Module 2 on workflow of CFS in ED and the ED frailty interventions. This course was made available to all ED nurses.
This team focused on preparing and supporting the process of the new initiative, and learnt to work around limitations- short time frame, realistic capabilities of IT enhancement, and logistic issues with setting up a new training course. Engaging the stakeholders led to successful CFS implementation, interface enhancement, and training course development. However more can be done and the next step will be focusing on preventing reversion of practice, maintaining compliance and accuracy on CFS assessment, retaining knowledge on frailty, and continuous training to new nurses.
Wei Ling MU, Elaine LEONG, Foo Chin LOI, Xin Yu KOH, Arron ANG, Clara SEAH (Singapore, Singapore), Barbara ROSARIO
00:00 - 00:00
#41663 - Integrated Emergency Centers in Germany - A digital Workflow to reduce crowding and to redirect low-urgency patients to an ambulatory care facility within the ED.
Integrated Emergency Centers in Germany - A digital Workflow to reduce crowding and to redirect low-urgency patients to an ambulatory care facility within the ED.
Background: Emergency departments (ED) are influenced mainly by external factors. The preload is the sum of patients brought or coming to the ED. The scarcity of available hospital beds for ED patients who must be admitted is typically described as afterload. High levels of pre- and afterload lead to potentially crowded EDs, which threatens patient safety, healthcare quality and staff content.
The German healthcare system faces increasing staff shortages in both sectors and the closing of many small hospitals. Therefore, A better alignment of the health sectors in emergency care could lead to more efficient resource consumption and better, more appropriate care. Thus, health policy stakeholders have conceptualized so-called Integrated Emergency Centers (IEC). The concept refers to emergency care facilities with a conventional ED and an independent general practitioner (GP) track. The lack of a tool to triage patients upstream of these two tracks has hampered the implementation of IEC until now.
Our study aimed to implement a fully functional IEC, including serially aligned digital tools to foster the trans-sectoral patient allocation in the triage.
Methods: We developed a comprehensive digital workflow consisting of a triage upstream of the two care sectors, a waiting management system (WMS) and a clinical decision support system (CDSS) for the triage nurses. The triage software (CDSS) algorithm was developed through a consensus process with Emergency physicians, GPs, traumatologists and neurologists. The consensus results were implemented in the CDSS, and additional danger zones for vital signs were added. In a prospective observational study, we analyzed the change in patients per triage category, the number of patients crossing the sector border from the GP track to the ED, and the 30-day mortality of ambulatory patients.
Results: In the first six months of the new IEC, we treated 32’432 patients, 22’601 of which presented as ambulatory visits (69.69 %). We assigned 8’145 ambulatory patients to the separate GP track (08:00 to 24:00), accounting for 36.04 % of all ambulatory patients. The conventional ED experienced a drop in ESI 5 patients minus 57.70 % and ESI 4 minus 10.06 %. The overall decline in patients in the conventional ED track was minus 6.94 %, while the overall amount of patients in the whole IEC increased by 24.53 %.
The mean waiting time to be called into the triage by the WMS was 1.43 minutes. The triage itself, including the assignment of urgency, sector, and documentation of chief complaints and vital signs, took 3.32 minutes. The average door-to-triage time was 5.76 minutes.
7.2 % of patients in the GP track were referred to the conventional ED and most often discharged home later (80.00%). The 30-day mortality rate of patients assigned by the new CDSS was 0.11 %. All except one of these patients (who was admitted 49 minutes later) were assigned to the conventional ED track.
Conclusion: We implemented a safe, efficient, effective, timely and patient-centred triage workflow with a CDSS that facilitates IEC operations.
LB received funding through the Berta-Ottenstein-Programme for Clinician Scientists from the Faculty of Medicine, University of Freiburg. FPH was funded by the Baden-Württemberg State Ministry for Science, Research and the Arts (as part of the multinational Clinnova consortium (GdGI)).
Felix Patricius HANS (Freiburg - Germany, Germany), Leo BENNING, Hans-Jörg BUSCH
00:00 - 00:00
#42364 - Interest of melatonin in the treatment of SARS-CoV 2 in an outpatient multicenter randomized double-blind study.
Interest of melatonin in the treatment of SARS-CoV 2 in an outpatient multicenter randomized double-blind study.
Introduction: The SARS CoV-2 pandemic is one of the most serious health crises the world has experienced in more than a century. The pandemic which has weighed heavily on the global economic and health plan. The uncertainties, the fears, the new way of life have affected the majority of the world on a psychological level. Recent studies have proven the anti-inflammatory, antioxidant and sedative effect of melatonin. The main objective of this study is to study the effectiveness of melatonin in patients consulting the emergency room with signs of a syndrome flu.
Patients and methods:
We included any patient under the age of 60 consulting for an influenza-like illness. For each patient, we collected the clinical, biological and anamnestic parameters on a specific form. Treatment will be provided by medical staff to discharged patients at home. Two groups were identified: group 1 (treatment group) and Group 2 (Placebo). A telephone call will be made on D5, D10, D15 and D30 by a research associate to report any adverse effects and note the clinical progress and compliance of each person. On D30, the assessment of anxiety and depression were assessed using the HADS and Hamilton questionnaires respectively. At D90, the PCL-5 score allowed us to assess post-traumatic stress in our study population.
Results: There was a significant difference between the treatment group and the placebo group according to the disappearance of all initial signs, present on admission, on the 5th day with a p value 0.041. In the group that received melatonin, 49.4% of patients no longer had symptoms on day 5. On the 10th day of follow-up, statistical analysis revealed a significant difference between the 2 groups with a p-value of 0.038 : 66 patients in group1 showed complete recovery and only 55 other patients recovered in the placebo group. There were no significant differences between the two groups in terms of recovery during the 15th and 30th days of follow-up. Higher frequencies of occurrence of post-traumatic stress, anxiety and depression were noted in the Placebo group compared to the group treated with melatonin. The treatment was well tolerated and no serious adverse events were reported throughout the trial.
Conclusion: Our results showed that daily doses of melatonin significantly reduced the duration of symptoms accelerating its disappearance as well as the rates of depression, anxiety and the occurrence of post-traumatic stress in patients consulting for symptoms of COVID-19.
Khaoula HLIMI, Hajer YAAKOUBI, Rahma JABALLAH, Rym YOUSSEF, Jalloul ESSID, Emna TRABELSI (Sousse, Tunisia), Farah MANSOUR, Imen TRABELSI, Houda BEN SALAH, Asma ZORGATI, Lotfi BOUKADIDA, Riadh BOUKEF
00:00 - 00:00
#42332 - Interest Of The Plethysmography Variability Index (PVI) In The Management Of Acute Septic Conditions In Emergency Departments.
Interest Of The Plethysmography Variability Index (PVI) In The Management Of Acute Septic Conditions In Emergency Departments.
Introduction: Identifying the risk of sepsis in the emergency room is an essential step in their management. Recent scientific data demonstrate the major importance of early treatment. In addition to rapid treatment of the initial infectious site, early vascular filling is a fundamental element to improve the prognosis.
The objective of our study is to test the accuracy of PVI in predicting the severity of septic conditions in the emergency room.
Methodology: it is a prospective study with an analytical aim; including all patients aged 18 or over who have consulted the emergency room and present with acute sepsis. All patients had classic non-invasive monitoring, including a Masimo" Radical 7 pulse oximeter. We will monitor the clinical and biological evolution of patients with the evolution of the PVI. We evaluated whether the PVI allows to evaluate the hemodynamic state and predict the prognosis of patients during the management of acute septic states in the emergency room. We also evaluated the evolution of the patient's hemodynamic state in particular HR, MAP, peripheral signs of shock. , diuresis; evolution of biological parameters in particular decrease or increase in lactates, normalization of PH; length of stay in the emergency room;
Results: During the study period from January 2023 to June 2023, we included 200 patients whose average age was 65 ± 14 years. A male predominance is observed. The SOFA score was 3 ±2 in the good prognosis group versus 5 ±2 in the poor prognosis group with a significant difference between the two groups (p<0.01). The SOFA score had good discrimination with an area under the ROC curve equal to 0.726 (95% CI 0.670-0.840). The lactate level at H0 had good discrimination with an area under the ROC curve equal to 0.685 (95% CI 0.576-0.793). PVI on admission had good discrimination with an area under the ROC curve equal to 0.735 (95% CI 0.627-0.843). Delta lactatemia is the lactate level between H2 and H0 of admission; it had good discrimination with an area under the ROC curve equal to 0.525 (95% CI 0.406-0.643).
Conclusion: PVI makes it possible to assess the hemodynamic state and predict the prognosis of patients during the management of acute septic conditions in the emergency room.
Lobna MHJOUB, Houda BEN SALAH (sousse, Tunisia), Hajer YAAKOUBI, Rahma JABALLAH, Rym YOUSSEF, Emna TRABELSI, Wael ZOUARA, Imen TRABELSI, Asma ZORGATI, Lotfi BOUKADIDA, Riadh BOUKEF
00:00 - 00:00
#41703 - International expert consensus on criteria of home treatment of patients with acute pulmonary embolism.
International expert consensus on criteria of home treatment of patients with acute pulmonary embolism.
Background
Several trials have evaluated the safety of home treatment of patients with acute pulmonary embolism (PE), usually defined as discharge within 24 hours following PE diagnosis. Although, recurrent venous thromboembolism (VTE) at 3 months is commonly used as safety outcome, other outcomes and a different follow-up period may be more appropriate. Furthermore, a change in the outcomes might translate in a change of their predictive factors used as triaging criteria for home treatment.
Aims
To establish a consensus definition of serious adverse events, their timeframe and the maximum acceptable incidence to employ as safety outcomes and to define a novel rule of triaging criteria for home treatment of PE patients (the EARTH rule).
Methods
After a literature review on possible outcomes and triaging criteria, an international panel of experts was asked their opinion using two Delphi surveys. For each proposition, experts answered using a Likert scale. Proposals receiving a score of over 75% were either retained (agreement) or rejected (disagreement), the others were reformulated on the basis of experts’ comments and re-asked to the experts until a consensus was obtained.
Results
Fifty-five experts were invited and 38 experts from 11 countries participated (69%). Experts identified six adverse events, provided they required specific treatment: 1/ New onset of hypoxemia (<90%); 2/ New onset of severe hypotension or shock index > 1; 3/ New symptomatic cardiac arrhythmia; 4/ Major bleeding (International Society on Thrombosis and Haemostasis definition); 5/ Symptomatic recurrent PE or proximal deep-vein thrombosis; and 6/ Death possibly or confirmed to be related to PE. The timeframe was set at 7 days after discharge and the maximum acceptable incidence at 2.0%.
Fourteen criteria contraindicating home treatment were selected for the clinical rule: Four hemodynamic and respiratory criteria: Systolic blood pressure < 100mmHg, heart rate > 110bpm, unequivocal syncope or presyncope without explanation other than PE, new reduction in oxygen saturation < 92% or new increased need of supplemental oxygen; Seven criteria of high risk of bleeding: Recent (i.e., within 14 days) major or clinically relevant bleeding, recent stroke, recent major surgery, thrombocytopenia < 50,000/mm3, uncontrolled hypertension, severe liver impairment, severe renal failure; and three other conditions requiring hospitalization: social or system reason complicating outpatient management, PE diagnosed during anticoagulant treatment, and uncontrolled acute pain. In addition, three biological or imaging criteria were identified: repeated lactate ≥ 2 mmol/L, clot in the heart, and right ventricular dysfunction on echocardiography.
Conclusion
The EARTH expert panel developed a new triaging rule for home treatment of PE patients and established a set of adverse events, a maximum risk tolerance and a relevant time frame to be used as safety outcomes in future trials. The EARTH rule should now be assessed in a prospective trial before implementation in clinical practice.
No funding, registration not required
Mathieu SERVENT, Scott D. CASEY, William B. STUBBLEFIELD, Delphine DOUILLET, Federico GERMINI, Andrea PENALOZA, Christopher KABRHEL, Menno V. HUISMAN, David VINSON, Pierre-Marie ROY (Angers)
00:00 - 00:00
#41563 - Interventions for improving critical care in Low- and Middle-Income Countries: A systematic review.
Interventions for improving critical care in Low- and Middle-Income Countries: A systematic review.
Background
Quality Improvement (QI) interventions play a fundamental role in healthcare, but originate primarily from high-income countries. They encompass various strategies often targeting multidisciplinary team working and communication. Their effectiveness hinges on numerous clinical and contextual factors resulting in difficulties successfully translating these QI interventions across different healthcare settings. As healthcare inequalities and inefficiencies persist globally, particularly in Low- and Middle-Income Countries (LMICs), there is growing interest in how the implementation of QI interventions can address these issues and make sustainable, impactful change. LMICs face unique challenges in healthcare delivery especially to critically ill adults. Therefore, this review aimed to categorise and evaluate the QI strategies in adult critical care within LMICs, assessing the quality of evidence and identifying implementation barriers and facilitators.
Methods
This systematic review was conducted between 21st March 2022 and 1st September 2022 and aimed to identify the number, type and effectiveness of QI interventions. Studies were included if they described the implementation of QI interventions for adult critical care in LMICs, available as full text, in English and published after 2000. Risks of bias were assessed using the ROB 2.0/ROBINS-I tools. Intervention strategies were categorised according to a knowledge translation framework. Interventions’ effectiveness was synthesised by vote counting and assessed with the binomial test. Barriers and facilitators to implementation were narratively synthesised.
Results
3215 publications were screened, and 78 studies were retained for data extraction and analysis. The risk of bias was high. The most common intervention strategies were Education, Audit & Feedback (A&F) and Protocols/Guidelines/Bundles/Checklists (PGBC). Two multifaceted strategies improved both process and outcome measures: Education and A&F (p=0.008 for both processes and outcomes); and PGBC with Education and A&F (p=0.001, p<0.001). Facilitators to implementation were stakeholder engagement, organisational readiness for implementation, and adaptability of interventions. Barriers were lack of resources and incompatibility with local systems. There was a lack of evidence from Low-Income Countries.
Conclusions
Quality of care (or a lack thereof) accounts for considerable excess morbidity and mortality in critically ill patients. Our findings indicate the evidence for QI in critical care in LMICs is scarce; coupled with a high risk of bias in existing studies. Notably, there has been a positive trend in publication frequency over the last decade. PGBC with Education and A&F strategies demonstrated significant effects at improving both clinical processes and patient outcomes. Multifaceted interventions are most effective. The review suggests two to three intervention strategies for optimal effectiveness, with a potential ceiling effect observed necessitating careful consideration of intervention complexity and implementation time.
Despite variable study quality, with a predominance of observational designs, our recommendations emphasise the need for greater methodological rigor, including consideration of hybrid study designs, process evaluations and adherence to recognised reporting guidelines. This would also improve the evidence base. Co-designing interventions with and engaging local stakeholders, communicating relative advantages, employing local champions and adapting to feedback can improve implementation. This might also improve QI intervention scalability and sustainability in both High-income and LMICs.
The review was registered with PROSPERO. MEDLINE, EMBASE, Cochrane Library and ClinicalTrials.gov; in accordance with the PROSPERO guidelines and registered in March 2022 (registration number CRD42022314328),
Consent
This study is a systematic review and as such does not include patient, provider, or public involvement. The data was collected from already published research. No consent was sought.
Benefits
This study synthesises existing evidence on approaches used, outcome measures employed to estimate effects and the nature of implementation challenges. This evidence will directly inform the design of future QI interventions internationally as part of CCAA (CRIT Care Asia; a Wellcome funded collaboration for registry enabled research, implementation, and training for critical and acute care in Asia and Africa)18. The beneficiaries of these published findings will thus be patients, clinicians, and researchers on critical care units in Asia, Africa and more globally.
Participant confidentiality
This study does not include patient identifiable data. Since all data used for analysis is freely accessible through the registries, no additional measures for data storage need to be taken. All collected data will remain the property of the contributing registries.
Compensation and Funding
Resources to conduct the study are provided by the Wellcome Flagship Innovations award. (“Collaboration for Research, Implementation and Training in Critical Care in Asia and Africa”, reference 224048/Z/21/Z).
Duncan WAGSTAFF, Sumaiya ARFIN, Alba KORVER, Patrick CHAPPEL (Glasgow, ), Aasiyah RASHAN, Rashan HANIFFA, Abi BEANE
00:00 - 00:00
#41253 - Intestinal obstruction secondary to antibiotic treatment for helicobacter pylori eradication: an unusual presentation.
Intestinal obstruction secondary to antibiotic treatment for helicobacter pylori eradication: an unusual presentation.
A 60-year-old female presented to the emergency department with a four-day history of persistent upper hemiabdominal pain accompanied by multiple episodes of bilious emesis. She denied experiencing fever but reported jaundice. She also denied acholia. The patient had previously undergone a 15-day treatment indicated by gastroenterology for the eradication of Helicobacter pylori. The treatment regimen consisted of amoxicillin and clarithromycin. She noted the onset of mild epigastric pain by day 12 of treatment; however, the pain worsened in severity and became continuous over the subsequent five days, that's why she decided to consult.
Upon admission, the patient was alert, conscious, afebrile, with grade II dehydration, and reported pain intensity of 9/10. Physical examination, the patient exhibited abdominal distention, absence of bowel sounds, multiple episodes of vomiting, and oral intolerance. Initial laboratory evaluations were conducted, revealing unremarkable findings. The complete blood count demonstrated no leukocytosis, anemia, or thrombocytopenia. Liver function tests were within normal limits, and renal function was deemed appropriate for her age group. Additionally, C-reactive protein (CRP) levels were within the normal range, and both serum amylase and bilirubin levels were also within normal parameters.
A plain abdominal X-ray was subsequently performed, revealing findings consistent with a small bowel obstruction. The imaging suggested a mechanical obstruction at the ileocecal valve, likely secondary to foreign bodies. Specifically, multiple radiopaque images were identified, which were consistent with medication capsules. Dilatation of the small intestinal loops was evident, with a diameter extending up to 36mm. The dilation extended up to the ileocecal valve, where two hyperdense images were noted. Furthermore, sections of thickened intestinal loops appeared collapsed on imaging.
Given these diagnostic findings, the initial management strategy was implemented, which included the insertion of a nasogastric tube for decompression and the administration of intravenous fluids to treat dehydration. Additionally, preparations for a colonoscopy were initiated with polyethylene glycol and Monosodium Biphosphate enemas. On the third day of hospitalization, a total colonoscopy was conducted to further investigate the underlying cause of the obstruction. The procedure ruled out any structural abnormalities and failed to visualize any medication capsules within the gastrointestinal tract. Following careful observation, symptom resolution, and multidisciplinary input, the patient was stable for discharge.
In conclusion, the presented case underscores the significance of recognizing mechanical intestinal obstruction as a potential complication secondary to antibiotic therapy of Helicobacter pylori due to the high number of capsules the patient must consume daily. Such cases require comprehensive multidisciplinary management. Importantly, our experience highlights that successful medical management can often be achieved without the necessity for surgical intervention.
Clinical Implications: Our study emphasizes the critical role of timely and accurate diagnosis by emergency physicians. It is imperative to consider intestinal obstruction secondary to antibiotic therapy for Helicobacter pylori eradication as a pivotal differential diagnosis in similar clinical scenarios.
Valentina VILLARREAL HERNÁNDEZ (Bogotá, Colombia), Carlos José PÉREZ, Pablo SANDOVAL
00:00 - 00:00
#41596 - intoxication with Castor beans.
intoxication with Castor beans.
Castor beans, extracted from the seeds of the Ricinus communis plant, are among the most formidable plant toxins known to man. Ricin, a highly toxic protein present in these seeds, acts by inhibiting protein synthesis at the cellular level, resulting in widespread disruption of biological functions and potentially leading to multi-organ failure and death.
A case report details the presentation of an 11-year-old child with no previous history of the disease and good psychomotor development to the emergency department with repeated vomiting for 6 hours following voluntary ingestion of 8 castor beans.
Upon initial examination, the child was found to be asthenic and complaining of abdominal pain. Clinical examination revealed mild polypnea with no signs of struggle, pulmonary auscultation without abnormalities, and correct oxygen saturation on room air. His blood pressure was within normal limits, his heart rate was elevated at 110 beats per minute, and he did not exhibit any peripheral signs of shock. His skin recoloration time was 2 seconds. The electrocardiogram demonstrated sinus tachycardia.
The child was afebrile but conscious, with no neurological signs. Additional examinations revealed no abnormalities except for hypokalemia at 3.1 mmol/l.
The quantity of the substance ingested was minimal, which accounts for the relatively mild presentation of this accidental intoxication.
The patient's condition improved significantly, with the resolution of the presenting symptoms and correction of the electrolyte imbalance within 48 hours.
Haifa BRADAI, Chebbi NABIL (Tunisie-Sousse, Tunisia), Sondes LAAJIMI, Dorra LOGHMARI, Rabeb MBAREK, Naoufel CHEBILI
00:00 - 00:00
#41269 - Intracranial hemorrhage due to transdermal methyl alcohol poisoning.
Intracranial hemorrhage due to transdermal methyl alcohol poisoning.
Introduction: The primary poisoning factor is metabolic acidosis in methyl alcohol poisoning. Poisoning most often occurs after oral ingestion, but absorption through the lungs and skin may also occur. Cases of intracranial hemorrhage due to methyl alcohol poisoning have been reported. Whether intracranial hemorrhages are due to hemodialysis or methyl alcohol poisoning has not been clearly determined. Intracranial hemorrhage may be due to heparin during hemodialysis.
Case: A 65-year-old male patient was admitted to the emergency department with nausea and visual impairment. It was learned that the patient had severe arm pain due to a rotator cuff injury in the left shoulder, and his brother poured alcohol on cotton and hugged his arm. He stated that his arm pain was relieved, but he still had nausea and blurred vision. The patient appeared anxious. The patient's left arm was wrapped with cotton soaked in alcohol. He described that his hands and lips were numb, and that he had tightness and restlessness in his chest. The patient's general condition was fair and he was conscious. Vital signs: Fever: 36.0 C Pulse: 68 beats/min BP: 100/60 mmHg, SO2: 97%, respiration: 30/min, neurological examination was normal, there was no motor or sensory loss. The cotton wrapped around the left arm was removed and the arm was washed. There was redness and bandage marks on the arm. The ECG was normal sinus rhythm. In arterial blood gas; pH: 7.22, pCO2: 25.8, pO2: 142, lactate: 1.2, Base Ex: -17.2, HCO3: 10.5. With these findings, methyl alcohol poisoning was considered in the patient. Vascular access was established and NaHCO3 treatment was started. Glucose: 123 mg/dl, ethanol: 0 mg/dL, other results were within normal limits. The patient was transferred to the ICU for hemodialysis and follow-up. In the ICU, the patient's general condition and his mental state deteriorated, and laboratory studies were repeated. UREA: 78, CR: 2.71, CK: 2345, amylase: 161 U/L, K: 3.38 mmol/L, hsTroponin I: 143.45 (0-46.47ng/L). NaHCO3 treatment was continued and hemodialysis was applied. Since he remained hypotensive, noradrenaline infusion was started. The patient developed a coma on the 2nd day of hospitalization and underwent brain CT imaging. Hematomas with hypodense edema surrounding them, measuring 43x13 mm on the right and 60x25 mm on the left, were observed in the basal ganglia. The patient's blood pressure did not increase despite inotropic agent. The patient developed multiorgan failure and died on the 10th day of hospitalization.
Conclusion: Methanol poisoning may occur through the skin. Although the mechanism of intracranial hemorrhage following methanol intoxication remains unclear, it is known that it can progress rapidly and lead to serious and irreversible complications. Therefore, more detailed evaluation and urgent neuroimaging are required in cases with methyl alcohol poisoning and impaired consciousness. In our case, methanol poisoning developed through the skin and there was severe metabolic acidosis. After receiving hemodialysis, consciousness developed. In our patient, intracranial hemorrhage opening into the ventricle was detected on CT. There was no coagulation disorder in our case.
Nalan KOZACI, Ismail Erkan AYDIN, Huriye UDUM, Durmus Ali ERSAHIN (Antalya, Turkey)
00:00 - 00:00
#41998 - Intracranial sharp foreign body following stabbing.
Intracranial sharp foreign body following stabbing.
Introduction :
Stabbings are traumatic events that can have serious consequences for the physical and mental health of victims. These acts of violence represent a real challenge for healthcare professionals and public authorities.
We report here on the case of a man who was the victim of an assault resulting in an intracranial blocked foreign body.
Observation:
Patient A.E, 50 years old, diabetic on oral antidiabetics and hypertensive on monotherapy, admitted to the emergency department following a stabbing incident resulting in cranial, thoracic and abdominal point-of-impact trauma.
On admission, the patient was conscious 15/15, with no sensory or motor deficits.
Hemodynamically, he was normocardic at 80 bpm, and normotensive at 126/74 with no signs of peripheral hypoperfusion.
Respiratory status was eupneic at 17 cpm with SpO2 98%, with no signs of respiratory struggle or cyanosis.
General examination revealed three wounds, one on the face, opposite the left zygomatic arch. A second was on the thorax, above the left mammary. A third was in the lumbar region, to the left of the 11th dorsal vertebra.
No foreign bodies were visible to the naked eye.
The patient was referred to radiology for a body scan, which revealed the following:
- Presence of a sharp foreign body, entering between the mandibular incisure and the zygomatic process, crossing the infra-temporal pterygo-palatine fossa, left nasal cavity, nasal septum reaching to the medial wall of the right maxillary sinus flush with the bony palate.
- A voluminous haematoma measuring 53x75 mm and extending over 45 mm was present in the posterior cavity of the epiplons, the site of active bleeding surrounded by extensive hematic infiltration of the surrounding fat with a small haemoperitoneum.
A complete laboratory work-up was ordered. It showed a Hb of 12.7 g/dL with PNN hyperleukocytosis (WBC of 31,000/mm3 and PNN of 26,000/mm3) and platelets of 347,000/mm3. Haemostasis was normal and fluid balance was normal.
The patient was referred to the operating room for extraction of the foreign body and exploration of the active intra-abdominal bleeding.
The surgical procedure lasted approximately 6 hours, under general anaesthesia, with extraction of a sharp metal object (half a knife) (fig.3) and discovery of active bleeding at the expense of a gastric vessel, with haemostasis assured.
The postoperative course was marked by the onset of diabetic ketoacidosis and respiratory and hemodynamic instability. These complications led to the patient's death.
Discussion :
The presence of an intracranial foreign body remains a rare, serious and potentially fatal event, especially in view of the hemorrhagic and infectious complications.
Clinicians should be aware of this condition and consider the possibility of intracranial foreign bodies in patients presenting with traumatic head injuries, particularly when symptoms do not correspond to superficial injuries.
Clinical examination must be meticulous, and should never rule out the existence of an occult foreign body when the circumstances are present, as in our case, which underlines the value of imaging.
Multidisciplinary management and careful evaluation are essential to improve clinical outcomes and quality of life for affected patients.
Aymane DOUHAL, Mohamed Anass FEHDI (Casablanca, Morocco), Asmae DAFIR, Badria AGGOUG, Mohamed MOUSSAOUI, Mohammed MOUHAOUI
00:00 - 00:00
#41391 - Investigating the Relationship between Emotional Intelligence and Burnout in Emergency Medicine Residents.
Investigating the Relationship between Emotional Intelligence and Burnout in Emergency Medicine Residents.
Background and Purpose:
Emergency medicine residents (EMRs) face a demanding work environment characterized by high stress and pressure. This can lead to job burnout, a state of emotional exhaustion, cynicism, and reduced sense of accomplishment. Considering that emotional intelligence (EI) may enhance a person's ability to cope with stressful situations and potentially prevent job burnout, this study aimed to investigate the relationship between EI and job burnout among EMRs working in Tehran University of Medical Sciences hospitals during the year 2018.
Materials and Methods:
The current research is a correlational study that was conducted cross-sectionally and using random stratum sampling on 62 emergency medicine assistants. Maslach Burnout Inventory (MBI) standard burnout questionnaire and Wong and Law Emotional Intelligence Scale questionnaire (WLWIs) were used to collect information. The collected data were analyzed in SPSS 20 software.
Findings:
Rephrased: "There was a significant positive correlation (p < 0.000) between job burnout and all dimensions of emotional intelligence assessed: emotional self-evaluation, evaluation of others' emotions, use of emotions for decision-making, and regulation of emotions. Additionally, a significant negative correlation (p = 0.007) was found between job burnout and age. The regression model analysis revealed a significant F value (5.015, p < 0.01), indicating that emotional intelligence and age together significantly explained job burnout.
Conclusion:
The core message about the relationship between EI and burnout and the potential for training is still present. These findings suggest that interventions promoting emotional intelligence skills in EMRs could be beneficial in reducing job burnout and improving overall well-being.
N/A
Atousa AKHGAR (Tehran, Islamic Republic of Iran), Hamideh AKBARI
00:00 - 00:00
#42173 - Investigating the relationship between emotional intelligence and problem solving skills in Torbat-e Heydariyeh emergency medical technicians.
Investigating the relationship between emotional intelligence and problem solving skills in Torbat-e Heydariyeh emergency medical technicians.
Background: Emergency medical technicians have to make many critical decisions on a daily basis as part of their professional duties, which are very important to save patients' and injured ones' life. This process which is sometimes known as problem solving, may be affected by many factors. Some studies suggest that one of them is emotional intelligence. Emotional intelligence is a form of intelligence with which individuals can deal with a crisis, managing the stress and emotions, alter situations, solve problems and achieve goals through a set of capacities and abilities to take the best decisions. The purpose of this study was to investigate the relationship between emotional intelligence and problem solving skills in medical emergency technicians at Torbat-e Heidarieh city (At the northern east of Iran).
Methods: About 120 staff was working as EMT at the time of the study, of them 90 peoples were selected by stratified random sampling and agreed to enroll the study by signing a consent form. The research tool was a questionnaire containing demographic questions, Barr-On emotional intelligence and Hepner and Patterson problem solving inventories. The data were analyzed using SPSS version 20 software and Chi-square and Mann-Whitney statistical tests.
Results: The findings of the study showed that emergency medical technicians' emotional intelligence score had a significant relation with their problem solving skills score. Mean and standard deviation of problem solving skills and emotional intelligence of participants were as 73.02±10.21 and 67.59±16.86, respectively. Also, a positive and significant correlation was observed between emotional intelligence and problem solving skills scores (r=0.2, P Value≤0.05).
Discussion & Conclusions: Paying attention to improve emotional intelligence capability and teaching problem-solving skills by educational interventions should be considered for the emergency medical technicians and students. So that professionals of this field can practice working in critical situations that require concentration and avoiding negative emotions, confidently.
This study was funded by Mashhad University of Medical Sciences (Mashhad, IRAN) and has the university ethics committee approval (ID: IR.MUMS.MEDICAL.REC.1402.071).
Seyed Masoud HOSSEINI (Mashhad, Islamic Republic of Iran), Ali EMADZADEH, Maliheh DADGAR MOGHADAM, Seyed Jaber HEIDARI, Seyed Mohammadreza HOSSEINI
00:00 - 00:00
#41105 - investigating validity and reliability of Cristal Role in predicting the short-term mortality rate of elderly patients of hospitals Imam Khomeini, Sina and Shariati.
investigating validity and reliability of Cristal Role in predicting the short-term mortality rate of elderly patients of hospitals Imam Khomeini, Sina and Shariati.
Introduction: Generally elderly patients comprise one quarter of all the patients of Emergency ward. Elderly patients near end of life are the target group of most of health-care services namely; Ambulances, emergency service, hospital wards and Intensive care units. Investigations have shown that most of these patients die during their hospitalization period. Moreover, spending more time in Emergency ward. regarding increased life expectancy, increased age on mortality, the need for specific heath care for elderly patients and paving the way for more preventive measures on improving quality of life, we decided to investigate the conditions of mortality in this group of patients-based Cristal Roll.
Methods and Materials: This study aimed to investigate the validity and reliability of the Cristal roll in predicting short-term mortality of elderly patients referred to the emergency room of Imam Khomeini, Sina and Shariati hospitals. The obtained information was entered into SPSS software version 26, then quantitative data was reported as mean and standard deviation and qualitative variables were reported as frequency and percentage, also to check the relationship between variables based on normal and non-normal distribution from parametric and non-parametric tests. Appropriate parametric was used.
Results and Discussion: According to the results, we conclude that Cristal role has a potent capability in the estimation of severity and mortality of elderly patients admitted to emergency ward. therefore, the more score on incapability, incompetency, impaired consciousness upon admission, the more mortality rate will be expected. likewise, the one-month mortality rate has been reported more times over the three months.it seems that Cristal role has a high correlation regarding the prediction of mortality rate of elderly patients admitted to hospitals.
N/A
Hamideh AKBARI, Reza JAVDANI (Tehran, Islamic Republic of Iran), Atousa AKHGAR
00:00 - 00:00
#42086 - Investigation of the Effect of Cytochrome P450 Polymorphisms on the Efficacy and Safety in Cases of Convulsions Treated with Diazepam: A Prospective Pharmacogenetic Study.
Investigation of the Effect of Cytochrome P450 Polymorphisms on the Efficacy and Safety in Cases of Convulsions Treated with Diazepam: A Prospective Pharmacogenetic Study.
Introduction: It is known that diazepam, administered as first-line therapy in the management of convulsions, does not have similar effects in terms of dosage (single dose, repeated dose) in every patient, nor does it exhibit the same side effects (temporary desaturation, respiratory depression) at the same dosage. In this regard, genetic and pharmacogenomic factors are highlighted. Diazepam is primarily metabolized by CYP2C19 and CYP3A4, with the main active metabolite being nordazepam. Our aim is to determine the relationship between polymorphisms in the CYP2C19 gene [CYP2C192(c.681G>A) (slow enzyme activity), CYP2C193 (c.636G>A) (normal enzyme activity), CYP2C1917(-806C>T) (rapid enzyme activity)] affecting diazepam metabolism and response time to treatment and side effects in the emergency department.
Materials and Methods: Children presenting to the pediatric emergency department (ED) with febrile and afebrile seizures between January 2021 and May 2023 were prospectively included. At the time of admission, 2 ml of blood sample with EDTA was obtained from all patients for genetic analysis. Clinical findings, laboratory tests, response to treatment, and observed side effects were evaluated. Polymorphisms CYP2C192(c.681G>A) (slow enzyme activity), CYP2C193 (c.636G>A) (normal enzyme activity), CYP2C1917(-806C>T) (rapid enzyme activity) were evaluated in blood samples using next-generation sequencing.
Results: A total of 100 pediatric patients experiencing seizures were included in the study. The median age of the patients was 4.5 years (min 2 months - max 17 years), and 61.0% were male. The ratio of afebrile to febrile seizures was 54/46, and 43% had a diagnosis of epilepsy. The duration of seizures in the emergency department was most commonly 5-10 minutes (75%), followed by 10-30 minutes (12%), 30-60 minutes (10%), and >60 minutes (3%). Seizure control was achieved with the first diazepam (iv) (0.2 mg/kg) administration in 70% (n=70); with the second diazepam (iv) (0.2 mg/kg) administration, it was 38.1% (n=n. Temporary desaturation and respiratory depression were observed in 4% (n=4) and 3% (n=3) of patients after the first diazepam treatment, while after the second diazepam, it was 9.5% (n=2) and 4.8% (n=1), respectively. Among the patients, 54% had heterozygous (GA) polymorphism in CYP2C192(c.681G>A) (slow enzyme activity), 3.7% had homozygous (AA); 46.3% had heterozygous (CT), 3.7% had homozygous polymorphism "CYP2C1917(-806C>T) (rapid enzyme activity)", while no patient had "CYP2C193 (c.636G>A) (normal enzyme activity)" polymorphism. In patients with seizure duration <10 minutes in the emergency department, the "CYP2C192(c.681G>A) (rapid enzyme activity)" polymorphism was significantly higher (%57.1 vs %19.1, p=0.037). However, the CYP2C192(c.681G>A) (slow enzyme activity) polymorphism was similar in seizure groups (%29.6 vs %20, p=0.251). There was no significant relationship between the development of respiratory depression and polymorphisms (p=0.349).
Conclusion: The CYP2C1917(-806C>T) polymorphism in the CYP2C19 gene involved in diazepam metabolism leads to a shortening of seizure and treatment response time in patients.
Funding: This work was supported by Ege University Research Foundation
Eylem Ulas SAZ, Elif ERGIN (izmir, Turkey), Caner TURAN, Muazzez SEKER, Durdugul AYYILDIZ EMECEN, Esra ISIK, Tahir ATIK, Ali YURTSEVEN
00:00 - 00:00
#40714 - Is ataxia, a exclusively neurological disease?
Is ataxia, a exclusively neurological disease?
Walking (gait) is a complex and unique motor beavior sonsisting of trhee primary components: locomotion, balance, and ability to adapt to the enviroment. Normal gaig requies a delicate balance among multiple interacting systems, includint ther major afferent sensory systems (visual, vestibular, and propioceptive sense), a locomotor efferent system (including nerves and muscles), and a strict surveillance by several structures of the central nervous system.
Most gait disorders are multifactorial and have both, neurologic and non neurologic components.
Gait disorder are a major cause of funtional impairment and morbidity in older adults and a several patters.
We present the case of a 77-year-old patient with a history of mitral insufficiency, arterial hypertension and hypercholesterolemia, osteoporosis as factors to highlight and being treated with omeprazole, lecardipine/enalapril 20/20 mg per day, Atorvastatin, magnesium 97.24 mg per day. , calcium 1 g per day, and alendronate 70 mg per week, who presented in the emergency room with generalized tremor, motor incoordination and dysbause with predominant imbalance or unsteadiness that had progressed to the need to use canes and which was attributed to the fact that 1 week before, he had administered the flu vaccine.
The physical examination showed ataxia in all 4 extremities, with no other findings of note, and the analysis showed the presence of severe hypomagnesemia and hypocalcemia.
Brain MRI without notable alterations
Parenteral magnesium is administered and the calcium level is corrected with complete remission of the ataxia.
After completing the study, the cause of hypomagnesemia and hypocalcemia was directed to chronic use of omeprazole.
Oscar BECERRA CREMIDIS, Hugo Gamaliel CABELLO ALARCON (Andorra, Spain)
00:00 - 00:00
#42232 - Is the intervention time longer if limitation treatment for terminally ill patients is applied by Advanced Life Support Ambulance teams?
Is the intervention time longer if limitation treatment for terminally ill patients is applied by Advanced Life Support Ambulance teams?
Introduction
Emergency Medical Services (EMS) often decide to set up limitation of medical treatment when they are called for acute distress in the context of a terminal illness.
This time-consuming procedure raises questions in the pre-hospital setting, and would probably be more appropriate in the emergency department.
The aim of this study was to ascertain whether the decision of initiating limitation of care (LOC) in the prehospital setting increased intervention time.
Methodology
It is a retrospective study, from January 2017 to December 2023. All adult patients interventions where a limitation of care (LOC group) or withdrawing therapies were performed by Advanced Life Support (ALS) teams were included. These patients were compared to ALS interventions where adult patients had no limitation of care (no-LOC group).
Age, gender, main chief complaint, day of call, place of intervention, outcome of the patients and duration of treatment were collected.
Comparisons were made with Chi-square and ANOVA tests.
Results
Three hundred and three patients were included in the LOC group versus 26,415 in the no-LOC.
Mean age was 85.9 years old (Standard Deviation (SD) 11.1) in LOC group versus 62.8 (SD: 20.4) (p<10-3) and men represented 45.9% of them in LOC versus 55.3% (p<10-3).
The intervention took place in a nursing home (NH) for 52.8 % in LOC group versus 4.1% for no-LOC (p<10-3).
Most interventions took place on Sunday (20.8% for LOC versus 12.9% for no-LOC) (p<10-3) or during working hours 67.3% versus 55.3% (p<10-3).
Main chief complaints for LOC patients were an altered general state of health (25.6% versus 4%) respiratory distress (32.2% versus 11%) or a neurological syndrome (15.3% versus 10.7%). (P<10-3).
Sixty one percent of LOC patients were left on scene versus 3.3% (p<10-3). Whereas 4.3% of LOC patients died on scene versus 7.14%.
Mean intervention time was 1 hour and 21 minutes in LOC group versus 1 hour 16 minutes (p=0,005). More specifically for those left on scene, mean intervention time was 1 hour and 19 minutes versus 52 minutes (p<10-3).
Conclusion
When an ALS ambulance decided to apply a LOC on scene, overall time was significantly longer.
Applying a LOC with transmission of the procedure to the NH staff allowed the resident to stay at his place of living with appropriate care. As a great proportion of these patients lived in NH, they could be left on scene under the supervision of nursing staff, except on Sunday when NH’s coordinating doctor and GP were on leave, explaining why most of intervention occurred on that day. Respiratory distress was the most frequent chief complaint, as this very uncomfortable status required emergency care.
Cecile URSAT (GARCHES), Pierre BISCARRAT, Arnaud GILLE, Anna OZGULER, Michel BAER, Thomas LOEB
00:00 - 00:00
#42071 - Is the timing of medication administration ımportant in adenosine-refractory supraventricular tachycardia?
Is the timing of medication administration ımportant in adenosine-refractory supraventricular tachycardia?
Introduction: Approximately one-fourth of children with supraventricular tachycardia (SVT) experience refractory SVT after adenosine doses. Ventricular dysfunction due to SVT in infants and young children is often detected late, leading to delayed adenosine therapy, which may reduce its effectiveness in terminating SVT episodes. Our aim is to investigate the relationship between the timing of adenosine treatment intervals and the development of refractory SVT in children.
Materials and Methods: Patients and episodes requiring adenosine presenting to the pediatric emergency department (ED) between June 2016 and June 2019 and January 2021 and June 2023 were analyzed. Continued attacks after two doses of adenosine were defined as "Refractory SVT." The time intervals from symptom onset to ED presentation and from ED presentation to adenosine administration were compared between responders and refractory SVT cases.
Results: A total of 53 patients and 70 SVT episodes were analyzed. The median age of the patients was 8.0 years (min 5 days - max 17 years), with 15.7% (n=11) being under 1 year old. Twenty-two episodes (31.4%) were identified as refractory SVT. Refractory SVT cases were more common in patients with congenital heart disease (46.4% vs. 22.5%; p=0.037), and the time from ED presentation to adenosine administration was longer in these patients (median, 35 vs. 15 minutes; p<0.001). Amiodarone (5 mg/kg) was administered in 17.1% (n=12) of patients, and 8.6% required cardioversion. The frequency of refractory SVT increased with decreasing age (p=0.018), particularly in patients under 1 year old (39.1% vs 4.3%, p<0.001). There was a significant relationship between the time from ED presentation to adenosine administration and refractory SVT (OR for a 1-minute increase, 2.04; 95% CI, 0.818–0.932).
Conclusion: Delayed adenosine therapy affects the development of refractory SVT in children. The risk of refractory SVT is particularly higher in young children, emphasizing the critical role of early diagnosis and prompt adenosine therapy in these children.
Funding : None
Elif ERGIN (izmir, Turkey), Caner TURAN, Hatice Esra DURUKAN, Resit Erturk LEVENT, Ali YURTSEVEN, Eylem Ulas SAZ
00:00 - 00:00
#41633 - Is there a room for a more effective management of recent-onset atrial fibrillation in elderly patients too?
Is there a room for a more effective management of recent-onset atrial fibrillation in elderly patients too?
Background: The approach to recent-onset atrial fibrillation (AF) in elderly people is still rather cautious, as the rate control is generally the strategy of choice. Moreover, when rhythm control attempted, amiodarone is still the widely drug for its presumed safety. Nevertheless the growing experience with class 1c agents could encourage their use in order to improve the management of AF in elderly too.
Aim: To assess whether class 1c agents could be considered effective and safe in elderly people, as well in younger, in terminating recent-onset AF.
Methods: In this retrospective observational study we evaluated a three-years experience in over 75 patients treated in the Emergency Department of University Hospital of Verona for recent-onset AF (< 48 h) from January 2018 to December 2020. We excluded patients submitted to electrical cardioversion and those in whom the choice of treatment was forced by clinical conditions or coronary and structural heart disease. Main outcome were effectiveness and safety in the two groups of treatment, class 1c agents vs amiodarone. Moreover we reported readmission rate for AF recurrences or related events in a three-years follow-up. Statistical analysis was performed using Chi-square test, with significance level set at p<0.05. As a retrospective study no ethical approval or informed consent was needed.
Results: We attempted at restoration of sinus rhythm in 264 patients older than 75 years observed for recent-onset AF from January 2018 to December 2020. According to exclusion criteria, the study population was restricted to 147 patients (53 males, 94 females; mean age 80 years, range 75-95) where the treatment depended on the physician's choice only. Most of these (90 pts, 61.2%) was treated with amiodarone, while in 57 (38.8%) class 1c agents were administered. Mean age was not significantly different between the groups (81 vs 78.5). After treatment, stable restoration of sinus rhythm was reported in 43 patients (47.7%) in amiodarone and in 47 (82.4%) in class 1c group (p<0.01). Median time of conversion was 240 minutes (range 30-680) in amiodarone while 60 (range 15-530) in class 1c group (p<0.01). Surprisingly, even the narrow sample did not reach any significance, the incidence of adverse events was notably superior in amiodarone group, both in number (5 cases) and seriousness (2 cases). Whereas in class 1c group we reported only one mild adverse event. At the end of observation, 43 patients (75.4%) in class 1c but only 38 (42.2%) in amiodarone group were discharged with stable sinus rhythm (p<0.02). The AF recurrence rate (25 cases) and the incidence of related events (16 cases) during the follow-up were not significantly different between the two groups, involving 27.7% of the patients in amiodarone and 28% in class 1c group respectively (p=ns).
Conclusions: Class 1c agents appear to be more effective and as safe as amiodarone in terminating recent-onset AF even in selected elderly people. Therefore a more decisive approach, both in terms of attempt to cardioversion and choice of antiarrhythmic drug, appears to be feasible in the management of AF in these patients.
Since no ethical approval was needed, the study has no trial registration
The study did not receive any funding
Dr Antonio BONORA (VERONA, Italy), Beatrice BAMPA, Federico BELTRAME, Simone CONTE, Natasha DVORNIK, Daniele GABBIANI, Anna PICCOLI, Antonio MACCAGNANI
00:00 - 00:00
#40982 - Ischemia and reperfusion under hyperthermia aggravates neuronal death through increasing oxidative stress and excitotoxicity in gerbil hippocampal CA1 region.
Ischemia and reperfusion under hyperthermia aggravates neuronal death through increasing oxidative stress and excitotoxicity in gerbil hippocampal CA1 region.
Background and aims: Impaired oxidant/antioxidant balance and excitotoxicity due to glutamate transporter dysfunction are well known as the major causes of selective neuronal death (loss) in the hippocampus after ischemia-reperfusion injury (IRI). Hyperthermia (HT) deteriorates ischemic neuronal damage in the hippocampus, but the underlying mechanisms remain unclear. This experiment was conducted to investigate the mechanisms of worse neuronal damage due to IRI under hyperthermia in gerbil hippocampal CA1 region following IRI.
Methods: Normothermia (NT; 37.5±0.2°C) or HT (39.5±0.2°C) was controlled for 30 min before and during IRI. The gerbils received IRI and were sacrificed 0 h, 3 h, 6 h, 12 h, 1 day, 2 days, and 5 days after IRI. Neuronal loss using NeuN (a neuronal marker) immunohistochemistry and Fluoro-Jade B (a marker of neuronal death) histofluorescence was examined. Oxidative stress, excitotoxicity, and reactive astrogliosis were evaluated using immunohistochemistry for 8-hydroxy-2'-deoxyguanosine (8OHdG; an oxidative DNA damage marker) and superoxide dismutase 2 (SOD2; an endogenous antioxidant enzyme), glutamate transporter 1 (GLT1), and glial fibrillary acidic protein (GFAP; a marker for astrocytes).
Results: Neuronal loss of pyramidal neurons was earlier detected in HT-IRI group than NT-IRI group. 8OHdG and SOD2 immunoreactivity in the HT-IRI group was significantly higher than NT-IRI group. Reactive astrogliosis was informal in both groups util 1 day post-IRI, showing that, at 2 and 5 days post-IRI, GFAP immunoreactivity was significantly stronger in the HT-IRI group.
Conclusions: In brief, this experiment indicated that severer oxidative stress and greater reduction in GLT1 in the HT-IRI group mighty contribute to earlier and severer neuronal death under hyperthermia in the hippocampal CA1 region.
Jae Seong NOH, Jun Hwi CHO (Chuncheon, Republic of Korea), Joong Bum MOON, Taek Geun OHK, Myoung Chul SHIN, Da Som HAN
00:00 - 00:00
#41836 - Ischemic stroke and septic shock: an unexpected association.
Ischemic stroke and septic shock: an unexpected association.
The existence of stroke mimics and chameleons is well known in literature. It’s crucial that Emergency Medicine doctors maintain a vast array of differential diagnosis. As a matter of fact, in patient presenting with symptoms most consistent with stroke the real underlying pathology can be surprisingly different.
A 55 year old male was evaluated at this hospital after Territorial Emergency Service activated a stroke code. He was found on the couch incapable of speech and plegic on the right side, last seen well 7 hours earlier. His previous history was unremarkable. On the patient’s arrival at the emergency department respiratory drive and hemodynamic status were normal. Mottling of the skin on the abdomen and a cold right limb without femoral pulse were observed. ECG showed sinus rhythm and capillary glucose was normal. The patient was awake but incapable of speech. He did not spontaneously move the right arm or leg or respond to tactile stimuli on that side. Shortly after partial seizures of the left limbs occurred and diazepam was administered. Patient’s Glasgow Coma Scale rapidly decreased to 3 and the trachea was intubated. The arterial blood gas analysis showed that oxygen saturation was 99% while receiving mechanical ventilation. Metabolic lactic acidosis and Hb 21 g/dl were also revealed. Bedside ultrasonography displayed the presence of ascitic free fluid, a thrombotic formation occluding the left common carotid artery and significant reduction of blood flow in the right iliac artery. We suspected aortic dissection given the presence of concomitant neurologic focal deficit and limb ischemia, so a whole body Computed Tomography Angiography was performed. No aortic dissection was detected, but an upper gastro intestinal perforation was revealed, along with a diffuse arterial thrombosis of many peripheral vessels. Laboratory test results showed high white cells count and normal coagulation status (white blood cells 17 x109/L, platelets 286 x109/L, aPTT 34 seconds, PT 13 seconds, fibrinogen 340 mg/dl). In the operating room emergency repair of the perforation was performed, followed by open surgical revascularization of the leg. The arterial occlusion could not be resolved and the limb became necrotic. A head Computed Tomography after 24 hours showed diffuse ischemic lesion and shortly after the patient died.
It remains unclear what could have caused such an hyperacute and fatal disease. It’s possible that the perforation was followed by a distributive septic shock leading to insufficient perfusion in the atherosclerotic iliac artery. In addition diffuse arterial thrombosis could be linked to sepsis-related coagulopathy and infection. However laboratory test results showed that hematocrit was 60% and hemoglobin 21 g/dl. This marked erythrocytosis and the extremely high hematocrit value could not be explained only by fluid loss. Hyperviscosity syndrome is a life threating complication of myeloproliferative neoplasm, in particular Polycythemia Vera (PV). Among clinical manifestations there are thrombosis in unusual sites, including splanchnic arteries leading to intestinal ischemia and perforation. Unfortunately mutated JAK2 was not searched for in this patient so PV cannot be ruled in nor out.
Francesco BENATTI (Reggio nell'Emilia, Italy), Natale VAZZANA, Nadia LO DUCA, Ivana Maria LATTUADA, Eleonora BERTI, Luca RONCUCCI, Lucio BRUGIONI, Pietro DALL'OLIO
00:00 - 00:00
#40861 - Isolated distal radio-ulnar joint dislocation.
Isolated distal radio-ulnar joint dislocation.
Background:
The forearm plays a significant role in contributing to the hand’s function, essential for many activities of daily living. The distal radioulnar joint (DRUJ) serves to stabilize the articulation of the radius around the ulna during supination and pronation of the forearm. Acute DRUJ dislocations usually occur due to trauma associated with fractures of the distal radius or radial head. Isolated dislocations and subluxations of the DRUJ are rare and commonly missed up to 50% in the acute period. Failure to diagnose and treat an isolated DRUJ dislocation can result in chronic and persistent dislocation or subluxation with subsequent instability and loss of function.
Case Presentation:
A 22- year- old male presented at the Emergency department after a fall with wrist pain. Xray demonstrated volar dislocation of the distal ulna. Closed manipulation and reduction (M&R) was performed under sedation with initial successful reduction. However, the wrist spontaneously dislocated shortly despite immobilisation. A second attempt at reduction resulted in overall improvement in the alignment of the wrist though the distal ulna remained slightly subluxed with a widened distal radioulnar joint space. The patient continued to have distal radioulnar joint instability on subsequent specialist clinic follow-up. This case reiterates the challenges in management of isolated DRUJ dislocations.
In most of the cases reported so far in literature, closed manipulation and reduction was carried out under general anaesthesia with successful reduction. Our case had M&R done under sedation in the Emergency Department. However, as in our experience, these injuries are unstable with risks of spontaneous recurrent dislocation or persistent subluxation. These injuries can still be managed outpatient but with early follow up with the hand or orthopaedic surgeons as they are inherently unstable. However, if there is a block to reduction and the DRUJ remains fully dislocated, emergent surgery would be required.
Conclusions:
DRUJ dislocations are highly unstable despite initial successful reduction. The injury can cause significant limitation in activities of daily living involving the hand or wrist. Clinicians should keep a look out for it and involve the hand or orthopaedic surgeon early.
Desiree Xin Ying LIM (Singapore, Singapore), Jin Xi LIM, Wei Ming NG, Beng Leong LIM, Wei Feng LEE, Yiwen KOH
00:00 - 00:00
#41589 - Isolated proximal ureter injury following low-impact blunt trauma.
Isolated proximal ureter injury following low-impact blunt trauma.
The patient has given consent to have details submitted and we ensure his anonymity.
To the emergency department was admitted a 62-year-old male by the ambulance with complaints of left flank pain, two episodes of macrohematuria following low-impact blunt trauma on admission day, history of fever for last four days. He fell at home hitting his left side against armchair because of sudden weakness and dizziness. On physical exam vital signs and body temperature were normal, abdomen to palpation was diffusely painful, observable costovertebral angle tenderness on the left side and there were bruises on the right side of the forehead and the left flank.
At first traumatic genitourinary system injury was not suspected because it is exceedingly rare after blunt trauma, moreover traumatic mechanism was low-impact, also he had history of four days fever before the fall. Lab work and initial radiological findings didn't give a clear idea towards correct diagnosis either. Blood workup was misleading, it showed leukocytosis – 12,55 x 103/uL on behalf of neutrophil count, elevated C reactive protein – 92,10 mg/L and procalcitonin – 0,16 ng/ml otherwise no major disturbances. Urine test strip analysis was positive for leukocytes and erythrocytes, nitrites - negative, color – orange, clarity – cloudy. Nasopharyngeal swab came back with positive Influenza type A virus RNA. CT scan of the head, chest X-rays, and abdominal ultrasonography were unremarkable with no acute traumatic changes. All these finding at the start led to believe that underlying problem is the Influenza type A and urinary tract infection.
However, what didn't add up was the sudden macrohematuria after the trauma which made to reconsider the main diagnosis. Just before transferring patient to another hospital last minute call was made for urologist and CT urography to exclude traumatic genitourinary system injury. CT scan showed rupture of proximal one-third of the left ureter with active contrast medium excretion retroperitoneally. Additionally, on the CT there were renal cysts and an incidental finding of a contrast collecting, round tumor in the urinary bladder for the first time. After that Foley catheter was inserted into the patient's bladder from which gross hematuria was noted in the collecting bag. The diagnosis was verified by retrograde pyelography. Patient recieved stent in the left ureter and was discharged home after a week long hospital stay without complications, to return at the later date for planned transurethral urinary bladder tumor resection.
As differential diagnosis initially was considered urinary tract infection, rib fractures on the left side. In the end actual diagnosis were laceration of the left proximal ureter, tumor of urinary bladder, influenza type A infection.
As ureteral trauma is very rare, especially isolated ureteral damage, it is easy to miss this diagnosis. Delayed diagnosis puts the patient's health and life at risk. Ultrasonography in the early post-injury phase tends to be unremarkable. Acute macrohaematuria, costovertebral tenderness, flank pain, bruises, and ecchymosis on the flank after blunt trauma even with negative ultrasonographic findings should warrant CT urography to exclude damage to the urogenital system.
Marks TUMASS (Riga, Latvia), Aleksejs VIŠŅAKOVS, Evija LEVENŠTEINA
00:00 - 00:00
#42280 - ISS and RTS in traumatology.
ISS and RTS in traumatology.
*Introduction :traumatic pathology is sometimesburdened with heavy morbidity and mortality and represent the main cause of mortality in young adults. The objective of this work is to determine the contribution of ISS and RTS scores in emergencies in the prediction of serious trauma.
*Methods :Prospective, descriptive and analytical study, extending over a period of two months (July and August 2023), carried out in the emergency department. We included all trauma patients admitted to the emergency department with calculation of severity scores. RTS scores < 6 and ISS score >24 are associated with serious trauma
*Results :Inclusion of 132 trauma patients. The average age was 40 years ± 14 years, with a clear male predominance (n=106; 80.3%). Accidents in public life were in first place (83.3%), followed by domestic accidents (10.6%) and work accidents (4.5%). . The main mechanisms of trauma were: vehicle collision (13.4%), skidding (7.6%), rollover (4.2%), motorcyclists (29.5%). Regarding gravity mechanisms, 43 patients were ejected (34.9%), with a fall beyond 4 meters in 11 patients (8.3%). The initial clinical examination found a SBP between 60 and 180 mmHg (mean 124.7mmHg) and a DBP between 40 and 100mmHg (mean 75mmHg). The average heart rate was 85 bpm with an initial shock index between 0 .33 and 1.37 (average 0.68). The average severity scores of severe trauma patients ISS, RTS, TRISS and MGAP were 24.36; 7.66; 12.64 and 26.5 respectively. The predictive factors of an ISS score >24 are: anisocoria (p=0.000); GCS (p=0.000); thoracic deformation (p=0.022); limb deformation (p=0.038); pelvic instability (p=0.008); open fracture (p=0.005); impingement fracture (p=0.05); GCS (p=0.000); PAD (p=0) .05); CPK (p=0.02); use of norepinephrine (p=0.001); Exacyl (p=0.000). The factors associated with an RTS score <6 were: ejection mechanism (p=0.004); pelvic instability (p=0.009); subdural hematoma (p=0.015), subarachnoid hemorrhage (p=0.00); brain contusion (p=0.000); liver contusion (p=0.000).
*ConclusionThe use of severe trauma assessment scores makes it possible to assess the initial severity of patients as well as the subsequent evolution. This allows optimal and targeted management of serious trauma patients..
Sirine KHABOUCHI, Khaireddine JEMAI (Tunis, Tunisia), Dhekra HOSNI, Hana HEDHLI, Mahrez BELAID, Ibtihel AISSAOUI, Aymen ZOUBLI, Sarra JOUINI
00:00 - 00:00
#41912 - It was the seat belt.
It was the seat belt.
We were called by the police to provide medical care to a patient who had suffered a car accident. She was a 65 years-old woman who had had a frontal impact at high velocity with another car which was driving in opposite direction. Our patient had to be extricated by the firemen because she was trapped. She was the driver of her car and the only occupant of the vehicle. She was using the seat belt and the airbag deployed during the accident.
When we arrived, the patient was lying on the spinal board. She was fully aware and oriented with a GCS of 15. She had a medical history of left breast cancer treated with surgery 14 years ago. Her vital signs were: blood pressure of 120/50 mmHg, heart rate of 120 bpm, respiratory rate of 25 rpm, SO2 of 94%, and a glycemia of 120 mg/dl. She complained of pain on her chest and her abdomen. She had abrasions and ecchymoses across the thorax and the abdomen corresponding to the position of the diagonal strap of the seat belt. There was a small hemorrhage on her left breast. Cardiopulmonary auscultation was normal. She had pain and crepitation at thoracic palpation on the left rib cage. Abdominal examination revealed moderate low abdominal tenderness without guarding or rebound tenderness.
We administered fentanyl for the pain and 250 ml of crystalloids, improving the heart rate and the respiratory rate.
At the hospital, a thorax x-ray and a full body CT were performed showing 5 left ribs fractures and an abdominal subcutaneous fat stranding without signs of intra-abdominal injuries. 24 hours later the abdominal pain increased, and a new abdominal CT scan was performed. The CT showed free fluid and air in the abdomen resulting from ileum wall perforation. The patient underwent a laparotomy, and a resection and anastomosis of the involved segment were done. She evolved favorably and was discharged 7 days later.
Seat belts are the most important safety system in motor vehicles. However, in high velocity motor vehicle collisions they can be the source and cause of serious injuries.
The seat belt sign is characterized by patterned bruising on the chest and/or abdominal wall seen in a restrained passenger involved in a traffic collision. Seat belt sign appears to be associated with an increased risk of underlying visceral injuries and passengers presenting with seat belt signs are more than twice as likely to sustain intra-abdominal injury, particularly involving the intestines or associated mesentery.
Intra-abdominal injury due to seat belt presents characteristically late and the typical findings of peritonitis might not be present initially. That’s why repeated examinations of the abdomen are essential to do the early diagnosis of intestinal injuries, mainly in those patients with persistent pain or tenderness despite a negative CT.
This case is an example of the importance of the presence of seat belt signs on the abdomen to suspect an abdominal injury, despite of the initial negative CT scan.
Vanesa Natalia ISAAC, Cristina BARREIRO MARTÍNEZ, Blanca GUERRERO MOÑUS, Noemi SOTO TOSTADO, Marta HUEDO JIMENEZ, Pilar VARELA GARCÍA, Miriam UZURIAGA MARTÍN (Madrid, Spain)
00:00 - 00:00
#42238 - Job burnout in Emergency Department - a problem still unsolved.
Job burnout in Emergency Department - a problem still unsolved.
Introduction: Burnout syndromes, or job burnout, is a condition in which a person suffers from chronic workplace stress that has not been successfully managed. While knowledge concerning burnout syndrome has grown exponentially, it continues to remain a focal issue in high demanding working fields. The risk of developing burnout is considerably higher in medical professionals working in more "demanding" sectors, such as emergency care. This can lead to important social and personal costs.
Method: In the period 2020-2024, we evaluated 100 people, employees of the emergency department in order to detect professional burnout in this category of medical personnel. We applied the Maslach - Human Services Survey professional stress assessment questionnaire. It was interpreted being correlated with other elements such as age, sex, lifestyle habits. All the diseases with which they are already diagnosed were centralized for the evaluated persons. The presence of burnout syndrome was identified in 95% of the emergency department staff. In the first place are hypertension and dyslipidemia as frequently correlated pathologies in people in job burnout, followed by musculoskeletal and circulatory problems.
Conclusions: Thus we have the right to evaluate whether certain pathologies are more frequent in people identified with job burnout. It is necessary to periodically evaluate the burnout syndrome in the emergency department because it can be correlated with debilitating cardiovascular and osteoarticular pathologies that lead over time to a decrease in efficiency at the workplace, even the necessity to needs to be changed.
Anca TELEHUZ (-Slobozia, Romania), Valerian-Ionut STOIAN, Violeta SAPIRA, Mihaela DEBITA
00:00 - 00:00
#41352 - Kehr's sign-- A clinical sign that can save!
Kehr's sign-- A clinical sign that can save!
A 59-year-old patient, hypertensive, with no other notable history, was admitted to the emergency room following discomfort described as lipothymic, associated with left scapular pain characterized by its accentuation with deep inspiration. The interrogation further specified the absence of associated trauma. On admission, the patient was conscious, oriented and afebrile; blood pressure was 85/45 mm Hg, heart rate was 108 beats per minute, and oxygen saturation was 96% in room air. Clinical examination revealed mucocutaneous pallor; the abdomen was supple with diffuse sensitivity to deep palpation, but without defense found. The rectal examination was painless and without visible blood. Examination of the left shoulder was unremarkable. The initial blood test revealed an inflammatory syndrome (C-reactive protein at 61 mg/l and leukocytosis at 19,500/mm3), a lactate level at 4.8 mmol/l, hemoglobin at 7.2 g/dl, a prothrombin level of 78% and a serum creatinine of 166 µmol/l (i.e. a glomerular filtration rate estimated at 39ml/min), without hydro-electrolyte disorders or disturbance of the liver balance. An emergency thoraco-abdominal CT scan revealed a large hemoperitoneum associated with a perisplenic hematoma, suggesting a ruptured spleen. An emergency hemostasis splenectomy was performed, the outcome of which was simple
Atraumatic rupture of the spleen is a rare clinical entity with high mortality. In a systematic review of the literature between 1980 and 2011 concerning 845 patients, the rate was 12.2% [1] The clinical presentation is not very specific, making its diagnosis sometimes difficult. The presence of pain in the left hypochondrium with left scapular radiation, called Kehr's sign, has an interesting orientation value [2]. This sign was described by the German surgeon Hans Kehr (1862-1916). This is a classic example of referred pain. Irritation of the diaphragm (by damage to a nearby organ) is transmitted by the phrenic nerve with pain localizing in the ipsilateral supraclavicular region. This projection is explained by the common cervical radicular origin (C3 and C4) of the supraclavicular nerve and the phrenic nerve. Thus, the association of scapular pain and hemodynamic instability without obvious etiological orientation should encourage the practitioner to look for an intraperitoneal effusion.
1. Gedik E, Sadullah G, Aldemir M et al (2008). Non-traumatic splenic rupture: report of seven cases and review of the literature. World J Gastroenterol. 14:6711–6
2. V. Klimpel (2004). Does Kehr's sign derive from Hans Kehr? A critical commentary on its documentation? Chirurg. 75:80–83
Hakim SLIMANI (Colmar), Philippe KAUFFMANN
00:00 - 00:00
#41559 - KEY ASPECTS OF PEDIATRIC LIVER TRANSPLANT PATIENT VISITS TO THE PEDIATRIC EMERGENCY DEPARTMENT.
KEY ASPECTS OF PEDIATRIC LIVER TRANSPLANT PATIENT VISITS TO THE PEDIATRIC EMERGENCY DEPARTMENT.
Introduction: Liver transplantation is a life-saving procedure for patients; however, short and long-term complications compose a significant risk. The main aim of our study is to describe the clinical features of pediatric liver transplant patients admitted to the emergency department and to identify the risk factors that may lead to intensive care unit admission.
Methods: We retrospectively included pediatric liver transplant patients who were admitted to the pediatric emergency department of Baskent University Hospital between 01/01/2023 and 31/12/2023. We noted their main symptoms, laboratory tests, hospitalization status, and final diagnoses. Clinical and laboratory features of patients admitted to the Pediatric Intensive Care Unit were compared with those who were not. Descriptive statistics were presented with frequencies for quantitative variables and mean and standard deviation or median and range for continuous variables. The chi-square test and independent sample t-test were used for variable comparisons, and p<0.05 was considered statistically significant.
This study received approval from the Ethical Committee and was conducted in accordance with the Declaration of Helsinki.Results: In a one-year period, 33 patients applied for 108 times to our pediatric emergency department. Of these, 46.3% were girls, and their mean age was 7.79±4.40 years for all visits. The median post-transplant day at the time of the emergency department visit was 622 days (10-6189 days).The most common symptoms were vomiting (48%),fever (46%), rhinorrhea and cough (34%). The median white blood cell count of the patients was 9,52x103/µL (680-55,90x103/ µL), and the median CRP was 33,5 mg/L (2-371,2 mg/L). The median ALT level was 34 U/L (11-585 U/L), median AST was 50 U/L (18-332 U/L). A total of 49 visits (45.4%) resulted in hospitalization. Five visits (4.6%) were resulted in PICU admission, two of these patients died (1.8%). The final diagnoses were acute gastroenteritis in 23 patients (21.2%), upper respiratory tract infections in23 patients (21.2%), and lower respiratory tract infections in 13 patients (12%). Cholangitis was diagnosed in 7patients (6.5%), intraabdominal infection in six patients(5.6%) and sepsis in five patients (4.6%). Seizures (2 patients,1.8%) and sepsis (5 patients, 4.6%) were significantly correlated with PICU admission (p=0.00). Post transplant day was significantly shorter in patients admitted to the intensive care unit when compared with the whole group (518±324 days in intensive care patients and 1498±1658 days in non-intensive care patients, p=0,000).
Conclusion: The most common diagnoses among pediatric liver transplant patients who were admitted to the pediatric emergency department were respiratory and gastrointestinal infections. Serious infections were observed in 18 (16.7%) patients. Half of the emergency admissions ended up hospitalized in the wards mainly for observation and supportive treatment, while a very small number required admission to the pediatric intensive care unit. Nevertheless, physicians caring for liver transplant patients should be aware of serious complications that may occur in these patients and should closely monitor them, especially during the early transplant period when intensive immunosuppressive treatment regimens are employed.
Ayse GULTEKINGIL (ÇANKAYA, Turkey), Mikail Hamza YUCEL, Ozlem TEMEL, Emre KARAKAYA, Figen OZCAY, Mehmet HABERAL
00:00 - 00:00
#41694 - Knowledge acquisition in an interprofessional emergency ultrasound course – a one-group pretest-posttest study.
Knowledge acquisition in an interprofessional emergency ultrasound course – a one-group pretest-posttest study.
Background:
Ultrasound is increasingly becoming a crucial component in medical education, extending its importance to emergency medical services and nursing staff. Interprofessional training formats provide a consistent education for all involved professions, benefiting both patient care and safety. Given that both educators and learners benefit from peer-teaching, a 16-hour interprofessional emergency ultrasound course in a peer-teaching format was conducted in June 2023 in Tuebingen.
The research aims to answer the following questions:
What knowledge acquisition do participants and tutors experience?
Are there differences between professional groups?
Methods:
The course content included ultrasound physics, abdominal sonography, eFAST (extended Focused Assessment with Sonography for Trauma), FATE (Focused Assessed Transthoracic Echocardiography), and RUSH (Rapid Ultrasound in Shock and Hypotension) protocols. After short lectures, practical application was taught in small groups of 4 participants by 2 tutors each. To examine knowledge acquisition, a longitudinal design with two measurement points (before and after the course) was employed. The used test consisted of 28 questions in short-answer-format (max. score: 30 points), supported by images and loops covering the predefined learning areas ultrasound-fundamentals, structures, pathologies, spatial thinking and ultrasound-protocols. All tutors and participants were invited to the study and could sign-up voluntarily.
After descriptive analysis, t-test and Wilcoxon rank-sum test were conducted. Significance was judged at the 5% level. Ethics approval from the Ethics Committee of the University of Tuebingen No. 446/2023B02. This study did not receive specific funding and did not require trial registration.
Results:
Out of 48 tutors and 40 participants overall, n = 32 questionnaires from 15 tutors (Response Rate (RR) 31.3%) and 17 participants (RR 42.5%) were included in the study (age = 26.3 ± 3.8; 56.3% female). Tutors (Pre-Mean = 23.7 ± 4.5; Post-Mean = 26.8 ± 2.3; p = .003; Pre-Median = 25.0; Post-Median = 27.0) and participants (Pre-Mean = 13.3 ± 6.9; Post-Mean = 22.2 ± 5.1; p < .001; Pre-Median = 12.0; Post-Median = 24.0) achieved a significantly higher total score after completing the course. Both tutors (Median = +3.0; z = 2.9; p = .004; r = 0.7) and participants (Median = +9.0; z = 3.6; p < .001; r = 0.9) showed a significant increase in total score. Breaking it down by professions, medical students (n = 24; Median = +3.5; z = 3.9; p < .001; r = 0.8) and emergency medical personnel (n = 7; Median = +11.0; z = 2.37; p = .018; r = 0.9) both showed significant increases, nursing staff non-significant increases (n = 1; Median = +8.0; z = 1.0; p = .31; r = 1). Additionally, significantly higher scores were achieved in the predefined learning areas. The study's limitations include the low response rate and uneven distribution across different professional groups, which could potentially skew the findings.
Conclusion:
Regardless of their profession, participants and tutors showed an increase in theoretical knowledge after participating the course, leading to an improved test performance. These findings suggest that interprofessional ultrasound training may become a valuable component of medical education.
Ethics approval from the Ethics Committee of the University of Tuebingen No. 446/2023B02.
This study did not receive specific funding and did not require trial registration.
Harald KNOF (Tuebingen, Germany), Katharina MUELLER, Christian GRIESE, Tino HOFMANN, Sophie-Luise SAENGER, Fabian EPPLER, Jan Philipp DOTTERWEICH, Sebastian KLUETZ, Robert GIRSHAUSEN, Navid AZAD, Anne HERRMANN-WERNER, Moritz MAHLING, Matthies WITTE
00:00 - 00:00
#42013 - KNOWLEDGE OF PATIENT SAFETY RELATED EVENTS IN HOSPITAL EMERGENCY DEPARTMENTS.
KNOWLEDGE OF PATIENT SAFETY RELATED EVENTS IN HOSPITAL EMERGENCY DEPARTMENTS.
Introduction:
In previous studies of Hospital Emergency Departments (EDs), between 3-12% of Adverse Events (AEs) were recorded, most of them being avoidable, and showing a low degree of incident notification. The objective of this study is to evaluate the department managers knowledge of the most frequent AEs, specifically those due to treatment and drugs, and to analyze the knowledge and the degree of event communication through the Incident reporting systems (IRSs).
Methods:
Cross-sectional descriptive study of the self-completed CAS-SEMES survey results, carried out in Spain between March and December 2023. It was piloted by telephone in 11 centers and sent to the remaining ones by email. A questionnaire was sent to the EDs responsibles included in the Spanish Society of Emergency Medicine (SEMES) database (279 centers). It was based on SEMES Accreditation and Quality Secretariat mandatory and/or recommended standards, including 109 questions selected and agreed upon by experts, divided into seven dimensions: Structure, Management of quality of care (QC) and patient safety (PS), Quality and safety policies, Objectives of the Quality Plan, Specific training, evaluation and improvement, and Functional units and residents. This work evaluates data from the “QC and SP Policies” dimension. The results were analyzed using SPSS version 24.
Results:
142 EDs were included. To the question “The main incidents reported correspond to”, only 56.34% of the surveyed answered (80), being the most frequent causes: drugs/treatment (46.25%), identification (11.25%), and circuits, management, computer tools, training and appointments (11.25%). Regarding problems related to treatment and medication, 54 centers did not answer (38.02%). 88 valid responses were obtained (61.98%). Only 3 centers (2.12%) pointed pharmacological AEs out of the total AEs, with an average of 21.12%. To describe the most frequent pharmacological AE types, a series of options were provided: 49 centers marked the proposed options in a non-quantitative way (34.51%), 51.02% choosing a single answer (25) and 48.98% choosing several. They selected in order of frequency: administration (59.18%), dose not administered (36.73%), regimen (34.69%), adverse effects (26.53%), allergies not considered (18.37%) and doubled dose (4.08%). The remaining 25.35% centers indicated the percentage of each pharmacological AE in relation to all pharmacological AEs: regimen (18.65%, 0-80), administration (16.91%, 0-61.50), allergies not considered (13.92%, 0-90), adverse effects (13.01%, 0-75), dose not administered (9.99%, 0-40) and duplicate dose (5 .82%, 0-40).
When asked about the number of incidents reported in the previous year (2022) in their ED, 84 centers (59.15%) answered, with 20.69 incidents reported on average (IQR 16.25).
83.10% of all the surveyed considered that the real AEs are greater than those declared compared to 14 who did not (9.86%), and 10 didn’t answer (7.04%).
Discussion and Conclusions:
Despite the growing implementation of SP strategies in EDs, half of the respondents did not have or were unaware of the number and type of most frequent adverse events reported in their centers, being the section of the survey with the poorest results of the overall set. Under-reporting of incidents seem to remain very high in comparison with expected real EAs previously described.
This study did not receive any specific funding. Ethical approval and informed consent: not needed.
María Teresa MAZA VERA (Vigo, Spain), Sònia JIMÉNEZ HERNÁNDEZ, Javier MILLÁN SORIA, Rosa IBÁN OCHOA, Alberto RUANO RAVIÑA
00:00 - 00:00
#42284 - KP meningoencephalitis in ICU.
KP meningoencephalitis in ICU.
Introduction :
Nosocomial infections are sometimes responsible for several complications. Postoperative bacterial meningitis is a rare but serious complication of cranial and spinal surgery.
Observation
A 68- year-old woman with a medical history of Lung Tumor, Pulmonary embolism diagnosed 5 months ago , spondylodiscitis operated 2 weeks before her admission , presented to the ED with altered consciousness and fever . The initial Clinical examination finds a Respiratory rate of 22 cpm , with free PA and SpO2 was 98%. The SAP was 120 mmHg and the DBP was 80 mmHg. The patient was febrile at 38.5. The neurological examination showed a GCS of 10/15 with neck stiffness, Kernig and Brudzinski signs . Then the neurological state worsened with a GCS=3/15 on neurological examination. The patient was sedated, intubated and ventilated due to neurological distress. Blood tests showed a biological inflammatory syndrome, a hyperleukocytosis with predominantly PNN (WBC=13930, PNN=11690) and CRP=349, hypokalemia and hyponatremia . A cerebral CT scan was performed showing subcortical hypodensity in the right frontal lobe . The diagnosis of meningoencephalitis was made. The lumbar puncture showed a cloudy aspect and 15 white blood cells with predominantly lymphocytic pleocytosis (70%) and PNN (30%) , hyperproteinorachy (4.7g/l) and a profound hypoglycorachy. The diagnosis of viral or tuberculous meningoencephalitis was suspected. Antibiotic therapy was instituted (Ampicilin, gentamicin) with antiviral treatment (Aciclovir) and anti-tuberculosis Quadritherapy. The culture came back positive for Klebsielle peumoniae . Antibiotic therapy was adjusted (Cefotaxime, gentamicin). The cerebral MRI showed a T2 , FLAIR and diffusion hypersignal ,a cardinal aspect of meningoencephalitis , and a right frontal nodular lesion surrounded by a perilesional edema suggesting a secondary lesion or an abscess. The result of the bone biopsy concluded to an adenocarcinoma. The diagnosis of a pulmonary neoplasia with bone and cerebral metastases with KP meningoencephalitis was retained. The patient then presented a septic shock requiring the use of vasoactive drugs, the blood cultures and the PTP came back positive to KP ESBL so the antibiotic therapy was adapted to the Antibiogram . The patient was then transferred in intensive care.
Conclusion
Klebsiella pneumoniae is responsible for serious nosocomial meningitis, with a difficult therapeutic management and therefore requires adequate preventive measures.
Sirine KHABOUCHI, Khaireddine JEMAI (Tunis, Tunisia), Hana HEDHLI, Dhekra HOSNI, Seif OUERGHI
00:00 - 00:00
#41191 - Kynurenic acid alleviated endothelial injury through GPR35 in fluid resuscitation of sepsis.
Kynurenic acid alleviated endothelial injury through GPR35 in fluid resuscitation of sepsis.
Background: Capillary leakage caused by endothelial injury is the core pathological mechanism of sepsis, and fluid resuscitation is an important treatment. The mechanism of metabolic changes during fluid resuscitation in sepsis is unclear. The aim of this study was to expound the metabolic changes in fluid resuscitation of sepsis and further find ways to alleviate endothelial injury in sepsis.
Methods: General characteristics of patients were collected. C-reactive protein (CRP), IL-1β, IL-6 and TNF-α were detected using ELISA. Circulation indicators of patients including mean arterial pressure, central venous pressure, urine output, central venous blood oxygen saturation, and lactic acid of patients was collected. Differential metabolites from fluid resuscitation were detected by non-targeted gas chromatography-mass spectrometry and enriched in relevant metabolic pathways through the KEGG metabolic pathway. Differential metabolites and clinical indicators was detected through correlation analysis. The effects of the metabolites on endothelial cells were confirmed using in vitro and in vivo experiments. The effect of kynurenic acid (KYNA) on proliferation of human umbilical vein endothelial cells (HUVECs) through cell counting kit-8 assay. The effect of KYNA on cell migration was detected by scratch test. The expression of junction protein was detected by western blot. Cecum ligation and puncture (CLP) was constructed. In vivo experiments, the effect of KYNA on vascular leakage was conducted using H&E and evans blue staining. The effect of KYNA on junction protein claudin-5 was detected by immunohistochemistry. The expression of KYNA receptor GPR (G-protein coupled receptor) 35 was detected by western blot and immunofluorescence. The downstream target genes of GPR35 were detected by transcriptome sequencing. The molecular binding relationship between GPR35 and mitochondrial solute carrier family 25A41 (SCL25A41) was further clarified through molecular docking. The effect of KYNA on endothelial cell was confirmed by ATP content.
Results: The tryptophan metabolism pathway was enriched during the first three periods of fluid resuscitation. A significant negative correlation was observed between KYNA and IL-1β, also between KYNA and lactic acid, it indicated that KYNA plays an anti-inflammatory role and could improve microcirculation in fluid resuscitation. High level of expression of both KYNA and IL-1β indicates the optimization period. The stable period is defined by a high level of KYNA but a low level of IL-1β. In vivo and in vitro experiments confirmed that KYNA had anti-inflammatory effects on lipopolysaccharide-treated HUVECs and reduced IL-1β and TNF-α in septic mice caused CLP. H&E staining indicated that KYNA could reduce the infiltration of inflammatory cells in the lung, alveolar collapse, and pulmonary vascular congestion in CLP-induced sepsis. Evans blue staining showed that KYNA could alleviate fluid leakage from lung tissue. The expression of KYNA receptor GPR35 was increased. Transcriptome sequencing showed that inhibiting GPR35 significantly reduced the expression of SCL25A41. GPR35 and SLC25A41 can be tightly bound through molecular docking experiment. ATP content was increased which stimulated by KYNA.
Conclusion: KYNA is a metabolite whose effect of improving endothelial injury in fluid resuscitation in sepsis. Administration of KYNA warrants investigation as a potential therapeutic agent for capillary leakage in sepsis.
This research was supported by National Clinical Key Specialty(Grant No. Z155080000004), the Construction and application of integrated management model for emergency and critical care (Grant No. SHDC 22021211), Construction of Shanghai infectious disease clinical diagnosis and treatment center and network system (Grant No. 04.05.01.21.03), Medical engineering cross research fund of "Jiaotong University star" program of Shanghai Jiaotong University (Grant No. YG2021QN84).
Cheng CHEN (, China), Ruilan WANG
00:00 - 00:00
#41322 - L-aspartic acid mitigates NLRP3 inflammasome activation by binding to NR1 and ASC proteins in necrotizing soft tissue infections.
L-aspartic acid mitigates NLRP3 inflammasome activation by binding to NR1 and ASC proteins in necrotizing soft tissue infections.
Objective: Necrotizing soft tissue infections(NSTIs) are life-threatening and rapidly progressive. Pyroptosis is the leading cause of cell death induced by pathogenic infections associated with NSTI. Although plasma metabolites contribute to disease diagnosis, their role in pyroptosis remains unclear. The study aimed to use non-targeted metabolomics to screen for metabolites that may contribute to the diagnosis of NSTI and study the role of metabolites on pyroptosis.
Methods: Non-target metabolomics was used to identify plasma metabolites in the discovery cohort, while an enzyme-linked immunosorbent assay was performed to assess the expression levels of crucial metabolites and pyroptosis-related factors in plasma in the validation cohort. Western blotting was used to detect the expression levels of pyroptosis-related proteins in cells and supernatants. Molecular docking, point mutation, and drug affinity-responsive target stability assays were utilized to verify the direct action site of L-aspartic acid (L-ASP) on N-methyl-D-aspartate subunit 1(NR1) and apoptosis-associated dot-like protein (ASC). Immunofluorescence and oligomerization assays were used to detect ASC spots and oligomerization, respectively.
Results: Disorders of amino acid and lipid metabolism were observed in the NSTI group. In the discovery cohort, six positive and five negative ion metabolites displayed better ability to diagnose NSTI. L-aspartic acid(L-ASP) was negatively correlated with several clinical indicators, such as glucose and lactic acid. In the validation cohort, L-ASP levels were negatively associated with ASC and lactate dehydrogenase (LDH). Subsequently, we demonstrated that L-ASP reduced Interleukin-1β and LDH release from macrophages by directly binding to the NR1 protein at Y367, thereby inhibiting NLRP3 inflammasome activation and regulating ASC phosphorylation at S195. Conversely, NLRP3 activation was restored in macrophages overexpressing NR1. L-ASP inhibits the interaction between ASC and NLRP3 by directly binding to the ASC protein at D191 and S195. Furthermore, L-ASP reduced inflammation in mice with type III NSTI.
Conclusion: Our findings indicate that L-ASP may act as an essential endogenous metabolite in patients with NSTIs, thereby suggesting a new therapeutic approach that may alleviate inflammation in NSTIs.
The study was registered in the Chinese Clinical Trial Registry(ChiCTR2100048949, ChiCTR2100048907). This work was supported by Zhejiang Research and Development Projects (2021C03072), Wu Jieping Medical Foundation Special Fund for Clinical Research(320.6750.2022-26-16), and the Province Nanchong City School Science and Technology Strategic Cooperation Project (18SXHZ0454).
Si LIU (Beijing, China), Zhongqiu LU
00:00 - 00:00
#42082 - Lacked and valued technical and non-technical skills among disaster responders.
Lacked and valued technical and non-technical skills among disaster responders.
Introduction:
The earthquake that hit Türkiye and Syria in February 2023 resulted in over 50,000 deaths and is one of the worst disasters in recent years. Disaster response include the provision of emergency services, technical support, equipment, or personnel resources. Disaster responders are an important part of the disaster response. However, despite large efforts to train disaster responders, there is a limited scientific knowledge on what competence and skills such responders actually uses or lack during a real mission. The aim of this study was to contribute to this knowledge by investigating used and needed skills among disaster responders responding to the earthquake in Türkiye and Syria 2023.
Methods: A cross sectional study using a non-randomized study sample was conducted. A total of 525 participants involved in the disaster response in Türkiye/Syria in February 2023 were included. The participants were recruited through invitations distributed to international organizations and data gathered through a web-based survey. The data was analyzed by descriptive and comparative statistics.
(preliminary)Results: The highest valued skills by all responders were teamwork skills (n=252, 59%), technical knowledge (n=204, 48%), leadership skills (n=105, 24%) and communication skills (n=114, 17%). There was a gender difference where women valued stress management (n=33, 26%) higher than leadership (n=24, 19%) Technical knowledge was valued higher among first time responders (n=168, 82%) compared to experienced responders (n=108, 54%, p-value <0.001) as well as among responders with shorter missions (<7 days, n=153, 82%) compared to longer missions (>8 days, n=144, 60%, p-value <0.001). Teamwork was valued higher among responders with longer missions (<7 days n= 93, 50%, >8 days n=159, 65%, p-value 0.002). The most lacked skills were how to build mental preparedness (n=237, 53%), the knowledge of management system of international response (n=132, 30%), stress management (n=105, 24%) and leadership (n=102, 23%).
(preliminary) Conclusions: The findings in this study align with previous research where there is an increasing need for exploring and understanding the need of non-technical skills for disaster responders. The study adds to the field by being based on responders actual experience and by the relatively large number of participants. The results show slightly different needs in the different phases of a response, as well as some differences between men and women, although both of these aspects could also be connected to the different roles of the disaster responders. Building mental preparedness was not one of the highest valued skills, but was one of the skills most lacked, and this discrepancy is an interesting finding. Deeper analysis and additional studies are needed to further understand and add knowledge to the field.
Funding: This study was partly funded by the department of EM, Örebro University Hospital, Sweden
Ethical approval and informed consent: The study was approved by the Swedish Ethical Review Authority was gained for the study (ref nr 2023-01369-02)
Anja WESTMAN (Örebro, Sweden), Lisa KURLAND, Karin HUGELIUS
00:00 - 00:00
#42338 - Lactate as a Predictive Factor for Complications in Sepsis.
Lactate as a Predictive Factor for Complications in Sepsis.
Introduction :
Sepsis is a life-threatening condition that results from the body's overwhelming response to
an infection. Lactate is a metabolic byproduct that accumulates in the blood when cells are
deprived of oxygen. Elevated lactate levels have been associated with increased mortality in
patients admitted for sepsis. However, the role of lactate as a predictive factor for
complications in sepsis is not fully established.
Aim :
The aim of this study was to investigate the association between lactate levels and the
development of complications in sepsis patients.
Methods :
It was a retrospective study conducted in the emergency department from january 2021 to
november 2023 including patient admitted for sepsis. Lactate levels were measured for all
patients.
The main outcome was the development of complication like shock, mechanical ventilation
and death.
Results :
We included 290 patients. 51.2% of these patients were elderly subjects.
Pulmonary and urinary sepsis were the 2 most common diagnoses found in our study, with
percentages of respectively 41.4% and 36.6%.
The lactate value was measured at T0 for all these patients with a mean of 3.01 ± 2.14
mmol/l.
A complication was observed in 33.8% of these patients. A progression to shock, recourse to
mechanical ventilation and death was observed in 23.4% 13.8% and 26.9% of cases
respectively.
A ROC curve study was performed to determine the predictive factor of lactate for
complications showing the following results: complication (AUC : 0,587 ; p : 0,13) shock
(AUC :0,556 p : 0,113) mechanical ventilation (AUC : 0,530 P : 0,398) and death (AUC :
0,568 p : 0,051).
Conclusion :
The relationship between lactate levels and complications may be complex and influenced by
other factors, such as the severity of sepsis, the type of infection, and the patient's underlying
comorbidities. Clearance of lactate measurement should be associated to improve the
prognostic value.
Khaireddine JEMAI (Tunis, Tunisia), Safia OTHMANI, Marouane SANAI, Asma JENDOUBI, Dhekra HOSNI, Roua HAJJI, Sarra JOUINI
00:00 - 00:00
#41316 - Lactate Levels and Clearance: Key Predictors of Prognosis for Septic Shock Patients in the Emergency Department.
Lactate Levels and Clearance: Key Predictors of Prognosis for Septic Shock Patients in the Emergency Department.
Abstract
Background: This investigation assesses lactate levels' predictive value and clearance in septic shock patients, particularly emphasising the comparative analysis between COVID-19 and non-COVID-19 patients in the emergency department. The study aims to elucidate the unique prognostic implications of lactate dynamics in these distinct patient groups, thereby enhancing the management of septic shock. Methods: An observational prospective study was conducted, enrolling 114 septic shock patients from the Emergency County Hospital Resita, Romania, and categorising them into COVID-19 and non-COVID-19 groups to examine initial lactate levels, clearance rates and their correlation with patient outcomes. Results: The study identified significant differences between the two groups' initial lactate levels and clearance rates, indicating higher initial lactate levels and slower clearance rates in COVID-19 patients. These factors were significantly associated with patient outcomes, emphasising their importance in patient management. Conclusions: Lactate monitoring, particularly clearance rates, is crucial in the prognostic assessment of septic shock patients. The findings highlight the need for targeted interventions in COVID-19 patients to improve outcomes, underscoring lactate dynamics as a vital component of septic shock management in differing patient populations.
Cosmin TREBUIAN (Timisoara, Romania), Adina MARZA, Dumitru SUTOI, Raluca RADBEA, Ovidiu Alexandru MEDERLE
00:00 - 00:00
#41471 - LACTATE LEVELS AS PREDICTORS OF SEVERITY OF ACUTE ASTHMA IN THE EMERGENCY DEPARTMENT.
LACTATE LEVELS AS PREDICTORS OF SEVERITY OF ACUTE ASTHMA IN THE EMERGENCY DEPARTMENT.
Introduction: the assessment of the severity of acute asthma in the Emergency Department (ED) is difficult and imprecise due to both lack of objective measures of disease severity and variability of signs and symptoms presentation.
Aims: to identify the possible predictors of severity of acute asthma in the ED.
Material and methods: we retrospectively enrolled 62 subjects referred to our ED for acute asthma. The end point of the study was the need for hospitalization. Blood gas analysis, clinical and laboratory data were obtained upon arrival in the emergency room.
Results: of the 62 subjects included 26 were males, 36 were females, the mean age was 43 ± 18 years old. 46.9% had an allergic diathesis, 14.1% were smokers. Mean pH was 7.41 ± 0.04, PaO2 60 ± 20 mmHg, mean P/F 322 ± 74, mean PaCO2 39 ± 6 mmHg, mean HCO3- 25 ± 2, mean lactate levels 1.17 ± 0, 7. 42.2% were hospitalized. Dividing our population into subjects discharged from the ED (group 1) and hospitalized subjects (group 2), we observed that group 2 had significantly lower P/F values (p < .001), higher lactate levels (p .003) and higher white blood cells (WBC) (p .027). No statistically significant differences emerged regarding age, sex, smoking, allergic diathesis, mean arterial pressure, heart rate, PaCO2, hemoglobin, C-reactive protein, creatinine and glomerular filtration rate. At univariate analysis we observed that the need for hospitalization was significantly associated with lactate levels (95% CI 1.561-35.458, OR 7.441, p .012), P/F (95% CI 0.948-0.98, OR 0.967, p .001) and WBC (95% CI 1.013-1.383, OR 1.184, p .033). At multivariate analysis lactate levels (95% CI 1.042-81.038, OR 9.190, p .046) and P/F (95% CI 0.939-0.989, OR 0.964, p .005) were able to predict the need for hospital admission regardless of age and WBC.
Discussion: results of our study suggest that lactate levels detected at the time of admission to the ED in subjects with acute asthma could be an independent predictor of a greater probability of being hospitalized and therefore of the severity of the acute asthmatic attack. It has been hypothesized that catecholamine levels secondary to respiratory distress may cause increased conversion of pyruvate to lactate or that hyperlactatemia occurs secondary to increased work of breathing, thus explaining the potential predictive role of hyperlactatemia. On the other hand, other studies have hypothesized that hyperlactatemia is caused by the administration of beta-2 agonist drugs and does not increase the risk of hospitalization.
Conclusions: the role of hyperlactatemia in acute asthma is still controversial. Lactate levels may be a predictor of acute asthma attack severity in the ED, but further studies are needed to verify this hypothesis.
Stefano DE VUONO (Perugia, Italy), Laura SETTIMI, Sokol BERISHA, Pasquale CIANCI, Luca PARRETTI, Giuseppe BATORI, Lorenzo VANNOCCHI, Paolo GROFF
00:00 - 00:00
#41331 - Late presentation of euglycaemic diabetic ketoacidosis in post-bariatric surgery patients on SGLT-2 inhibitors.
Late presentation of euglycaemic diabetic ketoacidosis in post-bariatric surgery patients on SGLT-2 inhibitors.
We present a case of a 37-year-old female with a background of type 2 diabetes mellitus.
She presented 5-weeks post endoscopic sleeve gastroplasty with acute abdominal pain of 1 day duration associated with nausea and near syncopal symptoms. She was compliant to dietician-prescribed very low calorie diet for 4 weeks and had just escalated to soft solid diet 5 days prior. She was on empagliflozin, a sodium-glucose cotransporter-2 inhibitor for management of diabetes mellitus, which was stopped 72 hours pre-operatively and resumed 2 weeks postoperatively.
Blood pressure on arrival was 91/52mmHg with heart rate 62bpm (post-operative day 1 blood pressure was 145-168/70-112mmHg with heart rate 76-97bpm). She was afebrile with no significant tachypnea and normal oxygen saturations. On examination, mucous membranes were slightly dry. She had significant tenderness with voluntary guarding over left iliac fossa with normal vaginal examination. The rest of the examination was normal.
Point of care test showed venous pH 7.262 with bicarbonate 16.8mmol/L, lactate 2.23 and glucose 7.0mmol/L. An urgent contrasted computed tomography of abdomen and pelvis in view of severe abdominal tenderness post-operatively with lactic acidosis revealed no intra-abdominal pathology. Ketones later returned as 6.6mmol/L confirming the diagnosis of euglycaemic diabetic ketoacidosis. She was started on intravenous insulin and fluid rehydration with resolution of ketoacidosis by day 2 of admission. Empagliflozin was stopped indefinitely.
Of note, she had also reported lightheadedness on 2 healthcare visits to the dietitian and gastroenterologist (who had performed her endoscopic gastroplasty) in the preceding 2 weeks, however normal capillary blood glucose and (albeit low-normal) blood pressure readings were reassuring and patient was discharged without further evaluation.
While euglycaemic diabetic ketoacidosis is increasingly well known and studied, the diagnosis remains easily missed in post-bariatric surgery patients. Their presentation with symptoms of malaise and lightheadedness can often be falsely dismissed with normal capillary blood glucose readings despite a very low calorie diet – as had happened in this patient. Her presentation with acute abdominal pain post-operatively with severe abdominal tenderness also often misleads the practitioner into considering post-surgical intra-abdominal complications. This case serves as a reminder of the increased risk of euglycaemic diabetic ketoacidosis in this post-bariatric surgery patients on SGLT-2 inhibitors, that can be present up to several weeks post-operatively.
Maehanyi RAJENDRAM (Singapore, Singapore), Aliviya DUTTA
00:00 - 00:00
#41972 - Left arm and right thigh swelling because pyomyositis or big muscular abscess, rare case in our ED.
Left arm and right thigh swelling because pyomyositis or big muscular abscess, rare case in our ED.
An 18-year-old male patient came to ED for fever, headache, left arm swelling and right thigh swelling. He is a newcomer from Africa to Qatar. He has a language barrier. The temp was 39 centigrade; heart rate 111 mild tachycardia, blood pressure was 111/59. He said he is a newcomer in Qatar, and he had swelling in his left arm and thigh since one week after he had played football . On examination : left arm, tense swelling and tender, and right thigh too . Lab results showed leucocytosis about 42000 , high C-reactive protein about 275.5 and a normal renal function test. Ultrasounds for left arm that showed: A well-defined thick-walled ligated collection noted in the proximal to distal arm, measuring 23 x 3.3 cm. The ultrasound for the right thigh showed there is a well-defined thick-walled elongated irregular structure with septation in the right thigh along the muscular plane measuring 20 x 6 cm approximately, that suggests an abscess. He got admission under surgical care. The blood and ureine culture had no growth and the tissue culture showed profuse growth of Staphylococcus aureus. The patient was not diabetic. HBA1c was 5.8. He got an incision and a drain. An intravenous antibiotic was given . He got well then discharged .
Learning points: the big left arm and right thigh abscess after hard physical exercise are non-frequent case presented in ED. The stress physical work and muscle trauma induce pyomyositis [ intramuscular abscess ]
Dr Islam ELROBAA (Al wakra, Qatar), Maarij AHMED
00:00 - 00:00
#40706 - Left neck soft tissue swelling and pain in a 4-year-old girl secondary to esophageal perforation: a case report.
Left neck soft tissue swelling and pain in a 4-year-old girl secondary to esophageal perforation: a case report.
Introduction/Objectives
Esophageal perforation in children is a rare life-threatening condition that accounts for 30-40% of mortality rate requiring prompt diagnosis and intervention in the Emergency Department (ED). Due to anatomical location of the esophagus, the presentation and diagnosis are often challenging. Pediatric esophageal perforation most commonly occurs secondary to chest/neck blunt injury, nasogastric tube insertion (NGT), endotracheal intubation, caustic ingestion, foreign body ingestion, and endoscopy-related procedures. Early recognition, diagnosis and treatment reduce complications and mortality rates.
Case Report
Case of four-year old girl who presented with moderate left neck swelling and pain without associated symptoms. Mom denied trauma, foreign body ingestion or recent instrumentation. Initial vital signs were adequate for age. Physical exam noted moderate swelling of the left aspect of neck without crepitus, airway compromise or evidence of trauma. Plain radiographs and CT of neck, chest and abdomen revealed extensive subcutaneous emphysema and pneumomediastinum requiring transfer to Pediatric University Hospital with suspicion of airway versus esophageal injury. At the Pediatric ED, patient rapidly deteriorated for which was intubated and started on IV antibiotics. Upon PICU stay, patient hemodynamical status compromised requiring vasopressors and surgical intervention by ENT service which performed a transcervical neck exploration with incision and drainage of brownish discharge along with esophagoscopy. Esophagoscopy uncovered an esophageal perforation which was left to heal by primary intention and NGT insertion. After two weeks of IV antibiotics, hemodynamical support and PICU care, patient recovered from mediastinitis and septic shock secondary to esophageal perforation of unknown origin. Patient safely discharged home after 32 days of inpatient medical care.
Conclusions
Rapid recognition of esophageal perforation and complications remains challenging in the ED, emphasizing the critical importance of suspicion, early diagnosis, and treatment. Clinical presentation can be subtle and nonspecific during initial stages. Early hemodynamic support and multidisciplinary approach are key to decrease complications and mortality rate.
Adriana C. CANDELARIA-JIMENEZ (San Juan, USA), Yanira MORALES TORRES
00:00 - 00:00
#42008 - Left sided dacryocystitis and abscess, a rare case presented in our ED.
Left sided dacryocystitis and abscess, a rare case presented in our ED.
A 40-year-old male patient presented as swelling on the medial side of his right eye for 8 days. The patient had no co-morbidities. He had swelling in the medial canthus for 8 days. he used antibiotic since 4 days ago . on examination has swelling at right eye on medial canthus,with erythema and tenderness extending to the nose, pain on palpation with fluctuation and collection . He had vital signs with normal variation. The blood workup showed mild leucocytosis, about 11000 and C-reactive protein about 42. The patient was seen by an ophthalmology team who requested CT orbit. The Orbit CT showed left sided dacryocystitis and collection with no evidence of orbital cellulitis. The blood culture was sent, and intravenous antibiotic was given. The patient got an incision and drained, the pus came out. The blood culture result showed : Methicillin Resistant Staph. aureus isolated.(MRSA) and gram negative bacilli . The patient got amoxicillin/clavulanate as an oral antibiotic and gentamicin 0.3% eye drops. After 7 days, he had improved to a normal appearance.
Learning points : dacryocystitis and abscess is non-frequent case in the emergency department needs empirical antibiotic , blood investigation , CT orbit to rule out any orbital infection. The drain with culture selected antibiotic are the definitive treatment . Diabetes should be ruled out any severe infection case.
Dr Islam ELROBAA (Al wakra, Qatar), Wael ELSAYED
00:00 - 00:00
#41422 - Leprosy: Vigilance in non-endemic settings.
Leprosy: Vigilance in non-endemic settings.
Submission title: Leprosy: Vigilance in non-endemic settings
Nature of the image (put X in front):
Other: Clinical Images X
Brief clinical details:
A 34 year old Bangladeshi gentleman presented to ED for worsening facial swelling.
He was part of the migrant population working in the construction industry in Singapore.
He reported developing rashes over his hands and body in the past year. His facial lesions started appearing 1 month ago.
He sought medical treatment in Bangladesh 2 months prior to presenting and was treated with antifungal therapy with no improvement.
He has no known past medical history. There were no constitutional symptoms and his family back home was reportedly well.
Due to characteristic features, he was admitted for evaluation and a skin biopsy done revealed the presence of acid fast bacilli, confirming the clinical suspicion of leprosy. He was subsequently started on multidrug therapy.
Description of the relevant abnormalities:
He was found to have indurated nodules over the face, involving the forehead, cheeks, nose, jaw line, ear lobes and posterior ear.
There were also scattered Indurated nodules over the nape of the neck, chest with overlying hypopigmented patches over the chest and trunk
His bilateral common peroneal and ulnar nerves were thickened.
Why this image is clinically or educationally relevant?:
Leprosy is a neglected tropical disease that has been eliminated under WHO’s classification as a public health problem globally. While rare in most developed countries, it is still prevalent in parts of the developing world. The disease can present anywhere with the migration of skilled workers and increased international travel. Heighted awareness and vigilance is required to recognise its presentation.
Where patients’ images are submitted please confirm you have adequate permission to use them. (compulsory question, no submission without an answer):
Yes. Signed consent has been obtained from the patient.
(one of the images taken have been attached)
Jocelyn TING (Singapore, Singapore), Magdalene LEE
00:00 - 00:00
#41728 - Let me try! Myasthenia gravis case report.
Let me try! Myasthenia gravis case report.
Background: Myasthenia Gravis (MG) is an autoimmune disease that affects neurotransmission via antibodies directed against nicotinic acetylcholine receptors at the neuromuscular junction. For the emergency physician there is apparently no challenge, as most cases being already diagnosed.
But what about those few cases, especially in elderly patients with no previous neurological diagnosis, who repeatedly come to the Emergency Department (ER) for either fever and weakness, headache, nasal slurred speech, dysphonia, or even double vision, with no alarming findings on blood tests or routine imaging?
Material and method: The usefulness of the provocative tests such as: Endomorfinum (Tensilon) or the Neostigmine test, and also the ice pack test or the prolonged upgaze test in the provisional diagnosis of myasthenia, is well described in the literature, but are they actually performed as routine or are some of them used in the differential diagnosis for other neuromuscular diseases?
We present a case of a 72-year-old hypertensive patient admitted to the ER for physical asthenia, inappetence, dysphonia, following a dental extraction two weeks prior with 5 days of antibiotic therapy at home, with another presentation a week ago for a lipotimic episode at home and fatigue.
At the first neurological examination the patient had bilateral palpebral ptosis, dysphagia for mild solids, no motor deficits, osteo tendon reflexes present bilaterally, blood pressure 100/65 mmHg, heart rate 65 beats per minute rhythmic. First biological samples taken, and brain CT scans showed no signs of acute pathology. Due to the clinical examination and apparently not other causes for the marked fatigue and ptosis and thus not associated with dental extraction, we raised the diagnosis of myasthenia. The patient and her family did not consent to be admitted to the neurology unit for further tests.
After a week, her muscle weakness worsened and she became dysphonic, which is why she returned to the ER.
Differential diagnosis: incomplete oculomotor nerve palsy, vertebro basilar stroke, progressive bulbar palsy, Lambert-Eaton Syndrome, Miller Fisher syndrome, orbitar abcess.
At this time, a chest CT scan was performed which revealed no thymic masses in the anterior mediastinum.
A neostigmine (Miostin) test was performed in the ER which had a positive response after 20 minutes, with an improvement in palpebral ptosis and dysphonia.
During hospitalization, all screens confirmed the diagnosis: the presence of Anti-acetylcholine receptor antibodies- present- 25.2 nmol/L (normal range below 0.25) and on electromyographic test a decrement of more than 15% for right ulnar nerve and bilateral trapezius- at repetitive nerve stimulation (RNS) with 3Hz. The patient was treated with anticholinesterase - parasympathomimetic (injectable - Miostin, alternating with oral Mestinon), Atropine, corticosteroid and was discharged with slight narrowing of the right palpebral fissure, normal oculomotricity, no nystagmus, no diplopia, clear improvement of the respiratory, speech and deglutition impairments.
Conclusion: Raising the suspicion of myasthenia in the ER is a challenge for young clinicians, highlighting both possible diagnostic errors and the limited but brave options for initial testing.
Cristina Ramona TASE, Cristina Ramona TASE (Constanta, Romania), Camer SALIM, Any AXELERAD, Alexandru Vlad PETCU
00:00 - 00:00
#41994 - Loge syndrome on venous thrombosis following MDMA intoxication.
Loge syndrome on venous thrombosis following MDMA intoxication.
-Introduction:
Loge syndrome is characterized by muscular ischemia following an abnormal increase in pressure in an osteoaponeurotic loge with little or no extensibility. We report the case of a compartment syndrome complicating a DVT of the upper limb, in a context of MDMA intoxication.
-Observation :
An 18-year-old patient, known to be a drug addict, was admitted to the life-threatening emergency room for apyretic disorder of consciousness with edema of the left upper limb.
His history revealed that he had been taking amphetamines (ECSTASY) for 48 hours prior to admission. He was found lying in lateral decubitus with his left shoulder for support.
On admission, the clinical examination revealed a patient with a glasgow score of 11/15, bilateral semi-mydriatic pupils with low reactivity, eupneic at 16cpm with Spo2 at 98% on free air, hemodynamically stable with BP at 13/07 and HR at 92 bpm, cardiac auscultation was without abnormalities, and he had a fever of 38°C. The rest of the examination revealed an oedematous left upper limb (purple tint) with phlyctenes, while radial and ulnar pulses were present and symmetrical.
At 12 hours after admission, he regained consciousness with a painful contracture to palpation of the lodge muscles, with anesthesia of the left hand .
The patient underwent a brain scan with no abnormalities, a venous and arterial echodoppler of the limb showing thrombosis in the humeral and axillary veins, and a standard X-ray of the MSG with no abnormalities. The electrocardiogram was normal, and an angioscanner was performed, showing thrombosis in the axilla and humerus.
Biological work-up showed cytolysis with ASAT at 160 and ALAT 135, rhabdomyolysis (elevated CPK and LDH), IRAF (urea at 0.78 and creatinine at 28), D-dimer increased to 13,000, and toxicology screening was performed.
The patient was treated symptomatically with rehydration and curatively with anticoagulation (curative dose heparin).
-Discussion :
Acute compartment syndrome usually results from an injury such as a fracture, contusion, venous thrombosis or muscle tear.
Its occurrence during MDMA intoxication is very rare.
Loge syndrome typically manifests as pain, tension and deficit signs related to the nerves passing through the loge, which are highly characteristic and the most reliable signs for positive and topographical diagnosis. However, the presence of consciousness disorders secondary to MDMA intoxication can make the diagnosis difficult, and the signs pointing to loge syndrome are those of rhabdomyolysis.
Localization in the arm is extremely rare. This is due to the flexibility of the arm aponeurosis and the scarcity of large tendinous and ligamentous structures at this level.
Several authors have described the association of rhabdomyolysis with MDMA intoxication. This rhabdomyolysis involved several muscle groups and seems to be related to the duration of exposure to MDMA rather than to a postural character. Consequently, in addition to the prolonged postural character that may explain the occurrence of a compartment syndrome during MDMA intoxication, a second mechanism may be involved, namely rhabdomyolysis related to the hypoxia and cellular toxicity engendered by MDMA .
Aymane DOUHAL, Mohamed Anass FEHDI (Casablanca, Morocco), Asmae DAFIR, Badria AGGOUG, Mohamed MOUSSAOUI, Mohammed MOUHAOUI
00:00 - 00:00
#41374 - Long Covid: predictive Factors and prevalence in population.
Long Covid: predictive Factors and prevalence in population.
Background. After weeks and months of a COVID-19 infection, many individuals suffer from specific symptoms. This disease is becoming a global problem and is limiting people's lifestyles. The collection of signs and symptoms experienced by individuals for an extended period of time after their initial recovery from COVID-19 is commonly referred to as Long COVID (LC). It is important to investigate one or more predictive factors of this disease in a heterogeneous cohort of patients, who suffer from several comorbidities, have different vaccination status and have contracted different variants of Sars-Cov-2.
Aim of the study. The study aims to identify predictive factors of LC and evaluate its prevalence, including vaccination status and comorbidities, to reduce incidence.
Material and Methods. We conducted a monocentric, observational, and retrospective study at Fondazione Policlinico Universitario Agostino Gemelli – IRCCS in Rome. We enrolled patients admitted to the Emergency Department (ED) between March 2020 and December 2022, over the age of 17 with Sars-CoV-2 infection confirmed by an antigen and PCR tests performed on oropharyngeal and/or nasopharyngeal swabs. Among all patients, we excluded patients with COVID-19 and other prevalent acute conditions affecting prognosis and patients who died in the ED. We contacted patients by phone to collect data on symptom persistence after acute SARS-CoV-2 infection and their likely duration.
Results. We enrolled 342 patients, of which 218 were male and 124 were female. Of the 342 patients we examined, 131 were found to be affected by long covid (LCP), while 211 were non-long-covid (NLC). Most of the demographic characteristics did not reach statistical significance, except for gender. The LCPs were 48.8% female while NCL were 28.4% (p=0.0001). No statistically significant difference was found when comparing comorbidities, laboratory findings, and vaccination status, except for domiciliary therapy: anticoagulants were reported in 83.9% of LCP and 73.9% of NLC (p=0.03). The main statistically significant differences concern the administered therapy between the two groups: corticosteroids were given to 68.7% of LCP versus 57.8% of NLC (p=0.04), Remdesivir was reported in 38.2% of LCP and 25.1% of NLC (p=0.01), and monoclonal antibodies were administered in 12.2% of LCP and 4.7% of NLC (p=0.02). In the multivariate analysis, we evaluate the statistically significant differences between the LCP and NLC. The variables significantly correlated to the onset of long-covid were the female sex, the values of D-dimer, the hospitalization time, and therapies with remdesivir and monoclonal antibodies.
Conclusions: It appears that being female and having a longer hospitalization time may increase the likelihood of experiencing long COVID. Additionally, the D-dimer test could potentially act as a predictive marker for long COVID, possibly due to its association with a pro-inflammatory state, which could be one of the underlying factors of the disease. Therapies involving the use of remdesivir and monoclonal antibodies may also represent risk factors.
Gloria ROZZI (Rome, Italy), Michela NOVELLI, Giacomo SPAZIANI, Francesco FRANCESCHI, Marcello CANDELLI, Giulia PIGNATARO
00:00 - 00:00
#41845 - Long-term Results of Non-surgical Management for Clavicular Middle Third Fractures.
Long-term Results of Non-surgical Management for Clavicular Middle Third Fractures.
Aims: Clavicle fractures are relatively common and most of them occur in its middle third. Fractures that are not displaced or displaced with no other indication for surgical intervention, are treated supportively; displaced fractures which have been managed non-surgically, have had acceptable outcomes. We designed a study to follow the long-term (6 month) outcome of these cases which have been managed non-surgically by emergency physicians.
Materials & Methods: This was an observational study carried on 432 patients with midclavicular fractures referred to a high level trauma center. All of patients were treated non-surgically and followed up for 6 months. The primary outcomes were patients’ function or disability, based on DASH (Disabilities of the Arm Shoulder and Hand) and UCLA (University of California at Los Angeles) scores. The secondary outcomes were the rate of pain relief, based on Verbal Numeric Scale (VNS) score and complications including mal-union, non-union, and need of secondary surgical intervention.
Results: 432 patients were enrolled. The rate of mal-union and non-union were 63.4% and 2.3%, respectively. The pain score was higher in patients with mal-union (p< 0.001). The average UCLA score of patients was 32.53, which equals to and good and excellent grades; it was significantly lower in those with mal-union (p<0.001). The mean DASH score was 5.92, and there was no significant difference between the two groups with mal-union and normal union (p-value > 0.05).
Conclusion: Our study showed low non-union rate, good function, and high satisfaction rate in patients with fractures of middle third of clavicle who were managed non-surgically.
Ashkan KHODAMORADI, Kourosh JAVDANI ESFEHANI (Dubai, United Arab Emirates), Mahdi REZAI
00:00 - 00:00
#41974 - Lung abscess and empyema presented in our ED with recent travel history.
Lung abscess and empyema presented in our ED with recent travel history.
A 16-year-old female patient came to our ED for cough and fever 8 days back. She has recently travelled outside the country, and she came back 8 days. Since she arrived she has had a cough and fever and got antibiotic couple of days back from a private clinic. For a couple of days she had coughing with brown sputum. She had a mild fever, her temperature was 37.4 then 37.9 centigrade, normal respiratory rate and normal oxygen saturation in room air. The chest X-ray done showed right lower lobe plural effusion and cavity with air fluid level like an abscess. A blood workup was done that showed a lot of leucocytosis. WBcs was 34500 and C reactive protein was 412.3. Renal and liver functions were normal. Sepsis workup done showed normal lactic acid , no growth in the blood culture . Antibiotic was given . The patient got admission under medical care for further investigations. The chest CT showed : Right lung abscess and Pleural empyema. The patient was seen by a thoracic surgery team who decided right lung decortication by video-assisted thoracoscopic surgery . COVID PCR was negative . Respiratory Viruses PCR were negative . Chest drain was applied, and the patient received intravenous antibiotics . she improved and went home .
Learning points: This case got delayed in her diagnosis for 8 days. Lower respiratory symptoms post travel need some attention in investigation like respiratory PCR, chest X-ray and blood test. Antibiotic may be required in any changes in sputum color. The patient was stable without clinical signs of sepsis maybe because she was on home antibiotic .
Dr Islam ELROBAA (Al wakra, Qatar), Amr ELMOHEEN
00:00 - 00:00
#41618 - Macarena the killer.
Macarena the killer.
Brief Clinical History:
The 62-year-old female patient, known for hypertension and dyslipidemia, presented to the emergency department after experiencing sudden dorsal and cervical pain while dancing. She also complained of paresthesias in her arms and legs, weakness, tremors in her lower extremities, and dyspnea. During transport by ambulance, she displayed hypertension, desaturation, and fluctuating dysphonia.
Misleading elements:
Despite the severity of the situation, the patient did not present headache, chest pain, visual disturbances, or dysarthria. Oxygen support was required, although desaturation was considered secondary to poor respiratory mechanics. There was also a tendency to somnolence, which could actually correspond to questionable bilateral ptosis. Considering the possibility of an underlying autoimmune pathology, corticosteroids were administered empirically, with partial improvement of neurological symptoms.
Helpful Details:
Further tests revealed respiratory acidosis and global respiratory failure, with negative hydroelectrolytic parameters, toxicology tests, and markers of myocardial damage. Imaging studies, including chest and cervical and dorsal spine X-rays, showed no significant alterations. An electrocardiogram indicated a sinus rhythm with a heart rate of 79 bpm, narrow QRS, and no repolarization alterations.
Diagnostic Workup:
Given the patient's clinical deterioration, a brain CT scan was conducted, revealing an epidural hematoma from C2 to D4 with secondary spinal cord edema. Subsequent MRI confirmed the diagnosis, and the patient was admitted to the Intensive Care Unit. A C2-C5 laminectomy was performed by the neurosurgery team, resulting in a favorable postoperative evolution with progressive improvement of the previous neurological deficit. Upon discharge, the patient was able to walk with assistance.
Differential and actual diagnosis:
Other possible diagnoses to consider include spinal cord infarction, compressive myelopathy due to disc herniation, spinal epidural abscess, intradural-extramedullary tumor, acute multiple sclerosis or disease relapse, spinal venous thrombosis, and traumatic spinal cord injury.
Educational and/or Clinical Relevance:
In conclusion, spontaneous spinal epidural hematoma is a rare but serious condition causing spinal cord compression. Risk factors include thrombophilias, anticoagulant and antiplatelet treatments, vascular malformations, and hypertensive crises or excessive efforts. Early recognition, suspicion, and diagnosis are crucial for prognosis. Urgent MRI is the diagnostic imaging of choice, followed by surgical decompression to relieve spinal cord compression and reverse neurological deficits. The timing of surgical treatment influences prognosis and possible sequelae, with better outcomes observed in patients with incomplete neurological injury before surgery.
This case emphasizes the importance of promptly recognizing and managing neurological emergencies such as epidural hematoma with spinal cord edema to prevent permanent neurological damage. It highlights the need to consider neurological emergencies in patients with acute cervical pain, especially those with cardiovascular risk factors. Additionally, it serves as an educational tool to emphasize the clinical presentation, diagnosis, and urgent management of this condition in the emergency department setting.
Alfredo PIRIS VILLAESPESA, Juan ANDUJAR TAVERAS, Paula FRADES ORTIZ, Daniel ROMERO PALACIAN (MADRID, Spain), Teresa CERDAN
00:00 - 00:00
#41775 - Machine Learning to improve predictive performance of prehospital early warning scores.
Machine Learning to improve predictive performance of prehospital early warning scores.
Background
Early warning scores (EWS), used to assess acute patients’ risk of critical deterioration, should be applied as early as possible in the healthcare pathway, preferably in the prehospital phase.
Previous research indicates that EWS only perform moderately in the prehospital setting. With the emergence of electronic prehospital medical records, including vital signs, and greater computational abilities by use of e.g., machine learning, the predictive performance of EWS could be improved. Our aim was to investigate the use of machine learning models to improve the performance of EWS in predicting short term mortality in an unselected prehospital population.
Methods
Population-based development and validation study based on a historic consecutive cohort of adult ambulance patients.
Setting
Denmark use unique civil registration numbers whenever a citizen has a health care contact or contact with other relevant authorities. In case of life- or limb threatening emergencies, the national emergency number 1-1-2 is available at all hours. In non-life- or limb-threatening situations, patients can contact their general practitioner during office hours and other primary care services out-of-hours. In 2016, a nationwide electronic prehospital medical record was introduced.
Participants
Patients aged 18 years or older using ambulance services in the North Denmark Region from July 1, 2016, to December 31, 2020, were included. Patients with no civil registration number registered, whose medical record linked to more than 1 person, whose time of death was registered before the record-creation date, who had no vital signs recorded, and who received diagnoses concerning death at hospital arrival, were excluded.
Outcomes
The primary outcome was 7-day mortality. Secondary outcomes were 30-day mortality and ICU admission.
Statistics
We applied four representative machine learning algorithms: gradient boosting machine (GB), random forest (RF), logistic regression (LR), and Bayesian network (BN). Selection of features were likewise assessed.
To provide a comparison with current practice, we included two EWS: the National Early Warning Score 2 (NEWS2; score range, 0-20) and the Danish Emergency Process Triage (DEPT; score range, 1-4).
Results
GB provided the best performance with similar performance observed for RF and LR. GB and LR were well calibrated for the primary outcome, while RF and BN tended to underpredict. Performance of all models increased with increasing availability of data, and age was the most important feature, followed by minimum SpO2, GCS, maximum heart rate and minimum systolic blood pressure. Comparing GB to NEWS and DEPT resulted in a significant lower number of false alarms per positive (from 10.0 to 2.7 and 10.3 to 5.1 respectively)
Differences in model performance were seen for some specific patient groups, when stratified according to ICD-10 diagnose subsequently given at hospital, and age groups.
Discussion & Conclusion
The study included both 1-1-2 and non-1-1-2 ambulance patients, who differ significantly. Likewise stratifying according to patient groups affected the performance.
However, the overall increased performance of the investigated models in a general ambulance population, has a significant potential for reducing the number of patients needed to screen. Thereby also improving early identification of both high- and low risk patients.
The project has been supported by the European Union European Fund for Regional Development through Life-Science Innovation North Denmark’s program “Sundhedsteknologisk Serviceprogram (Healthcare Technology Service Program),” project ID 036.
Logan WARD, Morten SØVSØ, Erika CHRISTENSEN, Mads MOGENSEN, Tim LINDSKOU (Aalborg, Denmark)
00:00 - 00:00
#40877 - Malrotation with midgut volvulus in an elderly patient.
Malrotation with midgut volvulus in an elderly patient.
Clinical history
An 85-year-old lady presented to our emergency department with an acute onset of generalized colicky abdominal pain for two hours, associated with three episodes of non-bloody, non-bilious emesis. Her bowel movement had been regular and her last bowel movement was the day before, with no per-rectal bleeding. She had a history of recurrent urinary tract infection (UTI), ischemic heart disease, complete heart block managed conservatively and no prior abdominal surgeries.
She was afebrile and haemodynamically stable. On initial examination, there was generalized abdominal tenderness on palpation. However, abdomen was non-distended, soft with no guarding.
Point-of-care ultrasound showed no intraperitoneal free fluid, unremarkable abdominal aorta and gallbladder. Venous blood gas showed mild metabolic acidosis with a normal serum lactate at 2mmol/L. Urinalysis was positive for nitrites. Abdominal x-rays did not show evidence of intestinal obstruction, and an erect Chest-xray did not show free air under diaphragm.
Misleading elements
The patient had dementia with cognitive impairment, which rendered her history and symptom-reporting inconsistent. The initial investigations did not provide strong indications to perform a computed tomography (CT) scan of the abdomen urgently in the emergency department. She had a history of recurrent UTI and her urinalysis was positive.
Helpful details
She was monitored in the emergency department with serial abdominal examinations, with occasional reports of abdominal pain and tenderness but otherwise appeared comfortable with a soft abdomen.
Differential and actual diagnosis
The initial differential diagnoses broadly included intestinal obstruction, ischemic bowel, lower urinary tract infection and possible intra-abdominal infection. She was eventually admitted under General Medicine with a diagnosis of urinary tract infection with mixed delirium.
Eight hours later, her serum lactate trended up, with worsening metabolic acidosis. Abdominal examination revealed a distended, tender and guarded abdomen. An urgent CT scan of the abdomen and pelvis showed malrotated bowel suspicious for midgut volvulus, with associated small bowel obstruction and ischemia.
The patient underwent an exploratory laparotomy and small bowel resection. There was 160cm of gangrenous small bowel found in closed loop configuration due to volvulus, with bloody ascites. Unhealthy bowel was resected and primary anastomosis and closure was done. Post-operatively, the patient was put on parenteral nutrition. She was eventually discharged well on post-operative day 20.
Clinical relevance
Midgut malrotation and volvulus usually presents in the first month of life, with 90% of patients diagnosed within the first year of life. Incidence of adult midgut malrotation is rare and has been reported between 0.0001% and 0.19%. A high index of suspicion for elderly presenting with non-specific abdominal pain, with close monitoring and serial abdominal examinations will aid with earlier recognition of a surgical abdomen.
A contrast-enhanced CT scan is the investigation of choice. It has the advantage of showing the abnormal location of the midgut, the reversed mesenteric anatomical relationship as well as any other intra-abdominal anomalies associated with malrotation. Timely recognition with prompt surgical intervention is crucial to limit morbidity and mortality.
Yet Hong CHIA (Singapore, Singapore), Shu Fang HO
00:00 - 00:00
#42354 - Management of acute pain in an emergency department: a preliminary study.
Management of acute pain in an emergency department: a preliminary study.
Background:
Despite the recently increased focus on the importance of pain control, management of acute pain (AP) has remained suboptimal.
Objective:
The objective of our study was to determine the clinical features and management of patients with AP in an emergency department (ED).
Methods:
A prospective, monocentric preliminary study was conducted during April 2024.Inclusion criteria: patients aged over 18 years presenting to ED with AP. Collection of epidemiological, clinical and therapeutic parameters.
Results:
Inclusion of 102 patients. The mean age was 53 +/-19 years. The gender ratio=0,8. Most common comorbidities (%): hypertension (79) and diabetes (56). Seventy-seven patients were smokers. The median consultation time was 4 hours. Type of AP (%): nociceptive (97), psychogenic (2), neurogenic (1). Primary presenting factor (%): chest pain (37), headaches (21), lower back pain (17), abdominal pain (12), pelvic pain (4), post-traumatic pain (5). The average numerical pain scale: 10 +/- 1; 8+/- 2; 6 +/- 2 ; 4+/-1; 3+/-1; 1+/-1 at 0 min, 15min, 30 min, 45 min , 60 min and 90 min, respectively. Analgesic treatment administered (%): intravenous infusion of paracetamol (96), morphine hydrochloride titration (50), nefopam (4). The average duration of pain relief was 100+/-19min.The mean length of stay in the ED was 12 +/-9 hours.
Conclusion:
Simple analgesics are most effective for treating acute pain. The development of standardized protocols may improve acute pain management.
Raja FADHEL (Ain Zaghouan, Tunisia), Ahlem HENDILI, Skander HACHANA, Syrine KESKES, Amira TAGOUGUI, Yosra MEJDOUB, Hanene GHAZALI, Sami SOUISSI, Ines CHERMITI
00:00 - 00:00
#42223 - Management of COPD patients by paramedics : GOLD 2023 recommendations adherence.
Management of COPD patients by paramedics : GOLD 2023 recommendations adherence.
Introduction: COPD is a slowly progressive chronic inflammatory respiratory disease that represents a major public health problem. Management of COPD exacerbation is codified and follows international recommendations. The objective of this work was to describe the paramedical management of COPD exacerbation in emergency ward.
Methods: It was a retrospective observational descriptive study during a three month period in the emergency department of Ben Arous Regional Hospital including adult patients with a history of known COPD presenting to the emergency room with an exacerbation.
Results: We collected 198 patients (158 men and 40 women). Mean age was 67 years. Main personal history were hypertension (20%), diabetes (17%), home oxygen therapy (10%) and atrial fibrillation (8%). Therapeutic management was divided into medical treatment and instrumental treatment : all patients had at least one nebulization and systemic corticosteroid therapy. Antibiotic therapy was prescribed in 24 patients. Simple oxygen therapy was required in 123 patients while non-invasive mechanical ventilation was performed in 37 patients and four patients were intubated.
Conclusion: The quality of life of patients with COPD exacerbation is significantly affected. Current epidemiology of COPD and future perspectives should lead to optimize hospital management of these patients where nurses play a key role in every step.
None
Ines CHERMITI, Naim MALLASSI, Raja FADHEL (Ain Zaghouan, Tunisia), Jihen JALLALI, Jihene SEBAI, Yosra MEJDOUB, Amel BEN GARFA, Hanène GHAZALI, Sami SOUISSI
00:00 - 00:00
#42326 - Management of febrile infants presenting to UK and Irish Emergency care. A prospective multicentre study.
Management of febrile infants presenting to UK and Irish Emergency care. A prospective multicentre study.
Background
Febrile infants ≤90 days of age present commonly to the emergency department (ED) for evaluation of fever. The evaluation and management involve clinical assessment, investigation, and administration of parenteral antibiotics. Multiple guidelines exist and can lead to practice variation. Variation in management has been reported in other jurisdictions but not explored within UK and Ireland, particularly in the post COVID era. The aim of this study was to evaluate the management of febrile infants and variation in practice.
Methods
This was a prospective multicentre study of febrile infants presenting to 35 Paediatric Emergency Research in the UK and Ireland (PERUKI) sites (emergency department and assessment units) from 6 July 2022 to 31 August 2023. Infants with a recorded temperature ≥38C at home or in a health setting within 24 hours were included. All infants received standard care as per local policy. Management included diagnostic test (blood, urine, cerebrospinal fluid (CSF) and respiratory viral test), antibiotic administration and disposition (admission and discharge from the emergency department). Variation in management was assessed by age (≤28 days vs ≥29 days) and by type (paediatric only vs mixed (adult and paediatric) of the ED.
Result
From 2173 patient screened, 1821 were included in the final analysis. The median age was 46 days (IQR: 30–64 days), with 1108 (61%) being male. Of the 1821 infants, 67 (3.7%) had IBI. Of the 1821 infants, 1626 (89%) underwent blood testing, 1483 (52%) had urine testing, 937 (52%) had CSF culture and 1395 (77%) had respiratory viral testing. Antibiotic administration in the ED was recorded in 1242 (68%) of participants. In terms of outcomes, 247 (14%) were discharged home while 1574 (86%) were admitted to the hospital. Paediatric only EDs were more likely to perform higher number of urine testing (84% vs 77% (p: <0.001), viral testing (78% vs 73% (p: 0.012) and administer antibiotics (70% vs 64% (p: 0.007) compared to mixed EDs. Similarly, Infants ≤28 days were more likely to undergo diagnostic testing and get antibiotics administered in ED compared to infants ≥29 days. However, there was no difference for viral testing for infants ≤28 days vs ≥29 days (77% vs 76% (p:0.742).
Discussion
Younger infants (≤28 days) and seen in paediatric only EDs are more likely to undergo investigation and antibiotic administration. This variation in practice demonstrates a need for a unified guidance for febrile infants presenting to UK and Irish EDs
Registered on https://clinicaltrials.gov/ (NCT05259683)
Etimbuk UMANA (Belfast, Ireland), Hannah NORMAN-BRUCE, Clare MILLS, Hannah MITCHELL, Lisa MCFETRIDGE, Steven FOSTER, Michael BARRETT, Chris WATSON, Damian ROLAND, Mark D LYTTLE, Thomas WATERFIELD, On Behalf Of PERUKI
00:00 - 00:00
#42327 - MANAGEMENT OF HEART FAILURES IN EMERGENCY DEPARTMENT.
MANAGEMENT OF HEART FAILURES IN EMERGENCY DEPARTMENT.
INTRODUCTION :
Heart failure is a chronic disease that requires regular medical monitoring and a healthy lifestyle to prevent worsening and limit the occurrence of episodes of decompensation.
Materials and methods :
We included heart failure patients who visited the emergency department and were discharged. All patients received medical monitoring and were classified into 2 groups: normal medical monitoring in the control group and frequent medical visits (every 15 days) in the intensive group. The follow-up duration was 90 days. The data will be analyzed by SPSS20 software.
Results :
In total, 55 patients were included in the control group and 43 patients in the intensive group.
The two groups were comparable regarding gender (40% are women in the control group versus 62.8% in the intensive group) and regarding BMI class with normal build in 25.5% in the control group versus 30.2% in the intensive group.
For ATCDS, the two groups were comparable (in the control group 74.5% were hypertensive compared to 79.1% in the intensive group, 54.4% were diabetic in the control group compared to 41.9% in the intensive group, 16.4% were smokers in the control group compared to 18.6% in the intensive group, patients who experienced ACS were 23.6% in the control group compared to 32.6% in the intensive group and patients with atrial fibrillation were 23.6% in the control group compared to 23.3% in the intensive group. intensive group.
a significant difference between the two groups was noted, the occurrence of cardiac decompensation was 16.4% in the control group and 2.3% in the intensive group and the occurrence of death was 18.2% in the control group compared to 2.3% in the intensive group.
Conclusion :
According to our study, close monitoring of heart failure patients has shown its value and has modified the prognosis and quality of life of patients.
Khaoula HLIMI, Hajer YAAKOUBI, Rahma JABALLAH, Rym YOUSSEF, Emna TRABELSI (Sousse, Tunisia), Tasnim BOUKRIAAT, Imen TRABELSI, Houda BEN SALAH, Asma ZORGATI, Lotfi BOUKADIDA, Riadh BOUKEF
00:00 - 00:00
#41966 - Management of mild traumatic brain injury in the emergency department.
Management of mild traumatic brain injury in the emergency department.
Background:
The management of mild head injury (MHI) in the emergency department (ED) is based on the identification of risk factors of intracranial injuries. However, the use of head computed tomography (CT) remains widespread in practice. The immediate consequences are additional costs and unnecessary congestion of emergency rooms.
Objective: To describe the epidemiology, clinical features, management and outcomes of patients with MHI in an ED.
Methods:
A single-center, prospective, observational study was conducted during ten months [July 2023- April 2024]. Inclusion criteria: patients (≥18 years of age) presenting to ED with MHI defined according to Scandinavian Guidelines by a Glasgow Coma Scale (GCS)≥14. Epidemiological characteristics and the management of those patients were described.
Results:
Inclusion of 91 patients with a mean age of 53±20 years and sex ratio=0.47. Patients' history (%): diabetes (24), high blood pressure (23), atrial fibrillation (10), epilepsy (10), psychiatric diseases (8). Aggravating factors (%): vitamin K antagonist (9), alcoholism (9), antiplatelet agent (8), psychotropic drugs (7), oral anticoagulants (1). The median consultation time was 2 hours. Circumstances of occurrence (%): syncope (24), domestic accident (21), fainting (21), aggression (17), seizure (15), public road accident (4). The main symptoms (%): headache (32), initial loss of consciousness (ILC) (23), vomiting (8), confusion (4), epistaxis (3), post-traumatic amnesia (2), visual disturbances (1). Average of ILC duration=3±1 minutes. Median GCS=15. Thirteen patients (14%) presented a scalp wound and 13 patients presented associated extracranial injuries. A head CT was performed in 62% of cases. Indications of CT scans (%): ILC (23), anticoagulant drugs (11), antiplatelet agents (7), vomiting ≥ 2 episodes (5), neurological deficit (4), seizure (3), periorbital ecchymosis (2), trauma with high kinetics (1). The median time to perform the CT was 6 hours. Six patients had intracranial hemorrhagic lesions (n): intracerebral hematoma (2), subarachnoid hemorrhage (2), extradural hematoma (1), subdural hematoma (1). Neurosurgery indication has been made in 2%. Twelve patients required hospitalization. The median length of stay was 6 hours.
Conclusion:
Brain imaging was frequent in our study. We emphasize the interest of following a precise protocol in order to establish the indication and timing for carrying out a CT scan.
Raja FADHEL (Ain Zaghouan, Tunisia), Ala NEIJI, Hana LAJDEL, Jihene JALLELI, Syrine KESKES, Hela BEN TURKIA, Amira BAKIR, Sami SOUISSI, Ines CHERMITI
00:00 - 00:00
#42187 - Management of pain in the Emergency Department.
Management of pain in the Emergency Department.
Introduction:
Pain is a common complaint for emergency department consultations. Despite the current codification of pain management based on well-established theoretical foundations, its practical application remains inadequate.
The objective of this study was to describe the management of pain within the emergency department.
Methods: We included 100 consecutive patients presenting to the emergency department with acute or chronic pain. Pain assessment was conducted using the visual analog scale (VAS). For each patient, we recorded the analgesic step prescribed in-hospital and post-discharge.
Results: The mean age of our population was 42.58±16.7 [16-90] years. There was a male predominance (64M/36F). Orthopedic emergencies accounted for 28% of cases, followed by surgical emergencies in 22% of cases, and cardiovascular emergencies in 20% of cases. Pain was acute in 87% of cases, nociceptive in 89% of cases, mixed in 5% of cases, neuropathic in 2% of cases, and psychogenic in 4% of cases. The mean VAS pain score was 5.74±2.24 [1-10]. In 53% of patients, pain was moderate (VAS between 3 and 6), and it was severe (VAS≥7) in 38% of patients. Fifty-four patients received injectable analgesic treatment in the emergency department: step 1 (54%), step 2 (15%), and step 3 (5%). The main reasons for not prescribing analgesic treatment in the emergency department were the need for emergency surgical treatment and the physician's judgment of insignificant pain. Analgesic treatment was prescribed at discharge in 85% of cases: step 1 (78%) and step 2 (27%).
Conclusion: We conclude from these data that pain management remains inadequate, particularly regarding the use of the 3rd step. Implementation of a training program for physicians and healthcare staff could contribute to optimizing pain management in the emergency department
Saloua HOUIMLI (la Marsa, Tunisia), Sarra AKKARI, Nour El Houda MAATOUG, Mohamed ASSADI, Syrine TROJETTE, Fatma HEBAIEB
00:00 - 00:00
#41744 - Management of patients with acute chest pain in emergency settings: a global survey.
Management of patients with acute chest pain in emergency settings: a global survey.
Background: Chest pain is one of the most common reasons for visiting emergency departments (EDs) worldwide. This symptom can be caused by life-threatening conditions, such as acute coronary syndrome, acute aortic syndrome or pulmonary embolism. However, in most cases, the causes of acute chest pain are benign. Making fast and well-informed decisions, making sure critically ill patients are treated at the right place in a timely manner, as well as identifying those not at acute risk, lays at the very heart of emergency medicine.
Methods: A cross-sectional online survey contained sections on ED setting, triage system and standard operating procedures (SOPs) used at EDs, available diagnostic tools at EDs, cardiologist involvement in patient management, patient follow-up, and willingness to participate in a follow-up study. We distributed the survey through the EMERGE and EUSEM networks, as well as other centers. We were collecting the responses from November 2023 till May 2024.
Results: 41 centers representing over four million annual patients completed the survey. Centers were located in Europe (n=25), Asia (n=10), the Americas (n=4), Africa (n=1) and Australia (n=1).
Patients with acute chest pain spend an average of 4 hours (Q1; Q3 = 3; 6) at the ED. Frequency of life-threatening conditions varied highly between <1% and 50% (median 10%), as did admission rate (<1% - 50%; median 20%). Many centers used their local triage systems and SOPs. Regarding risk scores, the Wells score was used in a majority of centers, and more than half also used the HEART score and PERC rule. All participants had access to ECG, ultrasound, CT, troponin tests and D-Dimers.
Conclusion: Characteristics and management of patients with chest pain varies greatly and is often guided by local guidelines. Despite variations, participating centers had access to essential infrastructure for ruling out life-threatening diagnoses in such patients.
This survey was not registered and did not receive any specific funding.
Karina TAPINOVA (Wien, Austria), Marco NEYMAYER, Prashant MAHAJAN, Dominik ROTH
00:00 - 00:00
#40961 - Management of patients with cerebral Hemorrhage in the Emergency Department according to standard bundle of care. MHED STUDY.
Management of patients with cerebral Hemorrhage in the Emergency Department according to standard bundle of care. MHED STUDY.
Background: Intracerebral haemorrhage (ICH) represents a major global health burden accounKng for 10- 20% of all strokes and responsible for disproporKonately high morbidity and mortality rates worldwide. Current internaKonal guidelines on the management of ICH have recommended that ICH be treated as a medical emergency. Recently, the care bundle protocol, which includes the early intensive lowering of systolic blood pressure (target <140 mm Hg), strict glucose control (target 6·1–7·8 mmol/L in those without diabetes and 7·8–10·0 mmol/L in those with diabetes), anKpyrexia treatment (target body temperature ≤37·5°C), and rapid reversal of warfarin-related anKcoagulaKon (INR raKo <1·5) within 1 h of treatment resulted in improved funcKonal outcome for paKents with acute ICH in low-income and middle-income countries.
Aim: to assess the efficacy of the care bundle protocol on in-hospital mortality and funcKonal outcomes in consecuKve ICH paKents. The study will be conducted in a terKary academic hospital in a high-income country.
Methods: Our study will conduct a comparative analysis between two distinct patient cohorts with ICH: A historical control group consisting of patients who were admitted to our Emergency Department (ED) from 2020 to 2023 will be compared to consecutive group of ICH patients admitted to our ED after the approval of the Ethics Committee and managed with a care bundle protocol.
Expected results:
We expect that applying a structured management protocol for ICH patients will substantially improve functional outcomes after an acute ICH event even in a tertiary academic hospital.
Alessandro BUFI (Perugia, Italy), Rossana REGINA, Daria GIUDICI, Francesco BOSSI, Valeria CASO
00:00 - 00:00
#42144 - Management of Pericardial Effusion and Cardiac Tamponade: Strategies for Urgent Cardiac Challenges.
Management of Pericardial Effusion and Cardiac Tamponade: Strategies for Urgent Cardiac Challenges.
This presentation focuses on pericardial effusion and cardiac tamponade, two conditions related to the accumulation of fluid in the pericardial sac surrounding the heart. The two-dimensional echocardiogram findings in cardiac tamponade are outlined, including the hemodynamic changes observed. Additionally, the differentiation between pericardial effusion and other conditions, such as intra-pericardial fat and pleural effusion, is discussed. The impact of fluid accumulation on hemodynamics is explored, considering factors such as volume and rate of accumulation, as well as the patient's vascular status. The presentation also highlights the clinical diagnosis of cardiac tamponade and the role of ultrasound in identifying physiological abnormalities. The indications and contraindications for pericardial drainage are presented, along with the procedure for ultrasound-guided pericardiocentesis.
To illustrate the management of pericardial effusion and cardiac tamponade, a case study involving a 40-year-old male patient is presented. The patient presented with a 3-day history of fever and chest pain, and point-of-care ultrasound (POCUS) revealed no signs of pericardial tamponade. However, diagnostic pericardiocentesis was still performed. The details of the procedure and its successful implementation are discussed, emphasizing the importance of timely intervention in these potentially life-threatening conditions.
Understanding pericardial effusion and cardiac tamponade is crucial in recognizing and managing these emergent situations effectively.
Lam IAN-SENG (Macao, China), Leong HOI-IP
00:00 - 00:00
#41216 - MATTERS: A Unique Model to Efficiently Link Patients with Opioid Use Disorder to Treatment.
MATTERS: A Unique Model to Efficiently Link Patients with Opioid Use Disorder to Treatment.
Background
The Medication for Addiction Treatment and Electronic Referrals (MATTERS) network, a comprehensive multi-state, seamlessly links patients from emergency departments and beyond to medication for opioid use disorder (MOUD) treatment sites. The need for a patient-centric network, independent of hospital affiliations, has surged during the span of the opioid epidemic. MATTERS was carefully developed to be scalable nationwide, adaptable to urban, suburban, and rural landscapes. The network ensures swift and secure connections between referring and receiving sites through an entirely electronic platform, enabling the referral process completion within 2-3 minutes, eliminating the need for time-consuming phone calls. Furthermore, MATTERS goes beyond mere referrals; it offers integrated "wrap-around services" like medication and transportation vouchers, as well as connections to peer specialists. These holistic efforts significantly enhance patient outcomes, emphasizing our commitment to comprehensive and compassionate care.
Methods
MATTERS showcases a replicable model for the United States and beyond. Its adaptability is evident in addressing the diverse needs of both urban and rural areas, bridging socioeconomic gaps. While the majority of treatment organizations embraced MATTERS, a few hesitated due to concerns about a "medication-first" approach conflicting with traditional counseling norms. Yet, most organizations successfully adapted, integrating into the network. However, it's crucial to acknowledge the challenges. Patients dealing with substance use and mental health issues often face formidable barriers, complicating their retention within the program. Overcoming these hurdles is vital to ensuring MATTERS' long-term effectiveness. The program's evolution highlights the potential for widespread implementation, offering hope for transforming mental health and addiction treatment paradigms nationally and globally.
Results
The onboarding process was highly successful, with over 100 hospitals, constituting approximately 41% of all hospitals in New York State, enrolled in the MATTERS program. Among these, 88 hospitals are consistently referring patients through our specialized platform. Additionally, we have integrated nearly 250 distinct treatment organizations into our network, each specifying the available daily "appointment slots" for referrals. Collectively, these sites offer over 2,250 weekly slots. The model extends beyond mere referrals. Patients are followed along the way, offering additional resources and support to ensure comprehensive care. This streamlined approach ensures seamless connections and enhances the overall efficacy of our network, fostering a robust framework for collaborative healthcare delivery.
Conclusion
MATTERS is a model demonstrating ease of use to increase access to medication for addiction treatment and efficient linkage to treatment from the emergency department and beyond. The program can be applied to both rural and urban environments, large and small hospitals, and a variety of other applications.
Joshua LYNCH (Buffalo, New York, USA)
00:00 - 00:00
#41362 - Mechanism of Injury and Disposition of Severe Polytrauma Patients at Kalafong Provincial Tertiary Hospital.
Mechanism of Injury and Disposition of Severe Polytrauma Patients at Kalafong Provincial Tertiary Hospital.
Background: South Africa is rated among the highest in the world, with regards to mortality from injuries, with a mortality rate of double the global rate for road traffic injuries.
The aim was to observe the MOI and disposition of severely injured polytrauma patients at Kalafong Provincial Tertiary Hospital (KPTH) Emergency Department (ED). A secondary aim was to observe associations between the MOI, severity of injuries, and patient outcome. This research may be useful to motivate for trauma services and influence staffing decisions in tertiary hospitals in SA.
Methods: A retrospective audit was done on files of patients who presented with severe polytrauma to KPTH ED from 01 July 2018 to 31 December 2019. KPTH is a tertiary, academic hospital in SA. The register at KPTH ED identified 208 patients as “polytrauma”. Of these, 191 met the inclusion criteria of adults ≥ 18 years and severe polytrauma with an injury severity score (ISS) ≥ 16. Associations were tested using chi-square, one-way ANOVA and Pearson’s correlations using STATA 15.
Results: The most severe polytrauma patients were black males aged 26-35 years. Motor vehicle accidents (MVAs) were the most prevalent mechanism, while patients involved in pedestrian vehicle accidents (PVAs) were most severely injured (mean ISS 45). Most patients were admitted to the Intensive Care Unit (ICU) with an average waiting time of 7,05 hours. The association between MOI and severity was statistically significant with a p-value 0.0045. There was a statistically significant relationship between MOI and time to admission from the ED (p <0.0001). Patients that sustained gunshot wounds (GSW) had the lowest mean ISS of 35 and most were taken straight to theatre. Fourteen percent of patients demised in the ED before admission or surgical intervention.
Discussion and conclusion: Severe polytrauma affecting younger males is consistent with local and international studies. Our study aligns with Norman et al. who observed that SA males involved in interpersonal violence had a high mortality rate. The trauma experienced in SA appears to be more severe than international counterparts, with a mean ISS of 22 in polytrauma patients in a German ICU, compared to 41 in our patients referred to ICU. Patients sustaining GSW had dispositions suggesting acute, severe injury. More than half went directly to the operating theatre, 8% demised in the ED and the rest went to ICU or HC with no general ward admissions. Despite this, the mean ISS in the GSW group was the lowest in our population, at 35. The underscoring of the ISS in penetrating injury has been suggested in numerous publications and our findings concur. Our study demonstrated an overall ED LOS of severe polytrauma patients ranging between 1-12 hours which is impressive compared to a retrospective Qatari study in which 9% of trauma patients stayed in the ED >24 hours.
While MVA was the predominant MOI for severe polytrauma patients presenting to KPTH ED, patients involved in PVAs were most severely injured. The majority of severe polytrauma patients were admitted to ICU.
The study was not registered as it is retrospective and descriptive. No patients were directly involved, the clinical notes were audited retrospectively.
This study did not receive any specific funding.
Onke TUSWA, Magdelena GEYSER, Vidya LALLOO (Pretoria, South Africa, South Africa), Almien SMIT
00:00 - 00:00
#40977 - Medication Errors in Home Care Setting: A 13-year Retrospective Study in Thailand.
Medication Errors in Home Care Setting: A 13-year Retrospective Study in Thailand.
Medication errors (MEs) are an important health problem which can occur in either a healthcare setting or in homecare. MEs result in morbidity or mortality in some patients. Most researches focus on MEs’ data primarily in health care facilities. However, there is limited study examining MEs in homecare setting, especially in Asia and in Thailand.
This study was conducted to assess the clinical characteristics and consequences of MEs that occur in a home care setting in Thailand.
We conducted a 13-year retrospective study (January 2011–December 2023) by analyzing data from the Ramathibodi Poison Center.
Results: In total, 1,245 patients were included in the study. Most (56%) patients were male, with a median age of 3 years (range, 2 days – 87 years). MEs were reported in every region. Approximately 80% of all occurred in patients under 15 years old. The most common MEs occurred via the oral route, accounting for approximately 96% of cases. Wrong drug administration was identified as the most frequent cause of MEs in the homecare setting. Calamine lotion, acetaminophen, asafetida, essential oils, and topical corticosteroids were the most common involved drugs in MEs. Different preparation or strengths of acetaminophen syrups was one key component that contributed to MEs occurred in children. No death was reported in this study. However, two patients required intubation due to errors involving sedative-hypnotic drugs. After approximately one day of intubation and supportive treatment, both patients recovered and were discharged from the hospital.
MEs in homecare setting carries health risk, especially in children. Although, death was not found in this study, MEs result a morbidity, increased unnecessary hospital visits or admission, increased expenses, and psychological effects to patients.
Strategies to reduce MEs, especially to prevent MEs in children, include improving communication with caregivers and patients, supporting the safe use of pediatric medications, and implementing child-proof packaging. Continued research and implementation of preventive measures are crucial to ensuring the safety and well-being of patients receiving care at home.
Phantakan TANSUWANNARAT, Monsicha WANGPIPATWONG (Bangkok, Thailand)
00:00 - 00:00
#42289 - Meningoencephalitis presenting as ischemic stroke in the Emergency Department.
Meningoencephalitis presenting as ischemic stroke in the Emergency Department.
Introduction :
Meningoencephalitis is a frequent reason for admission to the emergency room and intensive care unit. Their clinical presentation can simulate other neurological emergencies such us strokes.
Observation :
We report the case of a 68-year-old patient with a history of diabetes and hypertension. He consulted the emergency room for headache, vomiting, gait disorders and left hemiparesis. The initial physical examination found a Respiratory rate of 18 cpm, a SpO2 of 98% and a free PA. The SAP was 150 mmHg and the DBP 90 mmHg with a heart rate of 90 bpm. The blood glucose level was 1g/l. The neurological examination showed a GCS of 15/15 with left hemiparesis. An ischemic stroke was suspected. The biological assessment showed a hyperleukocytosis (WBC=31380) with PNN predominance (29260), a thrombocytopenia at 130,000, a correct renal function with a CRP at 243. The cerebral CT showed a cortico-subcortical hypodensity, right parieto-occipital evoking a recent ischemic stroke. The patient was hospitalized in a close monitoring unit, and the evolution was marked by a deterioration of the neurological state (GCS=10/15) and the occurrence of focal convulsive seizures of the left hemiface. The initial course of action was to administer an anti-epileptic drug (clonazepam). The neurological state deteriorated (GCS=7/15) with the occurrence of a status epilepticus, which led to the need for intubation and mechanical ventilation. A brain CT scan was performed showing a right parieto-occipital brain abscess. The biological investigation was completed by a lumbar puncture with a cloudy appearance and a pleocytosis (90% Lymhocytes, 10% PNN). Immediately, a meningeal dose of antibacterial therapy was administered: ceftriaxone, gentamicin, ampicillin. To better characterize the lesions, a cerebral MRI showed the aspect of a meningoencephalitis complicated by a parieto-occipital cerebral abscess and a sub dural empyema responsible for a deviation of the median line of 3 mm. The neurosurgery department was contacted for operative indication, then the patient was transferred to the intensive care unit.
Conclusion :
Meningoencephalitis is a rare and serious disease. Early diagnosis allows for early treatment and improved prognosis.
Sirine KHABOUCHI, Khaireddine JEMAI (Tunis, Tunisia), Dhekra HOSNI, Hana HEDHLI, Boukthir OUMAYMA, Seif OUERGHI
00:00 - 00:00
#41757 - Mental health consequences among relatives after an announcement made by phone of a decision to withhold or withdraw life-sustaining treatments in the emergency department.
Mental health consequences among relatives after an announcement made by phone of a decision to withhold or withdraw life-sustaining treatments in the emergency department.
Study objective: Announcements are complex and difficult in the context of emergency departments (EDs), and sometimes have to be made by phone. We aimed to assess the mental health consequences for relatives after such announcements.
Method: We conducted a prospective, observational, multicenter study in three emergency departments of a French university hospital. The Hospital Anxiety and Depression Scale (HADS) and the Impact of Event Scale – Revised were used to assess symptoms of anxiety, depression, and post-traumatic stress disorder in relatives of patients admitted to the ED 7 days and 30 days after an announcement of a decision to withhold or withdraw life-sustaining treatments made by phone.
Results: A total of 100 relatives were included (mean age 60.2 years). The majority of the relatives were patients’ children (73.0%). Most of the time, relatives were involved in the decision-making process (76%). At 7 days after the announcement, 29 (29%), 31 (31%), and 14 (14%) relatives displayed symptoms of post-traumatic stress disorder, anxiety, and depression, respectively. At 30 days symptoms were present in 21 (21%), 19 (19%), and 5 (5%) relatives for post-traumatic stress disorder, anxiety, and depression, respectively.
Symptoms of anxiety at 7 and 30 days were more frequent in relatives who were women (p=0.003 and p=0.01, respectively) and in those who had a history of anxiety (p=0.01 for both). Post-traumatic stress disorder symptoms at 30 days were also more frequent in woman (p=0.03).
Conclusion: The mental health consequences on relatives of these announcements made by phone in the EDs must be taken into account and call for improvements in communication between healthcare workers and relatives regarding these decisions.
Trial registration number: NCT04785807
Camille DELSOL, Bénédicte CLÉMENT, Chloe DUPUIS, Julien BERTHILLER, Anne TERMOZ, Karim TAZAROURTE, Sophie VESCO, Marion DOUPLAT (Lyon)
00:00 - 00:00
#41895 - Metabolic Acidosis Induced by Rectal Phosphate Enemas: A Case of Miscommunication and Patient Safety Incident.
Metabolic Acidosis Induced by Rectal Phosphate Enemas: A Case of Miscommunication and Patient Safety Incident.
The patient, a 60-year-old woman with no relevant medical history, presented to the emergency department with diarrhea, dizziness, and malaise. She was scheduled for a colonoscopy to investigate diverticula and had been prescribed two enemas for the night before the procedure. Instead of undergoing the colonoscopy, she came to the emergency department feeling very dizzy.
On arrival, her vital signs were stable, with a blood pressure of 108/72 mmHg, heart rate of 73 bpm, and oxygen saturation of 95%. Physical examination revealed mucocutaneous pallor and diffuse abdominal pain without signs of peritoneal irritation.
Blood tests showed metabolic acidosis with a pH of 7.14, bicarbonate (HCO3) of 15 mEq/l, potassium (K) of 3.5 mmol/l, sodium (Na) of 144 mmol/l, chloride (Cl) of 113 mmol/l, calcium (Ca) of 7.9 mg/dl, and phosphorus (P) of 5.2 mg/dl.
The patient had misunderstood the instructions and ingested two enemas (totaling 500cc) orally, instead of using them rectally. The enemas contained sodium phosphate, which can cause metabolic acidosis due to phosphate absorption in the colon, leading to the elimination of bicarbonate ions.
Differential and actual diagnosis:
In cases of metabolic acidosis, the anion gap allows us to identify the responsible disorder:
- Metabolic acidosis with an increased anion gap (normochloremic - the accumulated acids do not contain chlorine in their molecule). Causes include ketoacidosis, chronic kidney disease, lactic acidosis, and exogenous acid administration.
- Metabolic acidosis with a normal anion gap (hyperchloremic). These are mainly due to digestive losses of bicarbonate or renal tubular acidosis (selective impairment of the renal tubules' ability to acidify). In these metabolic acidosis cases with a normal anion gap, it is useful to determine the urinary anion gap as it helps differentiate between renal bicarbonate losses and intestinal losses: A negative value suggests intestinal loss, while a positive value indicates renal loss.
Enemas containing phosphate, as in the case of our patient, can cause metabolic acidosis due to phosphate absorption in the colon, leading to the elimination of bicarbonate ions.
She was urgently treated with intravenous fluid therapy and bicarbonate. After 24 hours, her electrolyte balance was restored without further consequences.
Sodium phosphate enemas are commonly used to treat constipation but can be dangerous. Cases of hyperphosphatemia due to these enemas have previously been reported, some with fatal outcomes. Although most cases are described in predisposed patients (renal insufficiency or intestinal transit disorders), they can also occur in healthy patients. The peculiarity of this case is that the problem arises from miscommunication with the patient, as she misunderstood that the route of administration was oral and not rectal. There is limited scientific literature on this matter, so management was based on the patient's clinical and laboratory abnormalities.
It is important to highlight that in this case, there was a failure in doctor-patient communication, and it represents a medication administration safety incident.
Alfredo PIRIS VILLAESPESA (MADRID, Spain), Juan ANDUJAR TAVERAS, Daniel ROMERO PALACIAN, Maria MESTRE LUCAS, Ana ROCA GARCIA, Teresa NUÑEZ GOMEZ ALVAREZ, Borja HERNANDEZ MORENO
00:00 - 00:00
#41818 - METABOLICS MATTER IN EMERGENCY MEDICINE: WHAT’S THAT SMELL?
METABOLICS MATTER IN EMERGENCY MEDICINE: WHAT’S THAT SMELL?
BACKGROUND:
Maple Syrup Urine Disease(MSUD), with an Irish incidence of 1:125000, is a rare inborn error of metabolism(IEM) characterised by deficiency of an enzyme complex that is necessary to metabolise three branch-chain-amino-acids(BCAAs) leucine, isoleucine and valine. This results in the accumulation of neurotoxic by-products. It is part of the Irish and UK newborn screen. However, milder forms of IEM may not be detected on newborn screens. Consequently, children present to emergency departments(EDs) with undiagnosed IEM.
CASE:
A 12month old boy with developmental delay presented to the ED with three days of vomiting and lethargy, becoming unarousable at home. He was encephalopathic, maintaining his airway with no signs of shock, and an unremarkable systemic exam. Although, he had a peculiar smell. He was treated for sepsis and administered intravenous fluids. Initial blood gas showed an uncompensated high anion gap metabolic ketoacidosis with normoglycaemia.
Urgent CTB, ECG, baseline bloods and toxicology were unremarkable. Ammonia increased from 58 to 88mol/L over 6hours. The metabolic acidosis remained despite adequate treatment with an increasing concern for an underlying IEM. After an urgent metabolic consult and screening, a fluid regimen containing dextrose(10%) and maintenance(150%) was commenced. He was transferred to PICU and subsequently diagnosed with MSUD. With tailored care for MSUD he rapidly recovered to baseline.
DISCUSSION:
MSUD Metabolic decompensation must be treated aggressively. A rapid depression of leucine levels through inhibition of protein catabolism and augmentation of protein synthesis is required. This is done through 10%dextrose, precursor-free amino acid mixture and protein intake inhibition.
CONCLUSION:
IEMs, like MSUD, must be considered in children with metabolic decompensation or encephalopathy, despite having evidence of normal new-born screening. A high index of suspicion for IEM is required in EDs as presentations are often non-specific. Timeous diagnosis and tailored treatment can prevent permanent organ damage or mortality.
Gideon-Phil MEYER (Dublin, Ireland), Mark GLYNN, Lizeri JANSEN, Anne Marie MURPHY
00:00 - 00:00
#42060 - Metamizole-associated agranulocytosis - A rare but underestimated adverse effect?
Metamizole-associated agranulocytosis - A rare but underestimated adverse effect?
Brief clinical history:
An 80-year-old female presented to our emergency department with a painful and erythematous swelling in the gluteal area, which had developed over the course of 2 days. She had already taken some pain medication at home. The patient was awake with stable vital signs and afebrile In the physical examination, dark blisters were noted on several fingers. In the anal area, an approximately 15x10cm erythematous abscess was observed, extending from the gluteal region into the anal fold.
Misleading elements:
The blood gas analysis revealed an elevated lactate level of 4.3 mmol/l. Whole blood count showed: leukocytes < 0.1/nl and neutrophils 0.02/nl, hemoglobin 13,7 g/dl, platelets 233/nl.
Helpful details
Due to the extensive abscess a computed tomography of the abdomen and pelvis was performed (Fig. 1 and 2) which demonstrated inflammatory changes in the rectum. After the lab results the patient was asked about the medications she had already taken and reported that she had taken Metamizole during the preceding week due to pain in the anal region.
Differential diagnosis and actual diagnosis
The first differential was extensive abscess due to an unclear immunosuppressed state. After the blood results and the more detailed history a metamizole induced agranulocytosis was considered.
In suspicion of a pilonidal abscess, emergency exploration was performed after initiating empiric antibiotic therapy, revealing an extensive Fournier's gangrene. Postoperatively, the patient developed septic shock and passed away the following day.
Educational and clinical relevance
In many countries, including the USA, United Kingdom, and Sweden, metamizole is not available due to the risk of agranulocytosis. In Germany, it is currently prescribed with low threshold. The main issue lies in the often absent, yet necessary safety briefing provided by the attending medical professionals. Strict medical indication, short duration of use, prescribing smaller package sizes, and solely clinical usage would help reduce the incidence of agranulocytosis. The manufacturer's recommended blood count monitoring lacks specific timing, especially considering that agranulocytosis can occur after the first intake or even months after the cessation of therapy.
Esther KLEMPERER (Hamburg, Germany), Dorothea SAUER
00:00 - 00:00
#40809 - Morbidity during recreational runs: a prospective analysis of a large amateur run.
Morbidity during recreational runs: a prospective analysis of a large amateur run.
Background: Marathon runs (42.2 km) pose a risk of injuries, life-threating heatstroke, and cardiac arrhythmias. Approximately 30,000 runners participate yearly in the Tel Aviv 5-42.2 km marathon (TLVM). In-race factors predicting runner injury have been well described, but pre-race factors and injury characteristics have not been evaluated in depth.
Purpose: To identify training-related and pre-existing medical conditions as predictors of race running-related injuries of the runners who required medical care during and immediately after the run.
Methods: Our Forward Emergency Care Facility (FECF) attached a questionnaire to a health declaration form distributed at registration on race day. Data were gathered anonymously and recorded according to the runner's registration number. Environmental conditions were also noted.
Results: One-fifth of the 20,698 participants completed the questionnaire. The ambient temperature on race day was 13-23C, 50%-60% relative humidity, and 20-21 discomfort index (a measure of heat load) units. Forty-eight runners were treated in the FECF, 23/48 (48%) were transported to a hospital, and 7/48 (14%) were hospitalized. Six runners sustained exertional heat stroke (EHS) requiring ice-water immersion to a target temperature of 38.0C. One runner had rhabdomyolysis, one had an ST-elevation myocardial infarction, seven had creatinine levels 1.5 times normal levels (one of them was hospitalized), and two had limb fractures requiring surgical intervention. Twenty (42%) of the 48 FECF patients ran a full marathon, while four of six EHS patients ran 10 km.
Conclusion: The increasing popularity of marathons mandates the construction of an algorithm to predict potential race-related health risks based upon pre-race runner characteristics and environmental conditions.
Noa SHOPEN (Tel Aviv, Israel), Pinchas HALPERN, Efrat ZANDBERG
00:00 - 00:00
#42257 - Multifocal tuberculosis and antibacillary hepatotoxicity: what to do?
Multifocal tuberculosis and antibacillary hepatotoxicity: what to do?
Introduction: Tuberculosis is still common in Morocco and is responsible for a high morbidity and mortality rate. The preferred site is the lung. The severity of the disease and the multiplicity of localizations depend on the individual's immune status. We report a case of multifocal tuberculosis with pulmonary and neuromeningeal involvement, complicated by antibacillary hepatotoxicity.
Observation: A 50-year-old female patient was admitted to the life-threatening emergency room with a progressive apyretic disturbance of consciousness. On admission, the patient was comatose with a GCS of 10/15, with left facial paralysis. She was polypneic at 28 c/min, with signs of respiratory struggle and an SpO2 of 94%. She was hemodynamically stable. Her capillary blood glucose was 2 g/L and her temperature 37.5°C. The patient was conditioned with a large-bore peripheral venous line, a high-concentration mask, urinary catheterization and placement of a nasogastric tube. A radiological work-up was ordered, revealing multiple nodular lesions above and below the tentorial surface on the cerebral CT scan, confirmed by cerebral MRI. A frontal chest X-ray showed a tubercular miliary appearance. A full laboratory work-up revealed lymphopenia at 750/mm3, and lumbar puncture revealed meningitis with clear, predominantly lymphocytic fluid. The patient was put on high-dose corticosteroid therapy and antibacillary treatment with the "4cp ERIP-K4/day" regimen. The evolution was marked by the appearance of hepatotoxicity to antibacillaries, requiring their discontinuation. On the advice of infectiologists, antibacillary treatment was resumed in view of the immediate life-threatening situation. HIV serologies came back positive, but treatment could not be started as the patient died on D+5, in a state of multivisceral failure.
Discussion: Multifocal tuberculosis is common in immunocompromised patients, mainly those infected with the human immunodeficiency virus (HIV). Pulmonary involvement is the preferred site of tuberculosis. In addition to signs of tuberculosis impregnation, standard chest radiography is a key examination for positive diagnosis. Although exceptional, neuromeningeal involvement is of particular importance due to its severity. The two most frequently observed forms are tuberculous meningitis and intracranial tuberculomas. Diagnosis is essentially based on radiology, with cerebral MRI being the key examination. Anti-tuberculosis treatment is mandatory, based on well-established protocols. Undesirable effects include liver toxicity, a major complication with an estimated frequency of 0.5 to 10%, pyrazinamide being the most hepatotoxic molecule. In the event of hepatotoxicity to antibacillaries, treatment should be discontinued and resumed only after the liver function has returned to normal, while administering the molecules separately and in progressive doses. This process must be combined with close monitoring of liver function to determine the molecule responsible.
Youssef MANDOUR, Mohamed Anass FEHDI (Casablanca, Morocco), Asmae DAFIR, Badria AGGOUG, Mohamed MOUSSAOUI, Mohammed MOUHAOUI
00:00 - 00:00
#42184 - Multilobar community-acquired pneumonia revealing endocarditis.
Multilobar community-acquired pneumonia revealing endocarditis.
Introduction :
Infective endocarditis is an infectious disease characterized by a wide range of clinical presentations. The diagnostic criteria have been well established by Dukes. However, some presentations may be atypical, delaying appropriate therapeutic management.
We report the case of a patient hospitalized in our ED for community-acquired pneumonia which subsequently revealed as a septic complication of endocarditis.
We declare that the patient has given consent to have details submitted, and that we ensure anonymity.
Case presentation :
We report the case of a 59-year-old man admitted to the intensive observation unit with a five-day history of fever and productive cough and later onset of dyspnoea. The patient had no previous medical history although COVID-19 pneumonitis without sequelae.
On initial examination, the patient was polypnoeic, desaturated on room air and had bilateral focal crackles on pulmonary auscultation. He had presented with atrial fibrillation at 150 bpm with no signs of acute circulatory or cardiac failure. He was afebrile with a normal level of consciousness.
Biological results showed an inflammatory syndrome with white blood cells at around 15 mg/dl and C-reactive protein at 217 mg/dl. Blood lactate was normal, and his sofa score was 2. Chest X-ray showed multilobar parenchymal images, suggesting bilateral infectious pneumonia.
After oxygen and hydration therapy and treatment with empirical antibiotics, the atrial fibrillation persisted, and he was getting worse. He underwent trans-thoracic echocardiography, which revealed a final diagnosis of mitral valve infective endocarditis causing pulmonary septic emboli.
Conclusion
This case suggests that healthcare providers should consider the diagnosis of infective endocarditis, particularly in cases of sepsis with cardiovascular presentations.
Sarra AKKARI, Saloua HOUIMLI (la Marsa, Tunisia), Mohamed ASSADI, Nessrine YAHYAOUI, Fatma HEBAIEB
00:00 - 00:00
#41379 - Multimarkers approach in chest pain management: a focus on the promising role of sST2 and suPAR.
Multimarkers approach in chest pain management: a focus on the promising role of sST2 and suPAR.
Introduction: chest pain is a frequent cause of admission to the Emergency Department (ED). Troponin measurement (0-1h) and ECG tracing represent the gold standard for acute coronary syndrome (ACS) diagnosis that requires immediate treatment. Patients with negative ECG are managed according to clinical course and troponin. Our purpose is to compare the diagnostic accuracy of hsTnI combined with soluble suppression of tumorigenicity-2 (sST2) and soluble urokinase plasminogen activator receptor (suPAR) in ruling out ACS compared to hsTnT alone.
Material and methods: This is a single-center observational, retrospective study. Patients over 18 years have been enrolled subsequently to their access to the ED with typical chest pain. The only exclusion criteria was renal failure. A Retrospective analysis of 34 eligible patients was done who had undergone sST2 and suPAR measurements in addition to standard hsTnI dosage and ECG tracing. Their correlations with the needing of in depth diagnostic and therapeutic investigations for ACS were performed. Our combined endpoints are: the correlation of suPAR and sST2 levels with troponin and second-level test results and the evaluation of these biomarkers as primary screening tools to minimize instrumental examinations.
According to reference hsTnI, suPAR and sST2 thresholds, we identified:
Patient with hsTnI >99th centile or Δ0-1h>20%
Patients with hsTnI >2.5 to 99th centile or Δ0-1h<20% divided into:
-sST2 <24.1 ng/ml and suPAR <3.0 ng/ml with negative second level test;
-sST2 > 24.1 ng/ml and suPAR > 3.0 ng/ml with positive second level test;
Patients with hsTnI < 2.5 ng/L further divided into:
-sST2 <24.1 ng/ml and suPAR <3.0 ng/ml with negative second level test;
-sST2 > 24.1 ng/ml and suPAR > 3.0 ng/ml with positive second-level test.
Results: Of the 34 patients considered, 7 were classified in the 1st group. Of these, 5 had elevated suPAR and sST2 (71%). In the 2nd group, 4 patients out of 6 had increased biomarkers (66%) and positive second-level tests, while 2 patients with biomarkers under the thresholds presented negative second-level tests. In the 3rd group 7 out of 21 patients had elevated sST2 and suPAR and a positive second level cardiological test (33%), while 14 patients had negative biomarkers and negative second-level tests (66%).
Discussion: our preliminary data suggest that increased sST2 and suPAR correlates with ischemic cardiac findings in second-line testing. In fact,increased biomarkers identified patients with high likelihood of positive secondary tests, while sST2<24.1 ng/ml and suPAR<3.0 ng/ml indicated patients with no significant evidence on secondary testing.
Conclusions: the introduction of a multimarkers approach in patients with chest pain results in a quick discharge with a safe and rapid rule out of ACS, or a prompt admission for patients who deserve further investigation.
N/A
Andrea PICCIONI, Licia Antonella SCATÀ, Marta SCACCIA, Martina CANDELA, Alessandra BRONZINO, Marcello CANDELLI, Marcello COVINO, Antonio GASBARRINI, Francesco FRANCESCHI, Andrea PICCIONI (ROMA, Italy)
00:00 - 00:00
#42244 - Multiple acute arterial thrombosis: a case report and literature review.
Multiple acute arterial thrombosis: a case report and literature review.
Introduction: Multiple arterial thrombosis is a rare pathological entity in the intensive care setting. They represent both a diagnostic and therapeutic problem, with a very high morbidity and mortality rate. Emboligenic pathology should be sought, in particular vasculitis of large- and medium-caliber vessels. The authors report a very rare case of a patient presenting with multiple acute thrombosis.
Observation: A 54-year-old patient with no previous pathological history was admitted to the life-saving emergency room with an apyretic disturbance of consciousness.
On admission, the patient was unconscious, GCS 6/15 (E1V1M4), left hemiparesis, isocore and reactive pupils. She was hemodynamically and respiratorily stable. Blood glucose was correct and temperature 37.2°C. We noted the presence of a hemodialysis catheter in the right internal jugular vein. The patient had been dialyzed 1 week prior to admission for acute renal failure.
A conditioning procedure was carried out, including intubation and assisted ventilation, and placement of a femoral central venous catheter, nasogastric tube and bladder catheter.
Cerebral CT showed a recent right ischemic stroke. Chest slices showed incomplete thrombosis of the aortic arch and right primary carotid artery. In this setting, acute renal failure was reported.
The patient was conditioned with intubation, assisted ventilation and placement of a femoral central venous catheter, nasogastric tube and bladder catheter. Cerebral CT showed a recent right ischemic stroke. Chest slices showed incomplete thrombosis of the aortic arch and right primary carotid artery. In this context, acute renal failure was reported as bilateral renal infarction, confirmed a posteriori on Uroscanner.
A laboratory workup showed kalemia at 4.5 mmol/L, urea at 3.02 g/L and creatinine at 60 mg/L, with no other associated laboratory abnormalities. The patient was given symptomatic treatment, cautious rehydration in view of the oliguria, and curative unfractionated heparin therapy. The presence of an aortic thrombus contraindicated a second hemodialysis session. The outcome was unfavorable, with death at 2 days post-hospitalization in multivisceral failure.
Discussion: The presence of multiple arterial thrombosis is a rare clinical situation and should prompt a search for an underlying emboligenic pathology, namely vasculitis of medium- and large-caliber vessels, a blood crase disorder, or a floating thrombus of the aortic arch. An exhaustive clinical and paraclinical workup is required to identify the various sites of involvement. Treatment includes heparin therapy with unfractionated heparin, as well as etiological treatment of the underlying cause. The authors suggest periarteritis nodosa vasculitis or Takayasu's disease in this patient, but this could not be confirmed in view of the patient's early death.
Ahmed YASEEN (Lilienthal, Germany), Mohamed Anas FAHDI, Badria AGGOUG, Asmae DAFIR, Mohamed MOUSSAOUI, Mohamed MOUHAOUI
00:00 - 00:00
#41075 - MY LIFE IS RUNNING OUT.
MY LIFE IS RUNNING OUT.
An 80-year-old male, type two diabetic smoker, dyslipidemia, hypertensive, called the emergency service due to general illness and palpitations.
Advanced life support with nursing is activated from the emergency coordination center.
Upon arrival, the patient was conscious and oriented and reported feeling nauseous and vomiting and feeling generally unwell for 1 hour with profuse sweating, ta 100/50 sat o2 95% glucose 210 afebrile.
He reported a lot of discomfort in the epigastrium, an electrocardiogram was performed and a rapid regular rhythm was observed at about two hundred and eighty beats per minute. Wide QRS with image of complete block of the right bundle branch of His bundle (BCRDHH), right axis with criteria for left posterior hemiblock. of the his bundle (HBPIHH) atrioventricular dissociation is also observed (one of the Brugada criteria for the diagnosis of ventricular tachycardia).
Due to criteria of hemodynamic instability, synchronized electrical cardioversion was decided and sedation-analgesia was administered.
When synchronized electrical cardioversion is performed, the patient emerges with a regular narrow QRS rhythm with positive P wave in II, III and AVF compatible with sinus rhythm.
Elevation of the ST segment from V1 to V6 is observed, compatible with an extensive anterior infarction.
The heart attack code proposed by the advanced life support nurse is activated, with a primary care doctor since the closest thing to us is the medical helicopter and it is busy, it is transferred with a primary care doctor and an advanced life support nurse.
Upon arrival at the hospital, a hemodynamically stable patient underwent emergent catheterization and critical occlusion was observed in the anterior descending and circumflex arteries, and 3 drug-active stents were implanted
Pilar VARELA GARCIA, Miriam UZURIAGA MARTIN (Madrid, Spain), Vanesa NATALIA ISAAC, Cristina BARREIRO MARTINEZ, Blanca GUERRERO MOÑUS, Noemi SOTO TOSTADO, Marta HUEDO JIMENEZ, Maria REDONDO LOZANO
00:00 - 00:00
#41941 - Myolysis and radiculo-neuropathy secondary to butane poisoning About a case.
Myolysis and radiculo-neuropathy secondary to butane poisoning About a case.
Introduction: Myolysis is defined as a lysis of skeletal striated muscle fibers leading to a
significant release of muscle enzymes and myoglobin into the general circulation. The severity of the clinical picture is essentially linked to the risk of hyperkalemia and renal failure. The circumstances in which this syndrome occurs vary greatly. We report a case of acute myolysis with radicular damage following accidental poisoning by butane gas.
Materials and Methods: 42-year-old patient, with no notable pathological history, was found by these neighbors in a room of her apartment lying in left lateral decubitus and unconscious for more than 12 hours, with the presence of a continuous gas leak coming from a 45 kg Butane gas bottle which was in the kitchen supplying the bath heater. His companion was found deceased in the bathroom. The patient was transported to our emergency room by civil
protection.
Results: The admission examination found a patient confused and obtunded with the presence of headaches. The hemodynamic state was stable. Spontaneous diffuse myalgias and those provoked by palpation were found as well as edema and muscular tension in the left hemibody, with a complete motor deficit in the area of the sciatic nerve.Bladder catheterization brought back dark urine. The biological assessment concluded that there was severe rhabdomyolysis. The carboxyhemoglobin assay was negative. Electromyogram (EMG) showed axonal sensory-motor radiculoneuropathy of both lower limbs. The patient was put on oxygen therapy by nasal probe with rehydration with 0.9% saline and alkalinization with 1.4% bicarbonate serum. Vitamin therapy was started. The evolution was favorable both clinically and biologically.
Conclusion: The occurrence of myolysis and radiculoneuropathy during butane poisoning must be detected early and treated to avoid complications. The dosage of CPK and the practice of an EMG must be systematic in the face of any butane poisoning
Neila MAAROUFI, Houcem ZAMIT (Sousse, Tunisia), Sabra OUAZ, Moufida NAOUARI, Jihen LAKHAL
00:00 - 00:00
#40907 - National early warning score 2 vs modified rapid emergency medical score to predict short-term mortality in extremely elderly people.
National early warning score 2 vs modified rapid emergency medical score to predict short-term mortality in extremely elderly people.
Background: Global population aging, and more markedly so in Europe, is an undeniable reality. This fact has meant that emergency medical services (EMS) increasingly have to provide care for elderly people, or even extremely elderly people (over 90 years of age). In this special age group, standard physiological variables may be modified, either by aging or by the association with comorbidities and unhealthy lifestyles. Therefore, the aim of this study was to explore the prognostic performance to estimate short-term mortality (2-day) of two early warning scores commonly used in EMS, i.e., National Early Warning Score 2 (NEWS2) and Modified Rapid Emergency Medical Score (MREMS).
Methods: Prospective, multicentric, EMS-delivery, ambulance-based, pragmatic cohort study extremely elderly people (> 90 years), referred to five hospitals (Spain), between January 2019, and February 2024. Patient treated consecutively by EMS with prehospital acute disease and transferred with high priority by ambulance to the ED was included in the study. Patients under 90 years of age, and cardiac arrest were excluded. Demographic data (age and sex) and vital signs were collected during the first contact with the patient in prehospital care. Data were obtained by reviewing the patient's electronic history. The primary dependent outcome was 2-day in-hospital mortality (all-cause). The area under the curve (AUC) of the receiver operating characteristic (ROC) of the two scores were calculated, and then the Delong test was used to test the statistical significance between both.
Results: A total of 560 extremely elderly patients with acute disease were included in our study. The mean age was 92.2 years (SD: 2.3), with a range from 90 to 104 years, with 202 cases (36.1%) of females. The rate of short-term mortality was 8.7 % (49 cases). The AUROC, sensitivity and specificity of prehospital NEWS2, and MREMS were 0.841 (95%CI: 0.77-0.91), 73%, AND 80% and 0.793 (95%CI: 0.71-0.87), 87 %, 58 % (p<0.001 in all cases). There was no statistically significant difference between the two scores (p=0.151).
Conclusions: the use of early warning scores is an incipient trend in prehospital care. NEWS2 performed better, despite the fact that MREMS includes age among its weighted parameters. EMS could benefit from the use of scores, even in extremely elderly people.
This work was supported by the Institute of Health Carlos III (Spain) and co-financed by the European Union [grant numbers DTS23/00010] for FM-R.
Francisco MARTÍN-RODRÍGUEZ, Raúl LÓPEZ-IZQUIERDO, Carlos DEL POZO VEGAS (Valladolor, Spain), Juan Francisco DELGADO BENITO, Irene SÁNCHEZ SOBERON, Raúl ALONSO AVILÉS, Pedro DE SANTOS CASTRO, Ana GIL CONTRERAS, María BLANCO GONZÁLEZ, Alberto CORREAS GALÁN, Alberto GÓMEZ DE DIEGO, Leyre PINILLA ARRIBAS, Miguel POSADAS MÚÑOZ, Rubén PÉREZ GARCÍA, Elisa INGELMO ASTORGA, Inmaculada GARCÍA RUPEREZ, Berta TIJERO RODRÍGUEZ, Virginia CARBAJOSA RODRÍGUEZ, Raquel TALEGÓN MARTÍN, Irene CEBRIÁN RUÍZ, Jesús ÁLVAREZ MANZANARES, Angela AREVALO PARDAL, Laura MELERO GUIJARRO
00:00 - 00:00
#42312 - Navigating severe overdose:management challenge, combined calcium channel blocker and betablocker toxicity.
Navigating severe overdose:management challenge, combined calcium channel blocker and betablocker toxicity.
CASE
A 29-year-old female presented to our emergency department after a deliberate suicide attempt, reporting she had ingested atenolol and verapamil approximately three hours prior. Upon arrival, she was conscious and oriented. Her vital signs showed a blood pressure of 85/51 mmHg and a pulse rate of 47 beats per minute. The electrocardiogram (ECG) indicated sinus bradycardia. To manage her hypotension, isotonic crystalloid fluid therapy was initiated. Gastric lavage and activated charcoal were not administered.
Initial arterial blood gas analysis revealed a pH of 7.46, bicarbonate (HCO3) level of 20.4 mmol/L, base excess of -2.3, and lactate level of 2.72 mmol/L. Additional tests for acetaminophen and salicylate were negative, and other blood parameters were within normal limits.
Shortly after the commencement of resuscitation, the patient's consciousness became clouded, and her blood pressure dropped to 60/40 mmHg. To counteract these changes, an intravenous administration of 30 ml of 10% calcium gluconate and a 5 mg bolus of glucagon were given. However, due to a lack of improvement, a second bolus of glucagon was administered. When her vitals
failed to improve, a norepinephrine infusion at a rate of 2 mcg/minute was started. With little improvement, high-dose insulin therapy was initiated, with an initial intravenous bolus of 1 unit/kg, followed by an infusion at a rate of 1 unit/kg/hour.
Despite these interventions, the patient's vital signs showed little to no improvement, prompting consultations with the cardiovascular surgery and cardiology departments to discuss potential extracorporeal membrane oxygenation (ECMO) and cardiac pacing. The patient underwent ventricular pacing, which resulted in an increase in pulse rate to 80 beats per minute and normalization of the electrocardiogram (ECG) to a normal sinus rhythm. However, the patient remained hypotensive with a blood pressure of 80/50 mmHg.
Given these persistent hypotensive episodes, the patient was admitted to the intensive care unit for continued treatment and further evaluation, including the consideration of ECMO.
Educational and/or clinical relevance
Calcium channel blockers (CCB) and beta blockers (BB) are widely used medications with a broad range of clinical indications, including hypertension, supraventricular dysrhythmias, angina pectoris, and migraine, among others. Given the high frequency with which these medications are prescribed, they are readily accessible, leading to potential risks for accidental or intentional overdose. Overdoses can result in significant morbidity and mortality, particularly when both classes of medications are involved, making management challenging even for experienced clinicians.
Initial management for both CCB and BB overdose typically begins with supportive care, given that hypotension and bradycardia are common clinical findings. Treatments may include glucagon, calcium salts, catecholamines, phosphodiesterase inhibitors, and insulin. In severe cases, non-pharmacological interventions such as intra-aortic balloon pump, extracorporeal membrane oxygenation (ECMO), and cardiac pacing might be necessary.
In this article, we present a case involving a patient who experienced severe intoxication with both calcium channel blockers and beta blockers, illustrating the complexities involved in managing such cases.
Merve KAYABAŞ UNUTMAZ, Ibrahim DILEKCAN (Ankara, Turkey), Kadir YENAL
00:00 - 00:00
#40893 - Neurogenic Shock or Hemorrhagic Shock? Considerations in a Major Trauma Case.
Neurogenic Shock or Hemorrhagic Shock? Considerations in a Major Trauma Case.
Abstract:
This case presentation highlights the importance of differentiating between neurogenic shock and hemorrhagic shock in a major trauma scenario. We discuss the initial assessment, management, and key learning points from a case involving a 50-year-old male with a history of depression who presented after a suicide attempt by jumping from a 4-meter height. The patient exhibited signs of significant trauma, including altered consciousness, hypotension, and suspected neurogenic shock. However, prompt recognition of potential hemorrhage and the implementation of appropriate interventions, such as pelvic binders and permissive hypotension, proved critical in stabilizing the patient's condition. This case emphasizes the need for a comprehensive approach, including thorough physical examination, imaging studies, and multidisciplinary collaboration, in managing major trauma cases. Early identification of potential sources of hemorrhage and appropriate resuscitation strategies can significantly impact patient outcomes.
Introduction:
Major trauma cases present unique challenges in terms of accurate assessment and appropriate management. Distinguishing between different types of shock, such as neurogenic shock and hemorrhagic shock, is crucial for guiding effective treatment strategies. This case report highlights the importance of considering hemorrhage as a potential cause of shock, even when neurological symptoms suggest neurogenic shock.
Case Presentation:
A 50-year-old male with a history of depression presented after attempting suicide by jumping from a significant height. On arrival, the patient displayed altered consciousness, hypotension, and signs of neurogenic shock. The initial assessment included vital sign measurements, eFAST ultrasound scan, and rectal examination, which revealed decreased sphincter tone. However, due to the nature of the major trauma, a comprehensive evaluation was undertaken, including pelvic examination and spine assessment. The patient was placed in a pelvic binder, and fluid resuscitation, blood products, and dopamine were administered.
Management and Outcome:
Following initial interventions, the patient's blood pressure improved, and consciousness levels returned. Subsequent trauma CT scan revealed the presence of L3-L4 and pelvic fractures. Despite the initial stabilization, the patient experienced a decline in blood pressure and consciousness levels upon returning to the resuscitation room. Immediate measures were taken, including RBC transfusion, intubation, and consultation with a general surgeon for external packing. Additionally, radiology performed DSA to facilitate embolization. The patient was then transferred to the ICU for further management.
Discussion and Conclusion:
This case serves as a reminder that in major trauma cases, it is essential to consider both neurogenic shock and hemorrhagic shock as potential causes of hypotension. Prompt recognition of hemorrhage, early implementation of pelvic binders, and adherence to the principle of permissive hypotension are crucial for successful management. Multidisciplinary collaboration, thorough physical examination, and appropriate imaging studies are essential for accurate diagnosis and timely intervention. This case underscores the importance of a comprehensive approach to major trauma management to optimize patient outcomes.
Lam IAN-SENG (Macao, China), Leong HOI-IP
00:00 - 00:00
#42246 - Neuroleptic malignant syndrome: case report and literature reviews.
Neuroleptic malignant syndrome: case report and literature reviews.
Introduction: Neuroleptic malignant syndrome is a severe and unpredictable drug reaction characterized by four symptoms: impaired mental function, fever, muscular rigidity and autonomic nervous system instability. We report the medical observation of a neuroleptic malignant syndrome following Amisulpride.
Observation: we report the case of the patient K.O, 30 years old, treated for schizophrenia for 4 months, put on Amisulpride, Lorazepam and Anafranil, admitted to a life-threatening emergency room for a febrile disorder of consciousness. On admission, the patient was unconscious with a GCS of 11/15, presenting myoclonus with generalized muscle rigidity; he was polypnea at 30 c/min, SpO2 94% on free air and tachycardic at 120 bpm, his blood pressure 160/100 mmHg. He was afebrile at 40.2°C with a capillary blood glucose level of 0.92 g/L.
Initial conditioning consisted of 2 large-bore peripheral venous lines, oxygen therapy with a high-concentration mask and a bladder catheter. Blood cultures were taken and a meningeal dose of Ceftriaxone was administered.
Cerebral CT scan was normal and lumbar puncture ruled out neuromeningeal infection. Biologically, the patient had a hyperleukocytosis of 158,000/mm3 , hyperkalemia of 6.9 mmol/L, calcemia of 78 mg/L, urea of 1.15 g/L and creatinemia of 35 mg/L. Muscle enzyme levels were high, with CPK at 9800 IU/L and LDH at 1200 IU/L. Blood gases showed metabolic acidosis, with pH 7.24 and HCO3- 16 mmol/L.
Given the rich history, the suggestive clinical picture and the biological abnormalities, the diagnosis of neuroleptic malignant syndrome was retained.
The patient was then placed on effective rehydration, and intubation-ventilation and deep, continuous sedation were decided upon in view of the lack of neurological improvement.
Discussion: The exact cause of NMS remains unknown. Depletion and blockade of the dopaminergic system, which may lead to body temperature dysregulation, and a Parkinsonian pseudo-syndrome have been suggested. The majority of cases are caused by antipsychotic drugs, although other active ingredients may also contribute to the onset of this syndrome. Neuroleptic malignant syndrome generally develops in the first two weeks following initiation of antipsychotic treatment, or after a change in dosage. Complications include renal failure, rhabdomyolysis and DIC. Treatment remains symptomatic, after immediate discontinuation of the treatment responsible. The use of Dantrolene remains controversial. The authors stress the need to eliminate differential diagnoses, and emphasize the non-negligible morbidity and mortality associated with this syndrome.
Ahmed YASEEN (Lilienthal, Germany), Mohamed Anas FAHDI, Badria AGGOUG, Asmae DAFIR, Mohamed MOUSSAOUI, Mohamed MOUHAOUI
00:00 - 00:00
#41406 - Nitrous oxide: from recreational highs to clinical lows and its challenges in the emergency department.
Nitrous oxide: from recreational highs to clinical lows and its challenges in the emergency department.
Introduction
Nitrous oxide (N2O) is commonly used in the Emergency Department (ED) for its analgesic and sedative properties. However, the recreational use of N2O has become increasingly popular in the UK, with it being the third most popular drug in 2018, 2019 and 2020 following cannabis and cocaine.
We describe the case of a patient who presented with neurological symptoms following N2O abuse.
Case
An 18-year-old female presented to the ED with a one-week history of patchy paraesthesia affecting her arms, legs and abdomen. Her symptoms were not consistent with a specific dermatomal distribution.
Examination revealed the following: reduced light touch sensation symmetrically over L2 and L4, sparing L3 in both legs, and reduced sensation to T8 and T12.
On further questioning, the patient conceded using N2O recreationally for years, up to four times a month.
Investigations showed a B12 level of 156 ng/L (normal range 197-771 ng/L), homocysteine level 58.9 μmol/L (normal range 0-15 μmol/L) and methylmalonic acid level 6866 nmol/L (normal range 0-378 nmol/L); a picture suggestive of functional vitamin B12 deficiency.
MRI scan of the whole spine demonstrated an abnormal signal between C2-C6, with the presence of the inverted “V” sign at C2-C3 levels suggestive of subacute combined spinal degeneration.
Therapy with IM Hydroxocobalamin and Folic acid supplement was initiated, and the patient had neurology follow up arranged.
Discussion
The recreational use of N2O is on the rise for its short-lived euphoric and dissociative effects. Heavy or prolonged use of N2O inactivates B12 resulting in its deficiency, paraesthesia which can further progress into peripheral neuropathy, megaloblastic anaemia, and subacute combined degeneration of the cord.
Subacute combined spinal degeneration is characterised by the degeneration of the dorsal columns and the lateral columns of the spinal cord due to demyelination. N2O inactivates B12, inhibits methionine synthetase, disrupts methylation and DNA synthesis thus leading to the injury of the neuronal axons which manifests as sensory deficit, paraesthesia, weakness, and ataxia.
Other reported complications associated with N2O abuse include pneumomediastinum, venous thrombosis, pulmonary embolism, and even death.
Recent report from the Royal London Hospital highlighted that N2O induced subacute combined spinal degeneration is almost diagnosed on a weekly basis.
Current management guidelines recommend the immediate cessation of N2O use and the initiation of B12 injections therapy that leads in majority of cases to a gradual recovery.
Conclusion
N2O induced subacute combined spinal degeneration can present to the ED with unusual neurological symptoms. Hence, detailed history is essential in such patients to establish the diagnosis.
Charlotte GRAHAM, Abdo SATTOUT (Liverpool, )
00:00 - 00:00
#40914 - Non-consensus transient ischemic attack : innocent or guilty? Major investigational findings and risk factors for acute stroke in classic and non-consensus transient ischemic attack patients: a comparative study.
Non-consensus transient ischemic attack : innocent or guilty? Major investigational findings and risk factors for acute stroke in classic and non-consensus transient ischemic attack patients: a comparative study.
Background and objective – Atypical transient ischemic attack (TIA) symptoms are frequently not
investigated nor treated as TIA at the emergency department (ED) and their clinical relevance is
often denied. In order to illustrate the clinical significance of non-consensus TIAs, risk factors for
acute stroke and major investigational findings were compared between classic and non-consensus
TIA patients.
Methods – Consecutive patients diagnosed with TIA in an ED TIA clinic underwent systematic
brain, arterial and cardiac investigations; stroke risk factors were ascertained as well. Stroke risk
factors and major investigational findings (source of cardiac embolism, ischemic brain lesions on
diffusion-weighted magnetic resonance imaging (DW-MRI), symptomatic intra- or extracranial
arterial stenosis ≥50% or arterial dissection on computed tomography (CT) angiography of head
and neck vessels) were compared between classic and non-consensus TIA patients.
Results – Among 162 TIA patients, 120 had classic TIA and 42 non-consensus TIA. Non-consensus
TIA patients did not have less cardiovascular risk factors than classic TIA patients. Prevalence of
atrial fibrillation or flutter, patent foramen ovale and atrial septal aneurysm were similar for non-consensus
and classic TIA. The frequency of ischemic lesions on DW-MRI was also similar for non-consensus
and classic TIA (13/42 [31%] versus 22/120 [18.3%]; p=0.087). No arterial dissection or
symptomatic intra- or extracranial arterial stenosis ≥50% on CT angiography was found.
Conclusion – Non-consensus and classic TIA patients have similar major investigational findings
and risk factors for acute stroke. Non-consensus TIAs may therefore not be as harmless as
previously considered. Both, non-consensus and classic TIA may herald impending stroke.
Sofie MOORTHAMERS (Brussels, Belgium), Olga REVIN, Hélène Tatiana BESSE-HAMMER, Marie-Dominique GAZAGNES, Olivier VERMYLEN
00:00 - 00:00
#41877 - Non-Emergency Department (ED) Interventions to Reduce ED Utilization: a Scoping Review.
Non-Emergency Department (ED) Interventions to Reduce ED Utilization: a Scoping Review.
Background
Emergency department (ED) crowding is a global burden. Interventions to reduce ED utilization have been widely discussed in the literature, but previous reviews have mainly focused on specific interventions or patient groups within the EDs. The purpose of this scoping review was to identify, summarize, and categorize the various types of non-ED-based interventions designed to reduce unnecessary visits to EDs.
Methods
This scoping review followed the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive structured literature search was performed in the databases MEDLINE and Embase from 2008 to January 2023. The inclusion criteria covered studies reporting on interventions outside the ED aimed at reducing ED visits. Two reviewers independently screened the records and categorized the included articles by intervention type, location, and targeted population.
Results
Among the 9,799 screened records, we included 139 studies, comprising 114 intervention studies and 25 systematic reviews. In the primary studies, care coordination/case management or other care programs were most commonly examined across 13 categories of interventions. The majority of interventions took place in clinics or medical centers, in patients’ homes, or in primary care settings - and targeted patients with a specific medical conditions.
Conclusion
A large number of studies have been published investigating interventions to mitigate the influx of patients to the EDs. Many of these targeted patients with specific medical conditions, frequent users and high-risk patients. Further research is also needed to address other high prevalent groups in the ED - including older adults and mental health patients (who are ill but may not need the ED). There is also room for further research on new interventions to reduce ED utilization in low-acuity patients and in the general patient population.
The authors received no external funding.
Målfrid NUMMEDAL (Trondheim, Norway), Sarah KING, Oddvar ULEBERG, Sindre PEDERSEN, Lars Petter BJØRNSEN
00:00 - 00:00
#42269 - Non-ST-segment elevation coronary syndrome (NSTEMI): evaluation of the ACTION ICU score.
Non-ST-segment elevation coronary syndrome (NSTEMI): evaluation of the ACTION ICU score.
Introduction :
NSTEMI is a form of myocardial infarction at risk of serious complications and mortality. The ICU action score developed in 2018, based on easily accessible clinical to identify high-risk patients with NSTEMI and guide the need for ICU hospitalization.
AIM :
The aim of this study was to evaluate the performance of the ACTION ICU score in predicting the risk of complications and mortality in patients with NSTEMI.
Methods :
This was a retrospective, descriptive and analytical study carried out in an emergency department, over a 20-month period, starting in January 2022,having included patients admitted to our department for NSTEMI. The ACTION ICU score was calculated for all patients.
The main outcome was the occurrence of major cardiovascular and cerebral events in the emergency department and during hospitalization in the cardiology cardiology department.
Results :
A total of 147 patients were included in this study, with a mean age of 64±11 years and a sex ratio of 2.41. The in-hospital mortality rate was 6.8%. The occurrence of major acute cardiac events was noted in 32.7% of patients. ACTION ICU score was significantly associated with in-hospital mortality in multivariate study:( P <0.01; (adjusted OR) = 0.69; IC [0.6-0.78]), as well as in ROC curve analysis, with an AUC of 0.83 with a confidence interval ranging from 0.76 to 0.89 and a p-value < 0.001. The cut-off value was 4.5, and sensitivity and specificity were 89.6% and 66.7%, respectively.
Conclusion
The ACTION ICU score could be an effective tool for identifying patients with NSTEMI at risk of complication. However, it needs to be tested on a larger sample.
Khaireddine JEMAI (Tunis, Tunisia), Yessmine WALHA, Wided BAHRIA, Intissar BOUSSAID, Wiem DEMNI, Nour Elhouda NOUIRA
00:00 - 00:00
#41620 - Nonapparent Occlusion Myocardial Infarction (OMI) in a bradycardic patient.
Nonapparent Occlusion Myocardial Infarction (OMI) in a bradycardic patient.
Brief clinical details: A 69-year-old man presented at the emergency department with changes in mental alertness and difficulty breathing persisting for 2 days. He had been coughing for one week before his arrival. He denied experiencing chest pain, and any other additional symptoms. His medical background revealed widespread peripheral arterial disease resulting in amputation of both legs, as well as a history of overcoming an ischemic stroke.
Description of the relevant abnormalities: The physical examination exhibited symptoms indicative of shock, such as hypotension and cool extremities. The electrocardiogram revealed significant bradycardia due to a complete atrioventricular (AV) block, and minimal ST segment elevation in inferoposterior leads (<1mm). Although the cath lab initially recommended stabilizing the patient and waiting for further results, we pushed for immediate action suspecting an OMI. The patient was finally diagnosed with cardiogenic shock due to a heart attack complicated by complete AV block and adequately treated.
Why this image is clinically or educationally relevant: This clinical image highlights that although this electrocardiogram does not meet the criteria for ST Elevation Myocardial Infarction (STEMI), any level of elevation in two adjacent inferior leads coupled with any ST depression in the aVL lead raises significant suspicion for inferior Occlusion Myocardial Infarction (OMI) and promptly treated.
Maja ALABER, Bruna BUŠIĆ, Maša SORIĆ (Zagreb, Croatia)
00:00 - 00:00
#42243 - Noninvasive management of fluid therapy in patients with sepsis/septic shock.
Noninvasive management of fluid therapy in patients with sepsis/septic shock.
Introduction:
After the administration of the first fluid bolus, as prescribed by the current guidelines, fluid
management in septic patients remains a topic of debate. A fluid overload is associated with increased in-
hospital mortality, but an inadequate fluid resuscitation can have severe consequences. Aim of the present
study was to evaluate the effectiveness of a protocol for the management of fluid therapy in septic patients
in the Emergency Department.
Methods:
Prospective study (March 2022 - July 2023). We enrolled patients admitted to the ED high-
Dependency Unit for sepsis. The first assessment was carried out within 12 hours of diagnosis (T0) and was
repeated at 12 (T12) and 24 hours (T24). Fluid-responsiveness (FR) was assessed by monitoring the
variation in cardiac output during provocative testing (Passive Leg Raising, PLR, or Fluid-challenge) using
bioreactance (Monitor Starling, Baxter). Fluid tolerance (FT) was assessed by chest ultrasound and
calculation of the Lung Ultrasound Score (LUS). Patients were considered FR+ in the presence of a change in
cardiac output during provocative testing >10%, while they were considered FT+ in the absence of
interstitial lung syndrome in at least 10/12 segments. Based on the result of these evaluations, the patient
was assigned to one of the following 4 subgroups: 1) FR+/FT+, with indication to continue volume
replacement with possible boluses or infusion at 1.5 ml/kg/hour, could be considered vasopressors, no
diuretics ; 2) FR+/FT-, with indication to continue fluid infusion at 1 ml/kg/hour and avoid diuretics; 3) FR-
/FT+, with indication to continue fluids infusion at1 ml/kg/hour and use diuretics as needed; 4) FR-/FT-,
with indication to continue infusion at 0.5 ml/kg/hour and maintain diuresis at at least 2 ml/kg/hour.
Laboratory parameters were collected at T0 and after 24 hours (T24).
Results: 52 patients were enrolled, age 74±13 years, 60% male. The source of sepsis was pulmonary in 40%
of patients, urinary in 30%, and abdominal in 10%. At T0, 13 patients were FR+/FT+, 17 FR+/FT-, 5 FR- FR+
and 17 FR-/FT-; all patients were re-evaluated at 12 hours, 32 at 24 hours. In following evaluations and in
different subgroups, the following percentage of patients became no longer fluid tolerant: FR+/FT+ group, 9
patients (38%); FR+/FT- subgroup 9 patients (50%), 1 (20%) from the FR-/FT+ subgroup. Conversely, from
the FR-/FT- subgroup, 12 patients became FR+ and 2 of them also became FT+. The LUS score (FR+/FT+
group: T0 0.25 [0.03-0.33], T24: 0.5 [0.12-1.0]; FR+/FT- group: T0 0.94 [0.54-1.69], T24 0.53 [1.06-1.72];
FR+/FT- group T0 0.13 [0.0-0.13], T24 0 [0-0.75]; FR-/FT- group T0 1 [0.94-1.63], T24 1.13 [0.63-1.38] all
p=NS in paired data comparisons) did not change significantly in the different subgroups between the first
and last evaluation.
Conclusions:
Non-invasive monitoring of FR and FT seems able to prevent fluid overload in approximately
one third of fluid-tolerant septic patients, while it was more effective in improving fluid tolerance in those
initially non-tolerant.
Roberta DI TEODORO (Firenze, Italy), Veronica VIGNA, Gianpiero ZACCARIA, Martino AIELLO, Martina DE MARCO, Ginevra FABIANI, Niccolò BEMBI, Chiara CHIZZOLINI, Andrea BAGLIONI, Valerio MAZZILLI, Francesca INNOCENTI
00:00 - 00:00
#41911 - Not a simple case of pneumonia.
Not a simple case of pneumonia.
A 54-year-old woman was admitted to the Emergency Department because of fever and dyspnea.
The patient was from China, and she lived in Spain for 8 years ago. She didn’t have toxic habits and had no diseases. In the last year, she had noticed asthenia and lost of weight, but she didn´t asked her doctor about this.
She had been in her usual state of health until 1 week before, when she noted progressive dyspnea, cough with purulent sputum, chills, and fever (with a temperature of 38.5°C), as well as 3 days-diarrhea that resolved spontaneously.
On examination, the patient appeared ill; she was tachypneic at 32 breaths per minute; blood pressure was 92/74 mm Hg, pulse 102 beats per minute and oxygen saturation 91%. Difuse crackles were present in both lungs.
Artery blood gasometry showed pH 7.45, pO2 45mm Hg, pCO2 24 mm Hg, and lactic acid 1.4 Mmol/l. First laboratory data showed 10800 x 1000/l leukocytes (83% neutrophils, 11% lymphocites), LDH 567 U/l, and C-reactive protein 5.34 mg/dl.
Chest radiography revealed bilateral interstitial infiltrate.
Nucleic acid testing of a nasopharyngeal swab was negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and for influenza virus, and treatment with Ceftriaxone and Levofloxacin was initiated.
Since the patient presented with severe bilateral pneumonia, urgent HIV serology was requested in the Emergency Department and was positive.
With the suspicion of Pneumocystis jirovecii pneumonia, trimethoprim sulfamethoxazole iv and corticosteroids were added to the treatment and the patient was admitted to the hospital.
During her hospital stay, HIV infection was confirmed, with a viral load of 2 million copies/ml and an initial CD4 cell count of 12 cells/ml.
Pnemocystis infection was confirmed by positive determination of betha D-glucan in blood and bronchoalveolar lavage, as well as positive staining in bronchoalveolar lavage for Pneumocystis. The patient completed treatment with trimethoprim/sulfamethoxazole and antiretroviral therapy was initiated before she was discharged.
Pneumocystis jirovecii is a common airway colonizing fungus that proliferates in case of immunosuppression, causing alveolar epithelial damage. Pneumocystis pneumonia is one of the most common opportunistic infections in persons with HIV infection, especially in those with CD4 count < 200 cells/ml. Patients with P. jirovecii pneumonia typically present with cough, dyspnea, fever, and hypoxemia. Chest radiography usually shows diffuse bilateral alveolointerstitial infiltrates. Although there is no specific analytical alteration, LDH is frequently elevated in patients with AIDS and Pneumocystis infection. The detection of (1,3)-betha-D-glucan in blood and bronchoalveolar lavage has a sensitivity of 90%, so that, although its specificity is low, infection by P. jirovecii is unlikely if betha-glucan is not detected in blood. Diagnosis is based on the detection of cystic or trophic forms in respiratory secretions (usually bronchoalveolar lavage) by staining, immunofluorescence or polymerase chain reaction (PCR). The treatment of choice is trimethoprim/sulfamethoxazole, and treatment with corticosteroids should be associated in case of severe pneumonia. In patients with AIDS, antiretroviral treatment should also be initiated within 2 weeks after starting treatment against Pneumocystis, and the need for secondary prophylaxis should be considered.
María CUADRADO FERNÁNDEZ, Ana Belen CARLAVILLA MARTÍNEZ, Isabel FERNÁNDEZ MARÍN, Luis PEREZ ORDOÑO, Luz Tamara VÁZQUEZ RODRIGUEZ, Lain IBAÑEZ SANZ, Juan VILA SANTOS, Ana MORLA SANCHEZ, María CUADRADO FERNÁNDEZ (Madrid, Spain)
00:00 - 00:00
#41971 - Not all chest pain is coronary disease.
Not all chest pain is coronary disease.
Brief clinical details (80 words):
An 98-year-old man with a medical history of pulmonary emphysema and chronic renal failure who suffers bruising to his head and chest after a fall. He was evaluated by a Traumatology who, after ruling out fractures, is discharged with analgesics. Back 48 hours later with chest pain and short of breath, He was evaluated by a doctor for suspected coronary disease. However, in the absence of alterations in the EKG and the blood tests, persistence of pain, admission to the geriatrics Ward.
Description of the relevant abnormalities (80 words):
When the patient was re-admitted, crackles were noted on palpation in the neck and jaw. The chest X-ray showed images suggestive of emphysema in the neck. That was the key to the case to suspect a Boerhaave syndrome. Finally due to the poor evolution of the patient and the suspected diagnosis the doctor requested a CT scan of the chest and neck where they found upper esophageal rupture.
Why this image is clinically or educationally relevant? (50 words)
I think that it is not a common image to see in a chest X-ray but that after clinical questioning it is the key to suspecting an esophageal rupture and thus gaining time for a potentially lethal pathology.
Where patients’ images are submitted please confirm you have adequate permission to use them. (Compulsory question, no submission without an answer)
Martínez Rivas JUAN JOSÉ (Granollers, Spain)
00:00 - 00:00
#41523 - Not as good as it looks – a case of poisoning from ingestion of Alocasia plant stem.
Not as good as it looks – a case of poisoning from ingestion of Alocasia plant stem.
Alocasia species, more commonly known as the Elephant Ear plant, are common ornamental house plants. While beautiful to look at, they cause toxic symptoms when ingested. A 48 year old Japanese lady presented for concerns of acute poisoning from the ingestion of an Elephant Ear plant.
Sashimi platters are often adorned with various edible garnishes for aesthetic and culinary appeal. While dining at a local Japanese restaurant, she had consumed the included raw vegetable, which she thought resembled a "lotus yam" (Hasuimo ハス芋) commonly found in such dishes. She immediately felt a spicy burning sensation in their mouth and tongue, together with throat pain, retrosternal chest pain and epigastric pain.
In the Emergency Department, she had no signs of upper airway compromise clinically. There were also no physical findings to suggest an allergic reaction. The Otolaryngologist reviewed her for assessment of airway involvement, and there was no airway edema on nasoendoscopy. Blood tests and X-Rays returned normal. A toxicology review identified possible Alocasia or Diffenbachia species consumption, resulting in toxicity from calcium oxalate crystals which cause irritation to the aerodisgestive tract. She was managed supportively with resolved symptoms by 24h of hospitalisation and was discharged well. The restaurant was notified immediately and subsequent reporting to the Singapore Food Agency allowed for prevention of other cases from occurring.
Images of the plant, courtesy of the restaurant, and the unconsumed piece of the plant stem were sent to a local phytologist who identified the plant as Alocasia macrorrhizos.
There are few reports of toxicity related to Alocasia macrorrhizos. More commonly kept as house plants, some species are consumed by tropical Asian communities. The stems and corm are commonly prepared in stir fried dishes of Southeast Asian communities, but is inedible when raw due to the calcium oxalate compounds. These insoluble needle-like crystals in the raw plant cause irritative local symptoms such as oral numbness, tongue pain and abdominal pain. In one report, a handful of patients developed angioedema requiring treatment. Nonetheless, systemic toxicity is uncommon due to the poor bioavailability of the insoluble calcium oxalate crystal, although a large consumption may result in high levels of oxalic acid, hypocalcemia and renal and hepatic toxicity. There have been accidental ingestions due to their similar appearance to the Colocasia stem (known as Hasuimo ハス芋 in Japan). An article and warning was published in a Japanese newspaper due to reported cases of similar poisoning.
Globalisation has expanded culinary culture such that foreign foods have become part of Singapore’s foodscape. This phenomenon is not uncommon in other parts of the world. In non-native countries, the Alocasia plant may be mistaken for its more edible Giant Taro relative. ED physicians should also be aware of the classical symptoms of mucosal irritation that can present with accidental ingestion. Appropriate identification and liaison can then be held with the local food authority to prevent further cases of poisoning.
(Consent from patient has been obtained for this publication)
Jocelyn TING (Singapore, Singapore), Yin Wen LAI, Daniel QUEK, Yanyi WENG, Dong Haur PHUA
00:00 - 00:00
#41302 - Nursing experience of palliative care for a patient with end-stage liver cirrhosis in the emergency department.
Nursing experience of palliative care for a patient with end-stage liver cirrhosis in the emergency department.
This article explores the emergency nursing experience of providing comfort care to a patient with end-stage liver cirrhosis and severe ascites who visited the emergency department. The author collected data through interviews, observations, physical assessments, and medical record reviews, conducting a comprehensive nursing assessment from physiological, psychological, social, and spiritual aspects. The main health problems identified for the patient were ineffective breathing pattern, pain, and death anxiety. The patient, aware of their end-stage liver cirrhosis, had visited the emergency department multiple times for symptom management in the short term but lacked information on palliative care and Advance Care Planning (ACP). This motivated the author to base care on comfort nursing during the care period, using aromatherapy and massage heat packs to alleviate the patient's pain. Breathing relaxation techniques were taught, and trigeminal nerve stimulation was used to relieve the patient's breathing difficulties, aiming to improve the quality of emergency care. Family meetings were arranged, and empathy was utilized to cultivate a good nurse-patient relationship, guiding the patient and their family to express their inner feelings and providing ACP options for the patient to choose in advance, respecting the patient's choices for future treatment. Cross-team collaboration enabled the patient and their family to navigate the four themes of life: gratitude, love, farewell, and apology. It is hoped that through this case nursing experience, emergency nurses' assessment of end-stage patients will be enhanced, their participation in ACP training courses will be increased, and the interdisciplinary care model will be adopted to refer to palliative care teams from various departments, providing clinical emergency nurses with references for caring for end-stage patients in emergency department settings.
Hsin-Jui LI (New Taipei City, Taiwan)
00:00 - 00:00
#41993 - Nutritional and functional intervention in frail patients.
Nutritional and functional intervention in frail patients.
Introduction: frailty is a clinical syndrome related to aging, characterized by a decrease in the functioning of multiple physiological systems. It can be considered a state prior to disability and contributes to negative health consequences, such as cognitive impairment, depression, difficulty carrying out daily activities, lower quality of life, falls, hospitalization, etc. With the aging of the world population, the management of frailty is presented as an important challenge for public health.
Objective: the objective of the study was to evaluate a nutritional and functional intervention in frail patients living in the community and evaluate their evolution over a period of 6 months.
Methodology: this study is a prospective mixed intervention that compares the results of a randomized clinical trial with two interventions in the daily life of the elderly, differentiating three groups: control group (no action is introduced), nutrition case group (introduced nutritional supplementation in their diet for six months) and sport group cases (individualized multicomponent physical activity is introduced for six months.) The variables used were: sociodemographic, anthropometric, visits to the emergency room and primary care, blood samples (triglycerides and glucose) and completion of a comprehensive geriatric assessment and the use of various scales (MNA, Tinetti, Conut, Yesavage).
Results: the average age of our sample was 80 years (SD: 4.892). Of the total sample, 54.5% were women compared to 45.5% men. There is a decrease between visits to Primary Care for the sample at the beginning versus the end of the study (p-value=0.009 mean: 3.33), while no differences were found in the number of times they went to the Emergency Room (p-value >0.200 mean: 0.65). The analytical values for HDL cholesterol and LDL cholesterol went from figures at the beginning of 57.84 (SD 16.8) and 122.16 (SD 19.5), respectively, to 53 (SD 18.3) and 114.89 (SD 26). ,3).
Conclusions: After exercise and nutritional supplementation interventions, values that show fragility, such as LDL cholesterol, decrease by up to 6%.
Ethical approval and informed consent: committee approval date July 22, 2020 (Hospital Universitari de la Ribera, Alzira – Valencia – Spain)
Luís GARCÍA-FERNÁNDEZ, Francisco José TARAZONA-SANTABALBINA, Immaculada TORMOS-MIÑANA (VALENCIA, Spain), María Ángeles RODRÍGUEZ-HERRERA, Pedro GARCÍA-BERMEJO, Rocio BODI-MARÍN
00:00 - 00:00
#42285 - Occupational Exposures Reported to the U.S. Poison Centers.
Occupational Exposures Reported to the U.S. Poison Centers.
Background: The National Poison Data System (NPDS) is a robust surveillance system containing approximately 2.2 million deidentified poison exposures reported to the Poison Centers (PCs) nationwide each year. Occupational exposures to a variety of substances can potentially cause a variety of acute health effects that cause individuals to seek treatment in the emergency department. Current trends in work-related acute poisonings have not been characterized using the poison center data. The present study sought to evaluate the recent trends in occupational exposures reported to the United States (U.S.) PCs.
Methods: The NPDS was queried for all closed, human cases of occupational exposures from January 1, 2020 through December 31st, 2023, using America’s Poison Centers generic code identifiers. We identified and descriptively assessed the relevant demographic and clinical characteristics. Routes of exposure and medical outcomes were particularly highlighted. Reports from acute care hospitals and hospital based EDs (ACHs) were evaluated as a subset. Trends in exposure frequencies and rates (per 100,000 human exposures) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2020) were reported with the corresponding 95% confidence intervals (95% CI).
Results: During the study period, there were 119,712 occupational exposures reported to the PCs. The frequency of exposures increased by approximately 29% (95% CI: 25.5%, 34.7%; p<0.001), and the rate of exposures significantly increased by 31% (95% CI: 24.3%, 37.5%; p<0.001). Of the total occupational exposure calls, the proportion of calls from ACHs was approximately 32%, with this proportion increasing from 31% to 33% through the study period. Multiple substance exposures accounted for 7.4% of the overall calls and 9% of calls from ACHs. Approximately 1% of the patients reporting occupational exposures were admitted to the critical care unit (CCU), with 53% of patients being released after evaluation and treatment. While 45% cases were enroute to the hospital when the PC was notified, 42% were managed onsite. Cases were predominantly male (61.8%), with the most common age group being 20-29 years (30.6%) followed by 30 - 39 years (22.2%). Serious effects (major outcomes and death) and moderate effects were seen in 0.9% and 13.4% cases, respectively. Inhalation was the most common route of exposure (39.7%). While bleach and carbon monoxide were the most commonly reported substances in exposures, in a large proportion of cases, it was not possible to specify the exact substance causing the effect. Irrigation and washing were the most frequent therapies reported. Dermal and ocular irritation were the most frequently reported clinical effects.
Conclusion: Occupational exposures reported to the poison centers during the study period increased significantly despite improvements in workplace safety and processes over the last decades. While it is difficult to outline reasons that may contribute to these exposures, this study illustrates that PCs can collect key data and provide real-time insights to potentially mitigate future exposures. Further, U.S. PCs can manage specific types of exposure cases without referral to the hospital, preventing unnecessary healthcare utilization.
N/A
Saumitra REGE, Rita FARAH, Scott SCHMALZRIED, Conner MCDONALD (Charlottesville, USA), Christopher HOLSTEGE
00:00 - 00:00
#42190 - Older patients with frequent visits to the Emergency Department at Landspítali - A retrospective observational cohort.
Older patients with frequent visits to the Emergency Department at Landspítali - A retrospective observational cohort.
Background: Although older visitors to emergency departments (EDs) often have multiple health problems that require specific resources and services, research describing the needs of frequent older visitors is lacking. The aim was to describe the older frequent visitors at the ED at Landspitali National University Hospital (LNUHI), their care and services.
Method: A retrospective descriptive cohort of 67 years and older with 10 or more visits per year during 2017-2021 using data from electronic medical records analysed descriptively and with chi-square test for differences.
Results: Out of 14.820 older patients with 77.804 visits, 92 (0,6%) patients met the inclusion criteria in 1549 (2,0%) visits. Men had 859 visits (55.5%) and most, 29.3%, were 75-79 years, 78% had 10-15 visits per year, but the most frequent had 71. The most common underlying diseases were cardiovascular (73.9%). The most common cause of visit was shortness of breath or dyspnoea (16%) and 71,5% visits were in ESI category 3. Most had 4-6 underlying chronic diseases (48.9%). Vital signs were measured in 75.9%. The age group 67-79 had higher NEWS than 80-99 but the older age group came more often with an ambulance (p<0,001). A geriatric emergency nurse consulted 62.2% with resulting enhanced community services for 38,3%.
Conclusion: Elderly people with frequent visits to LNUHI´s emergency department are a small group that could benefit from multiprofessional services. Further research is needed to better understand the needs of this group and their health challenges to improve the care provided in emergency departments.
No trial registration
Governmental funding
Björk Anne Peiser ÍVARSDÓTTIR, Guðlaug EIRÍKSDÓTTIR, Hafnhildur KJARTANSDÓTTIR (Reykjavík, Iceland), Þórdís Katrín ÞORSTEINSDÓTTIR, Ingibjörg SIGURÞÓRSDÓTTIR, Sigrún Sunna SKÚLADÓTTIR
00:00 - 00:00
#42322 - OLEANDER POISONING: REPORT OF THREE CASES.
OLEANDER POISONING: REPORT OF THREE CASES.
Introduction: The oleander or Nerium oleander (Defla) is a shrub widespread in Mediterranean regions. Although rare, oleander poisoning is a serious intoxication that can be life-threatening.
The symptoms of oleander poisoning are similar to those of digitalis poisoning due to the presence of cardenolide heterosides, particularly oleandrin, in all parts of the plant.
Case reports : We report here the observations of three patients, aged 27, 30 and 32 years, with no previous pathological history who consulted the emergency department following accidental ingestion of oleander leaves. The consultation time was 24 hours and the quantity ingested could only be specified for one patient: 3 leaves. In all three patients, the symptoms were primarily digestive, with nausea and vomiting. General signs such as dizziness and asthenia were also reported by all three patients, and precordialgia in one patient.
Their respective haemodynamic and respiratory states were stable and none of the patients had neurological signs. ECG tracings showed moderate sinus bradycardia in all three patients, with heart rates ranging from 45 to 50 bpm. The patients were initially referred to the CAMU, then kept for monitoring in the emergency department. Treatment was essentially symptomatic: monitoring, fluid and electrolyte intake and cardiac surveillance. The outcome was favourable for all three patients, two of whom were discharged after the bradycardia disappeared and one of whom was kept in the emergency department for 24 hours.
Conclusion: Oleander poisoning remains a rare but potentially fatal intoxication due to its toxicology, which is similar to that of digitalis. The symptoms of oleander poisoning are similar to those caused by digoxin. Treatment is essentially symptomatic; specific treatment with anti-digoxin antibodies may be proposed but is not available in Tunisia.
Mona TITEY (tunis, Tunisia), Saloua HOUIMLI
00:00 - 00:00
#41054 - Omega-3 fatty acids as potential predictors of sudden cardiac death and cardiovascular mortality: A systematic review and meta-analysis.
Omega-3 fatty acids as potential predictors of sudden cardiac death and cardiovascular mortality: A systematic review and meta-analysis.
Background: Sudden cardiac death (SCD) poses significant burden on the modern-day public health system; however, the underlying pathophysiology or a targeted prevention method remain nonexistent. We conducted a systemic review and meta-analysis to identify a blood nutritional biomarker that can predict and screen population groups at high risk for adverse cardiovascular events or SCD.
Methods: Based on previous literature research, we studied the association between omega-3 fatty acids (n-3 FA; eicosapentaenoic acid [EPA], docosapentaenoic acid [DPA], and docosahexaenoic acid [DHA]) and SCD and/or CVD mortality individually and in combination. We evaluated and selected 10 prospective cohort studies of 1,789 related publications. A multivariate adjusted hazard ratio (HR) with 95% confidence interval (CI) was calculated and sub-analyzed to obtain a general trend of reduced risk of SCD in a high n-3 FA intake group from the general population.
Results: We found an inverse association between circulating n-3 FA levels and SCD. The summary HR of SCD and CVD mortality for high versus low circulating n-3 FA levels (EPA+DHA+DPA) in serum plasma phospholipid was 0.55 (95% CI: 0.37-0.82) and that of EPA+DHA in RBC was 0.67 (95% CI: 0.45-0.99). Based on the sub-analysis, the HR of EPA (%) was 0.79 (95% CI: 0.60-0.82) and that of DHA (%) was 0.72 (95% CI: 0.60-0.87).
Conclusion: Our results demonstrate the cardioprotective effect of high EPA and DHA levels in blood. These results support maintaining above-average EPA+DHA levels as primary and secondary prevention methods for adverse cardiac events. Further supplementary research may allow clinicians and physicians to use blood n-3 FA levels to predict and screen high-risk individuals for potential SCD and devise prevention methods.
Eujene JUNG (352, Republic of Korea)
00:00 - 00:00
#41784 - ON THE ROAD TO HEPATITIS C ELIMINATION, THE NEED FOR SCREENING BEYOND RISK FACTORS.
ON THE ROAD TO HEPATITIS C ELIMINATION, THE NEED FOR SCREENING BEYOND RISK FACTORS.
Background and Aims:
The Hepatitis C screening guideline published by the Spanish Ministry of Health recommends hepatitis C screening only in people with exposures or risk situations for Hepatitis C Virus (HCV) infection. However, we know that many of the people who were infected years ago do not meet the screening criteria, so following these guidelines recommendations, many patients with HCV infection would remain undiagnosed.
We aimed to identify the prevalence of exposures and risk situations for HCV infection in patients diagnosed with active HCV infection, during the implementation of Hepatitis C screening in the Emergency Department (ED) in our hospital.
Methods
We established opportunistic screening for HCV infection in our ED since August 2021. With the "one-step strategy”, HCV antibodies were detected in adults (between 18 and 69 years old) who needed blood-work for any reason, and then viral RNA was quantified in positive anti-HCV patients. Patients with active infection were referred to the hepatology specialist for linkage to care and treatment prescription, recording any previous history of exposures or situations of risk of HCV infection. Likewise, in patients in whom we were unable to link with health care, we have recorded these antecedents after searching their medical records.
Results
A total of 20,394 patients were screened, diagnosing 75 active HCV infections(1.63% seroprevalence, 0.37% active infection). 83% of viremic patients have been linked to care. We have identified exposures or risk situations in 50% of the medical records of viremic patients. Injection or inhaled drug use (43%), being an immigrant (8%), a history of incarceration (7%), and HIV/HBV co-infection (6%) were the main ones. 77% of patients with active HCV infection had prior visits at the ED, and 91% had prior visits at primary care.
Conclusions
Half of the patients diagnosed with active HCV infection in our ED do not report exposures or risk situations for HCV infection, so following the recommendations of the current screening guideline they would never have been diagnosed. Therefore, a detection of HCV beyond the criteria set out in the screening guideline should be reconsidered for the elimination of Hepatitis C.
Gilead Sciences’ FOCUS Program funding supports screening & linkage to a first appointment after diagnosis regardless of how organizations handle subsequent patient care and treatment
Anny CAMELO CASTILLO (Almería, Spain), Antonio DUARTE CARAZO, Teresa JORDÁN, Manuel RODRÍGUEZ MARESCA, Teresa CABEZAS FERNANDEZ, Alba CARRODEGUAS, José Luis GONZALEZ, Jose VEGA SAENZ, Marta CASADO MARTIN
00:00 - 00:00
#41641 - One case of acute arsenic poisoning cured.
One case of acute arsenic poisoning cured.
Female patient, 48 years old. On July 5, 2022, the patient was admitted to our hospital for taking 8.3g of "realgar powder" by mistake, with left upper abdominal pain and palpitations for 3 hours. Physical examination: T 36.5 ℃, P 72 times/min, R22 times/min, BP116/66mmHg, SPO2 98%, normal mental state, no yellow staining on skin and sclera, and no abnormalities in heart, lung, and abdominal examination. Rinse the stomach with 3000ml of clean water, and the resulting product will turn yellow and turbid before turning clear. After gastric lavage, administer 250mg IV of sodium dimercaptosulfonate. Blood tests, urine routine, liver and kidney function, myocardial enzymes, coagulation, etc. are all normal. Urine volume 200ml, brownish red in color. Admitted to hospital 13 hours after taking realgar powder. Administer 250mg IV of sodium dimercaptosulfonate for 6h; Reduced glutathione 180mg IV drip, qd, and treatment to protect gastric mucosa, myocardium, liver and kidney function. On July 7, 2022, blood, urine routine, myocardial injury markers, and liver and kidney function were all normal during the follow-up examination. The blood arsenic level is 16ug/L (reference value<600), and the urine arsenic level is 1350ug/L (reference value ≤ 32). The patient's palpitations have improved compared to before, but they still have dizziness, discomfort in the throat, slightly lighter urine color, and stable vital signs. Adjust 250mg IV of sodium dimercaptosulfonate for 8h, and add blood perfusion therapy. On July 8, 2022, adjust the detoxification drug "sodium dimercaptopropane sulfonate" 250mg IV, q12h. Recheck blood arsenic at 5ug/L and urine arsenic at 108ug/L. On July 11, 2022, adjust the detoxification drug "sodium dimercaptopropane sulfonate" 250mg IV, qd, and discontinue blood purification treatment. Blood purification will last for 5 days from July 7, 2022 to July 11, 2022. On July 16, 2022, recheck the blood arsenic concentration at 3ug/L and the urine arsenic concentration at 32ug/L; On July 18, 2022, recheck the blood arsenic concentration at 2ug/L and urine arsenic at 11ug/L. The patient has no symptoms such as abdominal pain or palpitations, and the urine color is light yellow and clear. The vital signs are stable and the patient is in good spirits. The patient has recovered and been discharged from the hospital. Regular outpatient follow-up for six months is required, and blood arsenic and urine arsenic are rechecked twice, all of which are normal.
Huiqiang WANG, Danping LIU (, China)
00:00 - 00:00
#41223 - Online first-aid training.
Online first-aid training.
First aid saves lives. First aid should be initiated within minutes and administered correctly. Correct interventions until the EMS arrives, can keep one alive.
It is important to have hands on practice in first aid trainings because it enables theoretical knowledge to be transformed into practical skills. This ensures correct and effective interventions in case of emergencies.
The Turkish Emergency Medicine Association for All (TEMA) organized hands on first aid training courses through a voluntary effort, that was initiated eight years ago. Participation in these free of charge trainings is provided for every one that applies and completes the initial questioneer about personal information.
Hands on first aid training, which started with the "EMERGENCY NEIGHBOR" project launched in 2016 by TEMA. By naming it Emergency Neighbor, it was emphasized that the closest neighbors would come to help in case of emergency. The hands on first aid training has been carried to the online platform, right after the Covid-19 Pandemic Period.
Emergency Neighbor training is a two hour course which includes the following topics:
- First Aid and Emergency Care definitions;
- How and why to prepare a first aid kit;
- Calling the EMS;
- Fracture splinting;
- Stoping bleeding;
- Epileptic seizure;
- Drowning;
- Poisoning;
- Clearing airway obstruction in infants, children and adults;
- Basic life support for infants, children and adults.
3663 people have succeeded to get a Certificate after the two hour trainig. A total of 98 trainings were organized, where 45 trainings were organized before the pandemic period.
During the two-hour training, practical information and simple life-saving applications were taught. While manikins were used in the hands-on training process for chest compression and Heimlich Maneuver, conducted before the epidemic period, pillows were used instead, during the online trainings. The trainees were asked to turn their cameras on, so that the practices could be seen and evaluated by the trainers.
Trainees are also asked to take a pre-test which is followed by a post-test after the course to measure their knowledge of first aid, in order to get a Certificate of Attandance. In order for volunteers to receive a digital participation certificate, they must both successfully complete these tests and perform the practices without any error.
As a conclusion, online first-aid courses can be a life saving basic life support training. It is easy to reach a wide range of people, gives comfort to trainers and trainees. The course time is short which makes it attractive for busy and active working, studying groups. It is also simple to follow for trainees as most people are used to online platforms.
The trainings are free of charge for the public. There is no funding support from any Company.
Ulkumen RODOPLU (Izmir, Turkey), Utkan CAKAR, Busranur BERRAK, Mehmet ATAKLI, Yaren CANPOLAT, Gözde KESKIN, Fatma CALAYIR
00:00 - 00:00
#42100 - Opiods withdrawal syndrome: the importance of the clinical opiod withdrawal scale.
Opiods withdrawal syndrome: the importance of the clinical opiod withdrawal scale.
Background:
Drug withdrawal syndrome is a major complication of drugs consumption. The consumption of opioids is growing in the world and in Tunisia, thus opioids withdrawal syndrome (OWS) is becoming more and more frequent, and it has a high rate of morbidity and mortality. Yet not many studies describe drug withdrawal syndrome due to the lack of drug use declaration and to its various symptoms misleading the diagnosis.
The aim of the of our study was to describe the epidemiological profile of OWS and to determine the utility of the clinical opioid withdrawal scale.
Methods: We conducted a study at our emergency department, at the center of urgent medical care, Mahmoud Yaakoub, in Tunis, Tunisia from January 2021 to January 2023, including all patients who presented for opioids withdrawal syndrome.
Results: We included 82 patients who presented with OWS. Their mean age was 35.39 years old (std variation of 9.65). There were 76 men and 6 women with a sex ratio of 12.66. The main symptoms were: muscle ache in 45 (54.9%), insomnia in 24(30%), diarrhea in 19 patients (23.9%), vomiting in 14 (17.3%), a dysphoric mood in 9 patients (11.1%), restlessness in 3 patients (3.7%) and fever in one patient (1.2%). The withdrawal period varied from 1 hour to 120 days (2880 hours) with a mean duration of 171.94 hours with a standard variation 491.685. The mean delay of symptoms appearance was 19.4 hours (standard variation=28.235).
On examination: 3 patients had fever (4.4%), 1 patient had an elevated respiratory rate, 2 patients were tachycardic.
The laboratory findings of these patients showed: 2 patients had a creatinine > 100 mmol/L, 2 had a hyponatremia (129 et 132), 3 had a hypokalaemia (2.9, 3 et 3,2 mmol/L), 4 patients had cytolysis ,3 patients had rhabdomyolysis, 6 patients had an elevated leucocyte count, and 1 patient had thrombopenia equal to 104000.
We calculated the clinical opioid withdrawal scale: COWS score for every patient who was admitted for OWS and the results showed that: 62 patients had a mild OWS and 20 patients had a moderate OWS.
Conclusio: Opioids withdrawal syndrome is crucial to detect and diagnose. It is usually mid, but distresses should be looked for and treated. The orientation to an addictology consult or facility is necessary to prevent OWS.
Boutheina FRADJ (Mahdia, Tunisia), Mohamed KILANI, Hafedh THABET
00:00 - 00:00
#41929 - Optimal Airway Management in Cut Wounds to the Neck: Insights from the Emergency Department in the Context of Suicide Attempts.
Optimal Airway Management in Cut Wounds to the Neck: Insights from the Emergency Department in the Context of Suicide Attempts.
Objectives: The aim of this study was to examine the experience of the Emergency Department (ED) in managing airways in cases of cut wounds to the neck, especially in the context of suicide attempts, and to identify best practices for intervention and patient management in these situations.
Materials and Methods: We conducted a comprehensive literature review to identify relevant studies and clinical guidelines addressing airway management in cut wounds to the neck, with a focus on patients with a history of suicide attempts. We analyzed the protocols and methods used in managing these cases to evaluate effectiveness and impact on patient outcomes.
Results: Literature and practical experience in the ED indicate that managing airways in cut wounds to the neck in the context of suicide attempts is a complex challenge that requires an integrated and individualized approach. Rapid identification of lessions in the wound, proper assessment of the airway, and prompt surgical intervention are essential to prevent complications and death.
Conclusions: Airway management in cut wounds to the neck in patients with a history of suicide attempts requires a well-coordinated team involving emergency physicians, surgeons, psychiatrists, and other relevant specialists. Standardized protocols and adequate training of personnel can contribute to improving the management of these cases and reducing the risk of serious complications or death.
Daniel MUNTEANU, Victoria MELNICOV (Chisinau, Moldova)
00:00 - 00:00
#41711 - Optimizing feasibility studies for emergency trials: Navigating design and intervention challenges.
Optimizing feasibility studies for emergency trials: Navigating design and intervention challenges.
Background: The human and economic costs of clinical trials in emergency settings are significant. Evaluating the feasibility of the design and intervention is crucial, but often underreported in emergency contexts. In 2021, the Medical Research Council (MRC) published updated guidelines for developing and evaluating complex interventions in health, emphasizing how pilot work can help avoid serious challenges related to recruitment, intervention delivery, and data collection. This paper reviews the state of knowledge on feasibility and acceptability issues and their application in planning definitive trials in emergency settings.
Methods: A review of recent methodological recommendations was conducted to identify feasibility and acceptability issues using research questions related to trial design and intervention. The four categories of research questions were based on our published work on the methodology of pilot studies and the MRC revised guideline. First, is the design of the study feasible e.g., can it be successfully executed by the researcher and the research team? Second, are elements of the design acceptable from the point of view of the participants e.g., any retention issues? Third, is the intervention treatment feasible to deliver in an emergency context? And fourth, is the intervention suitable to the participants e.g., will eligible potential participants agree to participate? Feasibility studies conducted in emergency settings in Québec, Canada, will serve to apply these issues to concrete cases.
Results: Regarding trial design feasibility, participant identification, screening and randomization were challenging due to limited time, high variability in patient flow and condition, along the need to not disturb the clinical flow. Real-time electronic health records, automated alerts, and pseudo-randomization can facilitate streamlined screening and treatment allocation. Outcome measures based on standardized measures, such as reducing emergency revisits and hospital readmissions may lack sensitivity if they don’t align with the intervention's goals and context. The choice of outcomes and data linkage with hospital databases improved data collection quality. Pilot studies aiming primarily to test the efficacy in a small sample or to evaluate parameters to determine the planned effect size, although widely reported, is not recommended.
Intervention feasibility issues include identifying and training appropriate healthcare providers and navigating in parallel to the clinical regular flow may lead to intervention delivery variability. Standardized training protocols, highly trained professionals, and clear guidelines ensured uniform delivery, whereas the emergency context (patient and environmental variables) challenged efforts of standardization. Acceptability of the timing of an emergency discharge planning intervention provided just before leaving the emergency department was also an issue. Logging the intervention, tracking modifications, and regular meetings with the staff during and after the interventions helped identify gaps in content as well as determine the acceptability of the intervention.
Conclusion: Feasibility studies are recommended for planning successful definitive trials in emergency settings. Researchers can optimize clinical trial robustness by addressing design and intervention challenges identified during the feasibility phases of the project.
Montreal Heart Institute research center funding
Sylvie COSSETTE (Montreal, Canada), Patrick LAVOIE, Tanya MAILHOT, Nancy FEELEY, Alexis COURNOYER
00:00 - 00:00
#41737 - Optimizing mortality prediction in emergency care: evaluating venous blood lactate, serum albumin, and their ratio as prognostic indicators.
Optimizing mortality prediction in emergency care: evaluating venous blood lactate, serum albumin, and their ratio as prognostic indicators.
Background:
This study aimed to improve prognostic accuracy in the Emergency Department (ED) using venous blood lactate (VBL) and serum albumin (Alb) as well as the lactate to albumin ratio (L/A). The study established optimal biomarker cut-points to predict short-term (7-day) and medium-term (30-day) mortality, enhance clinical decision-making in emergency settings.
Methods:
A prospective observational analysis was conducted in the ED of a large university teaching hospital in Hong Kong, focusing on the prognostic utility of VBL, Alb, and L/A. The study spanned from July 2016 to June 2017 and was split into the derivation and validation phases. The derivation phase was to establish optimal cut-points for VBL, Alb, and L/A for predicting 7-day and 30-day mortality, and these cut-points were then tested in the validation phase. The participants included adult patients triaged as emergency or urgent cases, excluded pregnant patients or under the age of 18 years old. The statistical analysis comprised calculations of various demographic and clinical variables, sensitivity, and specificity, and employed ROC curve analyses to determine the area under the curve (AUC).
Results:
480 patients were recruited in the derivation phase. Optimal cut-points for 7-day mortality prediction were >3.19 mmol/L for VBL (sensitivity 66.7% and specificity 93.9%), <34 g/L for Alb (sensitivity 100.0% and specificity 78.2%), and >0.1136 for L/A (sensitivity 100.0% and specificity 98.7%). Optimal cut-points for 30-day mortality prediction were >1.74 mmol/L for VBL (sensitivity 76.5% and specificity 60.7%), <35 g/L for Alb (sensitivity 93.3% and specificity 74.3%), and >0.0768 for L/A (sensitivity 80.0% and specificity 91.4%).
The validation phase included 773 patients. For the 7-day mortality prediction, the AUC was 0.660 for VBL, 0.770 for Alb, and 0.741 for L/A; in the 30-day mortality prediction, the AUC was 0.700 for VBL, 0.760 for Alb, and 0.768 for L/A. Outcomes at various cut-points: In 7-day mortality prediction, the cut-points for VBL >3.19 and L/R >0.1136 identified more patients than Alb at cut-point <34, with the lowest mortality observed in patients with Alb >34. In 30-day mortality prediction, the highest mortality rate occurred in patients with an L/A >0.0768 and the lowest in those with Alb >35. The ICU admission rate was significantly higher for patients exceeding the VBL >3.19 or L/A >0.1136 cut-points.
Discussion & Conclusions:
The study confirmed the effectiveness of VBL, Alb, and L/A as valuable tools for mortality risk assessment in emergency departments. High L/A was associated with increased mortality and ICU admissions, while high Alb levels correlated with lower mortality.
Trial Registration:
N/A.
Funding:
This study did not receive any specific funding.
Shin Yan MAN, Kwong Hang YEUNG, Ling Yan LEUNG, Kevin Kei Ching HUNG, Colin A GRAHAM (Hong Kong, Hong Kong)
00:00 - 00:00
#42363 - Optimizing the initial diagnosis of pulmonary embolism: Evaluation of the effectiveness of the YEARS algorithm in reducing computed tomography pulmonary angiography.
Optimizing the initial diagnosis of pulmonary embolism: Evaluation of the effectiveness of the YEARS algorithm in reducing computed tomography pulmonary angiography.
Introduction: Pulmonary embolism (PE) is a serious and potentially life-threatening condition requiring rapid and accurate detection. The diagnostic approach requires the use of complementary tests, mainly computed tomography pulmonary angiography (CTPA), exposing patients to irradiation with non-negligible risks. The YEARS algorithm is an innovative approach aimed at optimizing the diagnosis of PE by allowing the use of a higher threshold of D-dimers. This study aims to assess the benefits of the YEARS algorithm in patients admitted to the emergency department with suspected PE.
Methods: We conducted a retrospective monocentric study on a prospective registry over a period of five years. We included patients admitted to the emergency department with suspected PE who underwent CTPA. We collected anamnestic, clinical, biological, and radiological data. All patients were evaluated for the presence of the three YEARS criteria: signs of deep vein thrombosis, presence of hemoptysis, PE as the most probable diagnosis. Patients were divided into two groups: group 1 (patients with at least one YEARS criteria) and group 2 (patients without any YEARS criteria). The D-dimer threshold used was 500 ng/ml in group 1 and 1000 ng/ml in group 2.
Results: The study included 160 patients with a mean age of 63.7 years +/-16.9. The gender ratio was 1.25. CTPA was performed in all patients, confirming PE in 111 cases. Group 1 comprised 44 patients, all with D-dimers exceeding 500 ng/ml. Group 2 consisted of 116 patients, with 98 having D-dimers surpassing 1000 ng/ml. Two patients in group 2 were diagnosed with PE despite negative D-dimer results. The first patient, a 43-year-old woman under hormonal contraception, presented with diabetes, dyslipidemia, obesity, varicose veins, and tested positive for COVID-19 and had a D-dimer level of 824 ng/ml. The second patient, a 59-year-old woman with a history of smoking, diabetes, hypertension, dyslipidemia, known COPD, and COVID-19 positive, had a D-dimer level of 773 ng/ml. The multimodal study of group 2 revealed a sensitivity of the D-dimer threshold of 97.44% with a specificity of 42.11%, a positive predictive value of 77.55%, and a negative predictive value of 88.89%. Our study revealed the reliability of the YEARS score in optimizing the diagnosis of pulmonary embolism in our specific population, with a reduction rate of CTPA of 15.51%.
Conclusion: By allowing the application of a higher threshold of D-dimers in patients suspected of PE, the YEARS algorithm offers a significant advantage by minimizing the considerable exposure to irradiation and the adverse effects of iodinated contrast agents, as well as reducing costs, while preserving diagnostic integrity without compromising patient safety or increasing the risk of missed diagnoses.
Ines CHERMITI, Mohamed ZOUARI, Ikram BEN BRAIEK, Raja FADHEL (Ain Zaghouan, Tunisia), Rihab DAOUD, Hanene GHAZALI, Sami SOUISSI
00:00 - 00:00
#41953 - Osteoarticular Infections in the Elderly: Epidemiological and Clinical Specificities.
Osteoarticular Infections in the Elderly: Epidemiological and Clinical Specificities.
Introduction:
In 2017, individuals aged over 65 represented 8% of the Tunisian population. Today, this percentage has exceeded 10%. Osteoarticular infections in the elderly are hindered by significant morbidity and mortality.
Objective:
To conduct an epidemiological and clinical analysis of osteoarticular infections in the elderly.
Materials and Methods:
This was a retrospective, descriptive study conducted in the orthopedic and trauma department of the Fattouma Bourguiba University Hospital (CHU) in Monastir, including all hospitalized patients for infection over a period of 6 years and one month from January 1, 2018, to January 31, 2024.
Results:
Twenty-six patients were included, characterized by a male-to-female ratio of 1.36. The mean age was 73.5 years. Regarding lifestyle habits, 34% of patients were smokers, and obesity was noted in 38.5% (BMI > 30). All patients had at least one comorbidity, with hypertension being the most common (53.8%). The ASA score was ≥ 2 for 84.7% of patients. The main reason for consultation was pain in 96% of cases, with the main diagnosis of infection being sepsis on medical devices in 53.84%. A positive biological inflammatory syndrome was present in 88.5% of cases. Bacteriological samples were negative in 19% of cases. Twenty-three percent of patients were on broad-spectrum antibiotic therapy with an average duration of 2.2 months. At 6 months, the outcome was favorable in 80% of cases.
Conclusion:
Osteoarticular infections in the elderly represent a major public health challenge. Their therapeutic specificities are crucial, requiring adaptation of the medical and surgical strategy.
no trial registration and no funding information .
Khouloud KHEMILI (Tunisia, Tunisia), Jacem SAADANA, Firas CHAOUECH, Said ABID, Amine SIOUD, Moez JELLALI, Hatem BELGACEM, Bilel FAIZI, Habib HADJ TAIEB, Ahmed MDAOUKHI, Iheb NTICHA, Aymen FEKIH, Abderrazek ABID
00:00 - 00:00
#41644 - Our new stethoscopes: Ultrasound probes.
Our new stethoscopes: Ultrasound probes.
A 77-year-old male patient was admitted to the emergency department with increasing dyspnoea after walking 8-10 metres.
The patient was admitted to the outpatient clinic 4 days ago with the same complaint but nothing was detected.
The patient had no history of any known disease or surgery.
On physical examination, vital signs were stable, lung sounds were normal, pretibial oedema was absent and other systemic examination was normal.
Bedside echocardiography performed in the emergency department revealed a mass in the right atrium.
The patient was operated by cardiovascular surgery and the mass compatible with thrombus was removed and discharged as healthy.
Is echocardiography really useful in the emergency department
The use of bedside ultrasonography, which has been increasing in recent years in emergency departments, greatly facilitates the work of emergency medicine. As in our case, many patients present to the emergency department with dyspnoea. However, there may be hundreds of causes of dyspnoea. It is very difficult to make a diagnosis among so many causes. However, thanks to ultrasonography, which is an easy-to-use, inexpensive method, our patient was diagnosed in the 15th minute of presentation to the emergency department and consulted to cardiovascular surgery. With the developing technology, our new stethoscopes have become ultrasound probes.
Ramazan KIYAK, Bahadir CAGLAR (Balikesir, Turkey), Muhammet CAKAS, Meliha FINDIK, Suha SERIN
00:00 - 00:00
#41864 - Out-of-hospital cardiac arrest attributed to drowning in Germany.
Out-of-hospital cardiac arrest attributed to drowning in Germany.
Background: The knowledge on out-of-hospital cardiac arrest (OHCA) attributed to drowning in Germany is limited. We describe a cohort of German patients with OHCA attributed to drowning.
Methods: Descriptive and comparative analysis of patients registered by emergency medical services (EMS) with good data quality (reference group) in the German Resuscitation Registry (GRR). We included patients who received prehospital cardiopulmonary resuscitation (CPR) attributed to drowning in the period from January 2013 to December 2023.
Results: Of the total of 68.719 patients with OHCA included in the analysis, 316 patients (0.5 %) had OHCA attributed to drowning. Patients with OHCA due to drowning were predominately male (70 %) and had a young mean age (48 ± 28 years). Nearly one in six patients (15 %) was younger than 11 years, while more than a quarter (27 %) was older than 70 years. Cardiac arrest was unwitnessed in 72 % of the cases, but 54 % of the patients received bystander CPR. Asystole was the initial rhythm in the majority of patients (74 %). While 31 % of the patients died on scene, 30 % were transported to hospital with ongoing CPR and 40 % showed a return of spontaneous circulation (ROSC) at hospital admission. In total, 15 % of patients with OHCA due to drowning survived until hospital discharge.
50 % of the cases occurred during the summer months of June, July and August. There was no change in the amount of OHCA attributed to drowning over the years, especially not with regards to before, during and after the COVID pandemic.
Discussion & Conclusions: In this study, drowning was a very rare cause of OHCA in Germany. Patients with OHCA attributed to drowning were predominately male and showed a young mean age. While children made up nearly one sixth of the cases, surprisingly people older than 71 years still accounted for more than a quarter of drowning victims. With 50% of arrests occurring during the summer months, this indicates that there is room for prevention of cardiac arrest due to drowning in vulnerable groups in Germany.
Funding: This study did not receive any specific funding.
Ethical approval and informed consent: This study was approved by the ethics commission of the Christian-Albrechts-University Kiel (Ref. no.: D 573/22) and the scientific advisory board of the GRR (Ref. no.: 2022-05). Informed consent was not required.
Christoph HÜSER (Cologne, Germany), Jan WNENT, Sadrija CUKOSKI, Christine EIMER, Matthias Johannes HACKL, Victor SUÁREZ, Jan-Thorsten GRÄSNER, Stephan SEEWALD
00:00 - 00:00
#42167 - Out-of-Hospital Cardiac Arrest Management Evaluation of General Practitioner Knowledge.
Out-of-Hospital Cardiac Arrest Management Evaluation of General Practitioner Knowledge.
Introduction:
Cardiac arrest represents an extremely life-threatening emergency. Family physicians play a crucial role in the initial management of out-of-hospital cardiac arrest.
We aimed to assess the theoretical knowledge of family physicians regarding the management of out-of-hospital cardiac arrest.
Methods:
It was a descriptive cross-sectional study conducted over two months (April and May 2023). An anonymous self-administered survey was used, distributed via Google Forms, consisting of two parts (the first part collected demographic data and information related to previous medical education, while the second part evaluated knowledge through 15 multiple-choice questions inspired by the French guidelines of the European Resuscitation Council from 2021).
Results:
We obtained 110 responses from physicians with a mean age of 34 ± 7 years. The male-to-female ratio was 0.32. Thirty-eight participants (34.6%) were practicing physicians. The average number of years in practice was 9 ± 7 years. Nearly half of the participants had received theoretical training: during specialty college courses (14.5%), postgraduate training days (31.8%), and additional certification courses (5.5%). Eighty-seven participants (79%) had received practical training through simulations. In 38.5% of cases, this training had taken place within the past year. Forty-three physicians (39%) had previously encountered an out-of-hospital cardiac. The mean evaluation score was 11±2 (ranging from 4 to 15). A score ≥11 was observed in 58 participants (52.7%). A "satisfactory" level of knowledge (score ≥11) was significantly associated with previous attendance of both theoretical (p=0.01) and practical (p=0.004) cardiac arrest management training, a training date within the past year (0.004), and experience in prehospital emergency medical services (0.04).
Conclusion:
The implementation of continuous theoretical and practical training in the management of out-of-hospital cardiac arrest appears necessary to ensure better care and improve outcomes.
Wafa DAYEM, Wiem DEMNI, Wided BAHRIA, Khaireddine JEMAI (Tunis, Tunisia), Ines ALOUI, Bassem GHERRI, Chaima TLIJANI, Nour Elhouda NOUIRA
00:00 - 00:00
#42217 - Outcome of nursing home residents after a call to the Emergency Medical Service.
Outcome of nursing home residents after a call to the Emergency Medical Service.
Introduction
Nursing home staff are not sufficiently trained to deal with the vital distress of dependent patients. The decision to refer them to hospital is the most frequent solution proposed by Emergency Medical Service (EMS) dispatch although numerous nursing home residents die within hours of being admitted to the emergency department.
Objective
The aim of this study was to describe the outcome of nursing home residents after a call to an EMS dispatch.
Methodology
This prospective study lasted from May 9, 2022 to May 8 , 2023. All emergency calls from nursing home were included, excluding calls for cardiac arrest. Age, sex were collected, as well as the reported autonomy scale (GIR). This scale reports 3 levels of autonomy: level 1 (GIR 1 and 2) for patients without autonomy whose mental functions are severely impaired, level 2 (GIR 3 and 4) for patient in loss of autonomy with retained mental functions and level 3 (GIR 5 and 6) for independent patient in all daily activities. The presence of do not attempt resuscitation (DNR) order, limitation of care, and the patient outcome at day 2 (D2) were collected. The primary endpoint was death at D2.
Results
One thousand eight hundred twenty-three patients were included. The sex ratio was 0.5. Mean age was 87.6 +/- 8.5 years old. The levels of autonomy were respectively 1 for 45 (2.6%), 2 for 546 (31.7%) and 3 for 1230 (65.7%) patients. One thousand three hundred forty-four (87.8%) patients were transported to the hospital, among them 108 (5.9%) with an Advanced Life Support (ALS) ambulance. DNAR orders were available in 193 (12.0%) cases, and were more frequent when patients were less autonomous (level 1) (p<0.004). When DNAR orders were available the patients stayed at nursing home more frequently (p<10-3). Therapeutic limitations were applied in 282 (15.5%) cases. Two hundred thirty-two (13.2%) patients were dead at D2. The occurrence of death was correlated with the patient’s autonomy level (p<10-3), with the presence of DNAR orders (p<10-3) and with leaving the patient on scene (p<10-3).
Conclusion
Thirteen percent of patients died after an emergency call from a nursing home within 2 days. Fifty seven percent died at the Emergency Department. Although DNAR orders are highly recommended, only 12% of patients had one. Training of nursing home staff is underway to increase DNAR orders rate and improve end of life procedures.
Margot CASSUTO (Garches), Cecile URSAT, Lucas PIERRARD, Anna OZGULER, Michel BAER, Thomas LOEB
00:00 - 00:00
#41910 - Overview of the Dengue epidemic in Ribeirao Preto- Brazil - 2023-2024.
Overview of the Dengue epidemic in Ribeirao Preto- Brazil - 2023-2024.
Dengue is a systemic and acute arbovirus transmitted by mosquitoes of the genus Aedes, which, due to the influence of resources such as water and climate, reproduces and spreads the virus throughout the world. When infected, an individual may, in most cases, be asymptomatic, but may also present symptoms. The severity of the clinical picture varies and can be fatal. During the first months of 2024 there was a large increase in the number of reported cases, which highlights the need to study therapeutic and preventive strategies to face the disease.
Methodology
This is a descriptive epidemiological study, based on data made available by the Municipal Health Department, referring to Dengue cases in the city of Ribeirão Preto - Brazil, reported in the period from 03/01/2023 to 02/28/2024.
Results
According to data from the Ribeirão Preto Epidemiological Surveillance, in the period from 02/01/2023 to 04/30/2024, 57,110 suspected cases of dengue were reported, with 30,754 cases confirmed and 15 deaths.
Regarding distribution by age group - confirmed cases were distributed as follows: 199 cases in children under 1 year of age, 948 cases in individuals aged 1 to 4 years, 2,364 cases in individuals aged 5 to 9 years, 5,190 cases in individuals aged 10 to 19 years old, 10,946 cases in individuals aged 20 to 39 years old, 7,428 cases in individuals aged 40 to 59 years old and 3,679 cases in individuals over 60 years old.
Regarding the seasonality of suspected and confirmed cases - there was a predominance of cases from March to May 2023 (14,867 suspected cases and 8,793 confirmed cases between March and May March) and in August there were the lowest number of suspected cases (710 cases) and in September the lowest number of confirmed cases (82 cases).
Discussion
DENV affects most tropical and subtropical countries in the world and produces epidemics annually, mainly after the disorderly urbanizations that occurred in the 20th century. Epidemiological research indicates that dengue infections affect two-fifths of the world's population, resulting in approximately 390 million people infected annually, with 500,000 hospitalizations and 20,000 deaths. In Brazil, from the last weeks of 2023 to the first months of 2024, an early increase in dengue cases compared to the same period in previous years was reported, contradicting what normally happened, since the seasonality of the disease occurs between January and May .
Conclusion
When analyzing the situation and circumstances that the number of dengue cases exhibit on a global level, the relevance of the disease's pathogenicity and epidemiological data can be observed. In this sense, the increase in the incidence of cases, despite being seasonal, reveals gaps in political management by associating socio-environmental problems with public health problems, since the increase in the mosquito population is a reflection of the lack of educational policies that teach the community to control the spread of the vector and the lack of preventive health strategies.
Ethical approval and informed consent: no need
Funding: This study did not receive anyspecific funding.
Ana Luiza Normanha ALMEIDA, Rosemary F DANIEL (ribeirão preto, Brazil), Priscila RONCATO, Tufik GELEILETE, Nyara CONTIERO, Silvia SILVA, Edilson CARITA, Livia SIMONI, Reinaldo BESTETTI
00:00 - 00:00
#41180 - Paediatric Emergency Medicine Specialists in the UK - are we meeting the needs of our children today? A descriptive workforce survey 2006-2023.
Paediatric Emergency Medicine Specialists in the UK - are we meeting the needs of our children today? A descriptive workforce survey 2006-2023.
Background:
Paediatric Emergency Medicine (PEM) is a relatively new subspecialty in the UK first recognised in 2001 with all doctors required to have a parent specialty - Emergency medicine (EM) or Paediatrics.
A survey in 2013 demonstrated that the intercollegiate gold standard of at least one PEM consultant in any department seeing >16,000 children was not being met. This standard was updated in 2018 to recommend that all Emergency Departments (EDs) treating children should have a PEM consultant. Audit data published in 2022 suggested that 41% of EDs did not meet this standard.
Methods:
For this descriptive survey we approached the GMC with a freedom of information request to determine the number of doctors with a subspecialty of PEM from either an EM or paediatrics from 2006 onwards.
We looked at the growth in numbers; overall, by college and by area of the UK, and mapped this to the numbers of children under the age of 16 in each region (ONS data 2022) and looked at ED attendances <16yrs. We compared our results to the 2013 census.
Results:
By December 2023 there were 565 UK-licenced doctors with subspecialty PEM. This represents a 17.6-fold increase over the last 17 years with on-average an additional 30 doctors / year achieving this. In 2023 there were 5.4 million ED attendances by children aged 0-16yrs, equating overall to 1 PEM doctor per 9,500 attendances UK-wide (1:16000 EM PEM).
384 (68%) had a primary specialty of EM and 181 (32%) Paediatrics. By comparison in 2006 there were 32 registered doctors with this subspecialty of whom 28 (87.5%) were from EM and 4 (12.5%) from paediatrics.
The 2013 census found variation across the UK in PEM provision when applied on a PEM doctor/ per million population basis. We have chosen instead to use number of doctors per 100,000 children under the age of 16. In 2023 most areas had an average of 4 PEM doctors / 100,00 children under the age of 16. The Northeast, and Southwest appear as positive outliers with >5 PEM consultants/100000 children, whilst the East of England has <2 per 100000.
Discussion and Conclusion:
With children <16 representing 23% of all UK ED attendances and those <4 representing 11%, the ability to manage these children across the whole spectrum of presentations is a fundamental skill required by emergency physicians.
This review has demonstrated that PEM has grown from a “niche” specialty in 2006 with only 28 PEM specialists, to a core part of the EM offering with >11% of all EM specialists dual accredited in PEM.
There are now enough PEM specialists in the UK to meet the gold standard. However, this survey only looked at raw numbers of PEM specialists and their location by registered address. What we do not know is the number of these doctors actively practicing PEM, the setting in which they practice, and the spread of job-planned time and activities this entails. Next steps would be to undertake a more detailed workforce census to understand this further.
Trial Registration and funding not required for this survey. Informed consent and ethical approval also not required for this descriptive follow up survey.
Anne FRAMPTON (Bristol, ), Rachel JENNER
00:00 - 00:00
#41176 - Paediatric Trauma Pearls: an outback Australian retrieval.
Paediatric Trauma Pearls: an outback Australian retrieval.
While paediatric trauma management benefits from experience in the world of adult trauma, understanding the nuances of the management of injured children improves care, outcomes and may be life saving. A paediatric trauma case will be discussed highlighting issues that are specific to paediatric trauma management and packaging for transport. Guaranteed learnings for all participants or full refund will be offered*.
*conditions apply
6 yo boy hit by a car in a small country town. Taken to local hospital and retrieval team dispatched. Concerns over head injury (large scalp laceration) and intubated for transfer. During transfer, deteriorated but was not recognised by retrieval team. Case presentation focuses on causes of deterioration using the observation chart as a discussion point. Issues that were identified were dropping BP and increasing HR due to occult bleeding (chest and abdomen), and rising CO2 due to extension tubing (increased dead space),. Discussion around retrieval issues and the differences between paediatric patients and adults.
John CRAVEN (Australia, Australia)
00:00 - 00:00
#42093 - Palliative and Emergency Care in the year 2023 – Karlovy Vary Region, Czech Republic.
Palliative and Emergency Care in the year 2023 – Karlovy Vary Region, Czech Republic.
Background
Emergency medical services (EMS) play a crucial role in delivering acute prehospital treatment, yet they are increasingly utilized by terminally ill patients and their informal caregivers during the final stages of life. Recognizing this trend, the Center for Palliative Care in the Czech Republic initiated a project aimed at extending support to patients requiring palliative care, even within the context of EMS interventions.
In 2023, the Emergency Medical Services of the Karlovy Vary Region commenced a systematic evaluation of this phenomenon. This abstract presents a preliminary analysis of the epidemiological data obtained from this ongoing project.
Methods
This study employs a mixed-methods approach, incorporating prospective patient identification for potential palliative care needs. Identification was facilitated through the application of the Rapid Palliative Care Screening Tool (Rapid-PCST), in alignment with national guidelines for palliative care within EMS settings.
All patients identified through palliative care screening underwent retrospective analysis, allowing for the collection of epidemiological data, including demographic information such as sex, age, diagnosis (oncological or other), trajectory of the patient.
Results
During a 9-month period from April to December 2023, a total of 350 patients were identified either through the medical dispatch centre or by paramedics in the field. The table below illustrates their basic characteristics. The oncological diagnosis was available in 105 (30%) of records of which 34 (32.4%) patients has recorded an oncological diagnosis.
Characteristics Male Female
Sex (n, %) 195 (55.7%) 155 (44.3%)
Age (mean, SD) 72 (12) 72 (14)
Oncologic diagnosis (n, %) 24 (70.6%) 10 (29.4%)
68 patients (17.4%) did not meet the criteria for another care, we were not able to contact 31 patients (8.9%) and 5 people were mismarked (1.4%). Palliative care coordinators were able to provide other care for 91 patients of the group (246) with benefit from palliative care (37%).
Type of care secured Number of patients referred
Hospice or mobile hospice 49
Visit of palliative care doctor 27
Pain outpatient department 15
Discussion
Patients and families call EMS at the end-of-life stages due to (1) limited availability of support from health care services; (2) insufficient planning of care; (3) decline in the health of the patient and (4) being lost and desperate.[1]
Improving end-of-life care in EMS requires educating healthcare providers to identify and support these patients effectively. By empowering EMS professionals with the skills to intervene appropriately, we can better address patients´ needs in the end-of-life period and reduce unnecessary hospitalizations.
Training EMS staff to recognize and respond to end-of-life needs enhances care quality and patient experience during this critical phase.
Conclusion
This study underscores the importance of integrating palliative care principles into the realm of emergency medical services. By equipping paramedics and physicians with the necessary support and competencies, we can effectively address the needs of terminally ill patients within the prehospital care system. This shift has the potential to positively impact patient needs and enhance the quality of end-of-life care delivery.
David PERAN (Karlovy Vary, Czech Republic), Vera LUHANOVA, Milos KUKACKA, Tatana MASKOVA, Jiri SMETANA
00:00 - 00:00
#40908 - Pan-scan for Trauma Patients at the Emergency Department.
Pan-scan for Trauma Patients at the Emergency Department.
Background: Pan-scan, which comprises computed-tomography (CT) scans of the head, cervical spine, chest, abdomen and pelvis, allows for the rapid evaluation of life-threatening injuries. We aim to describe the clinical utility of pan-scan in trauma patients for detection of clinically significant injuries and subsequent management in the emergency department (ED).
Methods: A retrospective review of trauma registry data from 18 August 2018 to 31 December 2022 was conducted. Information about demographic, circumstance and mechanism of injury, injury sustained and severity, pan-scan findings, clinical management and outcome were collected and analysed.
Results: Among 77132 trauma cases, pan-scan was performed in 126 (0.2%), all of which had trauma team activation. Seventy-eight (61.9%) pan-scans were positive with clinically relevant trauma findings, the top three being rib fractures (22, 28.2%), intracranial hemorrhage (19, 24.4%) and vertebral fractures (19, 24.4%). Seventeen (21.8%) interventions were carried out for positive pan-scans, of which the most common were emergency operating theatre (EOT) for craniectomy/craniotomy and/or intracranial pressure (ICP) monitor insertion (6, 7.7%), chest tube insertion (6, 7.7%), and EOT for laparotomy (3, 3.8%). Fifty-four (69.2%) cases had incidental findings not clinically relevant to trauma, with spondylosis (23, 29.5%), renal cyst (22, 28.2%), hepatic steatosis (16, 20.5%) being top three. The median length of stay for cases with pan-scans was 115 minutes (interquartile range (IQR) 76 to 157 minutes), compared to 93 minutes for those without (IQR 63 to 135 minutes) (p=0.004). The mortality rate for patients with pan-scan was 4.8%.
Conclusion: The proportion of pan-scan performed was low among trauma patients. Pan-scan translated to a significantly longer length of stay at the ED even though most of the clinically relevant findings did not require intervention. Adaptation of existing guidelines to the clinical setting may be necessary to better identify patients who would benefit from pan-scan at the ED.
Shannen SEE (Singapore, Singapore), Chee Yun Eunice CHAN, Shiun-Hwa Chantal LIM, Juinn Huar KAM, Jen Heng PEK, Hui En Hannah ANG
00:00 - 00:00
#42024 - Paradoxical bradycardia as a rare side effect of Nitroglycerin.
Paradoxical bradycardia as a rare side effect of Nitroglycerin.
INTRODUCTION:
The vasodilatory action of nitrates is secondary to the release of nitric oxide, a gaseous molecule that acts on the smooth muscle cells of the vascular system. Their widespread use for the treatment of hypertensive emergencies and angina derives from their dilation action at venous and arteriolar levels, resulting in a reduction in venous return and afterload, wall tension, and myocardial oxygen demand. The main side effects associated with the administration of nitrates are headache, flushing, dizziness, orthostatic hypotension, and tachycardia, due to sympathetic nervous system activation. However, rare clinical cases of “paradoxical bradycardia” onset after nitroglycerin administration, known as “Bezold-Jarisch reflex”, have been reported in the literature. This is a rare adverse reaction in which hypotensive status stimulates carotid baroreceptors, increasing myocardial contractility in a relatively empty ventricle due to preload reduction. This leads to inappropriate stimulation of ventricular receptors, causing a vagal response with bradycardia and reduced cardiac contractility, exacerbating hypotension.
CLINICAL REPORT:
A 48-year-old man arrived at the Emergency Department for chest pain (Chest pain score: 5) with an episode of arterial hypertension (Blood Pressure - BP 200/110 mmHg). In anamnesis, there were no noteworthy pathologies, and he reported a family history of ischemic heart disease and smoking. At clinical evaluation according to the ABCDE protocol, nothing relevant was found except for hypertensive status. His ECG showed a sinus tachycardia with a heart rate (HR) of 100 bpm with normal atrioventricular conduction, anomalies of the ventricular repolarization phase (predominant in the lateral area), and a Q wave in DIII. Therefore, a bolus of 0.5 mg of Nitroglycerin was administered, and after that a likely vasovagal crisis occurred with marked bradycardia (HR about 30 bpm). Therefore, two vials of Atropine and 500 cc of saline solution were administered with rapid recovery of hemodynamic status: BP 150/90 mmHg and HR 94 bpm. The new ECG showed no changes compared to the previous one, while echocardiography demonstrated no hypokinesia and it was overall normal. Troponin curve on blood tests was negative, so the patient, hemodynamically stable, was discharged (BP 140/85 mmHg and HR 80 bpm).
CONCLUSION:
Given the rare reports of this event after nitroglycerin administration, additional predisposing factors may be involved. This study aims to improve understanding and to expand the available case series, thus contributing to the state of the art.
Giovanna CRISTIANO, Claudia CARELLI (Naples, Italy), Anita COSTANZO, Rosanna ESPOSITO, Maria Paola URSI, Giovanni D'ANGELO, Raffaella EPIFANI, Giulia JACOBITTI ESPOSITO, Lucrezia PAGLIUCA, Andrea PICCOLO, Francesca PAUDICE, Mario GUARINO
00:00 - 00:00
#42097 - Paramedics prehospital workload evaluation : utility of codage activité smur score.
Paramedics prehospital workload evaluation : utility of codage activité smur score.
Introduction : Assessing of pre-hospital nursing workload is a crucial question to ensure quality of care provided to patients and to examine quantity of work and responsibilities that nurses face when working outside hospitals. The aim of our work was to evaluate the workload of the pre-hospital nurse using the SMUR Activity Coding (CAS) score.
Methods : We conducted a retrospective study at the Mobile Emergency and Resuscitation Service of Ben Arous for five months. We included all interventions and collected all data relating to the mission, clinical characteristics and actions and procedures performed. We calculated CAS score then we compared interventions with high workload versus interventions with low workload.
Results : We included 363 interventions of which 60% were secondary (n=216). Male predominance was found (n=231; 63,6%), either a gender ratio of 1,75. During these interventions, 1970 procedures were performed or monitored. Median CAS score was 4 [3-7]. Median CAS score of primary interventions was 5 [3-7]. Median CAS score of secondary interventions was 3[3-5]. Workload was high in 94 interventions. Workload was significantly higher during primary interventions (p=0.007), when the patient under care presented disorders of consciousness (p<0.001), when multiple types of injections were required (p<0.001 for IV injections and p=0.039 for subcutaneous injections), when the patient required nebulization (p=0.001) or when an ECG was performed (p<0.001).
Conclusions : CAS score has proved to be a valuable tool for assessing workload. It takes into account a variety of factors and allows an objective evaluation. Its use can help pre-hospital departments to better plan their human resources requirements according to the expected workload.
None
Ines CHERMITI, Safa MAAMOURI, Jihen JALLALI, Raja FADHEL (Ain Zaghouan, Tunisia), Hela BEN TURKIA, Amira BAKIR, Rahma DHOKKAR, Hanène GHAZALI, Sami SOUISSI
00:00 - 00:00
#42229 - Paraspinal pyomyositis presenting as progressive lower limb muscle weakness : a case report.
Paraspinal pyomyositis presenting as progressive lower limb muscle weakness : a case report.
Introduction: Pyomyositis is a primary bacterial infection of skeletal striated muscles. Its pathogenesis remains poorly understood. It is often observed in the immunocompromised or following trauma. Its occurrence in immunocompetent individuals is rare. We report a case of paravertebral pyomyositis leading to functional impotence of the lower limbs. Observation: A 45-year-old man with diabetes was admitted to the emergency department for diabetic ketoacidosis with a history of 10 days of fever and progressive walking difficulties. On examination, the patient was subfebrile at 37.8°C, hemodynamically stable, conscious and eupneic. The patient presented with muscular weakness of both lower limbs, abolished osteotendinous reflexes, and a flexor plantar reflex. Abdominal examination was strictly normal. Additionally, he had a post-traumatic swelling of the forearm. Laboratory tests showed a biological inflammatory syndrome with a CRP of 210 mg/l without leukocytosis. The rest of the workup was unremarkable. Initially, infectious spondylodiscitis was suspected. Medullary MRI revealed large intramuscular fluid collections in the left paravertebral and psoas muscles, extending to posterior intracanal epidural collections causing severe canal stenosis, associated with perisplenic collections. Ultrasonography of the forearm swelling suggested a superinfected hematoma. Echocardiography did not show lesions suggestive of infective endocarditis. Bacteriological samples were taken, and the patient was started on broad-spectrum antibiotic treatment with good clinical and biological evolution. Conclusion: The diagnosis of pyomyositis remains challenging and often delayed. It should be considered, despite nonspecific symptoms, in the presence of a septic syndrome associated with pain, to establish an early diagnosis and thus improve patient prognosis.
Saloua HOUIMLI (la Marsa, Tunisia), Sarra AKKARI, Nour El Houda MAATOUG, Amira TABKA, Syrine TROJETTE, Hajer HAMZAOUI, Fatma HEBAIEB
00:00 - 00:00
#42023 - Partial vocal cord paralysis in severe invasive Group A streptococcal infection: a case report.
Partial vocal cord paralysis in severe invasive Group A streptococcal infection: a case report.
A 46-year-old female with no significant medical history presented at the Emergency Department with symptoms of malaise, fever, and coughing lasting one week. The viral throat swab is positive for Influenza A, and a chest X-ray revealed an infiltrate, leading to a presumptive diagnosis of community-acquired pneumonia. The patient was discharged with amoxicillin based on a CURB-65 score of 0.
Two days later, the patient returned with worsening symptoms, including chest pressure, progressive dyspnea, and hoarseness. Physical examination noted significant and striking neck swelling with rapidly expanding redness and a septic profile marked by hypotension, tachycardia and high fever. The respiratory rate was 22 per minute, and oxygen saturation levels without oxygen supplementation were 90%. Due to the suspicion of a potentially compromised airway, an ENT doctor was consulted. Flexible scopy revealed necrotizing swelling above the larynx and paralysis of the right half of the vocal cord. Laboratory findings included a C-reactive protein (CRP) of 600 mg/L and a lactate level of 3 mmol/L. A CT scan showed filling of the vallecula closely related to the epiglottis and a phlegmonous inflamed aspect with extension to the parapharyngeal and deep soft tissues in the neck as well as subcutaneously.
Immediate treatment with ceftriaxone and clindamycin was initiated, suspecting invasive Group A Streptococcus (iGAS). The patient was transferred to the intensive care unit of a tertiary center and underwent Video-Assisted Thoracoscopic Surgery (VATS) due to pleural empyema on day 23. Besides the VATS, no additional surgical interventions were required. The vocal cord paralysis persisted throughout the admission.
We are currently experiencing a peak in the incidence of iGAS. The increased rates in 2022 and 2023 may be linked to COVID-19 measures and the prevalence of the M1UK serotype. Notification requirements and prophylaxis measures for household contacts were expanded as of January 2023. Clindamycin is included in the treatment regimen to inhibit toxin production. In cases of iGAS, including necrotizing fasciitis or streptococcal toxic shock syndrome, adjunctive therapy with intravenous immunoglobulins is recommended.
This case highlights the critical need for early recognition and prompt intervention in severe invasive bacterial infections, such as iGAS. Delayed treatment can result in significant morbidity and mortality, underscoring the importance of vigilance, especially with symptoms like rapidly expanding skin redness following an Influenza A infection. Effective management includes the use of targeted antibiotics to handle severe complications. Additionally, this case points to the evolving epidemiology of invasive Group A Streptococcus, emphasizing the need for ongoing surveillance and updated treatment protocols.
Ineke SCHOUTEN, Duveke DE GAAY FORTMAN (Amsterdam, The Netherlands)
00:00 - 00:00
#41825 - Particularities of the management of dyspnea in the Kairouan region.
Particularities of the management of dyspnea in the Kairouan region.
Introduction :
Dyspnea is a common reason for seeking emergency care; it is an important symptom Subjective which can be the expression of potentially serious and urgent pathologies.
The diagnosis is clinical, the questioning and clinical examination aim to clarify the severity of dyspnea, its origin. The context is sometimes that of an emergency vital, the causes are numerous and often intricate. The objective of our study was to evaluate the quality of the management of dyspnea in the environment hospital in the Kairouan region.
Methods :
This is a descriptive and retrospective study involving 44 patients admitted to the emergency service. The study period was 3 months from December 2023 to February 2024.
Inclusion criteria: age >17 years, all patients consulting for dyspnea within the framework of the different pathologies, those whose files did not have not found or incomplete.
Results :
Our study included 44 patients: 25 patients were male (56.8%) and 19 were male. female sex (43.2%), i.e. a sex ratio equal to (0.76). The average age was (66.2 +/- 14.4 years) with extremes of 17 years and 91 years.
32 patients consulting for respiratory causes, i.e. (72.7%): 26 patients consultant in the context of acute exacerbation of COPD i.e. (81.25%), the hypoxemic pneumonia is the main cause of decompensation (80.76%) followed by tracheobronchitis (19.24%).
12 consulting patients for other non-respiratory reasons, i.e. (27.3%), cardiovascular causes (75%) followed by renal causes (25%).
The assessment of the general condition was clarified in all patients: 44 patients i.e. (100%) have their neurological status preserved (GSG 15/15), the average saturation was (83.32% +/- 10.35%). The average value of systolic blood pressure was (128.7+/-25.6) and the mean value of diastolic blood pressure of (74.65+/-10.19). The GAD was performed in 12 patients (27%) with average (1.35+/-0.45).
. 24 patients were in hypoxia with Pao2 ranging from (45% to 59%) and 14 patients in hypercapnic acidosis.
Chest x-ray was done in (100%) of patients included in the study showing a alveolar-interstitial syndrome (65.9%), bronchial syndrome (20.4%), pleural syndrome a (6.6%). Chest CT was not only indicated in 2 patients or (4.5%).
26 patients (51.9%) were hospitalized urgently, with average length of stay at (3.35 +/- 2.63), 21 patients (47.7%) requiring oxygen therapy, 10 patients required ventilation mechanical (9 patients non-invasive ventilation (NIV) and 1 patient requiring use of invasive ventilation), 17 patients received antibiotic therapy either (38.6%), and 13 patients received paracetamol (30.2%).
The evolution of the patients is marked by the worsening of 3 cases i.e. (11.5%) including 2 died or (60.6%), the improvement of 26 cases or (59%). 10 patients were directed towards medical services or (22.7%), and 34 patients or (77.3%) are placed leaving after improvements.
Conclusion:
Our study concerns a frequent reason for consultation in the emergency department; it has made it possible to specify the mechanisms and severity of this symptom and to guide the treatment, similar studies must be carried out in order to better evaluate the quality of dyspnea treatment in the emergency department
Bouhamed CHAFIAA, Akrem ABEDI, Khouloud KHEMILI (Tunisia, Tunisia), Imen KETATA, Sarra SOUA, Chaima MANAI
00:00 - 00:00
#41942 - Particulate matter and emergency department visits in the Florence urban area between 2019 and 2022: a time-series study.
Particulate matter and emergency department visits in the Florence urban area between 2019 and 2022: a time-series study.
Background: Urban air pollution is currently a major public health concern, responsible for approximately 3.2 million premature deaths each year. Particulate matter (PM) has garnered attention due to its historical background, physicochemical characteristics, and pathological effects. Depending on its size, PM is deposited at different levels of the respiratory tract, with coarse particles (PM10) primarily in the upper airways and fine particles (PM2.5) in the lung parenchyma and absorbed in the circulation. Fluctuations in pollutant concentrations can heighten acute pathologies and exacerbations of chronic conditions, thus leading to an increased workload in Emergency Departments (ED). This study aimed to investigate the relationship between PM concentrations and ED visits in the urban area of Florence (Italy).
Methods: We performed a time-series analysis of a retrospective cohort of patients admitted to the ED of a Level-1 hospital in Florence (Italy) between 2019-2022. The daily concentrations of PM2.5 and PM10 were recorded by 14 stations of the Regional Agency for Environmental Protection of Tuscany within an urban area of around 100x100km. Patients were excluded if their residence address was outside the urban area investigated or could not be determined or geocoded. For each patient, pollutant concentrations at their residence address were interpolated by means of inverse distance weighting and averaged over various time windows up to 30 days prior to the ED visit. The relationship between ED daily visits counts and pollutant concentrations was investigated with generalized additive models, adjusting for the date and day of the week, and analysed according to age, sex and urgency code. The percent excess risk ratio (%Er) in ED visits for an interquartile increment of each pollutant was calculated.
Results: Of the 307279 ED visits included in this study, 51.5% were of male patients and 61.5% of patients younger than 65 years, with 48.9% non-urgent, 43.7% urgent and 7.4% emergent visits. Overall mortality of the study cohort was 1.3%. There were significant short-term correlations between air pollutants and ED visits (PM2.5 Day 1: 1.24 %Er; PM10 Day 2: 1.79 %Er). The most common primary complaints having a significant relationship with air pollutants were trauma, dyspnoea and skin conditions. While trauma showed a significant relationship with PM2.5 (1.29 %Er) and PM10 (2.14 %Er) in younger patients, ED visits for dyspnoea were primarily related to patients older than 65 years (PM2.5: 4.18 %Er; PM10: 4.99 %Er) and showed significant relationships with PM levels throughout all urgency codes. Effect-response curves suggests that PM levels were related to rises in ED visits at concentrations below the suggested air quality guidelines (AQG) of the World Health Organisation (WHO), with a steep increase in ED visits between 3-11 microg/m3 of PM2.5 (AQG 15 microg/m3) and 8-17 microg/m3 of PM10 (AQG 45 microg/m3).
Conclusions: Higher levels of PM2.5 and PM10, even within the suggested WHO AQG, are related to greater short-term ED workload, primarily because of more ED visits for traumatic events, dyspnoea and skin conditions.
Andrea ROSSETTO (Firenze, Italy), Alessio GNERUCCI, Paola FARAONI, Francesco RANALDI, Gabriele CAVALLARO, Ugo SANTOSUOSSO, Lorella BONACCORSI, Peiman NAZERIAN
00:00 - 00:00
#41466 - PATIENTS TREATED IN THE EMERGENCY DEPARTMENT WITH DIAGNOSES ASSOCIATED WITH MENTAL HEALTH PROBLEMS.
PATIENTS TREATED IN THE EMERGENCY DEPARTMENT WITH DIAGNOSES ASSOCIATED WITH MENTAL HEALTH PROBLEMS.
INTRODUCTION Mental illness is imposed as a great challenge for health, due to its high incidence and prevalence, its potential chronicity and severity, and the consequences for the family and society in general.
OBJECTIVE Describe the demand for urgent care for mental health problems attended in the emergency department of the Hospital Universitario de La Ribera (HULR).
MATERIAL AND METHODS Observational, descriptive and retrospective study carried out during the years 2000- 2022 in which data related to the characteristics of the patients treated and their origin were collected, to the care received by these patients in the HULR Emergency Department (time in being attended , priority of care assigned in triage, request for complementary tests, need for interconsultation with psychiatry, diagnosis and discharge destination), in the case of admission, its characteristics and variables associated with the demand for urgent care again in the following year at the initial visit.
RESULTS Emergencies due to mental health problems represented 1% of the total emergencies attended, doubling between the years 2020 and 2022. The patients were of both sexes and of all ages, came voluntarily, and were treated in a short period of time. , laboratory tests were requested and in very few cases it was necessary to consult a psychiatrist. Many of them were diagnosed with anxiety, self-harm or suicidal ideation, or problems related to substance use. The admission rate was 25%, and more than half of the patients returned to the emergency room in the year after the initial visit, with a percentage slightly higher than 50%, the reason for consultation being related to mental health.
CONCLUSIONS Preventive and primary care for psychiatric pathologies is not as resolved as for other specialties. Due to this deficiency, the patient goes to the hospital emergency department in search of help and guidance. Knowing the type of psychiatric patient, as well as the most prevalent pathologies, both the profile of the nursing staff and the type of means necessary to guarantee effective patient care could be adapted.
María CUENCA TORRES (alzira, Spain), Beatriz PARDO GARCÍA, Guillem LERA CALATAYUD, Luis MANCLÚS MONTOYA
00:00 - 00:00
#41885 - Pediatric emergencies in pre-hospital care: incidence, classification and severity.
Pediatric emergencies in pre-hospital care: incidence, classification and severity.
Introduction.
Pediatric emergency patients are liable population and require particular care and interventions. The difference between adult and pediatric anatomy, physiopathology, risk factors, drug dose and management requires the action to be taken thoughtfully. This differences reflect as well the most common medical emergencies in pediatric patients versus adult patients, like non-cardiac respiratory failure, trauma, neurologic emergencies as seizure. The severity of symptoms and mechanisms oscillates different from person to person and situations, from minimal damage to death
Materials and methods.
The current study was retrospective, observational and included 251 pediatric patients, from 0 to 18 years. Patient statistics were collected in the course of two years, from 1st of May 2022 to 1st of May 2024, the SMURD Mobile Intensive Care Unit Sibiu intervene, and describes the incidence of pediatric emergencies, severity, diversity of cases and the most affected gender and age interval.
Results.
From the original 2837 that required care in pre-hospital setting in the years analyzed, 8.8% were pediatric patients. Of those, the most frequent were: 36.7% called for trauma injuries, 27.9% were for respiratory failure and 11.2% for neurological causes.
According to current research, pediatric emergencies were commoner for males (59%) compared to females (41%) and 72.5% were in the age between 0-9 years, and 23.5% between 10-18 years.
The incidence of pediatric emergencies, increased from the first year analyzed compared to the second year with a percentage of 17.1%
The main mechanisms of trauma were: 71.7% road accidents, 12% falls, whether at the same level or at height and the rest of 16.3% for other traumatic emergencies. The most frequent trauma lesion was the traumatic brain injury in 32.6% cases and for 3.3% form trauma emergencies, it was fatal leading to death.
Risk factors for developing respiratory failure in pediatric population were in 18.6% foreign body aspiration, 14.3% pulmonary diseases and the rest were diverse congenital conditions.
In pediatric population, the most common neurological emergency, for 11.2% was found to be the seizure and 71.7% of all were febrile convulsions.
In 4.4% of cases, the emergency was a cardiorespiratory arrest, whence only 37.5% of patients were resuscitated from cardiac arrest. The primary cause of death, found in the current study, was traumatic lesions.
Conclusions.
The incidence of pediatric emergencies the Sibiu Intensive Mobile Care Unit intervened during the period analyzed is high-frequency with a percentage of 8.8%.
Predominantly case profile for pediatric emergencies is associated with trauma, caused by road accidents, with traumatic brain injury, male gander in the age between 0-9 years.
In the current research, arise a few mechanisms of pediatric injuries, that could have been prevented and points out the importance of reducing the risk factors in pediatric population.
Dina MIHALACHE (Sibiu, Romania), Iris Codruța MUREȘAN
00:00 - 00:00
#42290 - Pediatric Emergency visits at a tertiary Children's Hospital in Greece.
Pediatric Emergency visits at a tertiary Children's Hospital in Greece.
Pediatric Emergency visits at a tertiary Children's Hospital in Greece
Spyridon Karageorgos, Anastasios Panagiotis Chantzaras, Athanasios Exarchos, Vassiliki Theologi, Loukia Ioannidou, Anastasia Polytarchou, Stavros Antonopoulos
1 Pediatric Emergency Department, Aghia Sophia Children’s Hospital, Athens, Greece
Background
During the COVID-19 pandemic, pediatric emergency department (ED) attendances were reduced especially during the first phase of the pandemic (2019-2020). After lockdowns and restrictions were terminated, studies in the UK and Italy showed a timely increase to the pre-pandemic attendances. However, limited data are available in middle and low-resource countries.
The aim of this study was to present the pediatric ED attendances in a tertiary Children’s Hospital in Greece.
Methods:
Pediatric emergency attendances from January 2023 through April 2024 were recorded at Aghia Sophia Children's Hospital, a tertiary Children's Hospital with most pediatric subspecialties available. The Pediatric Emergency Department is divided into five main services (pediatric, surgical, ENT, ophthalmology, orthopedic). Some patients are seen by different specialties at the same visit. Attendances were recorded using the combined electronic and paper-based system in the ED.
Results:
During 2023 there were a total of 73,321 pediatric patients seen in the pediatric ED. Of these 39,949 patients visited the pediatric ED, 13,115 patients visited the orthopedic ED, 9,058 were evaluated from the surgical ED, 7,044 from the ENT team and 4,994 from the ophthalmology ED. In addition, 2007 pediatric patients were transferred to the ED using the Hellenic National Center for Emergency Care Services.
Higher attendances were recorded in November and December of 2023 with 6,160 and 7,547, respectively. From January 2024 through the end of April 2024, there were a total of 28,260 visits in the pediatric ED. Attendances showed an increase in 2024 compared to the same period of 2023 (28,260 visits in 2024 versus 24,160 visits in 2023).
Conclusion:
This study showed a steady increase in pediatric emergency department attendances during the winter months as well as during the first four months of 2024. Potential causes of the increased attendance in pediatric ED remain an area of focus for future studies.
Spyridon KARAGEORGOS (Athens, Greece), Anastasios Panagiotis CHANTZARAS, Athanasios EXARCHOS, Vassiliki THEOLOGI, Loukia IOANNIDOU, Anastasia POLYTARCHOU, Stavros ANTONOPOULOS
00:00 - 00:00
#41516 - Penetration Safety Margin of TASER 10 Conducted Electrical Weapon (CEW) Darts.
Penetration Safety Margin of TASER 10 Conducted Electrical Weapon (CEW) Darts.
Background: TASER Conducted Electrical Weapons (CEWs) are used by police and military forces worldwide for controlling violent persons in society. Until now, CEW darts were deployed at approximately 53.3 m/sec (175 ft/sec).
The TASER 10 is a newly introduced CEW featuring multi-shot darts that are of thinner-diameter, higher velocity, and launched via primer-ignited black-powder which classifies this new CEW as a “firearm”. It is important for emergency medicine professionals to understand the safety margin that these New CEW Darts (NCDs) operate within.
Objective: The objective of this project is to describe the safety margin for overpenetration of NCDs on human tissue and to educate the clinician about that risk when deployed as intended.
Methods: We fired 68 NCDs into live human tissue at multiple measured velocities with most exceeding the intended manufacturer’s NCD muzzle velocity of 62.5 m/sec (205 ft/sec) ± 9.1 m/sec (30 ft/sec). Target sites included the lower abdomen, mid-thigh and the buttocks. The NCDs were fired via adjustable velocity, compressed air cannon through a ballistic chronograph to record accurate projectile velocities. The tested maximum velocity (Vmax) was determined based on the speed at which the darts began to show stress from impact fatigue.
Results and Discussion: The range of tested NCD muzzle velocities were between 55.8-83.2 m/sec (183-273 ft/sec). Even at Vmax (273 ft/sec, 83.2 m/sec), no overpenetration of human tissue was noted. The manufacturer’s production velocity is 75% below Vmax.
TASER 10 has been introduced to and is being used in Europe. The NCDs it deploys are faster, of thinner diameter than prior CEW darts and utilize black powder propellant similar to a firearm. It is important for the forensic professional to be familiar with the performance of these NCDs in order to understand the risks associated with them. This work did not demonstrate detectable overpenetration, even when velocities were up to 75% faster than what the manufacturer produces. This indicates a large overpenetration safety margin.
Conclusion and Recommendation: We conclude that the NCDs operate with a significant margin of safety in terms of muzzle velocity and risk of human tissue penetration when fired as intended into recommended target areas.
Jeffrey HO (Minneapolis, USA), Donald DAWES, Sebastian KUNZ, Sarah KNACK
00:00 - 00:00
#41481 - Perceived need and help-seeking for psychosocial support among health and social care professionals: A Systematic Review.
Perceived need and help-seeking for psychosocial support among health and social care professionals: A Systematic Review.
Context: Health and social care workers are facing multiple challenges. Decreasing workforce, fast-aging population, continuous stressful work itself and pandemics may increase burden and stress among health and social care professionals. Preventing work-related mental health issues is fundamental to sustain workforce and improve quality of care. We investigate how health and social care workers have experienced need for psychosocial support and how many of workers in need of help have actually sought for it. Aim is to ascertain, how large-scale these issues are and secundary, how large costs do they cause to the health and social care industry.
Methods: We conducted a systematic review by searching literature about perceived need and help-seeking among health and social care professionals. Articles were searched systematically from PubMed, PsycInfo and Cinahl. We included articles that had quantitative outcome and were written in English, Finnish, Swedish, French or German. Articles selected must had been peer reviewed and had full text available. Covidence tool was independently used by two researchers to screen the results. We used the Quadruble aim framework to categorize the results.
Results: Our preliminary findings show that the perceived need for mental health support among health and social care workers is major. Many of those in need of help did not seek for it for various reasons, such as stigma. Also, the supply of mental health services provided by employers may be insufficient or they are not provided in many cases. However, measuring direct costs of work-related mental health issues proved to be complex.
Discussion: This study highlights the need for psychosocial support in health and social care field among workers. It is highly important to recognize this need not only for sustaining and improving health and social care professionals’ mental health but also for continued delivery of health and social care services and thereby patient safety. Recognizing the dichotomy between perceived need and already provided mental health support is important, so that employers are able to improve better support systems for workers and thereby sustain the workforce in health and social care field.
This is not a clinical trial. This is a systematic review so trial registration is not needed. Ethical approval is also not needed. Funding is provided by Finland's Ministry of Social Affairs and Health.
Oona KUOSMANEN (Kuopio, Finland), Erika JÄÄSKELÄINEN, Kalle SEPPÄLÄ, Paulus TORKKI, Eeva TUUNAINEN
00:00 - 00:00
#40674 - Perceptions of Residents and Assessors on the use of Mini-CEX and Multi-Source Feedback based on Entrustable Professional Activities in Emergency Medicine.
Perceptions of Residents and Assessors on the use of Mini-CEX and Multi-Source Feedback based on Entrustable Professional Activities in Emergency Medicine.
Background: The implementation of workplace-based assessment (WBA) has increased since the development of Entrustable Professional Activities (EPAs). This study investigated the perceptions of assessors and residents towards WBA, such as mini-Clinical Evaluation Exercise (mini-CEX) and Multi-Source Feedback (MSF), aiming to provide foundational data for future EPA-based training and evaluations in South Korea
Methods: This study examined the experiences and perceptions of emergency medicine (EM) residents and assessors who participated in the first pilot trial in South Korea of a WBA utilizing EPA-based mini-CEX and MSF. Through an anonymous online survey, feedback on experiences, perceptions, and recommendations for WBA was collected on a five-point Likert scale and analyzed by dividing the level of agreement by statement.
Results: EM Faculties perceived Mini-CEX positively, indicating strong integration during clinical supervision. EM Residents expressed comfort issues during assessments, highlighting a preference for immediate feedback and multiple evaluators. MSF was generally viewed positively by both assessors and residents, but discrepancies existed in the perceived utility of MSF rating scales and feedback types.
Conclusion: The study demonstrated the readiness and feasibility of embracing WBA methods in current emergency medicine training. However, perception variations between assessors and residents necessitate clear communication about WBA objectives and processes. The findings are crucial for shaping future EPA-based training programs, balancing traditional and WBA methods, and enhancing feedback quality.
Ju Ok PARK (Seoul, Republic of Korea), Kyung Hye PARK, Young Taeck OH
00:00 - 00:00
#41203 - Percutaneous drainage procedure rarely leads to septic shock in pyogenic liver abscess patients—a retrospective cohort study.
Percutaneous drainage procedure rarely leads to septic shock in pyogenic liver abscess patients—a retrospective cohort study.
Introduction
Drainage is a recommended treatment for pyogenic liver abscess (PLA). Septic shock shortly after drainage procedures for acute pyelonephritis and cholecystitis has been reported. Despite numerous studies exploring prognostic factors for PLA, few have investigated the relationship between drainage and the occurrence of septic shock. This study aims to determine the rate and the clinical risk factors of septic shock following drainage in PLA patients.
Methods
We conducted a multi-center retrospective cohort study of PLA patients confirmed by computed tomography in the emergency department of Taipei Veterans General Hospital (TPVGH) from 2010 to 2021 and Taichung Veterans General Hospital (TCVGH) from 1999 to 2022. The inclusion criteria were as follows: (1) diagnosis of ICD10 K75.0, (2) age over 18 years, and (3) liver abscess as the main cause for admission. Patients with unknown status regarding live or death upon discharge were excluded. Both needle aspiration and drainage tube insertion are defined as interventions. Patients’ demographic data, comorbidities, laboratory exams, and clinical outcomes were extracted. Septic shock is identified by persisting hypotension requiring vasopressors to maintain mean arterial pressure >65 mmHg and a serum lactate level >2 mmol/L despite adequate volume resuscitation. Logistic regression models were used for risk factor identification, and the chi-square test was used for determining the significance of nominal data.
Results
A total of 2219 PLA patients were included. The mean age was 63.8 years, and the majority (65.4%) were male. Among them, 1081 (48.7%) patients received drainage procedures. The rate of septic shock in the non-intervention group was 17.1%. In the intervention group, 279 (25.8%) had septic shock, although most cases of septic shock were recorded before the drainage procedure. Only 37 (4.4%) patients developed septic shock after the procedure. Mortality rate for non-intervention and intervention group was 12.1% and 4.9%, respectively (p=0.008). There’s no significant difference in mortality rate of patient who had septic shock before the procedure and 48 hours within the procedure (19.4% vs. 21.6%, p=0.76). Patients with malignancy are more likely to develop septic shock after drainage (p=0.003). Total length of stay of intervention group was significantly longer than that of the non-intervention group (26.6 days vs. 21.8 days, p<0.001). For procedure type, most patient (94%) received drainage tube insertion, and the septic shock rate after aspiration and drainage tube insertion was 1.2% and 4.6%, respectively (p=0.218).
Discussion & Conclusion
Percutaneous drainage procedure rarely leads to septic shock in pyogenic liver abscess patients. Malignancy is the risk factor of developing septic shock after drainage.
Ethical Approval and Informed Consent
The study was approved by the institutional review boards of TPVGH and TCVGH.
We received no funding and we disclosed no conflict of interest.
Tinghui CHIANG (Taipei, Taiwan), Fu CHI, Liu EN-TING, Jin-Wei LIN, Teh-Fu HSU, Yi-Tzu LEE
00:00 - 00:00
#41504 - Perforated Duodenal Ulcer Masked by Opioid Use Disorder.
Perforated Duodenal Ulcer Masked by Opioid Use Disorder.
The patient's information has been anonymized, and consent has been obtained for the submission of details.
Structure:
Compulsory question: What are the key clinical and diagnostic considerations that should prompt clinicians to suspect a perforated peptic ulcer in patients with complex medical histories and atypical presentations, such as altered mental status and chronic opioid use?
Answer: Key clinical considerations for suspecting perforated peptic ulcer: severe abdominal pain, rebound tenderness, imaging evidence of pneumoperitoneum, and acute metabolic disturbances. Risk factors like NSAID use and H. pylori infection should also be considered in the clinical history.
Brief clinical history: with relevant positive and negative features in both history and clinical examination.
A 71-year-old female with a complex medical history including insulin-dependent type 2 diabetes mellitus, hypertension, hyperlipidemia, hypothyroidism, dementia, diverticulitis, and chronic back pain presented to the emergency department with shortness of breath and altered mental status. Upon arrival, she was unresponsive, cyanotic in the extremities, and had abdominal distension and tenderness. Her family insisted that she taken too much pain opioid pain medication, and initially responded to naloxone. Initial labs revealed acute anion gap metabolic acidosis, low hemoglobin, and acute kidney injury. She was initially hypotensive but responded to fluids. Her continued pain lead to CT imaging. Imaging showed pneumoperitoneum, leading to a diagnosis of perforated duodenal ulcer. Despite immediate surgical intervention, she deteriorated and passed away.
Misleading elements – history, examination, investigations:
The patient's chronic medical conditions and family report of heavy opioid use initially misled clinicians, delaying the diagnosis of the perforated duodenal ulcer. Her altered mental status was attributed to opioid use rather than a surgical emergency.
Helpful details – history, examination, investigations:
The presence of abdominal distension and tenderness, along with pertinent laboratory findings and imaging showing pneumoperitoneum, were crucial in diagnosing the perforated duodenal ulcer.
Differential and actual diagnosis:
Differential diagnoses initially included opioid overdose due to the patient's altered mental status, acute pancreatitis, acute cholecystitis, bowel perforation, pneumonia with referred pain, sepsis. However, the actual diagnosis was a perforated duodenal ulcer.
What is the educational and/or clinical relevance of the case(s)?
This case highlights the challenges of diagnosing and treating perforated peptic ulcers, especially in patients with complex medical histories. It emphasizes the importance of maintaining a high index of suspicion and thorough evaluation, particularly in elderly patients with multiple comorbidities. Additionally, it underscores the need for increased awareness among healthcare providers regarding changing demographics and risk factors for peptic ulcer disease.
Wayne MARTINI (Scottsdale, USA), Nicole HODGSON, Shari BRAND, Matthew VAN LIGTEN, Andrej URUMOV, Marcie TORRES
00:00 - 00:00
#41420 - Pericarditis in a severe case of microangiopathy.
Pericarditis in a severe case of microangiopathy.
Pericarditis in a severe case of microangiopathy
Acute microangiopathy is a rare and severe condition. The association between microangiopathy and pleural effusion in the cases reported in literature unravelled a systemic lupus. We present a case of a 38-year-old female patient which presented at the Emergency Department with spontaneous bruises. She had had a common presenting cold two weeks before and following this episode she started having bruises and nose bleedings. She had no personal medical history but had a family history of lupus at her sister. Her symptoms included: chest pain, dyspnoea, multiple bruises, and epistaxis. Blood tests show a haemolytic anaemia with a Haemoglobin level at 6.5g/l, a platelet count at 126 G/L, LDH level 400 UI/L and 4.35% schistocytes. She had moderate renal dysfunction. Her initial blood test showed high DDimers but in the context of renal failure it was initially considered a false positive. The patient had a persistent chest pain and dyspnoea with normal oxygen levels. A Pulmonary Scintigraphy was performed which came out normal and a cardiac ultrasound finally showed a moderate pericardial effusion. The patient was admitted to the Intensive Care Unit. A wide range of immunologic test were done which came out negative as well as the viral and bacterial testing. She was placed under intravenous corticoid therapy at a dose of 1mg/ kilo for two weeks which largely improved her symptoms. She received also a blood transfusion and she completely recovered after 1 month and was discharged with a cardiologic follow up. Pericarditis and microangiopathy is a rare association which can be misleading by neglecting the cardiac symptoms. Rapid diagnosis and treatment in the ED significantly improves the outcomes of this patients.
Oana Maria DAN (Paris)
00:00 - 00:00
#41315 - Peripartum cardiomyopathy; About an observation.
Peripartum cardiomyopathy; About an observation.
Introduction: Peripartum cardiomyopathy is a rare and little-known entity defined as systolic heart failure occurring in the last month of pregnancy or the first five months postpartum, in the absence of known etiology or pre-existing heart disease. We report the observation of a young 22-year-old patient, with no particular pathological history, admitted to our department for extremely serious and refractory left heart failure requiring the use of veno-arterial extracorporeal circulatory assistance (ECMO). The peripartum context made us think about the diagnosis and motivated the performance of an echocardiogram which confirmed this entity.
Observation: 22-year-old patient with no particular medical history, notably no cardiac history. The patient is at 36 weeks of amenorrhea at delivery. This was a first monochorionic biamniotic twin pregnancy. Fifteen days after giving birth, the patient presented with respiratory distress (the oxygen saturation at 88% under 15 liters of oxygen/min) with significant hemodynamic instability; (blood pressure of 78/50mmHg and a heart rate of 125 bpm, quickly requiring vasopressor support with Noradrenaline up to 1.5gamma/kg/min and orotracheal intubation with mechanical ventilation. The electrocardiogram shows sinus tachycardia at 120/min without repolarization disorder. Frontal chest x-ray shows cardiomegaly with interstitial syndrome and signs of pulmonary vascular overload. On laboratory examination, we note renal and hepatic insufficiency, a lactate level of 12mmol/l. Troponin and NT-proBNP are elevated, respectively 164 ng/ml (N < 47.3ng/l) and 2055 pg/ml (N < 300 pg/ml). Cardiac ultrasound reveals an appearance of hypokinetic dilated cardiomyopathy with impaired left ventricular function and a collapsed ejection fraction, estimated < 15%. Left ventricular filling pressures were elevated and grade II mitral regurgitation was probably functional. A decision to implement extracorporeal circulatory assistance by Veino-Arterial ECMO was then quickly taken by the medical team. Faced with downward kinetics of troponin, the absence of chest pain, electrocardiographic repolarization disorder or segmental kinetics disorder on cardiac ultrasound, we judged the probability of coronary artery disease to be low and after discussion with the team of cardiology, we did not perform coronary angiography. The diagnosis of myocarditis was mentioned and given the absence of specific and contextual argument in favor, it was not retained as the main hypothesis. The evolution was favorable with decanulation on the 4th day. Therapeutically, the patient was put on medical treatment combining loop diuretics, ACE inhibitors and B-blockers allowing clinical and ultrasound improvement.
Discussion: The management of this pathology with unpredictable progression, sometimes fatal [1], with risk of refractory cardiogenic shock is, and must be, multidisciplinary. The implantation of mechanical circulatory support should be considered early as a rescue treatment in patients who cannot be stabilized by maximalist medical treatment alone [2].
1- Merson L, Stecken L, Morel N, Lelias A, Dabadie P. Défaillance cardiaque en postpartum : cas clinique d’une cardiomyopathie du peripartum. Ann Fr Anesth Reanim 2008;27:731–4
2- Napp LC, Kühn C, Hoeper MM, Vogel-Claussen J, Haverich A, Schäfer A,Bauersachs J. Cannulation strategies for percutaneous extracorporeal membraneoxygenation in adults.Clin Res Cardiol2016;105:283–296.
Hakim SLIMANI (Colmar), Esteban ROUBEZ
00:00 - 00:00
#41652 - Peritoneal carcinomatosis presenting as a mimic for DVT.
Peritoneal carcinomatosis presenting as a mimic for DVT.
Unilateral leg swelling presents a diagnostic challenge, with various potential causes including DVT, Baker's cyst, and cellulitis. This article stresses the importance of expanding differential diagnosis, especially when common causes are ruled out, as rare etiologies may indicate severe conditions. It presents a case highlighting the significance of considering atypical causes, particularly in patients with a cancer history, and emphasizes the need for a multidisciplinary approach and advanced diagnostic techniques for effective patient management. Clinicians must be aware of less common causes such as arterial insufficiency or systemic diseases, necessitating a broad differential diagnosis. The article introduces a unique case of upstream venous obstruction by peritoneal carcinomatosis, emphasizing the importance of thorough evaluation.
Case presentation:
A 55-year-old woman with a history of breast and endometrial cancer presented with unilateral leg swelling despite negative DVT findings and antibiotic treatment. Elevated D-Dimer levels prompted further investigation, revealing diffuse peritoneal carcinomatosis obstructing the right external iliac vein.
The case underscores the need for a comprehensive approach to unilateral leg swelling, considering both common and rare etiologies. Despite the potential severity of rare conditions like peritoneal carcinomatosis, prompt identification is crucial. The delayed diagnosis highlights the importance of early recognition and management, despite the poor prognosis associated with peritoneal carcinomatosis.
The case emphasizes the importance of broadening differential diagnosis for unilateral leg swelling and highlights the potential life-threatening nature of rare etiologies. A multidisciplinary approach, comprehensive laboratory assessments, and advanced imaging techniques are vital for accurate diagnosis and effective patient management.
Patrick NASRALLAH (Beirut, Lebanon), Mahmoud EL HUSSEIN, Yara MOUAWAD, Cima HAMIEH, Eric REVUE
00:00 - 00:00
#41587 - PERSISTENT HYPOGLYCEMIA - INSULIN OVERDOSE.
PERSISTENT HYPOGLYCEMIA - INSULIN OVERDOSE.
77 years old male with
Background of ESRF on Haemodialysis(HD), Type 2 DM on Insulin, HTN and Parkinson’s disease
Patient was noticed unconscious, on floor with insulin syringe next to him
Noticed Empty bottle of mixtard 30/70. He administered subcutaneous insulin at multiple sites.
He was in low mood for while
Blood glucose was extremyly low.
He was brought by paramedics to emergency department. His blood glucose and GCS continued to be low.
He was intubated and sent to ICU , required continous infusion of dexttrose and mutiple rounds of haemodialysis.
His low neurological status persisted because of neuroglycopenia, underwent MRI brain ,EEG
Gradually neurological status improved on day 7.
He subsequently recovered well and was sent to general ward with psychiatrist review and councelling.
Leanining points in dealing with Subcutaneous insulin overdose.
1. Multiple sites of large dose of Subcutaous insulin in obese patient results in sustained release for long.
2.Renal failure futher slows done the clearance
3.Multiple coomorbidities took longer time to recover
4.Patience in cases with overdose is the best stratergy to follow.
Shobhit SWARUP, Shobhit SWARUP (SINGAPORE, Singapore)
00:00 - 00:00
#40791 - PFKL-mediated hypoxia preconditioned BMSCs preserve mitochondrial function and protect neurons from cardiac arrest-induced pyroptosis in rats.
PFKL-mediated hypoxia preconditioned BMSCs preserve mitochondrial function and protect neurons from cardiac arrest-induced pyroptosis in rats.
Introduction: Cardiac arrest (CA) often leads to severe neurological dysfunction due to inflammation, mitochondrial dysfunction, and post-cardiopulmonary resuscitation (CPR) neurological damage. Bone marrow-derived mesenchymal stem cells (BMSCs) show promise for neurological diseases, but optimizing their therapeutic potential and neuroregulation post-CA remains unclear.
Methods: We established an in vitro co-culture model with BMSCs and post-oxygen-glucose deprivation (OGD) primary neurons, confirming that hypoxic preconditioning enhances BMSCs' resistance to neuronal pyroptosis. We induced an 8-minute CA model through asphyxia induction and assessed hypoxic preconditioned bone marrow-derived mesenchymal stem cells (HP-BMSCs) on post-resuscitation neuronal mitochondrial oxidative stress and pyroptosis using neurological deficit scores (NDS), brain tissue oxidative stress markers, apoptosis-related proteins, mitochondrial area, and damage markers. Mechanistic studies knocked down PFKL expression in HP-BMSCs via si-RNA, verifying potential mechanisms in animals and cells.
Results: Hypoxic preconditioning boosted BMSCs' neuroprotective effect against neuronal pyroptosis, possibly through MAPK and NF-κB pathway inhibition. Consequently, we pursued HP-BMSCs as a neuroprotection strategy, with RNA sequencing suggesting liver isoform of phosphofructokinase (PFKL) as a regulatory molecule. HP-BMSCs significantly reduced neuronal pyroptosis, oxidative stress, and mitochondrial damage induced by CA. This manifested as improved oxidative stress markers, decreased apoptosis-related protein levels, enhanced cell membrane and mitochondrial structures, and reduced mitochondrial damage markers. Transfection of PFKL-targeted si-RNA into HP-BMSCs weakened their protective effects. We also established an in vitro co-culture model to confirm HP-BMSCs' role in improving neuronal energy metabolism following OGD. HP-BMSCs lowered apoptosis-related protein levels and mitochondrial damage markers in primary neurons. Intracellular and mitochondrial reactive oxygen species (ROS) levels dropped, as detected by DCFH-DA and MitoSOX probes. Notably, knocking down PFKL expression in HP-BMSCs reversed these protective effects.
Conclusion: In conclusion, HP-BMSCs offer a promising therapeutic approach for brain injury post-CA by reducing cell pyroptosis mediated by mitochondrial ROS, potentially linked to elevated PFKL expression following hypoxic preconditioning.
The experimental protocol received approval from the Animal Welfare and Ethics Committee of Fujian Medical University (License No. IACUC FJMU 2022–0577).
The present study was supported by the Natural Science Fund of Fujian Province (NO. 2020J011058), the Project of Fujian Provincial Hospital for High-level Hospital Construction (NO. 2020HSJJ12), the Fujian Provincial Finance Department Special Fund (No. (2021) 848) and the Fujian Provincial Major Scientific and Technological Special Projects on Health (NO. 2022ZD01008).
Xiahong TANG (Fuzhou City, China)
00:00 - 00:00
#41932 - Pink Coccoid: Sepsis on a Knee Prosthesis - A Case Report.
Pink Coccoid: Sepsis on a Knee Prosthesis - A Case Report.
Aim: In 1984, Gilardi and Faur described a new group of non-fermentative bacteria displaying pink pigmentation, resembling Methylobacterium extorquens. Termed the "pink coccoid" group by the Center of Disease Control (CDC), these organisms share common phenotypic traits. This paper discusses Roseomonas gilardii, an infrequent cause of human infections, focusing on a patient with sepsis on a knee prosthesis attributed to this bacterium.
Case presentation: A 62-year-old male presented with painful swelling of the left knee persisting for 8 years, attributed to knee arthrosis. He had been managed symptomatically with non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics. On examination, there was noticeable swelling, limping, and partial loss of function, with tenderness on palpation of the lateral collateral ligament (LCL) and medial collateral ligament (MCL). Subsequently, a total knee arthroplasty was performed, and the patient was discharged with an 8-day course of antibiotics and normal laboratory findings: white blood count of 9.2 × 10^9/L, hemoglobin levels of 163 g/L (reference values 132–162 g/L), and platelet count of 176 × 10^9/L (reference values 165–415 × 10^9/L). Sixteen months later, the patient returned with recurrent knee pain and swelling. Physical examination revealed a positive patellar shock and a waddling gait. He was readmitted for a knee joint puncture, which showed negative direct examination but with 90% neutrophils. C-reactive protein levels were elevated at 6.6mg/L. A CT scan revealed no signs of prosthesis loosening but confirmed the presence of effusion in the supra patellar pouch. Several bacteriological samples were taken, and from a single sample, a pathogenic pink gram coccus, Roseomonas gilardii, was isolated. It was effectively treated with antibiotics initially in the hospital setting and then continued orally, successfully managing this uncommon infection.
Conclusion: Less than ten cases of bone and joint infections related to R. gilardii have been reported to date. Risk factors include prior surgery, rheumatoid arthritis, advanced age, concurrent skin infections, and diabetes. A notable characteristic of this gram-negative organism is its susceptibility pattern to cephalosporins in particular.
Khouloud KHEMILI (Tunisia, Tunisia), Jacem SAADANA, Firas CHAOUECH, Said ABID, Bilel FAIZI, Habib HADJ TAIEB, Hatem BELGACEM, Moez JELLALI, Iheb NTICHA, Ahmed MDAOUKHI, Aymen FEKIH, Abderrazek ABID
00:00 - 00:00
#41351 - Pneumorachis associated with pneumomediastinum Spontaneous: A Benign Clinical Entity.
Pneumorachis associated with pneumomediastinum Spontaneous: A Benign Clinical Entity.
A 27-year-old patient consulted the emergency room for atypical respiratory-related chest pain associated with subcutaneous cervical emphysema that occurred a few hours after carrying a heavy load. The patient's only history was allergic asthma. On admission, the patient was hemodynamically and respiratory stable. The visual analog pain scale is rated 5/10. Clinical examination revealed discreet superficial polypnea with a respiratory rate of 22 cycles/minute. Palpation revealed subcutaneous emphysema predominating in the anterior cervical region with characteristic snowy crepitations. The remainder of the examination was normal. The biological assessment did not show any abnormality, in particular no inflammatory syndrome. Frontal chest x-ray confirmed the existence of pneumomediastinum associated with subcutaneous cervical emphysema. The cervicothoracic scan confirms the presence of air over the entire height of the mediastinum associated with pneumorachis and subcutaneous emphysema of the cervical soft tissues. On the other hand, there was no damage to the esophageal or tracheal wall. Given the absence of clinical severity criteria, the patient benefits from simple clinical monitoring for 96 hours. The evolution was favorable and the clinical and radiological signs improved. The patient is seen again a week later, in pulmonology consultation, completely asymptomatic with a strictly normal chest x-ray.
Spontaneous pneumomediastinum is defined as the presence of air in the mediastinal structures without an obvious cause. Its incidence is between 0.01% and 0.001% of patients seen in hospital (1). The mechanism most often cited in the literature is that of endobronchial hyperpressure with a closed glottis, which would be responsible for alveolar rupture near the vascular septa. It can be complicated by pneumorachis, usually with little or no symptoms, when air enters the epidural spaces through the conjugation holes (2). The clinical presentation is not very specific, however the presence of dysphagia and/or dyspnea should call into question the spontaneous nature of the pneumomediastinum. The positive diagnosis is made by the frontal X-ray which highlights an air border along the left edge of the cardiac silhouette and subcutaneous hyperlucency in the cervical region. The natural progression is towards healing in 48 to 96 hours. Recurrences are rare and complications are exceptional. Knowing how to recognize this entity allows it to be immediately distinguished from secondary pneumomediastinum and will thus prevent the patient from receiving inappropriate medical care.
1- Newcomb AE, Clarke CP (2005). Spontaneous pneumomediastinum: a benign curiosity or a significant problem? Chest; 128: 3298-302.
2- Hazouard E, Koninck JC, Attuci S, et al (2001). Pneumorachis andpneumomediastinum caused by repeated Müller’s maneu-vers: a complication of marijuana smoking. Ann Emerg Med 28:694-7.
Hakim SLIMANI (Colmar)
00:00 - 00:00
#41093 - POCUSing Extraordinary Etiology of Shock.
POCUSing Extraordinary Etiology of Shock.
A 70-year-old patient, previously healthy, was rushed to the emergency room late at night, the EMS report indicates that the patient experienced respiratory failure, which occurred during a meal. As a result, the patient was anesthetized and intubated in the field, on admission, the patient showed low BP of 60/35 mmHg and sinus rhythm heart rate of 120 BPM, no signs of acute ischemia on his ECG, ABG analysis showed mixed deep acidosis along with lactatemia, Point-of-care ultrasound (POCUS) findings indicated the absence of pericardial effusion and normal LV contraction, no evidence of right ventricular strain, inferior vena cava demonstrated adequate collapsibility, However, B-lines were observed bilaterally above both lungs, chest x ray shows bilateral infiltration, noradrenaline infusion started, vasopressin was later added due to lack of rise in BP, Initially, the diagnosis was Shock of Unknown Origin.
Anamnesis from patient's wife ruled out symptoms of angina prior to the event and there was no documented fever or signs of infection recently.
Blood tests revealed a normal hemoglobin level of 15 g/dL, chemistry results showed acute kidney injury and a mild increase in CRP levels.
Due to the combination of shock and pulmonary congestion, a re-POCUS using color Doppler revealed severe mitral valve regurgitation. Video recordings were sent to an echo expert via phone, who raised a high suspicion of papillary muscle rupture. Subsequently, a transesophageal echocardiogram (TEE) was promptly performed by on-call cardiologist, confirming the diagnosis of papillary muscle rupture.
Considering all parameters, the patient was connected to veno-arterial extracorporeal membrane oxygenation (VA ECMO) and urgently transported for mitral valve repair surgery after nearly two hours from admission, A few hours later, successful decannulation of ECMO was achieved, accompanied by improvement in all vital parameters, The next day, the patient was successfully weaned from artificial ventilation , a coronary catheterization revealed a diagonal artery stenosis, treated with drug-eluting stent effectively, blood culture were negative, A few days later the patient was discharged home.
The case described above underscores the necessity of POCUS use in cases of shock, particularly for timely diagnosis and appropriate management.
Loai MREISAT (, Israel)
00:00 - 00:00
#40858 - Point of Care Ultrasound and Headache.
Point of Care Ultrasound and Headache.
A young male presented with a global headache, moderate, constant, associated with nausea and intermittent vomiting for the last month. He denies fever, falls, or any co-morbid conditions. His neurological examination is unremarkable and hemodynamically normal. A point-of-care ultrasound (POCUS) is used to access the optic nerve sheath diameter bilaterally, which was found to be 6 mm, indicating bilateral papilledema with an elevation of the retina. CT head is done, revealing a left parietooccipital space-occupying lesion with a midline shift. He underwent surgical resection on an urgent basis by the Neurosurgical services. The biopsy showed grade IV astrocytoma, and he is undergoing chemotherapy. Due to his subtle chronic complaints and healthy clinical background, it is challenging to identify a critical diagnosis of a space-occupying lesion; however, point-of-care ultrasound has proven to be beneficial and a valuable clinical clue, in this case, highlighting its importance and utility in such borderline cases to conclude. The non-invasive nature of POCUS makes it practical to assess intracranial pressure when invasive techniques like lumbar puncture can be potentially substituted by it to identify raised intracranial pressure (ICP). The agreement on the cut-off for optic nerve sheath diameter related to raised ICP is lacking. However, more studies need to establish consensus, making POCUS a reliable tool to assess life-threatening midline shifts with the likelihood of herniation quickly.
Tahir SHAHZAD (Toledo, USA), Fatima Moulana MD JAMAL ULLAH
00:00 - 00:00
#42329 - Point of care ultrasound in the ED, a tool to manage life-threatening emergencies in resource-limited regions: a serie of 3 cases.
Point of care ultrasound in the ED, a tool to manage life-threatening emergencies in resource-limited regions: a serie of 3 cases.
Introduction:
Clinical emergency ultrasound has become increasingly widespread in emergency departments. It improves clinical assessment, enhances initial management decision-making, and expedites diagnostic and therapeutic interventions.
Observation:
Case #1:
69-year-old male with a history of poorly controlled hypertension and past tobacco use, presented with a 4-day history of moderate-intensity basal band-like headache, thoracic pain, shoulder discomfort, and fatigue. On examination, he exhibited elevated blood pressure (19/10 mmHg bilaterally) and a 2/6 diastolic murmur over the aortic area. Echocardiography revealed an enlarged, non-dilated left ventricle with preserved systolic function, a flap motion at the level of a dilated ascending aorta (44 mm), along with a small pericardial effusion and moderate aortic insufficiency. CT angiography confirmed a type 2 DeBakey aortic dissection extending to the aortic arch and origin of the right brachiocephalic trunk. He underwent emergent ascending aortic prosthesis placement. Postoperatively, he developed nosocomial bilateral pneumonia and a pseudoaneurysm at the left ventricular apex but stabilized over two months.
Case #2:
71-year-old male without significant medical history, presented to the ED with sudden severe retrosternal and epigastric stabbing pain radiating to his back for two hours. On admission, he was agitated, hypotensive (70/40 mmHg), tachycardic (126 bpm), cold with profuse sweating, and exhibited signs of right heart failure. POCUS Echocardiography revealed a non-dilated left ventricle with a large rounded mass compressing the left atrium and left ventricle, severe subaortic stenosis, and a normal aortic root. CT angiography confirmed an extensive type 3 DeBakey aortic dissection involving the descending thoracic and abdominal aorta. Despite stabilization, there were no surgical options available, and the patient suffered a cardiac arrest within three hours of admission, leading to death.
Case #3:
71-year-old female with a history of hypertension, diabetes, and atrial fibrillation, presented to the ED with sudden migratory chest pain radiating to her jaw and transient loss of consciousness. On arrival, she was dyspneic, hypoxic (90% saturation), hypertensive (140/90 mmHg), and initially obtunded, then aphasic with progressive hypotension (70/50 mmHg). POCUS Echocardiography revealed a dilated initial aorta, hypertrophied non-dilated left ventricle with preserved function, and circumferential pericardial effusion without significant aortic regurgitation. Aortic dissection type A was suspected. CT angiography was planned but delayed due to unavailability of a radiologist. Despite stabilization and early transfer to the cardiovascular surgery department for urgent intervention, the patient died during surgery.
Discussion:
Clinical emergency ultrasound plays a pivotal role in screening cardiovascular emergencies due to its ability to provide rapid and accurate diagnostic information at the point of care. By enabling timely identification of critical conditions such as aortic dissection, pericardial effusion, or acute myocardial infarction, it facilitates prompt initiation of appropriate interventions, ultimately improving patient outcomes. Moreover, its portability make it an invaluable tool in resource-constrained settings or when rapid assessment is essential. This leads to optimize the management of cardiovascular emergencies and reduce diagnostic delays and cost.
Conclusion:
Clinical emergency ultrasound rapidly identifies cardiovascular emergencies, aiding prompt interventions and improving outcomes. Its portability and non-invasive nature make it indispensable, crucial for saving lives in resource-limited settings.
Mohamed Ali NBAYA (Gabès, Tunisia), Amal KCHAOU, Khaireddine BEN AMOR, Omar HADDAR, Rahma KALLEL, Jihene HAMMADI, Imene REJEB, Hichem DENGUIR
00:00 - 00:00
#41621 - Point-of-care ultrasound (POCUS) as a guiding tool for diagnosing a multimorbid patient.
Point-of-care ultrasound (POCUS) as a guiding tool for diagnosing a multimorbid patient.
Brief clinical details (80 words): A 62-year-old male arrived at the emergency department experiencing a progressively worsening shortness of breath and cough that had been ongoing for three days. He denied having a fever and did not report any other associated symptoms. His medical history included chronic bronchitis, pulmonary tuberculosis, alcohol addiction, and a pancreatic pseudocyst. The possible diagnoses include pneumonia, pulmonary embolism, acute myocardial infarction, congestive heart failure, and various other potential conditions.
Description of the relevant abnormalities (80 words): The patient presented with hypotension, cyanosis, dyspnoea, and oxygen saturation of 64%. Upon palpation, the physical examination indicated a firm and tender abdomen with reduced peristalsis. Point-of-care ultrasound was performed, revealing dilated intestines and “to-and-fro” peristalsis with high suspicion for pneumoperitoneum. Therefore, a chest X-ray was performed which was unremarkable, but the abdominal X-ray and abdominal CT confirmed pneumoperitoneum, but with no additional information. The final diagnosis was made by exploratory laparotomy which revealed a perforation of Meckel's diverticulum.
Why this image is clinically or educationally relevant (50 words): The misleading symptom in our case was dyspnoea secondary to chronic bronchitis and elevated diaphragm due to ileus from perforated Meckel’s diverticulum. This clinical image also underscores the importance of using point-of-care ultrasound as a quick and non-invasive diagnostic method in emergency settings, especially for patients with complex medical histories.
Maja ALABER, Bruna BUŠIĆ, Maša SORIĆ (Zagreb, Croatia)
00:00 - 00:00
#41382 - Point-of-Care Ultrasound Development Program for the Emergency Medicine Faculty.
Point-of-Care Ultrasound Development Program for the Emergency Medicine Faculty.
Introduction
Although our department offers well-structured point-of-care ultrasound (POCUS) training for emergency medicine trainees, we have an acknowledged deficit in certified POCUS faculty. With this insufficient number, the quality of training provided to the trainees and patient care might be affected. Despite the interest of emergency medicine faculty in POCUS, it's still a self-development process and not addressed in the future departmental development plan.
Objectives
This project aims to develop a POCUS training program for the emergency medicine faculty. The program will help them hone their skills in acquiring and interpreting the POCUS images and ultimately qualify them as POCUS Independent Practitioners (IP) by the Oman Medical Specialty Board (OMSB), the authoritative entity for accreditation and certification.
Methods
In the emergency department of Sultan Qaboos University Hospital, Oman, our prospective observational study commenced in October 2022 after getting approval from the Medical Research and Ethics Committee. The study is for a minimum of 3 months and a maximum of one year. A need assessment survey was done at the beginning of the study among all the (22) emergency medicine faculty. They all confirm the department's need for structured POCUS training to improve, master, and maintain their skills. For the study, there were (8) physicians certified as POCUS-IP; (3) physicians were interested but preferred self-learning; (1) physicians were neither certified nor interested; (10) physicians were included. To be certified as POCUS-IP, The physician must go through three steps: first, attending a Core-POCUS course, then passing the written and practical tests, and completing the required number of scans for each of the (7) modules supervised by POCUS instructors.
The required number of scans are FAST (50), Echo (25), Lung (10), Gallbladder (25), Renal (25), AAA&IVC (25), and DVT (25). With the cooperation of OMSB, they agreed to do a Bootcamp course following the C-POCUS Course to help the candidates do as much as they can from the required number of scans under the supervision of POCUS instructors. Certified faculty are subject to tri-monthly skill verification via Direct Observation Procedure Skills (DOPS) and organized scan days, ensuring sustained competency.
Results
The program began with ten physicians; however, one of the candidates resigned before beginning the course. (9) candidates attended the C-POCUS and Bootcamp courses and completed the required number of scans in each module within three months. All the candidates passed the written exam, but only (5) of them passed the practical test and are becoming POCUS-certified as Independent Practitioners (IP). The other (4) physicians passed the practical exam after remediation in one module two weeks after the first attempt and then got certified as POCUS IP.
Conclusion
For emergency medicine physicians, mastering POCUS is essential to providing excellent patient care and standardizing ultrasound training. The path to POCUS certification is difficult but necessary, requiring stakeholders to work together in unison. Stakeholder synergy and focused faculty development programs make such initiatives possible and essential to advancing emergency care.
REF. NO. SQU-EC/ 055/2022
MREC #2723
Medical Research and Ethics Committee- Sultan Qaboos University Hospital- Oman
Ashraf ELSHEHRY (Egypt, Egypt)
00:00 - 00:00
#41719 - Pontine abscess: A tale of intracranial intrigue – A case report.
Pontine abscess: A tale of intracranial intrigue – A case report.
Brief clinical history:
A 41-year-old patient presented to the emergency department due to gradually onset occipital headache of a pressing nature. Additionally, he noticed decreased visual acuity when looking to the right. He denied nausea and vomiting. The pain subsided with the use of paracetamol. There was no photophobia or phonophobia. He denied recent trauma, fever, or recent infectious events. No tick bites. He has not had any significant illnesses before and does not take chronic drug therapy. Neurological examination revealed no deficits or lateralization. Laboratory findings were unremarkable, and urgent non-contrast CT scan showed no pathological substrate. Symptoms completely regressed upon intravenous ketoprofen administration, and the patient was discharged home.
The next morning, the patient returned to the emergency department due to weakness in the left hand and loss of balance while walking. On examination, the patient was in good general condition with normal vital signs and afebrile. Speech was mildly dysarthric, and in antigravity tests, the left limbs deviated towards the ground with a subjective feeling of heaviness. The left foot was mute. The gait was unstable with circumduction of the left leg, and in the Romberg test, there was titubation with retropulsion. Meningeal signs were negative. Visual field was normal. Examination of bulbomotor function revealed no nystagmus, but there was paresis of the right abducens nerve. No other deficits were found.
Misleading elements:
An urgent non-contrast brain CT scan showed no changes compared to the previous day's scan. No abnormalities were observed. A day later, CT angiography showed a discrete hypodense formation in the right posterior limb of the internal capsule, suggestive of an ischemic focus. Supra-aortic branches and vertebral arteries showed appropriate lumen width without stenotic changes. The diagnosis of ischemic stroke was made. Laboratory findings initially and in follow-up intervals showed no leukocytosis and normal values of inflammatory parameters. Cerebrospinal fluid was not analyzed.
Helpful details:
The patient's level of consciousness deteriorated, becoming stuporous. MRI of the brain showed an oval, heterogeneous T2 hyperintense, T1 hypointense lesion with irregular margins in the pons, measuring 23x20x30mm, suggestive of an abscess or malignancy. Surrounding edema was described, without previously described ischemia on CT. No other pathological substrates were found. Blood cultures came back negative.
The differential and actual diagnosis:
The differential diagnosis for this patient included cerebrovascular ischemic stroke, meningoencephalitis, primary/secondary malignancy, and brain abscess.
The patient underwent neurosurgical stereotactic biopsy, with histopathological findings consistent with a pontine abscess. Microbiological findings were suggestive of odontogenic origin of abscess. Additionally, CT of the paranasal sinuses revealed a defect in the cortical bone around the maxillary alveolar process.
Educational and/or clinical relevance:
The presentation of a pontine abscess without typical signs of infection or fever serves as a reminder that uncommon neurological conditions can manifest in atypical ways. The delayed diagnosis despite initial negative imaging findings emphasizes the role of advanced imaging modalities, such as MRI with contrast in identifying subtle abnormalities that may be missed on initial evaluation.
Adela MARINELLI, Mersiha BAČEVAC (Zagreb, Croatia)
00:00 - 00:00
#41086 - Pontine stroke - a complication of cervical epidural steroid injection.
Pontine stroke - a complication of cervical epidural steroid injection.
This is a 42 year old female with no cardiovascular comorbidities, only a history of chronic neck pain, who presented to the emergency department of an outside hospital with a sudden onset of left sided facial droop and left hemiplegia after undergoing a C2-C6 medial branch radiofrequency and cervical epidural injection for her cervical degenerative disease. MRI revealed evidence of a large hemi-pontine infarct along with scattered punctate foci of infarctions in the right cerebellar hemisphere, right vermis, and right occipital lobe. Upon arrival to our facility, the patient was hypotensive with a blood pressure of 86/66 and physical examination showed left upper and lower extremity weakness, facial asymmetry, and dysarthria. She had a GCS of 15 and an initial NIHSS score of 10. Immediate resuscitation was initiated and patient was sent for CT and CTA once she was hemodynamically stable. CT and CTA did not show hemorrhage or large vessel occlusion, respectively. However, an incidental finding of of pneumomediastinum was noted. Following the CT scan, the patient started to actively vomit, compromising her airway, and her GCS dropped to 7. She was then intubated and admitted under the neurological intensive care unit. Two days later, she was successfully extubated and weaned off of sedation.
Differential diagnoses include a cerebral ischemic stroke, cerebral hemorrhagic stroke, cerebellar infarct, brainstem stroke, brainstem hemorrhage, subarrachnoid hemorrhage, intracerebral hemorrhage, and a cerebral sinus venous thrombosis.
Educational/clinical relevance: cervical epidural injections are commonly used for pain management in various conditions, including our patient's condition in this case. However, the complications are thought to be uncommon and minor. Only minor complications such as headache and spinal nerve irritations were discussed in randomized and non-randomized clinical trials with major complications discussed in scattered case reports. The major complications mentioned in the literature include spinal abscess, epidural hematoma, spinal cord infarct, cerebellar or brain stem infarct, and even death. There are only a few reported cases with catastrophic neurological sequelae following a cervical epidural steroid injection, however, the the incidence of this complication is lacking in the literature.
There have been suggested mechanisms behind the etiology of complications that include an embolic mechanism where unintended intra-arterial injection of corticosteroid particles lead of distal infarction.
To conclude, it is important to stay mindful regarding the catastrophic complications of cervical epidural spinal injections since there holds a risk for significant neurological injury affecting the patient's quality of life.
Saweera SABBAR, Fatima AL KHYELI, Noura AL DOSARI (Abudhabi, United Arab Emirates)
00:00 - 00:00
#42231 - Practice variation in use of oral corticosteroids (OCS) to treat Preschool wheeze (PSW) in the UK and Ireland.
Practice variation in use of oral corticosteroids (OCS) to treat Preschool wheeze (PSW) in the UK and Ireland.
Aim:To describe practice variation in the use of oral corticosteroids (OCS) for pre-school wheeze (PSW) in Emergency Departments in the UK.
Method:Two surveys were circulated throughout PERUKI network membership [Paediatric Emergency Research In the UK and Ireland] in December 2023 via REDCap. Departmental practice and local guidance was reported by site leads in Survey-1 and individual practice was assessed in Survey-2 assessing responses to clinical vignettes.
Results:26 site leads responded. 46% of sites report having guidance specifying which children with PSW should receive OCS. Without local guidelines the majority are following national UK guidance. 60% of sites use prednisolone with significant variation in both age-based and weight-based dosing; for a minimum of three-days. 40% of children prescribed dexamethasone are receiving 600mcg/kg.
50% of ED sites have access to point-of-care (POC) testing for respiratory pathogens. However, only half of these are permitted to utilise them in children with PSW unless admitted.
We received 492 clinician responses broadly representing 84 trusts, a breadth of experience and specialities. 70% of clinicians would not prescribe OCS in a case of a 3-year-old with a moderate wheeze responsive to bronchodilator therapy. Severity of presentation and a failure to respond to bronchodilators were the most common ‘free-text’ answers used to validate clinicians’ responses. This echoes that “wheeze severity” was the most frequently ranked “most important” factor to prescribe OCS. Where some clinicians determined an admission or hypoxia would mark sufficient severity, others considered CPAP or PICU admission as the threshold of severity for OCS.
A child’s previous wheeze history and personal history of atopy were ranked the most important or highly important factors by 85% clinicians. There was an ongoing lack of consensus in what was deemed a significant wheeze history, or which features of a child’s history demonstrates ‘atopy’. A child’s family history of wheeze or atopy was less important, only half clinicians ranking this as a “highly important factor”.
Age was relevant to clinicians’ decision. Whilst 20% of clinicians would prescribe OCS to children <2 years, 20% reported a cut off of 2years, a further 20% >3years and 40% would be more likely to prescribe >5years.
Viral testing was ranked the least influential factor to prescribe OCS. When asked how it would influence clinicians’ decision, 67% were less likely to prescribe OCS if positive for any virus. Interestingly, in the clinical-vignette half the clinicians prescribing OCS initially, changed their decision if the child was RSV positive.
Conclusions:There is wide practice variation in the management of PSW across the UK. Three-day courses of prednisolone are the most commonly prescribed OCS despite evidence showing single doses of dexamethasone are better tolerated and non-inferior to prednisolone.
Clinicians are most likely to prescribe OCS based on severity, wheeze history and atopic risk factors. Although consistent with recent evidence and international guidance there’s concerning variation in the threshold of severity requiring OCS and the definition of atopy or recurrent wheeze. Age is a less important factor for clinicians prescribing OCS, with 40% clinicians prescribing OCS for children under 3-year-olds.
n/a
Hannah NORMAN-BRUCE (Northern Ireland, ), Helen GROVES, Thomas WATERFIELD
00:00 - 00:00
#41571 - Pre-hospital management of a shark bite.
Pre-hospital management of a shark bite.
Shark attacks are very rare, especially in European countries. With global warming and increased interaction of humans with their habitats, we may see more events in the future.
We present a case report of a 35-year-old fisherman who was attacked and bitten on the left leg by a blue shark in open sea, 167km off the Portuguese coast. After the incident, his crew asked for help from the Portuguese Navy and Portuguese Air Force. They applied a proximal tourniquet because of major hemorrhage but released it every 5 minutes and waited for the rescue team. After 4 hours, the fisherman was rescued by a helicopter of the Portuguese Air Force, and a rendezvous with the pre-hospital team at Aeroporto do Porto was made 30 minutes later, responsible for transporting the patient to the hospital. Resuscitation in accordance with the advanced trauma life support was initiated. At the initial assessment, the patient's airway was patent, he had no problem with breathing, and was hemodynamically stable; an adequate tourniquet was applied by the rescue team. Heated crystalloids and tranexamic acid were administered. Communication and anamnesis were difficult because the patient was not a native Portuguese speaker and did not speak Portuguese, English, or Spanish. Multimodal analgesia was initiated by the rescue team and continued, titrated by the facial pain rating scale (FPRS). Different plans for analgesia were made to be used if the initial strategy failed. FPRS of 10 was reduced to 2 after topping up analgesia. Distal pulses were measured, and although reduced, they were present. Distal motor and sensory function were difficult to measure because of communication difficulties. Because of the high risk of infection, the lesion was cleaned with saline and closed with compressed bandages. The patient was transported to the Emergency Department of the hospital without any major complications. Shark attacks are uncommon, but they should be managed like any other trauma. In many circumstances, help may not be capable of reaching the victims on time, so it is important to educate the general population in basic life support. Scores like FPRS may be used in instances where communication with the patient may not be possible.
Leonardo FERREIRA (Porto, Portugal), Sofia SILVA
00:00 - 00:00
#42090 - Pre-hospital management of newborns and infants: characteristics of interventions and clinical profile.
Pre-hospital management of newborns and infants: characteristics of interventions and clinical profile.
Introduction:
Pre-hospital care of patients under two years old in Tunisia is provided by polyvalent Mobile Emergency and Resuscitation Services (MERS). It involves primary and secondary interventions. The aim of our study was to evaluate clinical characteristics of interventions and clinical profile of newborns and infants.
Methods:
We conducted a retrospective, longitudinal, and descriptive study at Ben Arous MERS over a one-year period. We included pre-hospital interventions involving patients under two years old. We collected demographic and clinical data, as well as timing and procedures performed. We compared age subgroups and interventions’types. Workload was assessed using the score Codage Activité SMUR (CAS).
Results:
We included 65 interventions. For newborns, median age was 14 days. For infants, median age was 14 months. Male predominance was observed with a gender-ratio of 1.5. Ratio of primary to secondary interventions was 0.14. Inter-hospital transfers accounted for 88% of secondary interventions. Respiratory pathologies were the most frequent (63% in newborns and 60% in infants). Median departure time was 11 minutes. Mean medicalization duration was 52 minutes. The intervention team performed seventy-seven procedures. Median CAS score was 5 [4-11], ranging from 1 to 30. Workload was higher in newborns compared to infants (CAS score: 5[5-7] versus 4[0.4-8]; p=0.04).
Conclusions:
Pre-hospital activity for patients under two years old is frequent, involving usually high workload. Improvement in the existing polyvalent MERS performances and establishment of pediatric specialized MERS should be integrated into a national strategy to enhance care for this specific subgroup.
None
Ines CHERMITI, Nouha HAMOUDA, Raja FADHEL (Ain Zaghouan, Tunisia), Sirine KESKES, Hanène GHAZALI, Sami SOUISSI
00:00 - 00:00
#42291 - Predectivefactors of mortality from heat related patholoies.
Predectivefactors of mortality from heat related patholoies.
Introduction :
Exposure to extreme heat is a seasonal reason for emergency department visits, but this pathology can have serious and even fatal consequences this makes it necessary to detect severity and mortality factors in order to improve emergency department management.
Objectives :
Determine the predictive factors of mortality for heat-related pathologies in patients admitted to the emergency department.
Methods:
This was a descriptive, analytical, prospective, monocentric study conducted in the emergency department over a two-month period.
Inclusion criteria: age over 15 years, both sexes, patients admitted for heat-related illnesses.
Exclusion criteria: pregnant women, patients seen on an outpatient basis.
Results:
51 patients were enrolled, 51 patients were enrolled, sex ratio=2.4; mean age=68.4±11.1 years. Autonomy (p=0.320), medical-surgical history (p=0.360), altered state of consciousness (p=0.001), asthenia (p=0.054), dehydration (p=0.730), PAS (p=0.036), PAD (p=0.013), Heart R (p=0.005), HCO3 (p=0.035), AST (p=0, 008), presence of complications (p=0.007), hemodynamic distress (p=0.000), respiratory distress (p=0.175), neurological distress (p=0.000), multivisceral failure (p=0.000), orotracheal intubation (p=0.010).
Conclusion :
Factors predictive of mortality in cases of exposure to extreme heat are essentially altered state of consciousness, PAS, PAD, HR, bicarbonates, hepatic cytolysis, presence of vital distress on admission and recourse to orotracheal intubation.
Sirine KHABOUCHI, Khaireddine JEMAI (Tunis, Tunisia), Dhekra HOSNI, Seif OUERGHI, Hana HEDHLI, Safia OTHMANI
00:00 - 00:00
#41116 - Predict the Intensive Care Necessity of Unknown Source Sepsis with Triage Physical Parameters in Emergency Room: The Case-Control Study.
Predict the Intensive Care Necessity of Unknown Source Sepsis with Triage Physical Parameters in Emergency Room: The Case-Control Study.
Background
Unstable unknown source septic patients usually need the intensive care at emergency room(ER). When massive unknown source septic patients are sent to ER the chaotic condition would be expected and one simple and operative method should be used to find the necessity of intensive care among these patients. The present triage offers the physical finding including systolic blood pressure (SBP), diastolic blood pressure (DBP) heart rate (HR), breathing rate (BR), Glasgow coma scale (GCS). Some indicators including shock index (SI) and mean atrial pressure(MAP) are used to forecast the final results of shock, trauma or gastrointestinal bleeding patients. In this study these physical parameters are stretched to predict the necessity of intensive care without extra clinical working loading of nursing staffs.
Method:
There are 1330 patients from 2021-08-01 till 2022-08-01 included in this study. The patients of out-of-hospital cardiac arrest (OHCA) and incomplete medical record are excluded. The inpatients without definitive infection source are diagnosed by ER physicians and separated into two groups that is ward-admission group and intensive care unit(ICU)-admission group. The SBP, DBP, HR, BR, GCS, SI, MAP are used in the prediction of intensive care necessity. In this study the Mann-Whitney U test, binary logistic regression and receiver operating characteristic curve (ROC curve) study are used to find out the better indicators.
Results:
924 patients are admitted to ward and 404 patients belong to intensive care group. There are statics differences in HR, BR, GCS and SI at Mann-Whitney U test, binary logistic regression and ROC. The p valve is < 0.05. On the ROC curve study the SI and BR have the better correlation with the necessity of intensive care. The SI and BR present the AUC area, which is 0.674 and 0.625 among these indicators and MAP show the lowest valve of AUC area
Discussion and Conclusions:
The patients without definitive infection sources usually combine the extra work loading and extend the duration of medical decision and intensive care may be necessary. The SI and BR present the higher AUC area and better correlation with the necessity of intensive care. MAP is not good indicator in the prediction of intensive care necessity. The better regression model, which is used for the prediction of intensive care should include HR, BR, GCS and SI. The physical parameters provided at triage could be extended to expect the necessity of intensive care in these unknown source septic patients. These indicators can be built-in computer program to remind ER physicians making more meticulous and decisive medical decision and playing as one assisted part of medical care in future. In the prehospital care of pandemic period Emergency Medical Technician (EMT) staffs would make the better communication with charged doctors under the help of these indicators from remote area.
Approved number of St. Martin De Porres Hospital Institutional Review Board (IRB) : 21B-004
ClinicalTrials.gov ID: NCT05584098
This study did not receive any specific funding
Chia-Hsi CHEN (Chiayi, Taiwan, Taiwan), Hung-Wen CHEN, Jui-Fang HUANG, Hsiu-Chun CHEN, Yu-Ting HUANG, Jou YEONG-CHIN
00:00 - 00:00
#41887 - Prediction of cardiovascular mortality based on iron metabolism in patients with Cardiovascular-Kidney-Metabolic Syndrome: development and validation of clinical predictive model.
Prediction of cardiovascular mortality based on iron metabolism in patients with Cardiovascular-Kidney-Metabolic Syndrome: development and validation of clinical predictive model.
Background:
Iron metabolism is associated with cardiovascular disease (CVD) mortality in Cardiovascular-kidney-metabolism (CKM) syndrome patients, but its significance in evaluating their prognosis remain unclear. This study was aimed at evaluating incorporation of iron metabolism indicators as a predicting tool for CVD mortality in CKM syndrome.
Methods:
This cohort study was conducted on data of CKM syndrome patients collected from the National Health and Nutrition Examination Survey (NHANES) between 1999 and 2018. A total of 26,240 individuals aged 30-80 years old at CKM stage 0-2 without CVD at baseline were included in the analysis, among which, 65% were randomly assigned to the training set and 35% to the validation set. In detail, CKM and corresponding disease stages were defined based on the recommendations in the Presidential Advisory From the American Heart Association. In addition, by referring to this advisory, we excluded people whose systolic blood pressure was less than 90 or greater than 200 mmHg, total cholesterol level less than 130 or greater than 320 mg/dl, high density lipoprotein cholesterol less than 20 or greater than 100 mg/dl, body mass index less than 18.5 or greater than 40 kg/m². The outcome was CVD mortality. Predictors included iron metabolism indicators [iron, total iron binding capacity (TIBC), ferritin and transferrin saturation (TS)] and traditional risk factors. Cox proportional hazard models were performed to construct the model. The performance of model was assessed through Harrell’s C, NIR, IDI, AIC, BIC and decision curve analysis curves. The nomogram was depicted to predict CVD mortality risk.
Results:
Total of 26,240 patients were included, among which 12,692 (48.4%) were male, and the mean age was 51 years. Over a median follow-up of 9.7 years, there were 897 (3.4%) CVD deaths. Among the iron metabolism indicators, iron and ferritin were associated with CVD mortality, and the performance of model improved after adding to the basic model (Harrell’s C, 0.8188 vs 0.8756; NRI, 0.034; IDI, 0.026; AIC, 1451.692 vs 278.8336; BIC, 1523.242 vs 342.5252) in the training set. These were confirmed in the validation set. The model also showed superior performance in terms of reclassification and discrimination (Harrell’s C, 0.8261 vs 0.8913; NRI, 0.285; IDI, 0.047; AIC, 935.5182 vs 223.6404; BIC, 1001.722 vs 281.7644).
Discussion & Conclusions:
Iron metabolism disturbances are commonly seen among CKM syndrome patients, and associated with poor CVD outcomes, but are often overlooked in clinical practice. This study was conducted to develop and validate a model to predict CVD mortality for 30-80 years old CKM syndrome adults without CVD at baseline. Among the iron metabolism indicators, serum iron and ferritin were found to be the strong predictors and used to construct our prognostic model by combining the traditional risk factors. The statistical analysis showed that the model had a good performance after adding the serum iron and ferritin. Our prediction model based on the serum iron and ferritin accurately predicted CVD death for CKM syndrome patients.
Trial Registration: The data were derived from the public dataset, so it is not appropriate to register.
Funding: This study did not receive any specific funding.
Ethical approval and informed consent: The NHANES program was approved by the NCHS Research Ethics Review Board, and each respondent signed an informed consent form.
Ailifeire AIHAITI, Abulajiang SAIDAMING, Hasiyeti TUERXUN, Nan LI, Muyesai NIJIATI (Urumqi, China)
00:00 - 00:00
#40558 - Prediction of deterioration of patients with dyspnea in emergency department.
Prediction of deterioration of patients with dyspnea in emergency department.
Objective
Triage the initial severity classification of patients with dyspnea is essential to provide adequate care for many patients. Emergency centers in many countries are conducting triage of patients in variety way depending on the situation of each conutries, but they are working to develop better triage methods. Therefore, we would like to find out the triage method in patients with dyspnea and explore their usefulness, using the various factors available from patients visiting emergency centers. In response, we want to help inexperienced medical staff and others with rapid severity recognition and treatment in patients with dyspnea.
Methods
We collected the various factors that could be obtained from patients during visits to the emergency center. In addition, by using approximately 600,000 data from the National health insurance service in Korea, the proper value was obtained for frequency using the Rash analysis method. Using the proper values of various factors obtained from the Rash analysis method, the cutoff value for determining the patient's admission and discharge was determined by applying the appropriate value of the factor to about 154,383 patients visiting the emergency department from January 1, 2015 to December 31, 2018. Accordingly, we evaluated the accuracy of the program as to whether the decision to be admitted and discharged from program is consistent with actual hospitalization and discharge in patients with dyspnea who are visiting the emergency department from January 1, 2019 to December 31, 2020.
Results
To evaluate the significance of the program, we collected various factors, including age, sex, past history, blood pressure, pulse rate, respiration rate, and body temperature, etc of patients that could be obtained at the beginning of the visit, as well as blood sugar, hemoglobin, arterial blood oxygen concentration (PaO2), lactic acid concentration, etc. In order to evaluate the severity at the early stages of patients' visits, the accuracy of the program was analyzed by a combination of factors that could be obtained in early stages of patient's visits among various factors. 7,856 patients registered for experiment, and when the cutoff value was set at 315.5, the sensitivity of hospitalization was 72.9% and positive predictive value of discharge from a hospital was 82.1%.
Conclusion
The initial triage of patients with dyspnea in the emergency department is very important for the medical staff, and this study was shown to be significant. With the use of the more factors, accuracy will be improved and this study will contribute a lot clinically.
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Sung-Hyuk CHOI (korea, Republic of Korea)
00:00 - 00:00
#42356 - Predictive factors of a prolonged duration of care for patients consulting in the emergency department.
Predictive factors of a prolonged duration of care for patients consulting in the emergency department.
Problem: Emergency department (ED) overcrowding has been described as a global public health problem. Thus, if the international ED congestion crisis is to be resolved, it is crucial that interventions designed to address the problem are tailored to the appropriate causes. The duration of treatment is a key parameter of emergency flow as well as a saturation marker. Our service, like everywhere in the world, has experienced the phenomenon of overpopulation and congestion with the obligation to offer quality care.
Objectives of the work: Study the length of time patients spend in our emergency departments and identify the predictive factors for the increase in the duration of treatment for patients consulting the emergency departments.
Methods: This is a cross-sectional study with a descriptive aim, carried out in the ED. We included all patients who consulted our emergency departments in the external sector and whose DPU was greater than 4 hours during the period from January 1, 2021 until May 30, 2021.
Results: 500 patients were included in this study with male predominance, the average age was 46.8±21.2 years. Our study showed that the largest number of consultants whose visit time was greater than 4 hours was observed on weekends, this visit time was extended especially for elderly subjects. There are multiple causes for the increase in the length of time patients spend in the department: Excessive demand for additional examinations, Biological assessment was requested in 70% of cases, radiological examination in 65% of cases. The request for specialist advice was observed in 45% of cases. In our study, digestive pathology was the most frequent (24.5% of cases). The first hospitalization service was the general surgery service. Our study also showed that waiting was avoidable in 59% of patients and also showed the main factors of avoidable waiting on which we must act to improve treatment times for patients consulting emergency departments. After the multivariate analysis, we were able to retain the different statistically significant variables associated with waiting in the emergency room. Patients with limb trauma have a higher risk of having an avoidable wait during their consultation (OR 51.133 and a 95% CI [3.112-840.065]).
Conclusion: These results can be the starting point for making improvements and finding solutions to minimize the length of time spent in EDs as much as possible.
Lobna MHJOUB, Rahma JABALLAH (Sousse, Tunisia), Rym YOUSSEF, Fadi CHOUCHENE, Emna TRABELSI, Ons HMISSI, Houda BEN SALAH, Imen TRABELSI, Hajer YAAKOUBI, Asma ZORGATI, Lotfi BOUKADIDA, Riadh BOUKEF
00:00 - 00:00
#42216 - Predictive factors of intensive care unit admission of patients with diabetic ketoacidosis.
Predictive factors of intensive care unit admission of patients with diabetic ketoacidosis.
Diabetic ketoacidosis (DKA) contributes to 94% of admissions for diabetes complications with an increasing incidence. It’s management is complex and requires the application of a well-defined protocol and rigorous monitoring ideally in a resuscitation environment. The transfer to intensive care is not always possible as well, some studies compared the management of patients with DKA in intensive care (ICU) versus emergency (ED) without finding any difference in prognosis.
The objective of this study was to identify predictive factors of admission to ICU for patients consulting the ED for moderate to severe DKA.
Methods:
Multicenteric observational prospective study over two years. Inclusion of adult patients admitted for the management of moderate to severe ACD defined by GAD>=2.5 g/l, Acetonuria>=2, PH<7.3, HCO3-<15 and anionic hole (AT) > 12. Not including patients with chronic kidney failure and patients with serious pathology requiring admission to ICU. Exclusion of patients who died before transfer to intensive care.
All patients received the same treatment according to the protocol of the American Diabetology Association. Collection of epidemiological, clinical and biological parameters.
Comparative study of patients admitted to intensive care versus patients treated in the emergency department.
Results:
Inclusion of 178 patients with a mean age= 43+/- 18 years and a gender-ratio=0.6. the rate of ICU admission was 18.5% (n=33).
The comparative study of patients transferred to ICU versus (vs) patients treated in the ED found no significant difference in demographic parameters, comorbidities, physiological parameters at admission and decompensation factors. However, we found differences in the group of patients transferred to intensive care unit vs patients managed in emergency department regarding the incidence of neurological impairment (GCS <15) 30% vs 9% (p=0.001), the initial PH 6.99+/-0.17 VS 7.19 +/- 0.11 (p<0.001), the initial HCO3- 4.5+ /- 2.6 mmol/l vs 8.7+ /-3.3 (p<0.001). The median time out of acidosis in the emergency group was 12 hours with an average hospital stay of 33 hours. The average transfer time to resuscitation was 13 hours.
Logistic regression analysis found two predictors of ICU admission GCS<15 with OR=2.1, P=0.002 CI95% [1.31-3.35] and PH<7.10 OR=2.97, P=0.001 CI95% [1.9-4.5].
Conclusion:
The rate of admission to intensive care of patients in moderate to severe DKA is 18.5%. Initial neurological impairment and low level of PH are two predictors of admission to intensive care units.
Hela BEN TURKIA, Jihen SABAI, Raja FADHEL (Ain Zaghouan, Tunisia), Ines CHERMITI, Eya DAOUD, Rihab DAOUD, Hanene GHAZELI, Sami SOUISSI
00:00 - 00:00
#42378 - Predictive factors of mortality in elderly subjects with pulmonary embolism.
Predictive factors of mortality in elderly subjects with pulmonary embolism.
Introduction:
Pulmonary embolism (PE) remains an important cause of morbidity and mortality, particularly in elderly subjects, thus the identification of clinical and prognostic factors having a direct relationship with one-month mortality is imperative in the management of this condition.
The objective of this research was to study the predictive factors of mortality in elderly subjects with PE
Methods:
Retrospective descriptive study of patients aged 65, admitted to the emergency room for EP from January 2020 until February 2024.
Two groups were individualized:
G1: patients died within the month (23.5%)
G2: surviving patients (76.5%)
A comparison of the clinical and prognostic parameters of the 2 groups was carried out.
Results:
51 patients were included, average age is 74 ± 6 years. Gender ratio 0.9.
Medical History (%): sedentary lifestyle (52.9), recent immobilization (41.2), hypertension (51), diabetes (33.3), deep vein thrombosis (3.9), neoplasia (11.8), chronic respiratory failure (15.7).
Clinical parameters were (mean ±SD): SBP 120±21 MmHg, HR 101±25 bpm, FR 24±5, sp02 88 ±8%.
On imaging: 49% PE were proximal; 33.3% PE were bilateral and 59% PE were bilateral and proximal.
The results of this study indicated the absence of significant difference between the two groups regarding clinical and radiological presentation.
Conclusion:
The identification of risk factors for mortality linked to pulmonary embolism is crucial in order to improve the chances of survival of elderly people and promote healing.
Marouane SANAI, Asma JENDOUBI, Lamis JAAFAR, Khaireddine JEMAI (Tunis, Tunisia), Hana HEDHLI, Sarra JOUINI
00:00 - 00:00
#42027 - Predictive value of the modified early warning score on the in-hospital mortality in patients with renal failure.
Predictive value of the modified early warning score on the in-hospital mortality in patients with renal failure.
Background:
Renal failure (RF) is associated with high morbidity and mortality rates. Modified Early Warning Score (MEWS) is widely used in predicting mortality in intensive care unit and emergency department (ED).
Objective:
The objective of our study was to determine the predictive value of MEWS score on the in-hospital mortality (IHM) in patients with RF.
Methods:
A prospective observational monocentric study was conducted over 16 months [January 2023- April 2024]. Inclusion criteria: patients aged over 18 years, admitted to the ED with RF defined by a glomerular filtration rate <60 mL/min/1.73m2, calculated according to the Chronic Kidney Disease Epidemiology. Epidemiological characteristics and clinical features were described. MEWS score was calculated. Statistical analyses included: evaluation of the discriminative power of the score in predicting IHM and characteristics of the ROC curve, calculation of Youden’s index.
Results:
Inclusion of 266 patients with an average age of 65 ± 15 years. Gender ratio=0.94. One hundred ninety-five patients (73%) had renal chronic failure. One hundred sixteen patients were in the phase of haemodialysis. Comorbidities (%): hypertension (70), diabetes (57), dyslipidemia (20), coronary insufficiency (17), heart failure (12). Main symptoms (%): dyspnea (30), abdominal pain (18), chest pain (14), fever (6), dysuria (2), anuria (2). Diagnosis (%): acute heart failure (23), sepsis (20), hyperkalemia (14), anemia (12), metabolic acidosis (9), acute coronary syndrom (8). The IHM rate was 9%. The mean value of MEWS score was 2±1. The analysis of the ROC curve showed (AUC; p; cut-off value): (0.53; 0.05; 8). The characteristics were: sensitivity (78%), specificity (34%), Positive Predictive Value (10%), Negative Predictive value (94%), Youden index (0.3).
Conclusion:
MEWS score demonstrated low specificity in identifying the risk of intra-hospital mortality for patients with renal failure. However, our results need to be validated by studies on a larger scale.
Raja FADHEL (Ain Zaghouan, Tunisia), Ahlem HENDILI, Ibtissem BEN TAHER, Ala NEIJI, Syrine KESKES, Hela BEN TURKIA, Hanene GHAZALI, Sami SOUISSI, Ines CHERMITI
00:00 - 00:00
#41334 - Pregnant woman with vaginal bleeding.
Pregnant woman with vaginal bleeding.
Case Presentation
: A 36-year-old woman at 37 weeks’ gestation presented to the emergency department with sudden onset of massive vaginal bleeding and abdominal pain just before the visit. She had a history of oligohydramnios in antepartum examination and did not have coagulopathy or history of placental abruption. On physical examination, she was conscious and afebrile, with a pulse rate of 76 beats/min and blood pressure of 87/52 mm Hg. Point-of-care ultrasonography of the abdomen revealed fetal distress, with a fetal heartbeat of 197 beats/min, and others were performed.
Diagnosis
: Placental abruption with retroplacental hematoma. The patient received an emergency cesarean delivery. Placental abruption with retroplacental hematoma was confirmed intraoperatively and by pathology report. The patient and the infant were discharged uneventfully at 6 days and were asymptomatic at 3-month follow-up.
Placental abruption is defined as premature separation of the placenta before delivery, causing a 14-times-higher perinatal mortality rate compared with that of all other births. 1 Risk factors for placental abruption include drug use, preeclampsia, hypertension, and oligohydramnios. Ultrasonography is a highly specific tool. 2 Point-of-care ultrasonography can quickly detect placental abruption in pregnant women who need emergency delivery. Acute placental abruption is hyperechoic to isoechoic compared with the placenta. When the transducer applies a sudden pressure, the placenta may jiggle, which is the so-called "Jello sign." The placenta becomes hypoechoic and sonolucent within 1 and 2 weeks, respectively. Management depends on gestational age and degree of maternal and fetal compromise. Delivery is indicated in cases of abruption at term or near term with a live fetus.
George GOZARI (Changhua, Taiwan)
00:00 - 00:00
#42181 - Prehospital blood products administration by Advanced Life Support ambulances (ALS).
Prehospital blood products administration by Advanced Life Support ambulances (ALS).
Introduction
Transfusion of blood products is a rare practice in prehospital emergency medicine. It accounts for less than 1% of patients treated by Advanced Life Support (ALS) ambulances. In this context, specific procedures have been implemented to ensure the safe prescription and administration of blood products, and to monitor any transfusion-related incidents.
The aim of this study was to describe the incidence, main pathology and follow up of this practice in an Emergency Medical Service (EMS).
Method
All patients for whom a transfusion record was created during prehospital ALS intervention were included in an EMS population of 1.6 million inhabitants, over the last 10 years (01/01/2013 to 31/12/2023).
Data were collected in a permanent registry: gender, age, type of transport, indication of transfusion, type of blood products, immediate or remote adverse events such as red blood cell allo-immunisation.
Results
During 10 years, a total of 476 (0.83%) transfusion files were initiated, out of 56,870 ALS interventions.
Forty-one (8.6%) patients were transfused during on-scene transport and 435 (91.4%) during inter-hospital transfers.
Sex ratio was 0.9 and average age was 57.5 years (range 6-96 years).
Four hundred and forty-five (93.3%) patients were actually transfused.
Transfusion indications were: 1) hemorrhage for 383 (80.5%) patients, including 185 (48.3%) digestive hemorrhage, obstetrical for 72 patients (18.8%), traumatic for 14 patients (3.6%), vascular for 39 patients (5.7%), thoracic or pulmonary for 19 patients (5%), other hemorrhage for 54 patients (14%); 2) hematological pathology for 68 (14.3%) patients: anemia in 48 patients (70.6%), thrombopathy in 5 (7.3%) or another haemopathy for 15 patients (22%); 3) 25 patients (5%) required transfusion for another reason.
Seven hundred and five blood products were transfused, 600 (85.1%) packed red blood cells (RBC), 94 (13.3%) fresh frozen plasma (FFP) and 11 (1.6%) platelets.
Concerning previous transfusion history, 193 (40.5%) patients had been transfused previously, 133 (28%) had never been transfused, and the status was unknown for 150 (31.5%) patients. Twelve (2.5%) patients had a previous transfusion incident.
Two patients experienced an adverse reaction during transfusion. At post-transfusion follow-up, 7 (1.6%) patients had red blood cell irregular antibodies.
Three months outcome was death for 92 (20.9%) of patients, hospital discharge for 78.4% of them and still hospitalized for 0.7%.
Conclusion
Although rare in the pre-hospital setting, transfusion of blood products is a safe practice. No serious adverse events occurred in the last 10 years. The majority of patients transfused were hemorrhagic, but only 13% of patients benefitted from FFP transfusion. The current recommendation to transfuse 1 FFP for 2 RBC in this context could be easier to follow if plasma was more easily available. Lyophilized Plasma in prehospital setting could help achieve this objective.
Armelle SEVERIN (Garches), Anna OZGULER, Michel BAER, Thomas LOEB
00:00 - 00:00
#40902 - Prehospital hemoglobin and hospital transfusion-therapy in trauma-patients.
Prehospital hemoglobin and hospital transfusion-therapy in trauma-patients.
Background: Trauma-patients account for a major cause for emergency medical services (EMS) support. One of the challenges of EMS is to identify patients with active bleeding, and in a second step to proceed to its immediate control. In cases of internal bleeding, EMS-providers, in addition to standard advanced life support actions and volume-targeted resuscitation (mean arterial pressure greater than 65 mmHg and 85 mmHg if associated brain injury trauma), must, through analysis of the biomechanics of the trauma, clinical examination, and the new diagnostic tools available in some units (prehospital analysis and ultrasound), identify patients at risk of hypovolemic shock early and proceed with their priority transfer to a trauma center.
The objective of this study is to examine the ability of prehospital hemoglobin to predict hospital transfusion in trauma-patients.
Methods: Prospective, multicentric, EMS-delivery, ambulance-based, pragmatic cohort study of trauma-patients, referred to five hospitals (Spain), between January 2020, and February 2024. Patient treated consecutively by EMS with prehospital diagnosis of trauma and injuries and transferred with high priority by ambulance to the ED was included in the study. Patients under 18 years of age, pregnant women, non-traumatic patients, risk in the scene and patients discharged on site were excluded. Demographic data (age and sex) and venous sampling were collected during the first contact with the patient in prehospital care. Analyzer epoc® (Siemens Healthcare GmbH, Erlangen Germany) was employed to perform prehospital hemoglobin. The primary dependent variable was all-cause hospital transfusion (packed red blood cells) in the first 24-hour post prehospital trauma index-event. The area under the curve (AUC) of the receiver operating characteristic (ROC) of the mSOFA was calculated in terms of hospital transfusion.
Results: A total of 1449 trauma-patients were included in our study. The median age was 51 years (IQR: 30-74), with a range from 18 to 99 years, with 533 cases (38.1%) of females. The rate of hospital transfusion (first 24-hour), ICU-admission, emergency surgery, and hospital-mortality (30-day follow-up) were 136 cases (9.3%), 362 cases (24.9%), 341 cases (23.5%), and 214 cases (14.7%).
The AUROC and cut-off of prehospital hemoglobin were 0.800 (95%CI: 0.75-0.84; p<0.001) and 12.5 g/dL, with a sensitivity of 71%, specificity of 80% and negative likehood ratio of 0.964 (39 false negatives).
Conclusions: point-of-care testing is becoming exponentially more widespread in all advanced life support, physician-response units, and helicopter emergency medical service. They are simple, with a fast-learning curve and are reliable and easy to maintain. In this sense, the availability of baseline hemoglobin levels (post trauma-event), although it does not clearly indicate the need to activate the transfusion protocol, can provide valuable information to know the very short-term evolution of the trauma patient. Knowing a baseline hemoglobin compared with the hemoglobin obtained in the emergency department can guide the strategy to be followed and detect fine changes.
This work was supported by the Institute of Health Carlos III (Spain) and co-financed by the European Union [grant numbers DTS23/00010] for FM-R.
Francisco MARTÍN-RODRÍGUEZ, Raúl LÓPEZ-IZQUIERDO, Carlos DEL POZO VEGAS (Valladolor, Spain), Raúl ALONSO AVILÉS, María BLANCO GONZÁLEZ, Alberto CORREAS GALÁN, Pedro DE SANTOS CASTRO, Ana GIL CONTRERAS, Alberto GÓMEZ DE DIEGO, Leyre PINILLA ARRIBAS, Miguel POSADAS MÚÑOZ, Rubén PÉREZ GARCÍA, Ana RAMOS RODRÍGUEZ
00:00 - 00:00
#41553 - Prehospital pain management in trauma. What I felt and what I would change.
Prehospital pain management in trauma. What I felt and what I would change.
Introduction
Pain management plays a pivotal role in providing comprehensive and compassionate care to patients, particularly in the prehospital setting where timely interventions can significantly impact patient outcomes. When pain is effectively managed early in prehospital phase, patients experience an improvement in comfort and wellbeing, having an impact on their stabilisation. This, in turn can lead to a smoother transition to the hospital setting and potentially decrease the need for aggressive pain management in the emergency department. From a subjective standpoint, as a former trauma patient who suffered a horrifying rock climbing accident and who experienced excruciating pain caused by a fall from 5 meters with an extreme severe knee injury and elbow dislocation, I tried to rethink the possibilities of prehospital pain management in Romania.
Materials and methods
The research process is based on a narrative review which includes 21 relevant publications found on PubMed in Medline, Google Schoolar and Embase databases, using the search terms “methoxyflurane” or “Penthrox” and “analgesia” or “pain”.
Results
Published data on methoxyflurane in trauma pain show it to be effective, well tolerated, and highly rated by patients. The ease of use (inhaled), the self-administration, the fast analgesic action and the portability of methoxyflurane combined with its favorable safety profile, even when used by paramedics and no need for vein cannulation make it a useful nonopioid option for pain management.
Conclusions
The use of methoxyflurane can contribute to a streamlined patient care, optimized resource allocation and, if implemented in the Romanian emergency medical system, this can be considerably improved in terms of efficiency. In conclusion, by bridging the gap between practice and recommendations, prehospital medical personnel could deliver the highest quality prehospital pain management and improve patient outcomes, in a safe and easy to use manner.
Bianca BILT IANCU (Cluj-Napoca, Romania)
00:00 - 00:00
#42213 - Prehospital Respiratory Interventions During Six Waves of Covid-19: Results From the Israeli National EMS.
Prehospital Respiratory Interventions During Six Waves of Covid-19: Results From the Israeli National EMS.
Study Objective: Later variants of Covid-19 have higher transmissibility but lower case fatality rate. To date, there has been a paucity of studies investigating the extent to which the newer variants have affected the need for respiratory interventions in the prehospital setting.
Methods: This is a retrospective cohort study utilizing programmatic data from Magen David Adom, Israel’s national Emergency Medical Services (EMS). All EMS responses due to respiratory complaints, from January 1, 2019, to July 31, 2022, were included. Consecutive waves of Covid-19 were used as proxy for new variants as Covid-19 genomic data were not routinely collected at patient level. The proportions of prehospital respiratory interventions during each wave were compared to those of the previous one; those in wave 1 (W1) were compared to a pre-pandemic period accounting for seasonality. Proportions of dichotomous variables were compared using chi-square testing where a p-value <0.05 was considered significant. Data were extracted to Microsoft Excel and analyzed in JMP 16.
Results: A total of 207,854 responses were included. From W1, no endotracheal tubes (ETs) were used. The use of 90% oxygen by mask increased during W1-3 (32.7%[W1], 37.7%[W2], 40.0%[W3]; p=<0.05[consecutive wave pairs]), decreased between W3-4 (40.0%[W3], 34.1%[W4]; p=<0.05) and plateaued during W4-6 (34.1%[W4], 33.9%[W5], 34.1%[W6]; p=>0.05 [consecutive wave pairs]). Nasal cannula use increased across W1-6 (5.6%[W1], 8.1%[W2], 11.0%[W3], 15.2%[W4], 16.6%[W5], 19.7%[W6]; p=<0.05 [consecutive wave pairs]). The use of nebulized salbutamol remained <7% during W1-3 and increased during W4-6 (7.4%[W4], 8.2%[W5], 10.4%[W6]; p=<0.05[consecutive wave pairs]).
Conclusions: This study has contributed to the understanding of the population-wide needs of prehospital respiratory interventions during the Covid-19 pandemic in Israel. No ET tubes were used from W1 due to safety considerations. The analysis demonstrated a decreased use of high-concentration oxygen to maintain blood oxygen saturation which may in part be explained by the decreased pathogenicity of new strains as well as increased vaccination coverage. Additionally, an increased use of nebulized salbutamol was demonstrated, possibly owing to expanded use by providers and the re-emergence of non-covid pathogens as Covid-19 related restrictions were eased.
Maximilian NERLANDER (Växjö, Sweden), Avi ALPERT, Roman SONKIN, Ari LIPSKY, Eli JAFFE
00:00 - 00:00
#41789 - Prehospital time intervals in stroke care before and after the outbreak of COVID-19.
Prehospital time intervals in stroke care before and after the outbreak of COVID-19.
Background
A prehospital emergency medical system is essential in order to provide rapid treatment for stroke patients. After the outbreak of coronavirus disease pandemic (COVID-19), precautions and safety measures were introduced to limit the number of infections. This study analyzed how the prehospital stroke care protocol would manage during altered and challenging circumstances.
Methods
In this retrospective study, we examined the effects of the COVID-19 pandemic on the emergency medical care of patients transported to the Kanta-Häme Central Hospital because of suspected stroke. We collected prehospital data on the emergency medical services’ time intervals of suspected stroke patients, including on-scene time and total time. Emergency medical services’ time intervals of transported suspected stroke patients 24 months before and 24 months after the outbreak of COVID-19 were compared.
Results
During the study period, emergency medical services transported altogether 1,226 patients with suspected stroke to the Kanta-Häme Central Hospital emergency department, 552 before and 674 after the COVID-19 outbreak. The median on-scene time of these patients was 15.38 minutes before and 15.18 minutes after the outbreak (p = 0.93). The median total emergency medical services time had remained stable between the groups, 49.59 minutes vs. 49.86 minutes (p = 0.80) respectively.
Conclusions
The number of suspected stroke patients increased by 22.9% after the outbreak of the COVID-19 pandemic. However, the pandemic outbreak did not lengthen the pre-hospitalisation intervals for suspected stroke patients. These results allow us to assume that once the prehospital process of suspected stroke patients has been thoroughly reorganized, not even major disturbances will impair the function of emergency medical services.
The study was funded by the Ministry of Health and Social Welfare in Finland through the Medical Research Funds of Kanta-Häme Central Hospital and Pirkanmaa Hospital District, the Finnish Cultural Foundation, the Finnish Society of Emergency Medicine, the Hauho Savings Bank Foundation and the Renko Savings Bank Foundation.
Peetu HÄNNINEN (Hämeenlinna, Finland), Ville HÄLLBERG, Lasse HAKALA, Teemu KOIVISTOINEN, Ari PALOMÄKI
00:00 - 00:00
#40383 - prevalence and characteristics of patients who consulted in the emergency room of a tertiary hospital due to attempted suicide in 2022 and 2023 and compare them with data published prior to the SARS Cov2 pandemic in 2020.
prevalence and characteristics of patients who consulted in the emergency room of a tertiary hospital due to attempted suicide in 2022 and 2023 and compare them with data published prior to the SARS Cov2 pandemic in 2020.
Justification: The Mental Health Strategy of the National Health System contains, among its priorities, the approach and prevention of suicide through different measures, among which is the improvement of the detection and management of Suicidal Risk.
Methods
This is a retrospective cross-sectional study carried out between January 1, 2022 and December 31, 2023 in the Emergency Department of a third-level University hospital that covers a population of 600,000 inhabitants and in which patients were treated. 165,207 emergencies in 2022 and 170,359 in 2023.
A list was requested of those patients treated in the emergency room with the following diagnoses according to the International Classification of Diseases 10th Revision, Clinical Modification, Spanish Edition (ICD-10) in primary diagnosis and secondary diagnosis: T50.902A - DRUG POISONING , MEDICINES AND UNSPECIFIED BIOLOGICAL SUBSTANCES.
The data included demographic variables, such as age and sex; priority upon arrival and the destination of the patient once discharged from the emergency room (discharge for follow-up by Primary Care, discharge with follow-up by psychiatry in the mental health center, death, hospital admission in the psychiatry unit or escape)
Results
767 patients consulted for attempted suicide in 2022 and 748 in 2023, of which 64.7% and 61.8% were women, respectively. The mean age was (mean ± Standard deviation (SD)) 40.26 ± 16.9 and 39.47 ± 16.7 years.
At the time of emergency care, 11 patients (1.5%) in 2022 and 6 patients (0.8%) in 2023 were in a critical situation (understood as emergency care in priority 1); 559 patients (74.7%) and 590 patients (76.9%) in an emergency situation (understood as emergency assistance in priority 2). The rest of the emergencies attended in other lower priorities Urgency (understood as emergency assistance in priority 3) (123 patients (16.4%) versus 140 patients (18.3%)); P4/P5 priority 7.4% vs. 4%).
The average attendance time in 2022 was 1079.76 minutes; (DE: 995.37) and in 2023 1077.23 minutes (DE 764.47). In 2022, 435 people (56.7%) attempted suicide from Monday to Friday, while 332 people (43.3%) attempted suicide on the weekend. In 2023, 445 people (59.6%) and 302 patients (40.4%) respectively.
The referrals after being evaluated by the Emergency and Mental Health Service, 349 patients (46.7%) and 302 patients (39.4%) were discharged home; referred 108 patients (14.4%) to their primary care physician compared to 150 patients (19.5%); Referred to a specialist were 171 patients (22.9%) compared to 185 (24.2%); Admission to the ward: 65 patients (8.7%) compared to 75 patients (9.8%); transfers to other centers 23 patients (3.1%) versus 18 (2.3%); voluntary discharge 16 patients (2.1%) versus 13 (1.7%); and 13 patients escaped (1.7%) compared to 17 (2.2%) and n 2023.
In our population, the rate of suicide attempts is 127.83 per 100,000 rooms in 2022 and 124.66 per 100,000 inhabitants.
Discussion
Despite not having data from our hospital prior to the pandemic, we are impressed by an increase in cases. Taking into account the large consumption of resources in care, it seems important to us to work from Primary Care and Mental Health consultations in prevention and treatment.
Isabel MORALES BARROSO (Seville, Spain)
00:00 - 00:00
#40826 - Prevalence of Sepsis in Older Patients in the Adult Continuous Admission Service at the National Medical Center "e;20 de Noviembre"e;.
Prevalence of Sepsis in Older Patients in the Adult Continuous Admission Service at the National Medical Center "e;20 de Noviembre"e;.
Background
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It is considered a serious public health problem since there are 48.9 million cases and 11 million sepsis-related deaths worldwide, which accounted for almost 20% of all global deaths. Older patients are considered a risk population due to the loss of the natural reserve mechanisms and the aging of the immunology response. In addition, according to the WHO, regional disparities in sepsis incidence and mortality exist; approximately 85% of sepsis cases and sepsis-related deaths worldwide occurred in low- and middle-income countries. Therefore, we aimed to determine the prevalence of sepsis in older patients attending to the Continuous Admission Service for Adults of the National Medical Center "20 de Noviembre" during the year 2022.
Methods
This was an epidemiological, retrospective, and descriptive study. The number of patients attended in 2022 and those with sepsis diagnosis were obtained from the system of electronic medical records (EMRs) of the National Medical Center "20 de noviembre", Mexico, was consulted. In the Continuous Admission Service 12,913 patients were attended in 2022. The EMRs of older patients (equal to or greater than 65 years of age) were further analyzed. Prevalence of sepsis was estimated as the rate of number of sepsis cases/total of older patients evaluated.
Results
We found 68 older patients with sepsis diagnosis, with a prevalence of 28.2%. mean 73.87 and standard deviation 7.330. Patients with sepsis were all aged 65 years or older, 51% were female and 49% were male. According to the age distribution, about 62% of patients diagnosed with sepsis were between 65-74 years old. The documented infectious focus was the urinary tract in 42%, followed by pulmonary (28%), soft tissue (14%), abdominal (14%) and non-focus (3%) infections.
Discussion & Conclusions:
We observed a low frequency of sepsis among older patients attended in the studied service. The prevalence could be underestimated due to the clinical data of the older patients, and their comorbidities. The relevance of age and sex in sepsis diagnosis was observed in agreement with the literature. Sepsis is an increasingly frequent pathology, with a high morbidity and mortality, therefore, a sepsis code could be implemented in order to improve the quality of medical care, speed up and initiate medical management in a timely manner, and significantly reduce mortality in this age group of the population. Talking about the importance of studying sepsis in this age group of the population, according to the worldwide prevalence and incidence, will help us to identify if there are differences in prevalence according to sex, education, degree of disability and dependence.
Key words: Sepsis, older patients, continuous admission, infectious focus.
Trial Registration: no patients involved
Funding: This study did not receive any specific funding
Ethical approval and informant consent: The research was evaluated and approved by the National Medical Center "20 de Noviembre" Research Ethics Committee. When clinical records were reviewed, it was considered minimal risk and did not require informed consent.
We don´t have financing
Gabriela SORIANO (Ciudad de México, Mexico), Gustavo ORTEGA, Tirso ZUÑÍGA
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#42026 - Procedural sedation in the ED - Review of 321 cases in Iceland.
Procedural sedation in the ED - Review of 321 cases in Iceland.
Background
Procedural sedation is commonly performed in emergency medicine for painful procedures. Performing procedural sedation is associated with a risk of respiratory depression, hypotension, and other potentially life threatening complications. Significant training is required to perform procedural sedations in order to be able to manage all potential complications. Emergency physicians (EPs) in the emergency department at the Landspitali, The National University Hospital of Iceland, have since 2019 performed most of the procedural sedations done in the department. The objective was to review the procedural sedations done by EPs at Landspitali with regards to indications, methods, complications and outcome.
Methods
EPs at the Landspitali were required to follow a standard procedure for procedural sedation starting January 1st 2019. EPs performing procedural sedation were required to have airway training. A standardized checklist was followed prior to the procedure with full monitoring and airway equipment available. Procedural sedations were performed by EPs or by senior trainees under direct care of an EP with constant monitoring. The indication, medications given, complications from the sedation and success of the procedure were recorded. The data from January 2019 to December 2020 were analyzed. Data were collected on a form by the physician performing the sedation and were then reviewed retrospectively.
Results
A total of 321 sedations were performed by EPs during the study period. Age range was 4 to 109 years and mean age was 64 years. Women represented 36% of the sample. The most common indication for procedural sedation was electrical cardioversion in 183 cases and reduction of a dislocation or fracture in 129 individuals. In 7 cases, sedation was performed for investigations such as a spinal tap or imaging. Propofol was the most common sedative, used in 207 cases, of which in combination with other drugs in 59 cases. In 294 cases, sedation was performed without complications. Hypotension occurred in 10 cases, hypoxia in 10 cases, in 3 cases sedation was considered inadequate and in 3 cases the patient had emergence reaction due to the effects of S-ketamine. No serious complications (prolonged observation, ICU admission, intubation or death) occurred. The procedure requiring intervention was performed successfully in 304 of 321 cases.
Conclusion
On this two year review, results show that EPs at the Emergency department of Landspitali have safely provided procedural sedation without any significant complications. Propofol was the most commonly used medication for procedural sedation at Landspitali.
Hjalti Már BJÖRNSSON, Éric CONTANT (Saint-Jérôme / Reykjavík, Iceland), Rosemary Lea JONES
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#41480 - Profile and outcomes of patients presented with acute hemorrhage events in the Emergency Department. A single-center registry.
Profile and outcomes of patients presented with acute hemorrhage events in the Emergency Department. A single-center registry.
Background. Patients with bleeding events to the Emergency Department (ED) represent a major problem and adequate resuscitation is critical to the management. Moreover, many of them are already treated with anticoagulants which further increases morbidity and mortality. The present study aimed to document the profile of unselected, consecutive cases of acute hemorrhage presented to the ED and to describe the current practices regarding the initial management in this population.
Methods. This prospective, observational study was conducted in a two-month period (February -April 2024). Characteristics of the patients were evaluated in terms of age, gender, comorbidities, prior history of antithrombotic therapy and treatment strategy upon presentation in the ED (transfusion of red blood cells (RBC), platelets (PLT) or fresh frozen plasma (FFP), tranexamic acid, reversal agents for non-vitamin K antagonist oral anticoagulants (NOACs), vitamin K, fibrinogen, prothrombin complex concentrate (PCC)) and in-hospital mortality.
Results. A total of 123 patients were included in the study. The mean age was 66.07 20.01 and 64.2% were males. Forty-three (35%) patients had a history of antithrombotic agent use. Specifically, 21% were under treatment of acetylsalicylic acid, 21% acenocoumarol, 18.5% dabigatran, 16.2% apixaban, 14% rivaroxaban, 7% clopidogrel and 2.3% ticagrelor. Regarding comorbidities, 38.2% had hypertension, 18.7% diabetes mellitus, 17.1% atrial fibrillation, 12.2% coronary artery disease, 8.9% heart failure, 4% chronic kidney disease and 2.4% had a previous history of stroke. 38% of the study population presented to the ED due to gastrointestinal bleeding, 25.1% due to trauma-related bleeding, 17.8% due to intracranial hemorrhage, 9% due to hemoptysis, 7.2% due to hematuria, 1.5% due to epistaxis and 1.5% due to uterine bleeding. Interestingly, 35 (28.4%) of patients presented with life-threatening hemorrhage, in hemorrhagic shock which required resuscitation. The most common causes in hemodynamically unstable patients were gastrointestinal and traumatic hemorrhage. Indeed, 22(62.8%) patients were transfused with RBC, 7(20%) patients with FFPs, 17(48.6%) patients received tranexamic acid, 4(11.4%) patients received vitamin K and 3(8.6%) patients received PCC. No patient under treatment with NOACs needed a specific reversal agent during initial management.
Ninety-nine patients (80.5%) were admitted to the hospital and 23(23.2%) died during hospitalization. Patients with intracranial hemorrhage, gastrointestinal hemorrhage and trauma-related bleeding showed increased risk for in-hospital mortality.
Conclusions. The current study showed that one in three patients (35%) who presented to the ED with acute hemorrhage, were receiving NOACs. Gastrointestinal and trauma-related hemorrhages represented the most common types of bleeding. These patients were at greater risk for hemorrhagic shock and required resuscitation. Intracranial, gastrointestinal and traumatic hemorrhage were associated with increased in-hospital mortality. As the use of NOACs is expanding and specific reversal agents become more widely available, the incorporation of protocolized strategies for the management of life-threatening hemorrhage in the ED is crucial.
(ΤΕΠ,ΕΒΔ76/31-01-2024)
Maria VELLIOU (Athens, Greece), Panagiota DAMOULAKI, Rakel SASSON, Melina KARAOLIA, Diana VRYZIDOU, Maria KIOUSI, Sofia BEZATI, Christos VERRAS, Antonios DIAKANTONIS, Aikaterini MOUTOUPA, Christos GEORGIOU, Estela KIOURI, Maria-Panagiota ALMIROUDI, Lampros MARKOS, John PARISSIS, Effie POLYZOGOPOULOU
00:00 - 00:00
#41785 - PROFILE OF PATIENTS DIAGNOSED WITH ACTIVE HCV INFECTION IN AN EMERGENCY DEPARTMENT(ED) IN ALMERIA, SPAIN.
PROFILE OF PATIENTS DIAGNOSED WITH ACTIVE HCV INFECTION IN AN EMERGENCY DEPARTMENT(ED) IN ALMERIA, SPAIN.
Background and Aims:
On the way to eliminating viral hepatitis by 2030, as proposed by the WHO, Spain could be one of the first countries to achieve this goal, but in order to do so it is necessary to implement strategies to increase the diagnosis rate. In this sense, hospital emergency departments are an opportunity to diagnose patients who are not connected to our health system. Our aim was describe the profile of patients with active hepatitis C virus (HCV) infection diagnosed through an opportunistic HCV screening strategy (FOCUS Program) in an Emergency Department (ED) in Almeria, Spain.
Materials and methods
HCV screening was performed in all patients aged 18-69 years who required a blood test in the ED since August 2021. HCV antibodies (anti-HCV) were detected by chemiluminescence and viral RNA was determined by PCR. Patients with active infection were referred to hepatology specialists for linkage to care (LTC) and prescription of antiviral treatment. In addition, laboratory databases and medical records were reviewed, and the degree of fibrosis was determined by fibroscan or serological indices.
Results
We screened 20,394 patients for HCV, of whom 332 were anti-HCV positive and 75 had active infection; mean age 56±7 years and 83% were male. 43% of patients were current or former injecting or inhaling drug users, 45% were alcohol users and 10 patients were immigrants. Regarding fibrosis status, 50% of patients had stage F0-F1, 8% F2 and 42% F3-F4. 15 patients had decompensated cirrhosis. Regarding comorbidities, 5 patients had HIV, 2 patients had tuberculosis, 2 patients had terminal cancer and 1 patient had Huntington's disease. In terms of missed opportunities for diagnosis, 77% of patients had previously attended at ED, 91% in primary care, 41% in hospital and 17% in psychiatry. Finally, 83% of patients were on LTC, 5 patients were homeless or unreachable and 13 patients died after diagnosis.
Conclusions
A high percentage of diagnosed patients had an advanced degree of fibrosis, suggesting an advanced stage of their disease, with several missed opportunities for timely diagnosis in previous encounters with medical care.
Gilead Sciences’ FOCUS Program funding supports screening & linkage to a first appointment after diagnosis regardless of how organizations handle subsequent patient care and treatment
Anny CAMELO CASTILLO (Almería, Spain), Antonio DUARTE CARAZO, Teresa JORDÁN, Manuel RODRÍGUEZ MARESCA, Teresa CABEZAS FERNANDEZ, Alba CARRODEGUAS, José Luis GONZALEZ, Jose VEGA SAENZ, Marta CASADO MARTIN
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#42355 - Profile of Staff Affected by Burnout Syndrome.
Profile of Staff Affected by Burnout Syndrome.
Introduction: Burnout syndrome results from intense involvement with others and is characterized by emotional exhaustion, depersonalization of patients, and reduced professional accomplishment.
Professionals dealing with acute and serious situations are particularly exposed. The aim of this study was to determine the profile of staff affected by this syndrome and to assess its prevalence in the emergency department compared to other departments.
Patients and Methods: Prospective study, including healthcare personnel agreeing to participate in the survey. Each participant had to complete a questionnaire including sociodemographic characteristics, work circumstances (department, number of hours worked per week, number of shifts per month), and the 22 items of the Maslach Burnout Inventory.
Results: N questionnaires were distributed, and 79 were collected and analyzed. The overall participation rate was n%. Burnout was diagnosed in 58.2% of our population, with 26.6% of the sample severely affected: 42% with high emotional exhaustion, 43% with high depersonalization, and 39% with low personal accomplishment. The mean age was 33+/-9 years, M/F=0.46, and 56% of the population was married. Professionally, 47% chose the department, and 72% had been practicing for
< 10 years. The average weekly working hours were 41 hours. The pace of shifts was 2 shifts per week in 27%. Among sociodemographic factors, male gender was correlated with burnout, and female gender was associated with the lowest professional accomplishment score (p=0.03). Marriage was a predictive factor for burnout, with 23% of married individuals having a severe score. The general surgery department had the highest emotional exhaustion and depersonalization scores (73% and 64%), followed by the emergency department (56% and 60%); whereas the lowest professional accomplishment score was in the pediatrics department (14%), followed by the
emergency department (24%).
Conclusion: Healthcare personnel in the emergency department are susceptible to developing burnout. Males and married individuals are at higher risk. Prevention of burnout syndrome is essential and can be organized on several levels: individual, collective, and organizational.
Fatma HEBAIEB, Saloua HOUIMLI (la Marsa, Tunisia), Syrine TROJETTE, Mohamed ASSADI, Kaouther BOUKADIDA, Sarra AKKARI
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#42383 - Prognostic Impact of Pulmonary Contusion in Severe Traumatic Brain Injury.
Prognostic Impact of Pulmonary Contusion in Severe Traumatic Brain Injury.
Introduction: Severe traumatic brain injury (TBI) is a common condition associated with significant morbidity and mortality, particularly affecting young adults. Progress
in understanding pathophysiological mechanisms and combating secondary insults has contributed to improving the prognosis of TBI. Pulmonary contusion (PC), a
relatively common traumatic injury, can have deleterious effects on gas exchange, further worsening the prognosis of TBI. The aim of this study was to evaluate the
prognostic impact of PC in severe TBI.
Patients and Methods: A retrospective study conducted over 36 months included patients over 16 years old presenting with TBI. Pulmonary contusion was diagnosed
by thoracic computed tomography. Demographic data, severity scores, complications, length of stay in the intensive care unit (ICU), and mortality were
compared between the TBI with PC (PC+) and isolated TBI (PC–) groups.
Results: N=104. Pulmonary contusion was diagnosed in 34 patients (32.7%). There were no significant differences between the two groups regarding age, gender, and
initial Glasgow Coma Scale (GCS). Severity scores, Injury Severity Score (ISS), and Therapeutic Intervention Scoring System (TISS) were higher in the PC+ group (p<
0.001). Patients with pulmonary contusion had a lower initial PaO2/FiO2 ratio = 240 [160-380]) vs 430 [210-590] in the PC– group (p=0.009) with higher initial PaCO2
levels (43.5 mmHg [38-52] vs 38 mmHg [32-40] (p<0.001). The incidence of pneumothorax and hemothorax was higher in the PC+ group (p=0.003, p=0.021,
respectively). The occurrence of pneumonia and acute respiratory distress syndrome (ARDS) was significantly higher in the PC+ group (p=0.031, p=0.023, respectively)
with a shorter time to onset (6 days [6-10]) vs 13 days [8-16]; p=0.024) and (6 days [2-8]) vs 10 days [8-10]; p=0.016), respectively. The number of shock states was
comparable between the two groups (p = 0.174). Hospitalization duration was longer in the PC+ group (13.44 ± 6 days vs 12.44 ± 4 days, p<0.001). Overall mortality was 11.5% in the PC+ group and 7.7% in the PC– group (OR=4.22, 95% CI 1.527 to 11.703, p=0.004).
Discussion and Conclusion: The presence of PC associated with severe TBI appears to worsen its prognosis and be involved in secondary mortality. Its evolving nature is
crucial to consider, and it should be systematically sought and treated in the course of TBI.
Fatma HEBAIEB, Saloua HOUIMLI (la Marsa, Tunisia), Syrine TROJETTE, Nessrine YAHYAOUI, Mohamed ASSADI, Amira TABKA, Sarra AKKARI
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#41614 - Prognostic Implications of Hemoglobin to RDW Ratio for One-Year Mortality in ST-Segment Elevation Myocardial Infarction Cases: Insights from a Retrospective Cohort.
Prognostic Implications of Hemoglobin to RDW Ratio for One-Year Mortality in ST-Segment Elevation Myocardial Infarction Cases: Insights from a Retrospective Cohort.
Introduction
Anemia and Red Cell Distribution Width (RDW) have been identified as significant predictors of adverse outcomes in patients with acute coronary syndromes. While previous studies have highlighted the individual prognostic value of hemoglobin levels and RDW in predicting mortality and morbidity in patients with cardiovascular diseases, the ratio between hemoglobin and RDW has emerged as a novel marker for risk stratification. In patients with ST-segment elevation myocardial infarction (STEMI), the hemoglobin to RDW ratio (HRR) may provide valuable prognostic information regarding long-term outcomes. This study aimed to investigate the roles of HRR in predicting one-year mortality in STEMI patients.
Method
This retrospective cohort study was conducted at a tertiary teaching hospital, focusing on STEMI patients treated with primary percutaneous coronary intervention from January 2013 and December 2022. We collected data on demographics, medical history, and laboratory results. Receiver Operating Characteristic (ROC) curves were used to determine the prognostic value of HRR for 1-year mortality and identify optimal cutoff values via the Youden index. Kaplan–Meier survival analysis and multivariable Cox proportional hazards analysis were performed to assess the predictive capability of HRR on one-year mortality.
Results
The study included 807 patients diagnosed with STEMI, with 67 fatalities occurring within one year. The area under the ROC curve for the HRR in predicting 1-year mortality was 0.712. The optimal cut-off value for HRR was identified as 0.963. Kaplan–Meier analysis indicated that a high HRR (>0.963) was associated with a decreased cumulative risk of 1-year mortality (log-rank test P < 0.001). After adjusting for other risk factors in the multivariable Cox proportional hazards models, HRR was a significant predictor for 1-year mortality, whether it was analyzed as a dichotomized (high HRR vs low HRR) or a continuous variable. The corresponding adjusted hazard ratios (aHRs) were 0.389 (95% confidence interval [CI]: 0.223 - 0.678, P < 0.001) and 0.229 (95% CI: 0.084 - 0.628, P=0.004).
Discussion and conclusion
The retrospective cohort study highlights the importance of the HRR as a novel prognostic marker for predicting one-year mortality in STEMI patients. Combining Hb levels and RDW can enhance prognostic value. The HRR improves risk assessment and patient outcomes in managing STEMI, enhancing risk stratification and predictive accuracy for adverse outcomes. Further research and clinical validation are needed to fully integrate the HRR into routine risk assessment protocols for improved patient care in acute coronary syndromes.
Trial registration: This study is not a clinical trial.
Funding: This research did not receive external funding
Ethical approval and informed consent: The Institutional Review Board of the Ditmanson Medical Foundation Chia-Yi Christian Hospital (CYCH-IRB 2024010) has approved this study to be exempted from informed consent due to the retrospective nature of the study.
Shao-Ju CHOU (Chia-Yi, Taiwan), Yu-Ting HSIAO, Ya-Ni YEH, Ming-Jen TSAI
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#42211 - Prognostic value of blood glucose in non-ST elevation acute coronary syndrome.
Prognostic value of blood glucose in non-ST elevation acute coronary syndrome.
Introduction: For a long time considered as a simple marker of major acute stress, hyperglycemia in the acute phase is now considered as one of the major potential actors in the genesis of complications of acute coronary syndrome.
Objective: To evaluate the predictive value of blood glucose during non-ST-segment elevation acute coronary syndromes (NSTEMI).
Materials and Methods: Single-center prospective observational study. Inclusion of patients with age ≥ 18 years admitted to the emergency department for NSTEMI. Collection of epidemioclinical, biological and evolutionary parameters. The ROC curve was used to determine the threshold value of blood glucose on admission to predict intra-hospital complications.
Results: 100 patients were included. Mean age was 63 ± 14 years with a sex ratio of 2.8. The predominant cardiovascular risk factors were (%): smoking (49), hypertension (49), diabetes (47), coronary artery disease (38). The most common electrical abnormalities were: ST segment sub-shift (49), negative T wave (41), left bundle branch block (11). The average blood glucose level was 11 mmol/l ± 7. Twenty-nine patients developed complications, the most noted being: left ventricular failure (22%), atrial fibrillation (5%) and cardiogenic shock (2%). Blood glucose was predictive of intra-hospital complications from a threshold equal to 8 mmol/l with AUC 0.653, p=0.017, IC95% [0.532-0.774], sensitivity 79% and specificity 60%.
Conclusion: Hyperglycemia in the acute phase of non-ST-segment elevation coronary syndrome is strongly associated with the risk of complications.
Jihene JELLALI (2021, Tunisia), Chiraz BEN SLIMANE, Siwar JERBI, Maissa BACHROUCH, Nour El Houda BEN SLIMANE
00:00 - 00:00
#42210 - Prognostic value of C-reactive protein in acute coronary syndromes with ST elevation.
Prognostic value of C-reactive protein in acute coronary syndromes with ST elevation.
Introduction : C-reactive protein (CRP) is secreted in the acute phase of inflammation. Currently several studies have considered it as a prognostic marker of atherosclerotic disease.
Objective: To evaluate the predictive value of CRP during acute coronary syndromes with ST-segment elevation (ACS ST+).
Material and Methods: Single-center prospective observational study. Inclusion of patients ≥ 18 years of age admitted for ST+ ACS to the emergency department. Collection of epidemioclinical, biological and evolutionary parameters. The ROC curve was used to determine the threshold value of CRP to predict in-hospital mortality.
Results: This is a prospective study conducted over 8 months (January 2022-August 2022). Inclusion of 76 patients. Mean age = 60 +/-13 years, Sex-Ratio =4. Median time to consultation = 5 hours [1-72]. The predominant cardiovascular risk factors were(%): smoking (40), Hypertension (38), diabetes (38), coronary artery disease (16). Chest pain was the main reason for consultation (80% of cases). The affected territories on the electrocardiogram (ECG) were (%): inferior (39), anterior (35) and lateral (22) with extension to the VD in 21% of cases. Twenty patients (15%) developed complications, the most noted were (n): cardiogenic shock (7), supraventricular rhythm disorders (3) and left ventricular failure (3). Cardiorespiratory arrest occurred in 7 patients with asystole in 4 and ventricular fibrillation in 3. Pharmacological fibrinolysis was adopted in 35 patients with a mean delay of 13 ±5 min. The mean CRP was 69 ± 38 mg/l. Intra-hospital mortality was 6.6%. CRP was predictive of in-hospital mortality from a threshold of 103 mg/l with AUC 0.843, p= 0.04, IC95% [0.690-0.996], sensitivity 67% and specificity 88%.
Conclusion: CRP is a good prognostic factor for predicting in-hospital mortality in ST-segment elevation acute coronary syndromes.
Jihene JELLALI (2021, Tunisia), Nour El Houda BEN SLIMANE, Chiraz BEN SLIMANE, Siwar JERBI, Maissa BACHROUCH, Manel BAYAR
00:00 - 00:00
#41081 - Prognostic value of inflammatory markers for 1-year mortality in patients with ST-segment elevation myocardial infarction: a retrospective cohort study.
Prognostic value of inflammatory markers for 1-year mortality in patients with ST-segment elevation myocardial infarction: a retrospective cohort study.
Introduction:
The inflammatory response plays an important role in the pathophysiology of acute myocardial infarction. Readily obtainable inflammatory parameters, such as neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR) and platelet-to-lymphocyte ratio (PLR) have been shown to be associated with short-term major adverse cardiac events in patients with ST-segment elevation myocardial infarction (STEMI). However, the prognostic value of these inflammatory biomarkers for long-term mortality in STEMI patients remains uncertain. This study aimed to investigate the roles of NLR, MLR, and PLR in predicting 1-year mortality among STEMI patients.
Method:
A retrospective cohort study was conducted at a tertiary teaching hospital. Patients diagnosed with STEMI in the emergency department (ED) who underwent primary percutaneous coronary intervention were identified between January 2013 and December 2022. Patients’ characteristics, medical history, triage information, initial laboratory results, electrocardiograms, and coronary angiography reports were collected. NLR, MLR, and PLR were calculated. Receiver operating characteristics (ROC) curves were plotted to evaluate the area under the curve (AUC) for NLR, MLR and PLR in predicting 1-year mortality. The best cut-off values were determined using the Youden index. Kaplan–Meier survival analysis and multivariable Cox proportional hazards analysis were performed to assess the predictive value of these parameters for 1-year mortality.
Results:
A total of 689 STEMI patients were included, with 61 patients dying within 1 year. The AUC for NLR, MLR, and PLR in predicting 1-year mortality were 0.678, 0.656, and 0.626, respectively. The best cut-off values for NLR, MLR, PLR were 3.933, 0.266, and 101.177, respectively. Kaplan–Meier analysis indicated that high NLR, MLR, and PLR were associated with an increased cumulative risk of 1-year mortality (all log-rank test P < 0.001). However, after adjusting for associated factors in the multivariable Cox models, only NLR was significantly associated with the risk of 1-year mortality (aHR: 2.39, 95% CI, 1.37–4.17, P = 0.002)
Discussion and conclusion:
Inflammation is associated with the progression of atherosclerosis, thrombosis, and acute coronary syndrome. Studies on NLR, MLR and PLR in the role of inflammatory response have demonstrated elevated ratios correlated with higher risk of complication and worse short-term mortality rate in STEMI patients. Among these inflammatory biomarkers, our study found NLR emerged a potential useful parameter in predicting 1-year mortality after STEMI. It may serve as an affordable and readily obtainable prognostic marker for long-term outcomes in STEMI patients. Integrating NLR into existing predictive models may refine risk assessment, guide treatments, optimize resource allocation and improve patient outcomes.
Trial registration: This study is not a clinical trial.
Funding: This research did not receive external funding
Ethical approval and informed consent: The Institutional Review Board of the Ditmanson Medical Foundation Chia-Yi Christian Hospital (CYCH-IRB 2024010) has approved this study to be exempted from informed consent due to the retrospective nature of the study.
Kuan-Chung TING (Chiayi City, Taiwan), Yu-Ting HSIAO, Ya-Ni YEH, Jih-Chun LIN, Shi-Quan ZHANG, Ming-Jen TSAI
00:00 - 00:00
#42205 - Prognostic value of lactate in acute lung edema.
Prognostic value of lactate in acute lung edema.
Introduction: Lactate is recognized as a prognostic factor during critical states characterized by cellular anoxia. Acute pulmonary edema (APE) is a frequent cause of cellular oxygen debt.
Objective: To study the prognostic value of lactatemia in patients admitted to the emergency department for acute lung edema.
Materials and Methods: This is a prospective mono-centric study over a period of six months (June 2022 - December 2022) including patients admitted to the emergency department for acute lung edema. Collection of epidemiological, biological and evolutionary parameters. The ROC curve was used to determine the threshold value of lactate at admission to predict in-hospital mortality.
Results: Among 100 patients included, lactate determination at admission could not be done for only 40 patients. Inclusion of 77 patients. Among these patients the most frequent reasons for consultation were (%): Dyspnea (80%), altered neurological status (9%) and chest pain (4%). The mean blood pressure was 122 mmHg± 12. The mean pulse oxygen saturation was 88±4%. The diagnosis of lesional PAO was retained in 60% of the patients and it was of cardiogenic type in 40% of the cases. Therapeutic management. The mean lactate level was 1.8±0.5. Lactate was predictive of in-hospital mortality from a threshold of 3.1 with AUC = 0.800; p= 0.01; 95% CI [0.619-0.982] and sensitivity 71% and specificity 76%.
Conclusion: A lactate level higher than 3 appears to be a strong predictor of mortality in patients with acute lung oedema.
Jihene JELLALI (2021, Tunisia), Chiraz BEN SLIMANE, Nour El Houda BEN SLIMANE, Siwar JERBI, Maissa BACHROUCH, Salma ZARIAT, Manel BAYAR
00:00 - 00:00
#42240 - Prognostic value of the APACHE II score versus the MEWS score in the management of patients admitted to the emergency department.
Prognostic value of the APACHE II score versus the MEWS score in the management of patients admitted to the emergency department.
The management of critically ill patients in emergency departments (ED) must be rapid and well codified. Prognostic scores can be used to identify patients at high risk of mortality. The APACHE II score (Acute Physiology and Chronic Health Evaluation II) is a clinico-biological score used to classify severity. Its prognostic value has been demonstrated in patients admitted to intensive care units. The MEWS (modified early warning score) is a new simple clinical score recently adopted and not yet enough evaluated in the ED.
The aim of this study was to investigate the prognostic value of the APACHE II score and the MEWS score in terms of in-hospital mortality critically ill patients admitted to the ED
Methods:
Prospective observational study over a 5-year. Inclusion of patients ≥ 18 years old admitted to ED. Calculation of APACHE II and MEWS scores for all patients. Epidemiological, clinical and biological data were collected. The ROC curve was used to determine the threshold value for predicting in-hospital mortality.
Results :
Inclusion of 457 patients. The mean age was 62+/-19 years. The gender ratio was 1.3. The most common comorbidities were (%): hypertension (41), diabetes (35), chronic obstructive pulmonary disease (19), coronary artery disease (13), chronic heart failure (6) and chronic renal failure (11). The most frequent reasons for consultation were (%), altered mental status (30), altered general condition (18), dyspnoea (18), fever (14), chest pain (6). Main reasons for admission were (%): respiratory failure (30), sepsis (27), cardiac failure (26), shock (20). The median APACHE II score was 16 ± 8. The mean MEWS score was 8.5+/-3. Inhospital mortality was 36%. A MEWS score > 8 was predictive of mortality (AUC=0.734 P=0.001 and IC95% [0.684-0.784]) with a sensitivity of 70%, a specificity of 60%, a positive predictive value of 70% and a negative predictive value of 60%. The APACHE II score was predictive of mortality from a threshold equal to 14 AUC= 0.770 ; p=0.001 95% CI [0.721 -0.819] with a sensitivity (Se)=75% a specificity (Sp)=65%, a positive predictive value (PPV) of 50% and a negative predictive value (NPV) of 80%.
Conclusion : The performance of the APACHE II score and the MEWS score in predicting early mortality in patients admitted to the critically ill patients admitted in ED is good. The two scores are comparable. The use of the MEWS score, a simple score, is promising.
Jihene JELLALI, Hela BEN TURKIA, Raja FADHEL (Ain Zaghouan, Tunisia), Ines CHERMITI, Mohamed ZOUARI, Amira TAGOUGUI, Hanene GHAZELI, Sami SOUISSI
00:00 - 00:00
#42208 - Prognostic value of the GRACE score in non-ST-segment elevation acute coronary syndromes.
Prognostic value of the GRACE score in non-ST-segment elevation acute coronary syndromes.
Introduction: Risk assessment is an essential step in the management of non-ST-segment elevation acute coronary syndromes. The GRACE (Global Registry of Acute Coronary Events) score is the one recommended by the European Society of Cardiology.
Objective: To assess the predictive value of the GRACE score in non-ST-segment elevation acute coronary syndrome (non-ST+ ACS).
Materials and Methods: Single-center prospective observational study. Inclusion of patients ≥ 18 years of age admitted for non-ST+ ACS to the emergency department. Collection of epidemioclinical, biological and evolutionary parameters. The ROC curve was used to determine the cut-off value of the GRACE score to predict in-hospital complications.
Results: Inclusion of 100 patients with an age greater than 18 years, with a mean age of 63 ± 14 years and a sex ratio of 2.8. The predominant cardiovascular risk factors were: smoking (49%), hypertension (49%), diabetes (47%), and coronary artery disease (38%), 24% of whom were already stented. Electrical expression was predominantly st segment sub-shift (49%), negative T wave (41%) BBG (11%) BBD (5%) normal ECG (6%) wallens (4%). Twenty-nine patients developed complications, the most noted being: left ventricular failure (22%), atrial fibrillation (5%) and cardiogenic shock (2%). The median GRACE score was 94 ± 45 . Intra-hospital mortality was 5%. The GRACE score was predictive of in-hospital complications from a threshold equal to 154 with AUC 0.830, p < 0.01, IC95% [0.740-0.919 ], sensitivity 82% and specificity 76%.
Conclusion: The calculation of the GRACE score in non-ST elevation coronary syndromes allows a good evaluation of their intra-hospital prognosis.
Jihene JELLALI (2021, Tunisia), Chiraz BEN SLIMANE, Nour El Houda BEN SLIMANE, Siwar JERBI, Maissa BACHROUCH, Manel BAYAR
00:00 - 00:00
#41672 - Program of Medical Junior Leadership Training for Residents.
Program of Medical Junior Leadership Training for Residents.
Introduction
Residents are the future actors of the health system but they are exposed to many stressors. The purpose of our study is to evaluate the impact of a junior leadership training program for residents.
Method
Eighteen residents were included. The program took place over 4 months with 4 days of training (32 hours) and a 12 hours of mindfulness program. The program consists of four modules with the objective of learning skills in leadership-management, stress management, nutrition and sleep. The primary outcome measures was the satisfaction of the residents. The secondary outcome measures were the change before and 3,6 and 12 months after the training program of proportion of burn-out, anxiety and depression, relational skills, quality of sleep, the use of psychoactive substances and medical/psychological support.
Results
We presented the results corresponding of the complete follow-up. The average age was 28+/-2.6 with 53% male. The following criteria were considered excellent: conviviality (92%), organization (77%), interest (69%) and usefulness (61%). Concerning burn-out, we found a significant increase in personal accomplishment (40% at inclusion vs 60% after 12 months) and also an increase of depersonalization (18% at inclusion vs 33% after 12 months). There was a decrease of anxiety between inclusion and 12 months: 35% vs 26% and depression were stable. Relational skills were increased after 12 months: 24% vs 57%. The quality of sleep was not increase but the quality of waking and the quality of the state after waking up increased over time. There was a decrease in the use of psychoactive substances after 12 months: 77% vs 47%. We found also an increase in the use of medical-psychological support: 6% vs 20%.
Discussion
Our results show that after 12 months, residents had a better personal accomplishment, lower anxiety and decrease their consummation of psychoactive substances. They also improve their relational skills, their performance and the quality of waking. These results are encouraging because the benefits persist over time. However, it was a pilot study with a small number of participants and the results must be confirmed on a largest cohort.
Conclusion
A medical junior leadership program improves the mental health and leadership of the resident. Further studies are needed to evaluate this effect on a larger number of residents, especially those in emergency medicine.
NCT05561283
Marion DOUPLAT (Lyon), Stéphanie MAZZA, Olivier REVOL, Nathalie STREICHENBERGER, Jacques BRADWEJN, Anne TERMOZ, Martine WALLON
00:00 - 00:00
#41372 - Promoting helmet use in adult cyclists: a scoping review of non-legislative interventions.
Promoting helmet use in adult cyclists: a scoping review of non-legislative interventions.
Introduction: Helmets are effective in preventing brain injury and fatality in cyclists. Methods to promote their use include legislation and non-legislative interventions (NLIs) such as education, social interventions, and subsidies. These have been systematically reviewed and proven effective in paediatric populations. We conducted a scoping review regarding NLIs to promote helmet use amongst adult cyclists.
Methods: We conducted a scoping review of NLIs to promote helmet use amongst cyclists age 18 or older. PRISMA guidelines were followed. Databases searched included MEDLINE, EMBASE, CINAHL, PsycINFO, and SportDiscus, in addition to grey literature, from inception and prior to 2020. Articles were excluded if non-English, focused on age <18, on legislative interventions, or did not report on outcomes related to helmet use or ownership. Study inclusion and data extraction were conducted in duplicate. Data were extracted regarding participant demographics, setting, intervention details and effects, and were reported using descriptive statistics with a narrative synthesis. A limited quality assessment was conducted.
Results: A total of 16 papers were included, stratified as 4 randomized-controlled trials and 12 pre-post studies. Only 4 were specific to adults. Community cyclists (5/16, 31%) and community members were most commonly targeted, with most interventions taking place in the community (8/16, 50%) or in a healthcare setting (4/16, 25%). Most interventions were multi-faceted, involving components of community awareness programs, education, information distribution, helmet giveaways and monetary incentives, use of mass media, motivational interviewing, and social marketing. The studies were heterogeneous in quality. Changes in helmet rate use varied between -6% and 26%, with half the studies (8/16, 50%) noting a statistically significant increase. Duration of follow-up of helmet use rates following the intervention varied between 4.5 weeks and 11 years (median 1.38 years, mean 3.0 years.)
Discussion and Conclusions: There is a need for effective approaches to improve voluntary helmet use by adult cyclists. Non-legislative interventions to encourage bicycle helmet use were frequently multi-faceted and generally associated with an increase in use amongst adults. Studies were heterogenous in quality, varied in their targeted audiences and often not focused on adults. Further evidence is needed to better characterize the efficacy of non-legislative interventions to achieve sustained helmet use in adult cyclists.
This study was supported by a grant from the Dr. Tom Pashby Sports Safety Fund.
Steven Marc FRIEDMAN (Toronto, Canada), Arshia JAVIDAN, Abirami KIRUBARAJAN, Dongjoo LEE
00:00 - 00:00
#42255 - Propofol- should we use it in out-of-hospital Emergency Medical Service?
Propofol- should we use it in out-of-hospital Emergency Medical Service?
Emergency Medical Service staff (EMS) performs various procedures that can be painful. These are stitching, foreign body removal, incisions and drainage abscess, repositioning of dislocated joints or fractures with displacement, cardioversion, and placement of central venous catheter or thoracic drain. Procedural sedation and analgesia (PSA) are the use of sedatives, with or without analgesics, in order to facilitate patient tolerance and pain removal. The medicines used in PSA should have predictable effects on sedation, analgesia, amnesia and motor control. It would be ideal if they had rapid onset, steady maintenance of sedation and analgesia, short recovery (awakening) period, patient's minimal recollection of the performed procedures, and when they would have been without side effects or at least with mild and tolerable side effects. In clinical practice, we have many such drugs, but no drug has shown any results superiority for all medical conditions and all patient characteristics. In out-of-hospital EMS in Croatia, according to my knowledge, midazolam and propofol are only drugs used for PSA. Midazolam (Dormicum) is partly used, but according to our unpublished data, propofol is rarely or never used. That is the reason why I wanted to show the case of 14-year-old boy with a dislocation of the patella treated in the out-of-hospital EMS in Department in Vrgorac in Split-Dalmatia County in Croatia. This boy has injured the knee at Elementary School in Vrgorac on physical education, while he was playing basketball without the trauma. He was admitted to our Department where we have found out that he had a dislocation of the patella half a year ago. Because of this, he was treated in University clinical center (UCC) in Split. The clinical examination was, apart from the injured and very painful knee, normal and without pathological findings. The physician on duty decided to apply a short-term anesthesia with intravenous administration of 50 mg of propofol. All vital functions were monitored. Less than half a minute after administration, the patient lost consciousness, and the patella was repositioned. Our patient has woken up after less than 10 minutes. He was without any side effects, all the time monitored, and all his vital parameters were in normal range for his age. He was observed for 2 hours and discharged home with an elastic bandage. We gave him instructions and have made appointment with a pediatric surgeon in UCC Split next day. The purpose of this case-report is to make out-of-hospital EMS physicians aware of the advantages and properties of propofol, which, if properly administered, has a rapid onset, short action, good characteristics, and few side effects. It is important to note that an analgesic drug should be added to it, because propofol does not have an analgesic effect.
Andrija BABIĆ (Vrgorac, Croatia)
00:00 - 00:00
#40980 - Protective Effects Of Artificial Hypothermia And Olanzapine-induced Hypothermia Against BBB Disruption In Gerbil Striatum Following Ischemia-reperfusion Injury.
Protective Effects Of Artificial Hypothermia And Olanzapine-induced Hypothermia Against BBB Disruption In Gerbil Striatum Following Ischemia-reperfusion Injury.
Background and aims: The blood–brain barrier (BBB) is a crucial physiological barrier which separates the central nervous system (CNS; brain and spinal cord) from the CNS circulation that contains inflammatory mediators. The BBB controls molecular and cellular exchange for normal functions between the CNS blood vessels and parenchyma. It has been reported that neuroinflammation can destroy the BBB, resulting in various CNS diseases.
Methods: In this study, 15-minute transient cerebral ischemia (ischemia-reperfusion, IR) was developed in gerbils. The striatum, which is an important brain structure in extrapyramidal motor system, was used to compare the protective effects of artificial hypothermia and drug-induced hypothermia against BBB disruption on day 5 after IR, when striatal neuronal death occurred in the ischemic striatum.
Results: Immediately after IR, artificial hypothermia was induced by body surface cooling using ice and drug-induced hypothermia was developed using olanzapine, an antipsychotic medication able to treat several mental health conditions (i.e., schizophrenia and bipolar disorder), that has been discovered to have some beneficial effects beyond its original effectiveness.
Neuronal death (loss) was examined by cresyl violet histochemistry and Fluro-Jade B histofluorescence. BBB disruption was examined by immunohistochemistry using primary antibodies of glial fibrillary acidic protein (GFAP) for astrocyte endfeet (AFE) and caveolin-1, a scaffolding protein. In addition, BBB leakage was evaluated by immunohistochemistry using primary antibodies of immunoglobulin G (IgG) and albumin.
The effects of artificial hypothermia against IR-mediated neuronal loss, AFE damage (loss), caveolin-1 increase, and IgG and albumin leakage were tenuous; however, olanzapine-induced hypothermia significantly protected IR-induced damages.
Conclusions: Collectively, our findings revealed that olanzapine administration after IR apparently protected RI-induced BBB disruption, which might be closely related with IR-mediated neuroinflammation, in ischemic gerbil striatum. Thus, olanzapine can be a therapeutic agent for brain IR injury by protecting BBB disruption following cerebral ischemic insults.
Seong Mi HEO, Jun Hwi CHO (Chuncheon, Republic of Korea), Joong Bum MOON, Taek Geun OHK, Myoung Chul SHIN, Da Som HAN, Jae Seong NOH
00:00 - 00:00
#42051 - Provider Perception of Emergency Department Presentations with Nonspecific Back Pain: A Semi-Structured Interview Study.
Provider Perception of Emergency Department Presentations with Nonspecific Back Pain: A Semi-Structured Interview Study.
Background
The increasing number of low-urgency patients treated in the emergency departments (ED) poses challenges to delivering high-quality healthcare, predominantly by consuming resources required for high-urgency patients. Patients with non-specific back pain (NSBP) often present to the ED instead of primary care. While patient perspectives have been explored extensively, this study aims to add a provider perspective on reasons for ED presentation as well as the diagnostic and therapeutic approach for NSBP in the ED and primary care settings. Furthermore reasons for resource consumption and challenges to adhere to existing guidelines are explored.
Methods
In a qualitative content analysis, we interviewed physicians using a semi-structured approach to assess the approach to patients with NSBP in the ED and general practice. A hypothetical case of NSBP was presented to the interviewees, followed by questions on their diagnostic and therapeutic approaches. Two groups were analyzed: Emergency Physicians (EP) and General Practitioners (GP).
Results
In 16 interviews with seven EPs and nine GPs, we elucidated diagnostic and therapeutic approaches and perceived reasons for the presentations of those patients to the ED.
EPs applied two different strategies for the workup of NSBP. A subset pursued a guideline-compliant diagnostic approach, ruling out critical conditions and managing pain without extensive diagnostics. Another group of EPs applied a more extensive approach, including extensive diagnostic resources and specialist consultations.
GPs mostly emphasized physical examinations and stepwise treatment, including scheduled follow-ups and a better knowledge of the patient history to guide diagnostics and therapy.
Both groups attribute ED visits for NSBP to several patient-related factors: lack of understanding of healthcare structures, convenience, demand for immediate diagnostics, and fear of serious conditions. Furthermore, both groups reported an ill-suited healthcare infrastructure as a contributing factor.
Conclusions
The study highlights a need for improving guideline adherence in EPs and better patient education on the healthcare infrastructure. Furthermore, improving access and availability of primary care services could reduce ED visits of patients with NSBP.
No trial registration needed.
LB received funding through the Berta-Ottenstein-Programme for Clinician Scientists from the Faculty of Medicine, University of Freiburg.
FPH was funded by the Baden-Württemberg State Ministry for Science, Research and the Arts (as part of the multinational Clinnova consortium (GdGI))
Leo BENNING, Nora KÖHNE (Berlin, Germany), Felix Patricius HANS, Hans-Jörg BUSCH
00:00 - 00:00
#41273 - Pseudoaneurysm rupture, a rare but lethal complication in chronic pancreatitis.
Pseudoaneurysm rupture, a rare but lethal complication in chronic pancreatitis.
Brief clinical history A 51 years old man with history of alcoholism and frequent alcoholic pancreatitis episodes presented to our emergency department due to sudden onset of acute abdominal pain with cold sweating and syncope when resting on a chair. At triage, he was conscious and in much less pain. His vital signs were stable, body temperature 36.5 degree Celsius, heart rate 74 beats per minute, respiratory rate 18 per minute, blood pressure 105/67 mmHg. The physical examination revealed soft and flat abdomen and mild tenderness at epigastrium, without rebound tenderness or muscle guarding. Under the suspicion of abdominal vascular emergency due to his initial presentation of abdominal pain, we did the point of care ultrasound(POCUS) with negative findings of internal bleeding or abdominal aorta aneurysm or dissection. And the subsequent blood exam showed insignificant, the white blood cell count was 8610/uL, hemoglobin 14.8 g/dL, blood glucose 134 mg/dL, lipase 17 U/L, total bilirubin 0.7 mg/dL, glutamic oxaloacetic transaminase 27 U/L, serum sodium 135 mEq/L, potassium 3.6 mEq/L. We admitted him for suspect chronic pancreatitis, however, there was still concern of vascular emergency due to his initial presentation though he was quite stable now. The abdominal computed tomography(CT) disclosed large amount of high density fluid accumulation around pancrease and right anterior pararenal space, suspect peritoneal hemorrhage of unknown source. And the subsequent angiography revealed a pseudoaneurysm at right branch of superior mesentary artery, transcatheter arterial embolization was performed by the radiologist smoothly. The patient was discharged uneventfully after 20 hospital days. Misleading elements/Differential diagnosis/Educational points: Cognitive bias: A patient with alcoholism, recurrent alcoholic pancreatitis history and normal lipase level could easily lead us to the diagnosis of chronic pancreatitis. And the retroperitoneal hemorrhage when stopped and confined can be without showing peritoneal signs, just like our patient's presentation. And the retroperitoneal hemorrhage is not easily detected by POCUS. The only clue leading to the answer is his initial presentation, sudden onset of abdominal pain with cold sweating and syncope
Borhen WU (Taipei, Taiwan)
00:00 - 00:00
#41451 - Pulmonary Embolism Associated with miliary Tuberculosis: A Case Report.
Pulmonary Embolism Associated with miliary Tuberculosis: A Case Report.
Introduction: Pulmonary tuberculosis is endemic in our country. Its preventive and therapeutic management is well codified to prevent progression to severe forms, such as miliary tuberculosis.
Clinical Observation: We report the case of a 73-year-old female patient, hypertensive, type 2 diabetic on insulin therapy, hospitalized the previous year for 4 months in dermatology for the management of bullous pemphigus, with long-term corticosteroid therapy. She presented to our emergency department with basithoracic pain and asthenia, which had been evolving for 15 days, in a context of unspecified fever. Initial clinical examination revealed a patient with a BMI of 17 kg/m2, tachypneic at 23 breaths per minute, with peripheral oxygen saturation (SpO2) of 79% in ambient air, pulmonary auscultation revealing crackling rales at the bases of both lungs, blood pressure at 120/80 mmHg, tachycardia at 124 beats per minute, no signs of right heart failure, fever at 38.5°C, supple calves, and a normal neurological and abdominal examination. Arterial blood gas analysis at ambient air showed a shunt effect, and chest X-ray revealed diffuse alveolar syndrome. Thoracic angioscanner concluded the presence of a proximal right and distal left pulmonary embolism, without signs of severity on scanning, and an aspect consistent with miliary tuberculosis. Sputum cytobacteriological examination showed no acid-fast bacilli on direct examination. The patient was started on therapeutic doses of low molecular weight heparin (LMWH) and vitamin K antagonists (VKA). Over the course of the hospitalisation, her condition deteriorated worsened. The patient died on day 4 of hospitalization.
Conclusion: Our observation highlights that pulmonary embolism may also be associated with pulmonary tuberculosis, particularly in its severe and disseminated form. Therefore, considering the current endemic climate of this pathology, a high level of suspicion should be warranted to allow rapid initiation of appropriate treatment to achieve better clinical and laboratory outcomes.
Yasmine BENZARTI (tunis, Tunisia), Chadha BEN HMIDA, Marouane SANAI, Dhekra HOSNI, Sarra JOUINI
00:00 - 00:00
#42045 - Purple urine bag syndrome.
Purple urine bag syndrome.
Brief clinical details:
An 89-year-old male patient with background of Benign Prostatic Hyperplasia on long-term in-dwelling urinary catheter presents to the Emergency Department with concerns of purplish discolouration in his urine bag. There was no reduction in urine output and the urinary catheter was recently changed two weeks ago. The urinary catheter was draining well with no concerns of tube obstruction. The patient had a low-grade fever of 37.9 degree Celsius. He was otherwise asymptomatic. Abdominal and genitourinary examination was unremarkable.
Description of the relevant abnormalities:
The urinary tubing was draining clear brownish urine, but a purplish hue was noted along the urinary bag which had come into contact with the urine. A bedside urine dipstick performed was positive for both nitrites and leukocytes. Urine pH was 8.5. Urine cultures grew abundant Klebsiella pneumoniae (>100,000 CFU/ml) and Escherichiae coli (10,000-100,000 CFU/ml). The patient was treated with amoxicillin/clavulanic acid for one week duration and responded well. The purplish discoloration resolved soon after initiation of treatment and change of urinary bag.
Why this image is clinically or educationally relevant?
Purple urine bag syndrome is an uncommon condition. The purple hue is due to products of the breakdown of tryptophan which stain the urinary catheter, but the urine itself is not discoloured, as shown in the clinical picture. Tryptophan undergo metabolism by tryptophase-containing bacterial flora into indole. Indole subsequently undergoes hepatic conjugation to indoxyl sulphate, which is excreted in urine. Indoxyl sulphate undergoes metabolism by sulphatase and phosphatase enzymes found in urinary bacteria, forming indirubin (red) and indigo (blue) pigments, which precipitate and react with the synthetic materials of the catheter and urinary bag, resulting in purple discoloration. Risk factors for purple urine bag syndrome include increased urine alkalinity, chronic urinary catheterisation and high urinary bacterial load.
Darius Shaw Teng PAN (Singapore, Singapore)
00:00 - 00:00
#42104 - Quality Improvement Project in point of care ultrasound (POCUS) training in an Irish Emergency Department.
Quality Improvement Project in point of care ultrasound (POCUS) training in an Irish Emergency Department.
INTRODUCTION
Point of care ultrasound (POCUS) level 1 certification is expected of all Core Specialist Training in Emergency Medicine (CSTEM) and Advanced Specialist Training in Emergency Medicine (ASTEM) trainees. Each training site should have an US training lead. A Model 4 University Hospital in Ireland started a trainee focused POCUS training programme in July 2023.
The aim of this quality improvement project is to create a structured and individualised POCUS training and supervision programme which supplements and re-enforces the Royal College of Surgeons Ireland (RCSI) level one POCUS taught course material which will improve the confidence and experience of all doctors working in the Emergency Department (ED) to achieve POCUS level one certification.
METHOD
A baseline survey was conducted in July 2023. NCHDs’ experience, attitudes, barriers, and facilitators towards POCUS use in the ED was analysed. Next, educational sessions were offered that focused on ultrasound basics, image acquisition techniques and interpretation. After analysis, a phased approach to POCUS training was introduced focusing on the areas most mentioned in the baseline survey. A repeat survey was performed in December 2023 to determine improvements in POCUS experience and feedback on the training sessions.
RESULTS
At the baseline audit (35 respondents), one (3%) indicated substantial experience in POCUS and 24 (69%) showed considerable experience. Ten (28%) indicated to have modest to no experience in POCUS. On repeat survey (20 respondents), one (5%) indicated substantial experience in POCUS and 16 (80%) showed considerable experience. Three (15%) indicated modest to no experience. The modalities to focus on was eFAST (41%), AAA (38%) and echo (68%). There was increased experience gained in eFAST (83% to 89%), AAA (74% to 83%) and serratus anterior blocks (6% to 28%).
The most effective way to learn POCUS is through supervised training (89%), formal training in a solo setting (65%), formal training in a group setting (40%). However, the key barriers to training include finding time to scan during a work rostered shift (47%) and 38% expressed that there is no-one available for supervision when they want to scan. The key facilitators identified was dedicated ultrasound teaching (71%), supervision by experienced ultrasonographers (80%), and to allow time to practice scans during a work rostered shift (51%). By the end of the rotation five (26%) used online FOAMed to augment ultrasound training and four (21%) attended formal US training courses.
CONCLUSION
A combination of solo supervision and group training sessions, booked in advance to suite the busy ED shift work rota, facilitates attendance. Self-reflected NCHD POCUS experience and confidence can improve by using a structured and individualised training programme with trainee engagement.
Gideon-Phil MEYER (Dublin, Ireland), Mai NGUYEN
00:00 - 00:00
#42010 - Quality improvement: is it possible to improve a paediatric emergency and acute receiving team huddle?
Quality improvement: is it possible to improve a paediatric emergency and acute receiving team huddle?
Background and aims
Huddles and touchpoint meetings are well recognised strategies to improve information sharing across departments, assist patient flow and encourage flexible working.
In our tertiary paediatric hospital we have a twice daily multidisciplinary team (MDT) huddle across the emergency department and the acute receiving (short stay) ward.
We set out to produce a new huddle format with an aim to improve the effectiveness and efficiency of the huddle overall.
Methods
We had an MDT emergency department (ED) management meeting that identified the topics of discussion needed for an effective huddle.
We then designed a new huddle proforma which included all topics identified, to trial over an 8 week period.
We designed a questionnaire for members of staff who attend the huddle, to gain MDT views on the new huddle format.
Results
There were 37 responses (11 ED consultants, 15 medical consultants, 6 hospital coordinators/bed manager, 3 ED coordinators, 2 short stay ward charge nurses.)
32 responders had attended a new format huddle.
Since introduction of the new huddle:
• 59% agreed or strongly agreed the structure improved whilst 31% were not sure
• 47% thought the challenges of the day were more readily identified whilst 41% were not sure
• 50% thought communication across the ground floor had improved whilst 38% were unsure
• 68% thought the new huddle format improved the effectiveness and efficiency of the huddle
Overall 68% thought we should continue with the new huddle format.
Conclusions
It is possible to adapt and improve your huddles with collaborative MDT working.
Price REBECCA, Wendy LUNDY, Natalie BEE (EDINBURGH, )
00:00 - 00:00
#40824 - Quantifying the effectiveness of a global health partnership, measuring impact on individuals and their employer.
Quantifying the effectiveness of a global health partnership, measuring impact on individuals and their employer.
Background and Introduction:
Global health partnerships strive to achieve reciprocal improvements in the effective delivery of health systems in collaboration with the needs of partner organisations, in order to mutually improve patient care and experience and address inequalities in health care provision.
Since 2018, the Bristol Royal Infirmary has developed an emergency medicine collaboration between with Laikipia county in Kenya through Nanyuki Teaching and Referral Hospital. Emergency Medicine fellows and Emergency Nursing Fellows have been engaging in variable length deployments for between 2-3 months to work collaboratively with local staff to support the development of emergency care with a global view in both partner institutions.
THET (2023) states ‘This work brings benefit to health systems in low and middle income countries but is also having a beneficial impact on the NHS, as NHS staff return home with increased knowledge, improved leadership skills and a greater understanding of how to innovate in delivering healthcare with limited resources.’
It is often unclear or seemingly unresearched however, how these perceived benefits are measured to either partner, and how a variety of opportunities benefit different areas of skill, knowledge and practice development across the partnered institutions and their teams.
Objectives
To objectively assess perceived development of clinicians across defined domains, in order to better inform decisions around provision structure and funding of global emergency care opportunities within partnered institutions. This questionnaire seeks to improve understanding of impact of international placements, facilitating comparisons of different types of experience.
Methods/Description
The “Measuring the outcomes of volunteering for education” tool (MOVE-it) is a 40-item self-report questionnaire developed from a core outcome set for personal and professional development from international placements, identifying key domains of development, with evidence of good reliability and validity.
Outcomes are measured across 10 principle components:
Attitude to work
Adaptability
Adapting communication
Cultural sensitivity
Difficult communication
Confidence
Teaching
Management
Behaviour change
Life satisfaction
The aim is for this questionnaire to be provided to staff and completed pre-deployment, post deployment and around one-year post deployment.
Results/Outcome
The aim is to continue to collect ongoing data from clinical fellows and volunteers, but with a year of data currently analysed, comparing pre and post deployment responses to determine themes across personal and professional development across the domains of the questionnaire. Current responses show clear evidence of development for staff across multiple domains, with some evidence of clearer benefits around leadership and behaviour change within longer deployments evidenced by a higher post deployment score.
Conclusion
Positive personal and professional development themes are demonstrated within a well governed fellowship program, embedded in a health partnership. This suggests global emergency care partnerships, while aiming to address health inequalities and improve patient care, have a definable development benefit to UK staff that can form the basis of NHS trust decisions around support and funding for such opportunities.
This is not a trial
There is no funding allocation
Ethical approval is not required
Colin MACALINDIN (Bristol, ), Lucy OBOLENSKY, Andy LOCKYER, Christopher HOOK
00:00 - 00:00
#41760 - Racing against time: Emergency ambulance dispatches and response times in Region Zealand from 2013-2022, a registry-based study.
Racing against time: Emergency ambulance dispatches and response times in Region Zealand from 2013-2022, a registry-based study.
Background
The global strain on Emergency Medical Services (EMS) is reflected in the rising number of emergency ambulance dispatches over the past decade. Shorter EMS response times have demonstrated a clear effect on outcomes following out-of-hospital cardiac arrests, myocardial infarction, and stroke. However, it is unknown if an increase in the number of emergency ambulance dispatches negatively impacts EMS response times.
The primary aim of the study was to describe the trends in the number of emergency ambulance dispatches and response times from 2013 to 2022 in Region Zealand, Denmark. The secondary aim was to describe the demographic composition of the patients requiring an emergency ambulance (including age and comorbidities).
Methods
A register-based study was performed by use of administrative data from the emergency medical dispatch centre in Region Zealand linked with nationwide registers. Priority A (emergency) or B (urgent) ambulance dispatches were included. Trends were analysed overall and stratified by catchment areas corresponding to the four hospitals with emergency departments in the region. The study spanned from January 1, 2013, to December 31, 2022. Poisson regression and ordinal logistic regression were used to analyse the data.
Results
A total of 679,254 ambulance dispatches were included in the study with 55% and 45% categorized as priority A and B, respectively. Of these, 668,231 had a valid personal identification number allowing for further analysis, and 667,166 were included in the analyses stratified by catchment area. Within the study population, females comprised 48.5%, while the majority of patients (49.1%) were aged 65 years or older. Additionally, 47.5% had no comorbidities, 7.7% had mild comorbidities, and 44.8% had severe comorbidities. Further analysis revealed a higher proportion of patients with severe comorbidities in the southern area at 48.3%.
The number of emergency ambulance dispatches increased from 56,867 in 2013 to 81,080 in 2022 (143%). Correspondingly, the incidence rate of emergency ambulance dispatches per 1000 citizens increased from 69.2 [95% Confidence Interval (CI) 68.6;69.8] to 95.5 [95% CI 94.8;96.1]. Stratified by catchment areas, the rate differed significantly and in the southern area the incidence rate increased from 84.6 to 120.7 (Incidence Rate Ratio 1.47 95% CI 1.46; 1.49).
The median [IQR] response time for ambulance dispatches with a priority A was 7mins:14secs [4mins:42secs; 11mins:4secs] in 2013 and increased to 8mins:20secs [5mins:30secs; 12mins:22secs] in 2022. The median [IQR] priority B response time was 12mins:23secs [7mins:52secs; 19mins:54secs] in 2013 and increased to 15mins:6secs [9mins:24secs; 23mins:40secs] in 2022. Notably, while response times for both priorities A and B ambulance dispatches remained consistent in the southern area, they increased in the northern, eastern, and western areas.
Discussion & Conclusions
In the decade from 2013-2022, the number of emergency ambulance dispatches increased both in absolute numbers and per 1000 citizens. In the same period, ambulance response times increased for both priorities A and B. The study shows regional disparities according to both the rate of emergency ambulance dispatches and response times indicating challenges in how to distribute resources in the future to uphold the current standard of emergency care.
Registered in Region Zealand’s Research Registry, REG-145-2023. Ethical approcal not necessary.
Funded by The Danish Health Authority.
Josefine Tangen JENSEN (Copenhagen, Denmark), Thea Palsgaard MØLLER, Stig Nikolaj Fasmer BLOMBERG, Annette Kjær ERSBØLL, Helle Collatz CHRISTENSEN
00:00 - 00:00
#41693 - Radiographic warning signs of impending perforation of duodenal ulcer.
Radiographic warning signs of impending perforation of duodenal ulcer.
Brief clinical details:
A 52-year-old woman visited the emergency department (ED) for worsening left lower quadrant (LLQ) pain. She had taken 2 months of non-steroidal anti-inflammatory drugs (NSAIDs) for this pain.
At arrival, she had LLQ tenderness without peritoneal signs. Laboratory studies showed mild leukocytosis and pyuria. Computed tomography (CT) was performed two hours later. (Figure 1.)
The patient received two doses of Ketorolac within 12 hours for analgesia. However, the pain shifted from LLQ to the upper abdomen. 24 hours later, she developed muscle guarding and rebounding tenderness. Repeated abdomen CT was performed (Figure 2.)
Description of the relevant abnormalities:
In the first CT scan, there is no pneumoperitoneum and no ascites. However, three consecutive images demonstrated focal wall thickening of the duodenal first portion with a small outpouching lumen and adjacent fat stranding. (Arrows in Figure 1.)
The second CT scan showed pneumoperitoneum (Arrows in Figure 2.) and ascites (Arrowhead in Figure 2). Perforation at the duodenal first portion was confirmed during surgery.
Why this image is clinically or educationally relevant?
Routinely, surgery consultation for duodenal ulcer (DU) is indicated only when CT reveals extraluminal free air. However, the absence of pneumoperitoneum shouldn’t
preclude the necessity for surgery consultation.
When CT reveals focal thickening in the duodenal wall along with a small outpouching and fat stranding nearby, emergency physicians should raise the suspicion of impending duodenal perforation. Early surgery consultation is warranted.
Besides, when a patient presents with epigastric pain associated with a history of chronic NSAIDs use. NSAIDs should be avoided for symptomatic relief, preventing further mucosal injury and the risk of perforation.
Where patients’ images are submitted, please confirm you have adequate permission to use them.
Permission confirmed.
Hsu-Cheng HUANG (Taipei, Taiwan), Teh-Chen WANG, Pei-Hsun KUO, Yu-Chung CHANG
00:00 - 00:00
#41607 - Rationalising type and screen samples sent from the emergency department.
Rationalising type and screen samples sent from the emergency department.
Introduction
Minimizing excessive laboratory testing within healthcare facilities has emerged as a primary aim of quality enhancement efforts following the Choose Wisely Campaign. Although the campaign has gained momentum with many specialty societies, it has not been widely adopted in emergency settings.
During a lab audit, we found a significant number of unutilized Type and Screen (T&S) samples.
T&S is used for blood typing and antibody screening and then stored for matching to donor blood products when required. They are often sent from the emergency department (ED) for patients with anticipated major bleeding, undergoing emergency therapeutic interventions with anticipated major bleeding, or for emergency blood transfusions. Existing interdepartmental workflows mandate T&S for conditions such as acute coronary syndrome, gastrointestinal tract bleeding, acute ischemic or hemorrhagic stroke, acute limb ischemia, acute pulmonary embolism, active bleeding, cytopenia meeting transfusion thresholds and polytrauma.
Unnecessary T&S testing has negative impacts on patient care (pain, infection, iatrogenic anemia), finances ($29/test) and resource utilization (staff time, laboratory supplies), in addition to increased risk of errors and needle stick injuries
We used an approach of education, audit and feedback as an intervention to change ordering practices to reduce unnecessary T&S samples.
Methods
Pre-intervention, all T&S sent from the ED between 1-14 July 2023 were retrospectively reviewed for appropriateness. The indications for T&S were reviewed and if not specified, the ED electronic discharge diagnosis was used. We then collaborated with surgical, orthopaedic and anaesthesia specialties to create a T&S guideline for ED providers. Of note, we added specific recommendations for sending T&S to existing mandated T&S workflows described above. Following this, we educated our ED providers on the updated T&S sampling guidelines on 1 October 2023. Post intervention, we analyzed a systematic sample of every third T&S between October to November 2023.
Our primary outcome was reduction of unutilized T&S samples and secondary outcome was reduction of unnecessary T&S done.
Results
Out of 440 T&S sent from the ED during the pre-intervention study period, 264 (60%) were sent as mandated by existing workflows with 76 (17.3%) translating to blood product transfusions. The remaining 176 (40.0%) were sent for other reasons such as sepsis, minor head injury, seizures, hypoglycemia and appendicitis.
Post-intervention data analysed a total of 340 T&S samples (out of 1017) over a 6-week period from 1 October to 14 November 2023. Sixty-seven (19.7%) T&S translated to blood product transfusions with 258 (75.9%) sent in compliance with the newly implemented guidelines. Of the remaining 82 (24.1%) samples sent out of T&S guidelines, none received blood product transfusions within 72 hours of ED visit.
Discussion/Conclusions
While the percentage of T&S that translated to blood product transfusions remained similar post intervention, the proportion of unnecessary T&S sent out of guidelines has reduced significantly thereby translating to reduced risk, increased cost savings, and optimized resource utilization. More efforts to encourage compliance with suggested guidelines and interdepartmental reviews to update existing workflows mandating T&S can be explored to further reduce unnecessary T&S sampling.
Not applicable
Gou Jun KWEK (SINGAPORE, Singapore), Wenjian CHAN, Timothy Xinzhong TAN, Balpreet Kaur DILLON, Shin Ying THNG, Yi-En Clara SEAH, Guat Keng Yvonne GOH, Bao Yu Geraldine LEONG
00:00 - 00:00
#41681 - Readiness of hospitals to respond to disasters with mass casualty.
Readiness of hospitals to respond to disasters with mass casualty.
Background: Since the beginning of full-scale hostilities in Ukraine in 2022, mass incidents among civilians, unfortunately, have become a routine practice. First of all, this is connected with the daily shelling of cities in Ukraine by missiles and drones by the Russian military. During 2023 more than 500 cases were recorded and classified as mass casualty cases. The effectiveness of providing medical assistance to victims in case of mass casualty depends on the readiness of hospitals. We have analysed the readiness of hospitals to respond to emergencies with mass casualty. We used a comprehensive tool offered by WHO for hospital administrators and emergency management professionals.
Methods: The assessment of the readiness of hospitals was carried out based on the analysis of the answers to the proposed questionnaire. All questions were divided into 10 principal components: management and control; communication; security and protection; medical triage; mobilization potential; ensuring the continuity of basic services; human resources; logistics; recovery after an emergency; features in wartime. Each question contained three answer options: "created" - 1; "in the process of creation" - 0.5; "does not have" - 0. The total number of points was added up for each key component. Completion of the component was determined as a percentage of the maximum number of points. According to this questionnaire, 1,315 hospitals were surveyed online. A separate assessment was carried out in 108 hospitals after practical training. The data obtained were statistically processed. We used of the software STATISTICA (“StatSoft, Inc.”, USA).
Results: The online survey showed the following results: management and control - 84,2±10,5; communication - 93,1±2,5; security and protection - 86,9±6,9; medical triage - 89,6±4,5; mobilization potential - 83,4±6,6; ensuring the continuity of basic services - 87,5±6,7; human resources - 82,9±5,8; logistics - 83,7±6,9; recovery after an emergency - 65,3±9,2; features in wartime - 90,7±6,2.
The results of the on-site evaluation after the practical training showed the following: management and control - 32,0±6,1; communication - 15,7±4,7; security and protection - 29,1±6,3; medical triage - 35,9±5,4; mobilization potential - 30,7±4,3; ensuring the continuity of basic services - 48,8±7,2; human resources - 30,7±6,0; logistics - 60,1±8,1; recovery after an emergency - 14,8±1,3; features in wartime - 74,6±5,1.
Discussion & Conclusions: According to all key indicators, the readiness of hospitals turned out to be lower after practical training compared to the results of self-assessment. The most problematic component for all hospitals is recovery after an emergency. A more detailed analysis points to the presence of general problematic issues in the hospitals: lack of a clearly defined crisis response center/operational headquarters in terms of its location and staffing; insufficiently developed communication components before, during, and after the liquidation of the consequences of an emergency with mass accidents; the direct implementation of medical triage in health care facilities requires the development of clear standard operating procedures for medical personnel. It should be noted that changes to the response plans are planned in all hospitals where practical training using simulation methods was conducted.
Vitaliy KRYLYUK, Halyna TSYMBALIUK (, Ukraine)
00:00 - 00:00
#41525 - Real-time Prediction of Clinical Deterioration in the Emergency Department through a Novel Multimodal Data-Driven Clinical Decision Support System using Deep Learning Algorithm.
Real-time Prediction of Clinical Deterioration in the Emergency Department through a Novel Multimodal Data-Driven Clinical Decision Support System using Deep Learning Algorithm.
Background: Clinical decision making in the emergency department (ED) is challenging because of the vast array of complex and rapidly evolving patient data available. Traditional methods may fail to accurately predict critical patient deterioration in a timely manner.
Objective: This study introduces an advanced Clinical Decision Support System (CDSS) that employs a multimodal deep-learning-based approach to enhance the real-time prediction accuracy of acute clinical deterioration in the ED.
Methods: This study was conducted at a level 1 tertiary teaching hospital in South Korea, with retrospective data from March 2018 to February 2022 and prospective data from July 2022 to December 2022. The model performance was evaluated based on its ability to predict four critical outcomes: in-hospital cardiac arrest, inotropic support for circulatory shock, advanced airway, and admission to the intensive care unit. We developed an artificial intelligence (AI)-powered CDSS that integrates multiple data modalities, including electronic health records, vital signs, laboratory results, and imaging data. The system uses deep learning models, including a multilayer perceptron for structured data, Convolutional Neural Networks for continuous time-series data, and transformers for unstructured textual and imaging data.
Results: The AI-CDSS was trained and tested on a dataset comprised of 339,324 ED visits, with a final study cohort of 237,059 visits after exclusion. The model using only triage stage information demonstrated superior prediction capabilities compared with traditional logistic regression models, with significant improvements in the area under the precision-recall curve (AUPRC). In all outcomes, except for inotropic support, the trimodal approach demonstrated a higher AUPRC than the unimodal approach. Furthermore, analyses using prospectively collected continuous data revealed that the model's ability to predict the progression of shock in patients improved as vital sign information in waveform format was input at shorter intervals.
Conclusions: The implementation of an AI-based CDSS in the ED can significantly improve patient outcomes by enabling earlier detection and response to signs of deterioration. This study confirmed the feasibility of such systems in a high-stakes clinical environment and underscored the need for further research to refine AI models and ensure their reliability and effectiveness in diverse clinical scenarios. Future studies should focus on expanding the dataset, incorporating more real-time data, and testing the system across multiple centers to validate its generalizability and operational viability.
This study was funded by VitalCare ER Project through the Fund of the AITRICS (Project number 2022-31-1073)
Ji Hoon KIM (Seoul, Republick of Korea, Republic of Korea)
00:00 - 00:00
#41327 - Really George?
Really George?
The primary HIV (Human Immunodeficiency Viru) infection can show as a Mononucleosis Syndromen between two and six weeks after contagious in the 70% of the patients.
We present the case of a 28-year-old man in good health until eleven days before admission to the Emergency Department, when fever, sore throat, cough, arthritis, headache and enlarged nodes developed. Twenty-two days before admission he had just come from Brasil where he spent 2 weeks on holidays. No sexual relations during that time.Heterosexual with stable partner.
On examination, the patient appear ill, the temperature was 38,7º C. Examination revealed bilateral and painful cervical and inguinal lymphadenophaty.
The white-cell count was 7200 per cubic millimiter (56% neutrophils, 25% lymphocytes, 19% monocytes, 0% eosinophils,0% basophils). The hematocrit was normal and the platelet count 95000 per cubic millimeter. Levels of creatin,sodium, potassium and glucose were normal. The alanine aminotransferase level 1193 units, the aspartate aminotransferase level 465 units, glutamyl transpeptidase level 142 units. Leves of alkaline phosphatase and total bilirrubine were normal. The results of radiography of the chest was normal.
A rapid screening test for Epstein-Barr virus (EBV), Cytomegalovirus and Hepatitis B and C were negative but a rapid screning test for HIV was taken, with positive result. After telling de results to de patient he admitted having had sex without protection during the holidays.
He was admitted to the Internal Medicine unit with the diagnose of mononucleosic syndrome due to a primary infection with HIV.
As usual in medicine, the clinical suspicious must be high with certain epidemiological, clinical and analytical information.
The differential diagnosis includes those deseases that may cause a mononucleosic syndrome as EBV,HBV,HCV or CMV but we need to bear in mind other causes of fever as endemic infections like brucellosis or leishmaniasis or those less common in Europe but usual in other continents as black-water fever, breakbone fever or dock fever.
Luz Tamara VAZQUEZ RODRIGUEZ, Luis PÉREZ ORDOÑO, María CUADRADO FERNÁNDEZ (Madrid, Spain), Isabel Paloma FERNÁNDEZ MARÍN, Ana Belén CARLAVILLA MARTINEZ, Francisco JIMÉNEZ MORILLAS, Santiago BERMEJO LORERO, Luis YUBERO SALGADO
00:00 - 00:00
#41892 - Recognize the rash: a case of Drug-induced Reaction with Eosinophilia and Systemic Symptoms (DRESS) - without eosinophilia.
Recognize the rash: a case of Drug-induced Reaction with Eosinophilia and Systemic Symptoms (DRESS) - without eosinophilia.
Clinical case
An 84-year-old man, with no particular history, presented with a rapidly expanding and confluent morbilliform rash on the arms and trunk, facial oedema and fever (38,2°C). This started 4 weeks after administrating Amoxicillin Clavulanic acid for a tonsillitis which was switched to Clindamycin after one week. Vital signs were normal (HR 91bpm, BP 126/69, SpO2 96%, RR 15/min), barring fever. There was no mucosal involvement, no abdominal symptom, no enlarged lymph node. Nikolsky sign was negative. Laboratory results showed a leukocytosis (16.35 10^3/mcl) with neutrophilia without eosinophilia, normal liver enzymes, mildly impaired renal function (creatinine 1.26 mg/dl), mildly impaired CKs (248U/L) and sharply increased CRP 224.7 mg/l. Given the clinically suspicious picture after recent new medication, our main diagnosis was DRESS. To confirm, the dermatologist performed a skin biopsy which proved a toxicoderma with eosinophilia and plasma cells in the skin.
Pathogenesis and clinical features
DRESS is a medication induced skin and systemic response that occurs on average 2 to 8 weeks after drug (metabolite) exposure due to a T-cell medicated delayed-type hypersensitivity reaction.(1-4) High-risk medications are aromatic antiepileptic drugs, Allopurinol® and antibiotics).(1) The typical presentation consists of a high fever (>38°C), a pruriginous morbilliform rash (often > 50% BSA) with sudden onset, facial edema, mucosal involvement and lymphadenopathy. There is a heterogeneity of internal organ involvement including hepatic disorders, interstitial nephritis, interstitial pneumonitis and cardiac involvement.(1-4) Contrary to what its name suggests, eosinophilia occurs in 52-92% of patients(4) and, if present, can often take 1–2 weeks to appear.(1,2) Other possible hematological findings include leukocytosis/leukopenia, atypical lymphocytes or thrombocytopenia.(1-2) Mortality is between 2 to 10%, mostly due to hepatic failure, multiple organ failure and severe inflammatory response syndrome.(1-4)
RegiSCAR score
Several diagnostic scoring systems have been developed including the J-SCAR criteria (2006) and the European Registry of Severe Cutaneous Adverse Reaction Criteria (RegiSCAR score – 2013)(4), However, there is no clear consensus on which to use.(3) We reached a RegiSCAR score of 4 (meaning 'probable case').
Therapy
Patient was admitted and received systemic corticosteroids, antipyretics, intravenous fluids and topical cortisone cream resulting in biochemically normalizing renal function and a decrease of CRP. This syndrome must be recognized in time to stop the eliciting medication (1, 3-4), in this case Clindamycin was stopped. A Spanish guideline with a consensus-based stepwise approach according to disease severity recommends as first line therapy supportive therapy (fluid and electrolyte replacement, antipyretics)(5) and topical or systemic steroids (prednisolone 0.5-1mg/kg/d).(1-5) Second-line therapy consists of Cyclosporin (3-5mg/kg/d) if insufficient effect of corticosteroids or contraindication for corticosteroids but there is little evidence, as for the administration of intravenous immunoglobulin (IVIG). Upon suspicion of viral reactivation, antiviral agents such as ganciclovir iv 5mg/kg may add value.(1-5)
Conclusions
DRESS is important to recognize in the emergency room given the potential serious consequences. In this specific case there was no eosinophilia in the peripheral blood, but the skin biopsy confirmed our diagnosis. Timely treatment can help prevent specific organ damage and mortality.
Margaux DIERICKX (Leuven, Belgium), Stephanie D'HOLLANDER, Francis DE BURGHGRAEVE, Nynke BERGSMA
00:00 - 00:00
#42062 - Redirection – Do patients Reattend as planned ?
Redirection – Do patients Reattend as planned ?
Aims:
Increasing capacity in Emergency Departments continues to put pressure on delivery care in a timely & safe manner. Many departments have introduced "Redirection" to the triage process to not only reduce capacity but to insure they are treated in the most appropriate place. We introduced a minor injury redirection from 8pm
till 8am to allow those redirected to attend a dedicated minor injury service at 10am staffed by advanced nurse practitioners. We audited this to see if redirected patients reattended as planned and if not did they subsequently return to the ED.
Methods:
A prospective audit of the new service over the first 2 months.
The first 50 patients who were booked in for redirection were assessed on information from age, time of initial presentation, return on re-direction, later attendance if they did not attend redirection, category of minor injury and communication to their GP.
Results:
Of the 50 patients studied ,33/50 of them returned to their advised redirection appointment, with a further 3 patients being reviewed and treated after redirection. 14 /50 ( 28%) of patients did not return at any stage to be reviewed for their initial presentation after redirection. Of these patients 11 did not have enough clinical information to determine the cause of minor injury. 80% of all re-directed patients had communication to their GP about presentation and diagnosis if one was made.
Conclusion:
Overall, the redirection system was successful in enabling assessment while relieving department pressures. Eight fractures were identified at initial planned re-direction with a further nineteen soft tissues injuries being diagnosed and treated. No further fractures presented at any point after redirection. From the available data all significant injuries were successfully reviewed by a doctor. Further work is needed on how to ensure adequate communication to GPs and further documentation on type of injury.
none
Craig LUNDIE, Bulut DEMIREL (Glasgow, Turkey), Gordon MCNAUGHTON
00:00 - 00:00
#41119 - Reducing ED length of stay by utilizing emergency department attendings.
Reducing ED length of stay by utilizing emergency department attendings.
Background: Emergency department (ED) crowding has become a significant public health problem globally. The length of time spent in the ED is considered to be one of the greatest causes of ED overcrowding and has a negative impact on the clinical outcomes of patients. However, the definition of prolonged ED length of stay (EDLOS) is different across countries, for example, the definition of extended ED visits in the United Kingdom is 4 hours, in Canada and the U.S., it is 6 hours, and in Australia, it is 8 hours. The time spent in the ED can be divided into distinct periods that are characterized by time of arrival (triage registration), time of the start of care, time of the disposition decision (discharge or admission), time at the end of care, and time at ED departure. In the past 3 years, Greek Emergency departments have begun being staffed with dedicated medical personnel with special training. The aim of the study was the investigation of waiting time and time of the disposition decision of patients at ED in a large hospital in Athens, Greece. The major tested hypothesis is whether emergency department attendings doctors versus medical department attendings decreases the EDLOS of patients.
Methods: This is a retrospectve registry trial. We examined the waiting time (time from triage registration until time of the start of care) and the time that patients were cared in the ED until their admission to medical clinic (time of the start of care until discharge or admission). We randomized recorded time periods from 18 different days (second half of 2023, 8 a.m. to 8 p.m.) from the EMR dataset. The study was conducted in a large ED of Athens, Greece, with 125.000 visits per year. We enrolled non-trauma patients that visited the ED with medical problems. Totally, 2853 patients that were managed from emergency department attendings and 2719 patients that were managed from medical department attendings were included in the study. The IBM SPSS v. 27.0 statistic program was used for the statistical analysis. The comparison between the two groups of patients was done with t-test.
Results: We included 5.572 patients. The total waiting time of patients was 164.1±255.9 min (95% CI: 136,97-191,34) and the care time of patients was 41.3±74.1 min (95% CI: 33.39-49.12). The emergency department attendings had significant less waiting time of patients (126.4±264.7 vs. 199.1±243.2, p=0.008) and less patients were waiting for starting care (2.1±1.9 vs. 4.6±4.1, p=0.001) than medical department attendings. Also, the emergency department attendings had significant less time care of patients (37.3±76.8 vs. 45.6±70.9, p=0.048) than medical department attendings.
Discussion & Conclusions: The waiting time and the care time of patients are used by administrators and ED leaders as measures of the quality of care delivered in the ED. The longer these times, the higher the patient dissatisfaction and the worse their outcome. Our study confirms that specialized doctors improve the quality of care decreasing the waiting time and the care time of patients.
There was no funding
George INTAS, Konstantina GIANNAKOPOULOU (Athens, Greece), Napoleon TSOGAS, Dimitrios TSIFTSIS
00:00 - 00:00
#40759 - Relationship between the National Early Warning Score and mortality of elderly patients in non-traumatic comas.
Relationship between the National Early Warning Score and mortality of elderly patients in non-traumatic comas.
Background: Elderly patients arriving in a non-traumatic coma (NTC) at the emergency department (ED) present substantial risks and necessitate prompt and appropriate care. The National Early Warning Score (NEWS) is a promising tool that can efficiently evaluate this vulnerable population. This study aims to assess the effectiveness of the NEWS for predicting the severity of illness in elderly patients with NTC and identifying those at highest risk.
Methods: A retrospective case-control study was conducted involving elderly patients (aged ≥65 years) with NTC who were admitted to Chonnam National University Hospital between January and December 2022. NEWS and Modified Early Warning Scores (MEWS) were calculated at ED visits. Multivariate analysis was conducted to predict in-hospital mortality by using logistic regression of relevant covariates.
Results: Out of 683 patients, 202 were non-survivors (29.6%). The NEWS and MEWS values of non-survivors were significantly higher than those of survivors (NEWS, 7 [5–10] vs. 10 [8–12]; MEWS, 5 [4–6] vs. 7 [5–8]). The NEWS (adjusted odds ratio [aOR]; 1.253, 95% confidence interval [CI]: 1.181–1.329) and MEWS (aOR; 1.323, 95% CI: 1.206–1.451) were also significantly associated with in-hospital mortality. The area under the curve for the NEWS and MEWS was 0.721 (95% CI: 0.685–0.754) and 0.695 (95% CI: 0.659–0.730), respectively.
Conclusion: The NEWS can be an effective tool for predicting severity of illness via in-hospital mortality in elderly patients with NTC.
N-A
Sang U BAK (, Republic of Korea)
00:00 - 00:00
#41733 - Relationship Between Vitamin B12 and Vitamin D Levels with Length of Hospital Stay and Mortality in COVID-19 Patients: A Retrospective Cohort Study.
Relationship Between Vitamin B12 and Vitamin D Levels with Length of Hospital Stay and Mortality in COVID-19 Patients: A Retrospective Cohort Study.
Background: Micronutrients, such as vitamins, minerals, and trace elements, play an important role in the regulation and maintenance of host immune reactions. As these therapies are safe and easily tolerated, they have been used in the treatment of COVID-19. However, scientific uncertainty persists between clinical outcomes and these vitamins. In this study, we investigated the effects of vitamin D and vitamin B12 levels on hospital stay and mortality in COVID-19 patients.
Methods: We conducted a retrospective cohort study of 2771 PCR-positive patients hospitalized with a diagnosis of COVID-19 at Eskişehir Osmangazi University Hospital between June 2020 and December 2023. We collected data on the demographic characteristics, total vitamin B12 and vitamin D levels, treatment modalities, length of hospital stay, and mortality. A total of 328 patients with vitamin B12 levels and 152 patients with vitamin D levels obtained at the time of hospital admission were included in the study (patients who did not receive nutritional supplement therapy). We divided the patients into three groups based on their basal vitamin B12 and vitamin D levels at admission. The vitamin B12 levels were low (<150 pg/mL), low-normal (150-399 pg/mL), and normal (≥400 pg/mL). The vitamin D levels were low (< 20 ng/mL), low-normal (21-29 ng/mL), and normal (≥30 ng/mL). We compared the mortality rate and length of hospital stay between the groups according to vitamin level.
Results: The mean age of the patients was 66.62 ± 15.9 years, 52% were male in the vitamin B12 group, and 68.12 ± 14.3 years, and 53% were male in the vitamin D group. When the groups with low, low-normal, and normal vitamin B12 and vitamin D levels were compared, no significant difference was found in terms of length of hospital stay and mortality (Tables and figures 1-2). In addition, when vitamin B12 levels were divided into two groups (below and above 150 pg/mL), no significant difference was found in terms of length of hospital stay and mortality (p=0.61). When the groups below and above 20 ng/mL were compared for vitamin D levels, no significant difference was found in terms of length of hospitalization and mortality (p=0.13).
Conclusion: In addition to the existing treatments, treatments that provide secondary benefits are recommended for the treatment of COVID-19. Some studies have reported positive results, especially for vitamin D and vitamin B12 levels. However, no randomized controlled studies have been conducted on this subject. At the same time, The National Institutes of Health (NIH) stated that there is insufficient data on the use of supplements in the treatment of COVID-19. In our study, baseline vitamin D and B12 levels did not significantly differ in terms of length of hospital stay and mortality in PCR positive COVID-19 patients.
This study did not receive any specific funding
Evvah KARAKILIÇ (Eskisehir, Turkey), Nurdan ACAR, Engin ÖZAKIN, Filiz BALOĞLU KAYA, Mustafa Emin ÇANAKÇI, Mustafa DEMIR
00:00 - 00:00
#41447 - Reliability Evaluation of Themnography for Early Detection of Intracranial Lesions in Mild Traumatic Brain Injury Patient: a preliminary report.
Reliability Evaluation of Themnography for Early Detection of Intracranial Lesions in Mild Traumatic Brain Injury Patient: a preliminary report.
Abstract
Purpose:
Mild Traumatic brain injury is classified based on Glasgow Coma Scale (GCS13-15), it also involves transient alteration of brain function, which may lead to severe short- and long-term sequelae.
When treating a patient with a mild head injury outside the hospital, it is of crucial importance to decide whether to transport him to a spoke center without neurosurgery or to the hub center equipped with neurosurgery (primary centralization). No validated clinical criteria currently exist for primary centralization to a neurosurgical hub in mild traumatic brain injury cases. Recent decades have seen exploration of portable, non-invasive devices for intracranial injury and stroke detection, with microwave frequency electromagnetic field technology showing promising clinical outcomes. This clinical investigation aims to assess the diagnostic accuracy of the TES HT100 medical device, utilizing electromagnetic fields for endocranial lesion screening.
Patients and methods:
Patients with mild traumatic brain injury were randomly enrolled according to inclusion criteria. Twenty-three patients recruited from the Intensive Short-Term Observation (ISTO) unit at San Donato Hospital in Arezzo. The sensitivity and specificity of the TES HT were evaluated statistically against cranial computed tomography (CT), the gold standard.
Results:
In three months, 23 patients with mild traumatic brain injury (14 females and 9 males) have been enrolled, with an average age of 83 years. A preliminary analysis shows a sensitivity of 100% and a specificity of 100%. Based on these results, there is maximum concordance between the two examinations, and the AUC is 1. No adverse events related to the use of TES HT100 or the examination, which required an average time of 5 minutes as indicated in the user manual, were detected.
Discussion:
The TES HT100 is unable to distinguish whether brain lesions are acute or not, but solely detects their presence or absence. Therefore, in elderly patients like those enrolled in this study, the likelihood of pre-existing lesions or significant structural alterations, often associated with neurodegenerative conditions, is high. Indeed, in some patients where no trauma-related lesions were detected by cranial CT, significant areas of hypodensity related to previous ischemic/hemorrhagic events prior to the traumatic brain injury were found. This aspect should not be identified as a failure of the technique but rather as further impetus for expanding the study population. The technique indeed offers analyzable software that can be improved based on the amount of collected data. An artificial intelligence capable of increasing discriminative power in direct proportion to the breadth of the case history.
Conclusion:
The device's ability to differentiate patients with intracranial lesions from those without can streamline the diagnostic and therapeutic process, potentially leading to improved patient outcomes. Moreover, by extending the study to include Territorial Emergency involvement, we anticipate enhanced performance with the device's utilization, aiding centralized decision-making in patient care. Territorial Emergency personnel will directly enrol head trauma patients from the field. This direct use of the device by emergency personnel, in addition to standard evaluation, holds promise for prognostic improvement and reduced treatment time, ensuring prompt referral to the most suitable facility.
Ethics Approval and Consent to Participate
Ethics approval was acquired by the ethics committee CEASVE (number of protocol 01022). We were allowed from the dataset owner to use the information in databases for the purposes of the research. The present study involved the use of confidential or sensitive personal health information therefore the patient consent was required. The study was conducted in compliance with the Helsinki Declaration of 975, as revised in October 2013 and all data were kept anonymous.
Competing interests
The authors declare that they have no conflicts of interest in this work.
Founding
This work did not receive any specific grant from founding agencies in the public, commercial or not-for-profit sectors.
Sara MONTEMERANI (Siena, Italy), Cosimo FABRIZI, Cecilia SACCHI, Antoine BELPERIO, Lorenzo MORIANI, Samuele PACCHI, Cinzia GAROFALO, Giovanni SBRANA, Maurizio ZANOBETTI, Simone NOCENTINI
00:00 - 00:00
#41177 - Reliability of the Pediatric Rapid Arterial oCclusion Evaluation (PedRACE) Scale for Stroke Detection in Pediatric Emergency Care.
Reliability of the Pediatric Rapid Arterial oCclusion Evaluation (PedRACE) Scale for Stroke Detection in Pediatric Emergency Care.
Background:
Detecting strokes in children is challenging due to the scarcity of suitable diagnostic tools and the complexity of existing scales such as the Pediatric NIH Stroke Scale (PedNIHSS), which are often impractical for general emergency use. The "Rapid Arterial oCclusion Evaluation" (RACE) scale known for its simplicity and effectiveness, is used for early detection of large vessel obstruction (LVO) strokes, particularly those requiring acute arterial ischemic stroke (AIS) interventions in adult population. Our study aims to adapt the RACE Scale for pediatric use (PedRACE), assess its interrater reliability, and evaluate its feasibility for physicians without expertise in child neurology. This scale seeks to provide a reliable, accessible diagnostic tool for general emergency settings.
Methods:
This prospective case series from February 2022 to June 2023 involved pediatric patients triggering the Pediatric Stroke Code across various Catalonian settings. Exclusion criteria included pre-existing neurological disorders or age below 2 years or older than 18 years. The PedRACE scale was administered in prehospital and emergency settings by pediatric and non-pediatric medical staff, followed by assessments using both the PedRACE and PedNIHSS scales by child neurologists. The study assessed the scale's reliability and correlation with PedNIHSS through Spearman's correlation and evaluated inter-rater consistency. Approval was granted by the Hospital de la Santa Creu I Sant Pau's ethics committee.
Results:
Of 60 evaluated children, 50 were included in the final analysis, consisting of 27 boys (54%) and 23 girls (46%), with a mean age of 10.55 (SD = 4.47). High inter-rater reliability in total PedRACE scoring (Cohen's weighted kappa = 0.82) and a significant correlation with PedNIHSS (Spearman's rho = 0.852, p < 0.001) were observed, particularly among child neurologists. Perfect agreement (100%) was noted for the oculocephalic deviation and agnosia items. The PedRACE scale identified 9 patients (18%) with scores ≥5, suggesting a high suspicion of stroke due to LVO. A PedRACE score of 5 or more was significantly associated with the presence of LVO or intraparenchymal hemorrhage (p = 0.002 for prehospital/emergency, p = 0.003 for child neurologists) and strongly correlated with the presence of stroke (any type), validated by child neurologists (p = 0.011) and prehospital/emergency staff (p = 0.017). The median PedRACE score was significantly higher in patients with AIS involving LVO and intracerebral hemorrhage, averaging 3.38 (prehospital/emergency) and 3.23 (child neurologists), compared to 1.78 and 1.59 in patients without LVO or stroke mimics (p = 0.006). Neuroimaging confirmed 18 stroke cases: 7 AIS and 11 intracerebral hemorrhages, including 2 LVO that required thrombectomy.
Discussion and Conclusions:
The PedRACE scale demonstrates significant reliability in identifying pediatric LVO strokes, evidenced by its robust correlation with PedNIHSS and strong inter-rater reliability. Its straightforward and quick application allows for effective case differentiation, potentially reducing unnecessary hospital transfers and optimizing resource allocation for patients requiring specialized treatments such as reperfusion. As a result, PedRACE is a highly valuable tool in pediatric emergency settings, enhancing early diagnosis and improving clinical outcomes by facilitating prompt and accurate stroke identification and appropriate patient routing.
Xoan GONZÁLEZ RIOJA, Xoan GONZÁLEZ RIOJA (Barcelona, Spain), Eulalia TURÓN VIÑAS, Sara LÓPEZ TORRES, Elisabeth COCA FERNÁNDEZ, Laura DIAZ SIMAL, Irene BARCELÓ CARCELLER, Mireia SENSARRICH ROSET, Aida ARREVOLA ALONSO, Susana BORONAT GUERRERO
00:00 - 00:00
#42044 - Remote practical tutoring in point-of-care ultrasound in out-of-hospital emergencies.
Remote practical tutoring in point-of-care ultrasound in out-of-hospital emergencies.
Background
Bedside clinical ultrasound in the out-of-hospital emergency setting has some particularities. The aim of our work revolves around clinical ultrasound education in the emergency setting. For this purpose, a remote mentoring programme has been evaluated.
Methods
Prospective, observational, descriptive study in a sample of emergency phisicians, subjected to a remote mentoring programme for 12 months with a tutoring application via Medxat, a secure and private instant messaging platform, through an encrypted HTTPS channel, designed for use in healthcare environments, which allowed the student to contact a tutor in order to guide him/her in the acquisition and interpretation of ultrasound images.
A training programme was designed, with a total of 82 hours comprising 20 hours of online training carried out in one month, 32 classroom hours divided into 4 practical courses and 30 hours of distance tutoring over 6 months.
The tutoring phase took place from June 15 to December 15, 2022, and was carried out through Medxat.
Demographic and care variables were collected, focused on the application of the technique in clinical practice according to recognized ultrasound protocols: BLUE; E-FAST, RUSH... Interventions with teachers through MedXat and professional satisfaction were also collected.
Results
During the months of June to December 2022, 1317 attendances were registered in the two bases included. However, the number of ultrasound scans registered during this period was 320, making up 34.15% of the attendances. The percentage of doctors included in the mentoring programme attended 71.14% of the attendances. In 34.15% of these (320), ultrasound was performed through the tutoring application.
Of the protocols learned during the training phase, the management of acute dyspnoea was the most applied, compared to the others, with 23.5% of the cases recorded.
The remaining protocols, in cardiac arrest, severe trauma and shock scenarios (FEEL, EFAST, RUSH), were recorded through application in 11.6%, 15.3% and 13.1% of the cases attended. A total of 36.3% of the ultrasound recordings were carried out in other scenarios not defined in the tutorial phase.
Contribution of clinical ultrasound, as reported by the professionals enrolled in the programme, was high (2-3 on a scale of 0 to 3) in 65% of the cases, and low or null in 13.7% of the cases. The average score for professionals' satisfaction with the training programme, showed scores ranging from 4.69 to 5 points.
Conclusions
Remote support through authorised mobile applications facilitates implementation in clinical practice.
The ultrasound technique in emergencies generates a high diagnostic contribution for the professional
During 6 months of support, it is possible to detect improvements in image acquisition and maintenance of care times.
Trial Registration: The study wasn´t registered because no patients involved.
Funding: This study received an innovation grant for the Public Company of Health Emergencies
Ethical approval and informed consent: This study was review and approval by biomedical research ethics committee of Malaga, with the code 0278/209
Adriana GIL-RODRIGO (Alicante, Spain), María José LUQUE-HERNÁNDEZ, Carmen GUTIÉRREZ-GARCÍA, Carmen MARTÍNEZ-BUENDÍA, Lorena CUESTA-GARCÍA, Virginia MESTANZA-ÁVILA
00:00 - 00:00
#42169 - Renal colic in emergency department: epidemiology and clinical features.
Renal colic in emergency department: epidemiology and clinical features.
Background:
Renal colic (RC) is a frequent medical and surgical emergency. It is a painful lumb-abdominal syndrome caused by the sudden tension of the upper urinary tract due to an obstruction in urinary flow. Rapid and effective analgesia is required.
Objective:
The aim of our study was to describe the epidemiological and clinical features of patients with RC in an emergency department (ED).
Methods: This was a prospective, observational, and single-center study conducted over 16 months [January 2023-April 2024]. We included patients aged over 16 years presenting to ED with a lumb-abdominal painful syndrome suggestive of RC. We collected demographic, clinical, paraclinical, therapeutic, and outcome characteristics.
Results
Inclusion of 400 patients. Mean age=48 +/- 15 years. Gender ratio=1.1. Most common comorbidities (%): hypertension (19) and diabetes (20). Urological history (%): renal calculi (86), extracorporeal shock wave lithotripsy (14), J-J stent (4), renal tumor (1), renal malformation (1), solitary kidney (1). Pain localization (%): right lumbar (47), left lumbar (46), bilateral lumbar (7), right iliac fossa (6), left iliac fossa (5). The median consultation time was 9 hours. The average numerical pain scale: 8 +/- 2, 4 +/- 3, and 2 +/- 2 at 0 min, 30 min, and 60 min, respectively. Analgesic treatment administered (%): intramuscular anti-inflammatories (67) (Piroxicam (79%), dexketoprofen trometamol (12%), and ketoprofen (9%)), slow intravenous infusion of paracetamol (90), morphine hydrochloride titration (30). The average dose administrated of morphine hydrochloride was 8 +/- 5 mg. Adverse effects including vomiting (6 patients) and somnolence (4 patients), were observed. Imaging was conducted in 37% of cases, revealing pyelocaliceal dilatation in 86 patients. The mean length of pyelocaliceal dilation was 16 +/- 5 mm. Five patients presented urinary tract rupture and 5 patients obstructive pyelonephritis. Patient disposition (%): discharge with symptomatic treatment (71), transfer to urology department (29). Ten percent of patients experienced recurrence within 7 days.
Conclusion
Early recognition of risk factors and prompt therapeutic interventions are crucial in optimizing patient outcomes and guiding clinical management strategies for renal colic in emergency care.
Raja FADHEL (Ain Zaghouan, Tunisia), Jihene SEBAI, Anas NACEJ, Imen BEN ABDALLAH, Ibtissem BEN TAHER, Syrine KESKES, Hanene GHAZALI, Sami SOUISSI, Ines CHERMITI
00:00 - 00:00
#40438 - Renal colic: It's is not all stones.
Renal colic: It's is not all stones.
We report the case of a 53-year-old female who presented to the Emergency Department with acute, left flank pain. She reported diaphoresis but no fever, nausea, vomiting, or other urinary symptoms. She denied a history of urinary tract infections (UTIs) or nephritic colic. Laboratory analysis showed mild leukocytosis with neutrophil predominance. Urinalysis was significant for the presence of leukocytes but nitrites and culture were negative. Computed tomography (CT) showed a cystic structure arising from the atrophic upper pole of the left kidney with a tubular structure suggestive of a ureter extending into the lower pelvis (Figure). These findings were consistent with a duplex collecting system complicated by hydroureteronephrosis of the left upper moiety. The patient remained afebrile and hemodynamically stable and was discharged with a seven-day course of cefixime and analgesics. In the renogram requested by the urologist it was observed a double left excretory system, with the upper one not functioning.
A duplicated renal collecting system is a congenital abnormality of the urinary tract affecting 0.7–4% of the population, with females more commonly affected than males (2:1). While many duplex systems cause no symptoms, upper pole hydroureteronephrosis (secondary to ectopic insertion or an obstructive ureterocele) and lower pole vesicoureteral reflux are commonly reported findings. Duplex collecting systems are usually diagnosed perinatally or among pediatric patients but occasionally do not present until adulthood. These adult patients often remain asymptomatic, but can also present with hydroureteronephrosis, recurrent urinary tract infections (UTIs), or urinary incontinence.
Ureteral duplications can be complete or incomplete, unilateral or bilateral. The unilateral form is six times more common than the bilateral one. Incomplete duplication is caused by an anomalous bifurcation of the ureteral bud. There are two pelvises and two ureters that fuse at some point along their path, but with a single entrance to the bladder.
While newly symptomatic duplicated collecting systems are uncommon in adulthood, the diagnosis of a hydronephrotic duplex collecting system should be considered for patients presenting with flank pain and a cystic lesion in the upper kidney. Patients with refractory pain, UTI, and a nonfunctioning moiety can be managed with heminephroureterectomy of the affected moiety.
Rebeca GONZALEZ PEREDO (SANTANDER, Spain), Ramon FERNANDEZ PEREDA, Maria Jose RODRIGUEZ LERA, Pilar DE LUCIO DE LA IGLESIA, Pilar FOMBELLIDA GUTIERREZ, Sara SANCHEZ ORTIZ, Lara FUENTES ALVAREZ DE EULATE, Carlos CORTINA FERNÁNDEZ, Jaime RODRIGUEZ-CABELLO CIERVA
00:00 - 00:00
#41123 - Renal Malrotation and Ureteral Calculus: Diagnostic Challenge.
Renal Malrotation and Ureteral Calculus: Diagnostic Challenge.
Case information: A 46-year-old female presented to the emergency department with acute onset of intense right upper abdominal pain. Physical examination revealed tenderness in the right upper abdominal region with soft mass, Murphy sign postive, clinical highly suspected acute cholecystitis. However, an bedside echo yielded unexpected findings, demonstrating right kidney malrotation with hydronephrosis and proximal ureteral calculus. Complementary computed tomography imaging corroborated the ultrasound findings.
Discussion:Renal malrotation, a rare anomaly, involves aberrant rotation of the kidney during embryonic development. In this case, malrotation likely predisposed the patient to ureteral calculus formation, resulting in obstructive complications such as hydronephrosis and hydroureter. The initial symptomatology of right upper abdominal pain was misleading, resembling cholecystitis, necessitating thorough investigation to uncover the underlying renal anomalies.
Conclusion:This case report underscores the importance of considering renal anomalies, including malrotation and calculi, in the differential diagnosis of acute abdominal pain. The atypical presentation of right upper abdominal pain in this 46-year-old female led to the serendipitous identification of right kidney malrotation, concurrent with a ureteral calculus, hydronephrosis, and hydroureter. Awareness of these renal anomalies is pivotal for accurate diagnosis and appropriate management, averting potential complications and optimizing patient outcomes.
Lam IAN-SENG (Macao, China), Leong HOI-IP
00:00 - 00:00
#41423 - Respiratory Support in the Emergency Care Setting-Meta-analyses of Randomised Controlled Trials.
Respiratory Support in the Emergency Care Setting-Meta-analyses of Randomised Controlled Trials.
Background
According to published evidence, up to 20% of patients require respiratory support (RS) therapies whilst in the emergency department (ED). The evidence also suggests that one of these RS therapies, namely nasal high flow (NHF), reduces the necessity for ongoing RS. Evidence-based decision-making regarding RS in the ED is challenging, and a current, clear and inclusive systematic review (SR) of the qualifying evidence reporting on this subject was needed. A SR may better inform the ED evidence base for practice and identify the gaps in this same evidence base. This SR of RS compared NHF to conventional oxygen therapy (COT) or non-invasive ventilation (NIV) in adult ED patients.
Methods
The methods employed for this SR and meta-analysis (MA) reflect the Cochrane Collaboration methodology. Six databases were searched for randomised controlled trials (RCTs) comparing NHF to COT or NIV use in the ED. Three clinically significant summary estimates were reported: need to escalate care, mortality, and adverse events (AE).
Results
This SR and MA of 18 RCTs included a total of 1874 participants. Two of the five MA conclusions were statistically significant. NHF resulted in a 45 % reduction in escalation when compared to COT (RR 0.55; 95% CI = 0.33 - 0.92, p = 0.02, NNT = 32); however, identified no statistically significant differences in mortality risk (RR 1.02; 95% CI = 0.68 - 1.54; p = 0.91) and AE risk (RR 0.98; 95% CI = 0.61 - 1.59; p = 0.94). Compared with NIV, NHF appeared to increase the risk of escalation by 60% (RR 1.60; 95% CI = 1.10 - 2.33; p = 0.01). However, a high level of clinical heterogeneity with NIV was evident. The risk of mortality was not statistically significant when comparing of NHF versus NIV (RR 1.23, 95% CI = 0.78 - 1.95; p = 0.37).
Discussion & Conclusions
In this SR, NHF was found to be superior to COT and had a reduced risk of escalation. In contrast, NHF was not superior to NIV for this same outcome. Notably, substantial clinical heterogeneity was demonstrated in the NIV delivery. Research considering NHF versus NIV is needed. Like polio, the COVID-19 pandemic has shaped emergency care and confirmed the ED research gaps whilst exposing new ones. Whilst the pandemic has compromised the progress of most ED research, this research must now be pursued once more.
Other information
Registration: PROSPERO CRD42021222517
Funding: NZ Health Research Council (HRC 22/855)
Ethical approval: Not applicable
PROSPERO CRD42021222517
Jane O'DONNELL (Auckland, New Zealand), Alison PIRRET, Mcdonald ELISSA, Kruger MARLENA, Karen HOARE
00:00 - 00:00
#40933 - Resuscitation in a diving bell - development of a new algorithm and defining an industry standard.
Resuscitation in a diving bell - development of a new algorithm and defining an industry standard.
Aims
Management of cardiorespiratory arrest in a diving bell has multiple clinical, technical and environmental considerations that standard resuscitation algorithms do not address, and no situation-specific algorithm exists. The development and iterative testing of an algorithm to guide the management of cardiorespiratory arrest in a saturation diver working at depth is described.
Methods
The algorithm development builds on two previous studies, the first evaluating the efficacy of manual resuscitation techniques in a diving bell, the second evaluating the efficacy of a new chest compression device specifically designed for use in this environment (the NCCD).
An iterative approach to algorithm development was adopted, consisting of round table discussion, algorithm design, testing with direct observation and video recording, debrief, and algorithm revision and refinement. ALS principles were followed unless deviation was mandated by contextual factors. The team had use of two diving bells and project-specific simulated environment. These were equipped with diving equipment producing a high-fidelity environment for algorithm testing. 11 divers and 2 Dive Supervisors, together with senior industry representatives, participated in algorithm development, simulation and testing. A Resusci-Anne qCPR intelligent manikin was used to record resuscitation outputs and guide algorithm development.
During the development period focus groups were carried out exploring the divers' experiences of casualty recovery and resuscitation during their career.
Results
Clinical and technical aspects of the resuscitation are addressed. Key priorities that conflict with standard ALS principles are the prioritisation of rescue breaths, the use of mechanical CPR whenever available, and the provision of CPR in a seated position where necessary.
Conclusion
The presented algorithm incorporates ALS principles, environmental and clinical expertise, and all available data about compression technique effectiveness. Refinement in a high fidelity simulation setting with active divers is required.
The project would not have been possible without generous support from the following organisations:
Boskalis provided financial support for the overall project, and provided the divers and equipment for the development of the algorithm.
Professional Diving Academy, Dunoon, hosted the team and facilities for the study.
Sub Marine Products (SMP) Ltd provided the diving bells and other equipment.
Members of the these organisations provided industry-specific expertise in developing the algorithm.
Equinor, Total Energies, Shelf Subsea, TechnipFMC, KD Marine, Rever, K-Subsea, DFS Diving, Subsea 7, Unique Hydra (PTY) Ltd and Well-Safe Solutions provided funds for the project.
These funders had no role in the design or implementation of the protocol or the decision to publish.
TAC Healthcare sponsored the work of one of the authors: Dr P Bryson
Graham JOHNSON, Philip BRYSON, Nicholas TILBURY, Benjamin MCGREGOR, Alistair WESSON, Gareth HUGHES, Gareth HUGHES, Lianne HUFTON, Elisha COUSINS, Fredrik BAERHEIM, Rebecca ELDER, David JONES, Andrew TABNER (Derby, )
00:00 - 00:00
#40897 - Retrospective study on the utility of whole-body CT for trauma in a Singapore Emergency Department.
Retrospective study on the utility of whole-body CT for trauma in a Singapore Emergency Department.
Background: Whole-body computed tomography (WBCT) scan, which encompasses scans of the head, cervical spine, thorax, abdomen, and pelvis, enables swift assessment of critical injuries. Our goal is to outline the practical value of WBCT in trauma cases, focusing on detecting significant injuries and subsequent management in the emergency department (ED).
Methods: We conducted a retrospective analysis of de-identified trauma registry data spanning from 18 August 2018 to 31 December 2022. We gathered and analysed information on demographics, injury circumstances and mechanisms, injury severity, WBCT results, clinical management, and outcomes.
Results: Among 77,132 trauma cases, WBCT was performed in 126 (0.2%) cases, all of which had triggered trauma team activation. Of these, 78 (61.9%) had positive WBCT results with clinically relevant trauma findings. The top three findings were rib fractures (22, 17.5%), intracranial haemorrhage (19, 15.1%), and vertebral fractures (19, 15.1%). Seventeen (21.8%) cases required interventions based on WBCT results, with the most common being emergency operating theatre (EOT) procedures such as craniectomy/craniotomy and/or intracranial pressure (ICP) monitor insertion (6, 4.8%), chest tube insertion (6, 4.8%), and laparotomy in the EOT (3, 2.4%). Incidental findings unrelated to trauma were present in 54 (42.9%) cases, with spondylosis (23, 18.3%), renal cysts (22, 17.5%), and hepatic steatosis (16, 12.7%) being the most frequent. The median ED throughput duration for WBCT cases was 115 minutes (interquartile range (IQR) 76 to 157 minutes), compared to 93 minutes for non-WBCT cases (IQR 63 to 135 minutes) (p=0.004). The mortality rate for trauma patients undergoing WBCT was 4.8%.
Discussion & Conclusions: WBCT utilization was low among trauma patients. WBCT led to a notably longer ED stay despite most clinically significant WBCT findings not requiring immediate intervention. We propose that an adjustment of guidelines to better identify trauma patients who would benefit from WBCT in the ED setting may be warranted.
Nil
Kuhan VENUGOPAL (Singapore, Singapore), Yan Lin Shannen SEE, Shao Hui KOH, Jen Heng PEK, Juinn Huar KAM, Chantal Shiun-Hwa LIM
00:00 - 00:00
#41468 - RETURN VISITS TO THE EMERGENCY DEPARTMENT.
RETURN VISITS TO THE EMERGENCY DEPARTMENT.
INTRODUCTION: The rate of return visits (patients who, after being treated in the emergency department and being discharged, return to the emergency department within 72 hours) is a parameter of quality in hospital urgent care.
OBJECTIVE: To determine the rate of return visits and variables associated with them in the Emergency Department of the University Hospital of La Ribera (SUHLR).
MATERIAL AND METHODS: A descriptive and retrospective observational study was conducted on patients over 14 years of age who revisited the SUHLR in 2023. The following were reviewed in the medical records: age and sex, priority and area of care, request for complementary tests, length of stay and destination at discharge. In addition, a sub-study was conducted with a sample of patients to compare whether there were changes in priority, request for tests, and diagnosis in both episodes.
RESULTS: The rate of revisit was 4.86% and occurred in patients of both sexes, with a median age of 50 years, who were classified as not very urgent, attended in the consultation area where they stayed for 2 hours and with little request for tests who were discharged with varied diagnoses to their family physician. In the sample, the priority of care only increased in 58 patients and the request for tests was made if it had not been made at the first visit, to 17% (laboratory) and 13% (imaging). Diagnoses were unrelated in 22% of cases.
CONCLUSIONS: The results obtained have made it possible to propose the implementation of improvements to reduce the number of visits and thus strengthen these services and provide more effective and efficient care.
María CUENCA TORRES (alzira, Spain), María ESPLUGUES PENADÉS, Josep ESPLUGUES MARRAHI, Ricardo MUÑOZ ALBERT, Luis MANCLÚS MONTOYA
00:00 - 00:00
#42072 - Reversible posterior encephalopathy syndrome in the emergency department : About a case.
Reversible posterior encephalopathy syndrome in the emergency department : About a case.
Abstract :
Introduction :
Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological entity characterized́ by the variable association of seizures, disorders of consciousness, headache, visual disturbances, nausea, vomiting and focal neurological deficits with typical changes on brain imaging (MRI or CT).
These manifestations can be severe and life-threatening, as when they take the form of coma or status epilepticus.
There are many etiologies associated with PRES, dominated by exposure to toxic agents and acute hypertensive crisis.
Observation :
We report here a case of a 20-year-old male with chronic renal failure at the hemodialysis stage who presented with status epilepticus consisting of repeated convulsive seizures lasting more than 5 minutes, with no recovery of consciousness between seizures. accompanied by elevated blood pressure unusual headaches after the last haemodialysis session, followed by a gradual onset of confusion preceding the seizure,. MRI revealed parieto-occipital lesions in T2 hypersignal.
The patient progressed well on anti-epileptic and anti-hypertensive treatment, with complete recovery of consciousness and hemodynamic stabilization.
Discussion :
Posterior reversible encephalopathy is a rare, probably underdiagnosed entity, first described by Hinchey et al. In 1966 from a series of 15 cases with a common clinical and radiological picture.
Contributing factors :
There are many circumstances that favor the onset of RPE. Arterial hypertension is the most common, and was the first factor described (hypertensive encephalopathy). Other factors include chronic renal failure and dialysis, autoimmune diseases and certain chemotherapies (e.g. cyclophosphamide).
In our patient, the factors considered were hypertension secondary to CKD in the hemodialysis stage.
Clinical manifestations :
Clinical manifestations are varied. Four neurological symptoms are variably associated : headache, seizures, disturbances of consciousness and visual disturbances, most often accompanied by rise in blood pressure.
Radiological examinations :
Imaging is essential, and must be performed as soon as possible to enable early diagnosis.
Computed tomography (CT) is frequently abnormal, with diffuse posterior hypodensities that do not take contrast.
Magnetic resonance imaging (MRI) : is often characteristic, enabling the diagnosis to be made in an evocative clinical context, but may also be normal.
Conclusion:
The diagnosis of PRES must be evoked́ before any acute encephalopathy and especially in a context of hypertension or a favoring factor. MRI is the reference examination for making the diagnosis, ruling out other differential diagnoses and assessing prognosis using the diffusion coefficient. Prompt, appropriate treatment can prevent irreversible lesions and neurological sequelae.
Mohsine RAMZI (, Morocco), Mohamed Anass FEHDI, Asmae DAFIR, Moussaoui MOHAMED, Mohammed MOUHAOUI
00:00 - 00:00
#41497 - Revolutionising Emergency Doctor Education: Virtual Reality Teaching in Medical Training.
Revolutionising Emergency Doctor Education: Virtual Reality Teaching in Medical Training.
Introduction:
Virtual reality (VR) teaching has become a groundbreaking approach in medical education, particularly in Emergency Medicine. Through immersive VR environments, learners can visualise and interact with both common and complex clinical scenarios.
This experiential and vivid simulation-based training is used to improve clinical and non-technical skills such as situational awareness and preparedness of physicians for real-life emergencies, while fostering competency development.
Methods:
Southend University Hospital has access to state-of-the-art VR technology with high-resolution screens and motion tracking technology. Training simulations are customised using the Oxford Medical Simulation (OMS) platforms.
Training days for registrar doctors or residents are held regularly in our Emergency Department (ED). Recently, our training approach has changed to emphasise active learning, critical thinking and the development of problem-solving skills. VR-based learning with registrar grade doctors was the first such approach of its kind in the East of England region.
Discussion:
Southend University Hospital ED has worked hard to develop a consistent training strategy. It is because of a supportive leadership and management team, our training days are now protected learning events, enabling the clinical team to deliver good quality training. Regular training ensures that clinicians are better motivated, up skilled and more efficient.
12 registrars took part in this VR learning session. Scenarios covered ranged from decision making and situational awareness in deteriorating patients to common emergencies such as sepsis, anaphylaxis and massive blood loss. Individual debriefings and feedback were obtained.
The event was very well received and rated overall as excellent to outstanding in terms of learning content, delivery and usefulness. The team benefited from the advantages of virtual realism.
The benefits of VR teaching in medical education are manifold: it provides a safe environment for practicing procedures, personalized learning experiences, greater learner engagement and the opportunity to improve decision-making skills. It also provides ample opportunity for repetition, feedback, assessment and reflection to help learners retain the information better. Implementation strategies will focus on efficient onboarding and transition to practice, utilizing the versatility of VR scenarios.
Looking to the future, the prospects for new methods such as VR in emergency medicine training are promising. Advances in the digitised world, such as haptic feedback systems and the integration of artificial intelligence, hold the potential for even greater realism and effectiveness. Collaborative research efforts will aim to refine the methods and expand the application possibilities in various medical specialties to create a more competent and adaptable healthcare workforce. This will go hand in hand with understanding the potential side effects of changing realities. However, some of the biggest obstacles remain, particularly financial constraints and technical limitations.
Conclusion:
In summary, VR teaching in Emergency Medicine offers unparalleled opportunities to enhance the learning experience and prepare future healthcare professionals for the complexities of emergency care. By utilising immersive VR capabilities, educational institutions can improve the quality, effectiveness and inclusivity of medical education.
More research is needed to refine the methodologies.
Hein ZAW, Michael ACIDRI (Southend on Sea, United Kingdom), Dalip KUMAR, Ahmed ELMANZALAWI, Claire WILLIS, Ionut NEGREA
00:00 - 00:00
#40925 - Revolutionizing Medical Education: Harnessing the Power of AI in Simulation.
Revolutionizing Medical Education: Harnessing the Power of AI in Simulation.
In the realm of medical education, the integration of Artificial Intelligence (AI) into simulation training has emerged as a groundbreaking advancement with far-reaching implications. This presentation delves into the profound impact of AI on medical simulation education, showcasing how this technology is revolutionizing the way healthcare professionals acquire and refine their clinical skills.
AI in medical simulation education represents a paradigm shift, offering a dynamic and interactive learning environment that mirrors real-world scenarios. By leveraging AI algorithms, simulations can adapt to individual learner needs, providing personalized feedback and guidance to enhance skill development. This tailored approach not only accelerates learning but also fosters a deeper understanding of complex medical concepts.
One of the key benefits of incorporating AI into simulation training is the ability to create highly realistic and immersive scenarios that mimic actual clinical settings. Through advanced algorithms and machine learning, AI can simulate diverse patient cases, ranging from routine procedures to rare emergencies, enabling learners to practice critical decision-making under varying conditions. This experiential learning not only enhances clinical proficiency but also instills confidence in healthcare professionals when faced with challenging situations in real practice.
Moreover, AI-powered simulations offer a safe and controlled environment for learners to make mistakes, learn from failures, and refine their skills without compromising patient safety. By providing a risk-free space to practice procedures and interventions, AI in medical simulation education promotes a culture of continuous improvement and professional growth among aspiring and seasoned healthcare providers alike.
Through compelling case studies and practical examples, this presentation will illustrate how AI is reshaping the landscape of medical education. From virtual patient encounters to interactive surgical simulations, AI technologies are empowering learners to engage in hands-on practice that transcends traditional didactic methods. By immersing students in realistic scenarios and offering instant feedback based on performance metrics, AI-driven simulations are revolutionizing the learning experience and setting new standards for competency-based training.
Join us on this enlightening journey as we explore the transformative potential of AI in medical simulation education. Discover how this innovative technology is not only enhancing the skills and knowledge of healthcare professionals but also shaping the future of patient care through proficient, empathetic, and well-prepared practitioners. Embrace the possibilities that AI brings to medical education and embark on a path towards excellence in healthcare delivery.
N/A
Jackson DÉZIEL (Cullowhee, USA)
00:00 - 00:00
#41700 - Rhabdomyolysis, AKI ,liver injury, Myositis and Upper GI bleed. Is African herbal medicine the cause?
Rhabdomyolysis, AKI ,liver injury, Myositis and Upper GI bleed. Is African herbal medicine the cause?
A 42-year-old African gentleman came to our ED for lower back pain in the gluteal area. The left side has more pain than the right side. He cannot walk from the pain. Patient was not cooperative during the examination because of the severe pain. Vital signs were normal, painkiller given. During re-examination, the patient has tenderness and tension in the left gluteal area like an abscess. The patient had no past medical history and he denied any co-morbidity. His job was security and his duty long was 12 hours . He had lower back pain too . He had no foot drop. He can control urine and stool. He had normal rectal tone . Normal general exam . Musculoskeletal ultrasound done to rule out deep gluteal abscess but it’s showed subcutaneous edema and no abscess or collection. The blood test showed: leucocytosis 12.5 , high urea about 17.4 , high creatinine about 353 , high liver enzyme ALT was 189 and AST was 691. CRP was 262.9. He had high CK more than 22000 and a high myoglobin 14894. Lactic acid was 3.1. Intravenous rehydration started, blood culture was sent and it was negative. Empirical antibiotic was given too. The patient got admission for further investigation. The MRI pelvis showed myositis [Multifocal diffuse myositis involving the pelvic muscles] . The MRI lumbar and thoracic spine showed mild disc bulges L3/L4 and L5/S1. He had mild plural effusion too . During the admission he got an episode of upper gastrointestinal tract bleeding , so upper endoscopy decided that he showed gastric ulcer. Abdominal US showed Coarse liver. The patient had supportive treatment during 26 days of admission. He got a few sessions of renal hemodialysis . Finally, he got normal blood result [ renal , liver , CRP , CK , myoglobin and Wbcs all became normal ] then discharged to home. Before discharge, he told his physician he got some African herpal medications few days before his attack and he thought maybe it was the cause of his disease. He said he took it to clean his stomach . The patient is doing well now.
Rhabdomyolysis, AKI ,liver injury, myositis and Upper GI bleeding may be the result of side effects of African herbal medication. The ED physicians showed be aware of herbal medicine side effects.
Dr Islam ELROBAA (Al wakra, Qatar), Faisal KHAN
00:00 - 00:00
#41828 - Right atrial and ventricular strain analysis for prognostication in patients with acute pulmonary embolism, a pilot study.
Right atrial and ventricular strain analysis for prognostication in patients with acute pulmonary embolism, a pilot study.
Background
Acute pulmonary embolism (PE) is a common and potentially fatal condition, with mortality rates varying based on clinical severity. While patients with hemodynamic instability face the highest short-term mortality risk, the majority of patients are hemodynamically stable and identifying normotensive patients who may benefit from aggressive management remains controversial.
Right ventricular dysfunction (RVD) is a known prognostic marker in PE but it is not standardized. Moreover, several indexes are currently used to identify RVD but which index or group of indexes are the best predictors is not well defined. Our aim was to investigate the prognostic role of new indexes of ventricular function, ventricular and atrial strain, in patients with PE.
Methods
Consecutive hemodynamically stable patients diagnosed with acute PE were included in the present pilot study. The diagnosis of PE was confirmed by pulmonary CT angiography (CTPA). RVD was defined as the presence of at least one of the following criteria on transthoracic echocardiography: TAPSE < 17 mm, right ventricular diameter > 35 mm (apical 4 chambers), septum paradoxical systolic movement. Global longitudinal (GLS) and circumferential strain (GCS) calculations of the right atrium and right ventricle were performed offline using 2D speckle-tracking analysis. The primary outcome was the combination of death due to pulmonary embolism or hemodynamic instability/complicated course occurring during hospitalization. Complicated course was defined based on the presence of at least one of the following: systolic blood pressure <90mmHg for at least 15 minutes, the need for catecholamine administration due to persistent arterial hypotension or shock, the need for thrombolytic therapy, the need mechanical ventilation or the need for cardiopulmonary resuscitation, death from PE. Comparison of echocardiographic parameters between patients who achieved or did not achieve the primary outcome was performed using ANOVA.
Results
We included 24 patients (mean age 80 years, female 45.8%). Among the whole cohort 15 out of 24 patients (62.5%) had an RVD. Eight of the 24 patients (33.3%) developed the primary outcome, no patient died from PE during hospitalization. Considering traditional methods of assessing right ventricular function, patients who achieved the primary outcome showed lower TAPSE values (14±3.7 mm vs 20.7±4.4 mm, p=0.005) and a larger right ventricle, considering the mean end-systolic diameter (37.9±14.8 vs 26.3±9.1 mm, p=0.026). None of the RV strain parameters was significantly different between the two groups (Table 1). Conversely, right atrium GCS was significantly reduced in patients who achieved the primary outcome compared to those who remained hemodynamically stable (12.9±4.9 vs 21.6±10.4% respectively, p=0.037).
Discussion & Conclusions
Right atrial global circumferential strain appears to identify normotensive patients with pulmonary embolism who will develop hemodynamic instability or a complicated course better than RV strain parameters.
None
Ginevra FABIANI (Firenze, Italy), Alessio PELLEGRINO, Lorenzo PELAGATTI, Ilaria GALLI, Francesca INNOCENTI, Francesca CALDI, Peiman NAZERIAN, Pietro Amedeo MODESTI, Simone VANNI
00:00 - 00:00
#41591 - Right Atrial Mass in Pulmonary Embolism-Suspected Patient, Misled by Unfamiliarity: A Case Report.
Right Atrial Mass in Pulmonary Embolism-Suspected Patient, Misled by Unfamiliarity: A Case Report.
Background:
Point-of-care ultrasound (POCUS) is a valuable bedside tool for emergency physicians (EPs) to uncover critical diagnoses in patients. Right atrial (RA) thrombus is a concerning lesion occasionally found in patients diagnosed with pulmonary embolism (PE). We report a symptomatic patient in which a RA mass identified by cardiac POCUS was initially misinterpreted as RA thrombus to illustrate the POCUS images mimicking RA thrombus and review how to differentiate this lesion from an actual benign anatomical variant, a Chiari network.
Brief clinical history:
A 20-year-old female known for systemic lupus erythematosus and antiphospholipid syndrome presented to the emergency department with left-sided pleuritic chest pain and shortness of breath for three weeks. On arrival, her vital signs and her physical exams were normal. Electrocardiography and chest film radiography were unremarkable. Laboratory investigations revealed markedly elevated D-Dimer (2288 mcg/L).
Misleading elements:
Cardiac POCUS performed by the Emergency physician (EP) illustrated a hyperechoic mobile structure within the RA. Due to the patient's high suspicion of pulmonary embolism (PE), the EP initially misinterpreted it as a right atrial (RA) thrombus. The patient immediately received intravenous low-molecular-weight heparin.
Helpful details:
The Computed tomography pulmonary angiography confirmed PE. However, comprehensive transthoracic echocardiography during admission reported a prominent Chiari network within the RA, with no evidence of RA thrombus. Subsequently, the patient was treated with an oral anticoagulant and discharged home without complications.
Differential and actual diagnosis:
The differential diagnosis of a RA mass included a RA thrombus versus a Chiari network and other benign anatomical variants. The actual diagnosis in this case was a Chiari network.
Educational and/or clinical relevance:
Recognizing the Chiari network as a potential misleading element on POCUS is crucial. This case highlights the need for EPs to differentiate between this benign finding and a life-threatening condition like a RA thrombus. It emphasizes the importance of interpreting POCUS images within the appropriate clinical context and the need for additional ultrasound views, expert consultation, or confirmatory tests when managing stable patients with any RA mass seen on POCUS to ensure appropriate treatment plans.
Krongkarn SUTHAM (, Thailand), Laurie ROBICHAUD, Paul BRISEBOIS, Rungsrit KANJANAVANIT, Joel PHILIP TURNER
00:00 - 00:00
#41747 - Right Atrium Rupture After Blunt Trauma.
Right Atrium Rupture After Blunt Trauma.
Case: A 14-year-old boy was taken to our emergency department from another hospital by
ambulance. He was intubated. On examination he had bruises, ecchymosises on several parts of
the body. Then we evaluated the patient with US. As soon as we saw pericardiac fluid about 30
mm, we immediately prepared for the pericardiocentesis procedure. Then we performed
pericardiocentesis and removed 125 cc of fluid, and this fluid resembled a hematoma. After we
saw hematoma at first, we consulted the patient with cardiovascular surgeon for emergency
surgery, thinking the patient had a wall rupture of heart. After cardiovascular surgeon evaluated
the patient, he took the patient to the emergency operating room. After the surgery, we saw that it
was written in the surgical report, "The right atrium wall was observed to be ruptured. The right
atrium wall was closed with primary suture." Then the patient transfered to pediatric intensive
care unit for follow-up.
Conclusions: Blunt traumatic cardiac rupture is rare but highly fatal. This results in shock and
death if not acted upon emergently. An autopsy series revealed that up to 65% of blunt trauma
patients have a cardiac injury, but in clinical series, less than 1% of blunt trauma patients who
survive have this isolated finding. The incidence of blunt cardiac rupture among hospital
admissions for trauma is only approximately 0.16%–2%. IRAR most commonly occurs following
motor vehicle accidents as the result of blunt chest trauma. Rupture occurs at four distinct sites
and is most commonly at the right atrial appendage. IRAR is a diagnostic challenge and requires
a high index of suspicion, as patients' hemodynamics can rapidly deteriorate. The presentations
vary depending on multiple factors including rupture size, pericardial integrity, and concomitant
injuries. Cardiac tamponade may have a protective effect by prompting the search for a bleeding
source.
Expeditious use of cardiac FAST on the initial evaluation of chest trauma patients is essential to
the early diagnosis of hemopericardium and timely intervention before clinical deterioration, which
improves survival. Two-dimensional echocardiography with TTE subcostal views and TEE
transgastric views is the optimal echocardiographic modality for the detection and evaluation of
cardiac tamponade.pericardial window can be diagnostic and therapeutic in IRAR. Outcomes are
favourable with timely recognition and prompt surgical intervention.
Bora BALTACIOGLU (Nigde, Turkey), Deniz KILIC, Mehmet AY
00:00 - 00:00
#41982 - Right facial swelling with perforated ulcer of hard palate, a rare case in our ED.
Right facial swelling with perforated ulcer of hard palate, a rare case in our ED.
A 38-year-old male patient. He denied any co-morbidity. He came for perforated hard palate since one month with pus coming out. He has a frontal headache. He has right maxillary swelling and tenderness. Blood work up was requested and CT head decided . He had stable vital signs. Blood test showed: normal leukocyte, mild anaemia- haemoglobin was 10.5 , C reactive protein was 10.2 , normal renal and liver functions , He had noramal lactic acid and HBa1c. A blood culture sent that had no growth . CT head showed : Complete opacification of all Para-nasal air sinuses with bony erosions and suspected small intra-cranial extension. The finding was most suggestive of infectious etiology likely fungal sinusitis, or a less likely neoplastic process. The patient got admission under ENT team care . He was seen by a maxillofacial and neurosurgical team who requested MRI for him. The MRI showed: Complete opacification of the sinonasal spaces and paranasal sinuses with bony erosions and bilateral orbital extraconal extension, subtle intracranial anterior fossa extension, and left diffuse facial cellulitis. The MR features are suggestive of an acute invasive pyogenic pansinusitis with extensions and effects as described, while the possibility of underlying neoplastic process is unlikely. The MRI and CT report showed a hard palate ulcer, not a complete perforation . The patient got clarification from neurosurgery , maxillofacial and ophthalmology teams. The ENT gave him antibiotic and antifungal therapy. They suggested fungal mass or severe pyogenic sinusitis. The patient underwent to surgical procedure for right sino-nasal mass biopsy to explain his histopathological problem. The histopathological report showed : Extranodal T cell lymphoma, nasal type. The patient refers to a hematologist for definitive treatment.
Learning points: non – frequent case in emergency department. Perforated hard palate or hard palate ulcer may be result of pyogenic infection or cancer. That area was a dangerous area. It is covered venous drainage of orbit, brain and nasal-maxillary sinuses [face dangerous triangle] .
Dr Islam ELROBAA (Al wakra, Qatar), Aftab MOHAMMAD UMAR, Eslam MOHAMED
00:00 - 00:00
#41863 - Risk negotiation in prehospital critical care dispatch: a cross-sectional interdisciplinary study in Wales, UK.
Risk negotiation in prehospital critical care dispatch: a cross-sectional interdisciplinary study in Wales, UK.
Background:
A European consensus report in 2011 identified dispatch for prehospital critical care as one of the top five research priorities (Fevang et al 2011). It has significant impact on patient safety, equitable access, and cost-effective use of resources. With the new reality that emergency medical services (EMS) are facing increasing demands and more complex pressures, there are urgent needs to study and enhance dispatch. Yet, dispatch criteria and systems are still under-researched. Our project addresses this gap by being the first in the UK to look at dispatch of prehospital critical care in Wales, which provides limited rapid response vehicles and helicopters to both urban and rural terrains. We study how decision to dispatch is made by teams in emergency operations centres (EOCs) adopting the Medical Priority Dispatch System (MPDS), specifically how risk and severity indicators in emergency calls are identified and negotiated among operational and clinical teams across the dispatch decision making process.
Methods:
Our ongoing project started in October 2022. It adopts a cross-sectional, multi-method study design. It is an interdisciplinary collaboration between medical professionals and sociolinguists. The project uses complementary datasets routinely collected in an EOC. They include original audio recordings of emergency calls, audio recordings of spoken interactions among teams, and Sequence of Events records (SOE). Policy documents relating to prehospital critical care in Wales were also collected. A hundred representative cases were chosen to form the corpus for analysis (in progress). The linguistic analysis draws on Interactional Sociolinguistics, an established approach for analysing the relationship between linguistic choices and communication practices that signal risk and display risk uptake.
Results:
Our analysis shows there is high risk of information loss in the decision-making pathway. We identify instances when the risk signalled in emergency calls does not map on the risk recorded in SOEs. We show that it is challenging for call-takers to balance completing scripted, strictly sequenced protocol of MPDS, adding extra textual remarks when a caller’s response goes beyond or outside the scope of a particular scripted question. Although risk indicators might be added and transferred later through other sources, such as on-scene crew, timeliness of dispatch may still be impeded.
Discussion & Conclusions:
The implications of our project are twofold. First, the analysis on how risk indicators are lost or kept from emergency calls to other operational and clinical teams sheds light on communication training that could be provided to these teams to enhance precise transfer of risk indicators, hence accurate risk negotiation and decision making. This is the next step of our project. Second, our project demonstrates the importance of interdisciplinary research for a holistic exploration of complex issues, such as emergency medical dispatch.
The project is funded by Health and Care Research Wales.
Shawnea S. P. TING (Coventry, UK, ), Jo ANGOURI, Matthew BOOKER, David RAWLINSON, Lauren WILLIAMS, David LOCKEY, Lyba NADEEM, Nigel REES
00:00 - 00:00
#42296 - Risk scores in the evolution of NSTEMI.
Risk scores in the evolution of NSTEMI.
*Introduction :
Non-ST-segment elevation acute coronary syndromes (non-ST+ ACS) are a frequent reason of hospitalization in emergency departments, with a variable course and a high risk of complications or recurrence of coronary events. Early risk stratification plays a central role in therapeutic strategy, and the risk of subsequent events.
*Objectives : the aim of this study was to compare the predictive values of risk scores for the occurrence of complications in NSTEMI .
*Methods :Comparative study conducted over a 4-month period. Patients hospitalized in the emergency department for NSTEMI were included. Intra-hospital complications such as angina recurrence, acute pulmonary edema, rhythm and conduction disorders, and myocardial infarction were investigated. The predictive values of different risk scores in the occurrence of acute complications were studied.
Results:Inclusion of 85 patients hospitalized for NSTEMI. Mean age was 61 ± 11 years with extremes ranging from 32 to 88 years . Male predominance was observed (67%), with a gender ratio of 2. The main cardiovascular risk factors and antecedents were: hypertension in 51 patients (60%), diabetes in 55 patients (64.7%), dyslipidemia (31; 36.5%), coronary insufficiency (38; 44.7%) with a history of angioplasty in 21% of patients and heart failure (7%). The main reasons for consultation were pain (81.2%), followed by dyspnea (15.3%) and epigastralgia (2.4%).Complications were encountered in 21% of cases: OAP (15.3%), angina recurrence (11.8%) and MI (5.9%). The mean GRACE, TIMI, HEART, CRUSADE and PURSUIT scores were 137.7, 3.81, 7.67, 33.4 and 19.6 respectively. NSTEMI is a pathology associated with risks of major complications. These complication events have been incorporated into several risk scores. The Grace score is the most validated tool for risk stratification in NSTEMI.
*Discussion :
NSTEMI is a pathology with a risk of major complications.The occurrence of these complications requires appropriate diagnostic and therapeutic strategies. To do this, these major complication events were incorporated into several risk scores.The Grace score constitutes the most validated tool in risk stratification during NSTEMI.Thanks to this stratification, optimal medical treatment as well as an early invasive revascularization strategy is recommended in high-risk patients.[1].Other scores have been established.ICU (ACTION) score predicts risk of cardiovascular events requiring hospitalization in an intensive care unit. This score includes:age, heart rate, systolic blood pressure, troponin and creatinine dosage, ST segment depression, signs of acute heart failure. The study carried out byAlexander CFanaroff et al. showed a good prognostic value of this score with an AUC = 0.72 of the ACTION ICU risk score[2]with acut-off at 34[3].Other scores have been developed such as China AcuteMyocardial Infarction(CAMI) score.Rui Fuet alconcluded that the performance of the CAMI-NSTEMI risk score was superior to the GRACE score(AUC, 0.81 vs. 0.72; P<0.01)[4].
*Conclusion: the management of non-ST+ ACS is based on recommendations . Risk stratification scores are used to adapt therapeutic management and revascularization strategy.
Sirine KHABOUCHI, Khaireddine JEMAI (Tunis, Tunisia), Dhekra HOSNI, Seif OUERGHI, Hana HEDHLI
00:00 - 00:00
#40934 - Robotic endotracheal intubation: a theoretical application for the custom bougie technique?
Robotic endotracheal intubation: a theoretical application for the custom bougie technique?
Background: Airway management is a core procedural competency in the profession of medicine. The endotracheal intubation skill set ascends the learning curve. The emergent airway remains a unique clinical procedure for an emergency medicine physician. Advancement of airway ideas, techniques, materials, skills and clinical understanding should be valuable. The author proposes a theoretical idea in simple artistic sketch format with implied general force vectors for robotic endotracheal intubation. The idea is based on simulation experience with the custom bougie technique guided by a magnet imaged with fluoroscopy and sonography initially described at EUSEM 2018 Congress in Scotland, further explored in 2019, and 2023.
Methods: The following was obtained for the custom bougie technique: SunMed Introducer Adult Bougie 15Fr x 70cm with Coude Tip, Hillman Group Ook 18 Gauge Steel Galvanized Wire, MAC 3 laryngoscope, trauma shears, and tegaderm. Shears were used to cut the bougie at the 55cm mark. The proximal segment of the bougie was removed to allow insertion of the guide wire into the distal hollow bougie. The proximal segment was then replaced back over the guide wire modification of the distal segment and sealed together with tegaderm to create the custom device. A rare earth NdFeB, Grade N52 DISC Magnet NiCuNi: 377.6 lb Pull Force, 2 dia x 2 thk (in) supplied the magnetic field to the distal bougie via the anterior neck. Sensation of tracheal rings was used as tracheal confirmation. Imaging was performed with portable fluoroscopy and sonography. The artistic rendering was performed by the author with pencil and paper, then converted to digital format with editing software.
Results: The custom bougie technique creates two additional properties of potential robotic utility in the device. The introducer bougie becomes magnetic, and radiopaque. The implied general force vectors for the procedure could be replicated with robotic functionality. (Figure 1)
Conclusion: A modern era of robotics in health care procedures has arrived. The full potential for robotic endotracheal intubation is unknown. The authors’ unique simulation and laboratory experience with a novel custom bougie technique that creates supplemental properties of magnetism and radiopacity in the professionally accepted difficult airway bougie device may have clinical utility in robotics. Appropriate resources and regulation are warranted for further evaluation. Expanding the scientific domain of endotracheal intubation cognitive and material resources could have the potential to positively impact the core competency, scale and scope of airway management in the clinical setting.
Matthew VASEY (Tampa, USA)
00:00 - 00:00
#42182 - Rupture of the upper urinary tract during renal colic: about six cases.
Rupture of the upper urinary tract during renal colic: about six cases.
Background:
Renal colic (RC) is an acute painful lumbosacral abdominal syndrome. Complicated forms are rare, accounting for 6% of cases. We report six cases of patients presenting to the emergency department with RC complicated by rupture of the urinary tract.
Clinical presentations:
There were four men and two women, with an average age of 60 +/- 14 years. Among them, only one patient had a history of urological issues related to extracorporeal shock wave lithotripsy. Clinical symptoms included right-sided lower back pain radiating to the external genitalia in 5 patients and left-sided lower back pain in one female patient, associated with hematuria and dysuria in 3 patients. None of the 6 patients had a fever. The median consultation time was 4 hours. Tachycardia was observed in four patients. The initial median numerical pain scale (NPS) score was 10 for all patients. Abdominal guarding was noted in one patient and abdominal tenderness in the others. Laboratory test results were normal. Therapeutic management included intramuscular administration of anti-inflammatory drugs and slow infusion of 1 gram of paracetamol, followed by titration with morphine hydrochloride with a mean total dose of 14 +/- 5 mg. Radiological exploration with an uroscan revealed a right or left renal obstructive syndrome caused by a calculus associated with rupture of the urinary tract and ureteropelvic junction dilation with a mean diameter of 20 +/- 2 millimeters. Pain relief was observed after 60 minutes after administration of analgesic drugs. All patients were transferred to an urology department for surgical treatment.
Conclusion
Non-traumatic rupture of the urinary tract secondary to renal calculi is a relatively rare complication, but it should be considered in cases of sudden relief of pain.
Raja FADHEL (Ain Zaghouan, Tunisia), Jihene SEBAI, Anas NACEJ, Salma BAYA, Imen BEN ABDALLAH, Syrine KESKES, Sami SOUISSI, Ines CHERMITI
00:00 - 00:00
#41279 - Safer Care for Elderly in Emergency Department.
Safer Care for Elderly in Emergency Department.
BACKGROUND/PROBLEM STATEMENT
The number of over 75 year old patients (O75YOs) presenting to our Emergency Department(ED) has increased by 35% since 2020 and continues to rise. It is well documented that older people present more frequently to EDs with a higher level of illness severity, a higher rate of admission or re-attendance and are at a greater risk of adverse outcomes such as falls, delirium, prolonged ED and/or hospital stay and ultimately mortality (Tan et al. 2012) .
The primary aim of our safety huddle was to establish a platform to identify and reduce such risks to O75YOs presenting to our ED, thereby improving their outcomes.
QI METHODS
Our 10 minute huddle took place each day in the ED at 3pm (peak occupation time of O75YOs). An ED physician, nurse, physiotherapist and Geriatrician/Registrar were required to attend.
The huddle script was developed based on feedback from EM consultants, geriatricians, MDT and a literature review on risks associated with an ED presentation in older adults.
The script focused on recording resourcing issues critical to patient care. The primary risk factors recorded included falls risk, delirium, administration of time critical medications and PET times.
Following the huddle, HCPs involved in the patients care were updated by the relevant member of the MDT in attendance.
The core working group met at regular intervals over the study period to revise the huddle script and feedback mechanisms in order to optimize the effectiveness and efficiency of the huddle.
RESULTS
We observed a decrease in the number of falls from 2 to 0. Delirium screening improved from 0% to 26%. Identification and administration of time critical medications improved from 0% to 78%. PET times increased slightly (2%), however our admission rates have decreased indicating value added to the patients’ journey. Whilst we acknowledge there is still room for improvement, these results will clearly have a positive impact on patient outcomes.
LESSONS LEARNED & NEXT STEPS
We encountered many barriers to the implementation of our huddle. Audits identified gaps in education, communication and completion of critical documentation. Cycles of training and education and repeated measurements demonstrated a gradual improvement.
We learned that measurement, education, perseverance and inclusion are integral to the success of this initiative. The safety huddle is an efficient way to improve communication and reduce risks to patient care. We plan to continue to huddle daily, involve more staff and focus on further education to continue to reduce risks to this group. We strive to exemplify excellence in safe emergency care of our older population.
Not registered for any trials and there is no funding.
Eamonn MCMACKIN, Subramaniam DINESHKUMAR (Portlaoise, Ireland), Antoinette BRADY, Caitriona QUIRKE
00:00 - 00:00
#41300 - Scleroderma: Case Report.
Scleroderma: Case Report.
Scleroderma is an autoimmune connective tissue disorder which is characterised by fibrosis of visceral organs, skin and blood vessels. This condition can be localised or systemic. Its prevalence is 250 cases in a million and it is more common in women than in men. The first specific clinical sign of scleroderma is the swelling on the skin of hands and fingers. The aim of this case report is to present some clinical characteristics of a 37 year old patient diagnosed scleroderma.A 37-year-old female patient was referred to the ER of KCCG because of swelling on the skin of hands and fingers. The joints are getting stiff and enlarged, especially in the ankle area, the fingers, and toes. She had generalised body weakness, and dry cough associated with chest pain. The patient denied fever, chills, nausea, vomiting or any loss of blood. She also complained, skin dryness, cold sensitivity of fingers and tightness of the face.Review of systems was positive for joint pain and muscle weakness. Physical examination findings included facial telangiectasias. In her laboratory analysis in ER complete blood count was in range, glucose in full blood 6,7, creatinine 31, AST 33, ALT 39, Na 135, HsTnI 36.
Because of chief complaints and finding on examination, a patient was sent to rheumatologist who admitted her to the department for further investigation and to prove systemic progressive scleroderma.Through this case report we have tried to emphasise the importance of a general examination when diagnosing rare systemic diseases such as scleroderma.
Marina PEROVIĆ (Podgorica, Montenegro)
00:00 - 00:00
#42077 - Scorpion envenomation: epidemiological characteristics and predictors of progression to stage 3.
Scorpion envenomation: epidemiological characteristics and predictors of progression to stage 3.
Introduction:
Scorpion envenomation is prevalent in southern Tunisia, especially during the summer. It occurs due to scorpion stings, arachnids belonging to the arachnid class. This study aims to investigate the epidemiological features of patients admitted for stage 2 scorpion envenomation management and identify clinical and paraclinical factors predictive of progression to stage 3.
Materials and Methods:
This prospective analytical cohort study included patients admitted to Gabès University Hospital's emergency department in 2022 and 2023 with a diagnosis of stage 2 scorpion envenomation. Exclusion criteria was the absence of consent to participate in the study. Studied characteristics were demographic, ecological, anamnestic, clinical, paraclinical, therapeutic modalities, and outcomes were assessed. Clinical follow-up at Day 15 and Day 30 post-hospitalization was conducted via telephone.
Results: 69 patients were enrolled, comprising 31 men and 38 women, with a mean age of 35 years (median: 33 years). Age distribution showed 27.5% aged 0 to 14 years, 56.5% aged 15 to 65 years, and 16% aged over 65 years. Androctonus australis accounted for 57.9% of stings, followed by Buthus occitanus (35.5%) and Androctonus aeneas (6.6%). The predominant functional sign was vomiting (61.4%). The average systolic blood pressure was 131 mmHg, with 14 patients having systolic blood pressure >140 mmHg. Electrocardiogram abnormalities were observed in 5 patients, and chest X-ray abnormalities were noted in 4 patients.
Most patients had a normal left ventricular ejection fraction on echocardiography. Ultimately, 62 patients (89.9%) were classified as stage 2, and 7 patients (10.1%) progressed to stage 3.
Among these patients who progressed to stage 3, 5.7% had no clinical signs of myocarditis or cardiogenic shock. However, they had echographic signs in TTE such as left ventricular filling pressures elevated, left ventricular ejection fraction and segmental left ventricular wall motion abnormalities. This permitted an earlier detection of progression to stage 3 and earlier management of these cases.
All patients received antivenom therapy. Ventilatory support via non-invasive ventilation was required for 3 patients, including 1 pediatric case, and dobutamine was administered to 1 patient.
The majority of patients (86.2%) were discharged within 12 hours. Some necessitated transfer to the intensive care unit (10.1%) or pediatric ward (3.7%).
Follow-up: At Day 15, 5 patients reported chest pain, and 7 reported palpitations. By Day 30, no complaints were reported.
Discussion:
Scorpion envenomation in Tunisia varies geographically, with three main species causing most cases. Symptoms typically range from local pain (stage 1) to systemic signs (stage 2), with severe cases progressing to cardiogenic shock (stage 3). Our study found that patients without prior heart issues or obvious clinical/biological signs of progression often showed echocardiographic signs of advanced stages (altered LVEF, LV wall kinetic abnormalities, elevated LV filling pressure) when point-of-care ultrasound (POCUS) is realized. This facilitated timely intervention and made possible preventing severe complications.
The conclusion suggests that all stage 2 envenomation patients should undergo point-of-care ultrasound screening to detect potential progression to stage 3. This approach could significantly improve patient outcomes and guide appropriate management strategies for scorpion envenomation in Tunisia.
Mohamed Ali NBAYA (Gabès, Tunisia), Emna REKIK, Aziza TALBI, Ahmed CHALBAOUI, Imene REJEB
00:00 - 00:00
#41083 - Sensitivity and specificity of different appendicitis scores in PED.
Sensitivity and specificity of different appendicitis scores in PED.
Background
Abdominal pain is one of the most frequent reasons for referring to pediatric emergency department (PED) with appendicitis being the most common reason for surgical care. Delayed or missed diagnosis of acute appendicitis can lead to morbidity and mortality, thus differential diagnosis is crucial. Therefore, several scoring systems have been developed. In this study, we aimed to clarify sensitivity and specificity of three different scales: HAS, Alvarado and PAS in children presenting with abdominal pain.
Methods
A retrospective study was conducted at the Lithuanian University of Health Sciences Kaunas Clinics. Data of all children with abdominal pain from 1-17 years old, who visited the PED in September 2018 were collected. Exclusion: chronic diseases, psychiatric illnesses, toxic poisoning, abdominal trauma. Collected data: demographics, past medical history, clinical history (complaints, vital signs), physical signs (location and characteristic of pain, associated factors, such as nausea/vomiting, loss of appetite, fever), laboratory results (complete blood count (CBC), C-reactive protein (CRP)), abdominal ultrasound results. As no scales were documented, we calculated different appendicitis scores for all the children, including the HAS (includes abdominal ultrasound), Alvarado score, and PAS. Statistical analysis was performed with SPSS 28.0. P value <0.05 was considered significant.
Results
The study included 254 patients experiencing abdominal pain, with 52.8% being female and a mean age of 9.26+/-4.64 years. Appendicitis was diagnosed in 53 patients (20.9%), predominantly in children ≥10 years. Most children were referred to PED within 12 hours of symptom onset, and they were more often discharged than hospitalized compared to other groups. Alvarado and PAS scores were significantly higher in older patients (p<0.05 both) and the appendicitis group.
Regarding specificity and sensitivity, Alvarado's score with a cutoff value of 5.5 (AUC 0,612, CI95% 0.521-0.702) had specificity of 93.5% (p=0.016) to predict appendicitis. Whereas, HAS score with a cutoff value of 2.5 (AUC 0.599, CI95% 0.520-0.678) had a specificity of 98.0% and PAS score cutoff value of 6.5 (AUC 0.614, CI95% 0.520-0.708) was highly specific (96.5%) to predict appendicitis in children with abdominal pain. However, all scales were of low sensitivity. No significant differences were found between age groups (<10 vs. >= 10 years), except for Alvarado score when symptoms lasted <24h (p=0.039, cutoff 4.5, AUC0.625, CI95% 0.507-0.743). Among gender, only HAS score been significant for females (p=0.014, AUC 0.644, CI95% 0.529-0.760): at cutoff 0.5, specificity was 70.0%, and sensitivity – 54.5%).
Conclusion
Our study confirms that Alvarado, PAS, and HAS scales are highly specific in appendicitis prediction in children referred to PED with abdominal pain. It is of note, that one of the scales should be included into the routine diagnostics and documentation when child is referred due to abdominal pain.
Urte ONIUNAITE (Kaunas, Lithuania), Jurate PAKROSNYTE, Lina JANKAUSKAITE
00:00 - 00:00
#41444 - Sepsis research is hampered by the lack of a clear definition of suspected infection.
Sepsis research is hampered by the lack of a clear definition of suspected infection.
Background
A widespread method used in sepsis research involves the combination of blood cultures combined with antibiotic treatment to identify patients with suspected infection. However, this definition has not been validated. In the present study, we propose the hypothesis that several patients admitted with suspected infection may not undergo culture testing. This might be due to variability in physician ordering behavior, compliance with guidelines, and instances where cultures may be deemed unnecessary if the source of infection is evident from the patient's history or clinical signs. Using the suggested criteria for infection in cohort studies may, therefore, constitute a risk of misclassification bias.
Aim
To calculate, characterize and compare infectious patients admitted to an emergency department with and without obtained cultures and to estimate mortality according to culture status.
Methods
We conducted a secondary analysis of prospective collected electronic health record data among adult patients with infection and admitted from October 1, 2017 to March 31, 2018. The study examined the number of patients who underwent any body culture collection and antibiotic treatment, comparing their 28-day mortality rates to those of patients treated solely with antibiotics, without cultures obtained. Exact differences with 95% confidence intervals were used to examine differences between proportions. Logistic regression analyses were used to determine group differences in mortality odds.
Results
A total of 2,055 (48.5% male) patients with a median age of 73.1 years were included, with 1,441 (70.1%) having at least one body culture obtained alongside antibiotic treatment. Among 614 (29.9%) patients without cultures obtained, 163 (26.6%) had a Sequential Organ Failure Score (SOFA) ≥ 2 on admission compared to 528 (36.6%) among patients with cultures obtained (difference: 5.7-14.3). The 28-day mortality rates were 7.3% and 7.7% (difference: ÷2.1-2.9), respectively. Age, SOFA, and Charlson Comorbidity Index were independent predictive variables in both groups.
Conclusion
Using the combination of obtained body cultures and antibiotic treatment in cohort studies as a definition for suspected infection poses a substantial risk of misclassification. In the current study, a substantial number of patients without obtained cultures exhibit a SOFA score indicative of sepsis and have similar mortality rates. However, they would not meet the criteria of infection in a study using the suggested criteria. Misclassification bias may, therefore, be a serious methodological problem that challenges sepsis epidemiological research.
This study was funded by the Regional Zealand Research Foundation.
Lana CHAFRANSKA ANDERSEN (Hilleroed, Denmark), Rune SØRENSEN, Osama Bin ABDULLAH, Thomas ANDERSEN SCHMIDT, Finn Erland NIELSEN
00:00 - 00:00
#41520 - Septic pulmonary embolism in intravenous drug users - a case report and clinical insights.
Septic pulmonary embolism in intravenous drug users - a case report and clinical insights.
Septic pulmonary embolism (SPE) poses a significant clinical challenge, often arising from infective endocarditis (IE) and exacerbated by intravenous drug use (IVDU). This case report presents a 41-year-old man with a history of IVDU, who presented with fever, respiratory distress, and pulmonary infiltrates consistent with SPE. Despite the absence of classical cardiac symptoms, imaging modalities including computed tomography revealed characteristic findings indicative of septic emboli. Blood cultures confirmed Staphylococcus aureus as the causative agent, suggesting potential staphylococcal septicemia. Prompt initiation of broad-spectrum antibiotics and source control formed the basis of management, with the patient's stable vital signs facilitating transfer for further care. This case underscores the intricate interplay between IVDU, IE, and SPE, emphasizing the importance of heightened clinical suspicion in at-risk populations. Imaging plays a pivotal role in early diagnosis, guiding therapeutic interventions. Notably, rapid cavitation in lung nodules distinguished SPE from neoplastic etiologies. Treatment strategies encompass broad-spectrum antibiotics and infection source eradication. Mortality primarily stems from septic shock, underscoring the urgency of early detection and intervention in improving outcomes. In conclusion, SPE remains a rare but serious condition with significant morbidity and mortality. Vigilant surveillance and rapid intervention are paramount for optimizing outcomes in affected individuals, highlighting the need for increased awareness and early intervention in similar clinical scenarios.
Wei-Lun CHEN (Taipei, Taiwan), Tzu-Yao HUNG
00:00 - 00:00
#42303 - Severe and complicated forms of tuberculosis in the elderly: clinical study of three cases.
Severe and complicated forms of tuberculosis in the elderly: clinical study of three cases.
Introduction :
Tuberculosis is an endemic pathology and can present itself in serious form in fragile patients
such as the elderly.
Objective :
Diagnosing serious forms of tuberculosis in the elderly to improve the prognosis
Clinical Observation 1:
This is an 83-year-old patient, with no previous history, admitted for dyspnea for several days.
The clinical examination finds a polypneic patient, arterial hypotension, gas shunt effect, SIB,
elevated D dimer and troponins. Chest CT angiography showed a proximal bilateral
pulmonary embolism and an appearance of active pulmonary tuberculosis. The patient was
put on treatment then transferred to pulmonology.
Observation 2:
This is a 73-year-old patient, hypertensive, diabetic, bullous pemphigus, on corticosteroid
therapy, admitted for basithoracic pain. A clinical examination of a polypneic patient.
Gasometry has a shunt effect. A chest CT angiogram showed a right proximal and left distal
pulmonary embolism, and an appearance of miliary tuberculosis. The patient was put on
treatment with unfavorable outcomes.
Observation3:
74-year-old patient with diabetes and hypertension admitted for back pain and pain in both
lower limbs, she was stable, SIB with gas shunt effect, chest CT angiography ruled out
pulmonary embolism, spinal MRI showed an appearance of probably tuberculous
spondylodiscitis complicated by abscesses of the psoas muscles. The patient was transferred
to orthopedics for further treatment.
Conclusion :
Tuberculosis is an endemic pathology in our country and can be fatal in the elderly
Khaireddine JEMAI (Tunis, Tunisia), Dhekra HOSNI, Hana HEDHLI, Safia OTHMANI, Marouane SANAI, Chedhe BEN HMIDA, Ghada MARZOUGUI, Sarra JOUINI
00:00 - 00:00
#41527 - Severe dehydration and chronic diarrhea – ordinary symptoms of extraordinary syndrome.
Severe dehydration and chronic diarrhea – ordinary symptoms of extraordinary syndrome.
Diarrhea is a common yet not the most dangerous problem for Emergency Physicians as most of the patients are being treated symptomatically. However, chronic diarrhea, especially in elderly patients, can cause severe metabolic disturbances. Secretory diarrhea, electrolyte imbalance, acute kidney injury – this triad is a ‘red flag‘ in the Emergency Department (ED) and it is important to consider less common causes. Rarely, the reason of chronic diarrhea is McKittrick-Wheelock syndrome. It is caused by a villous rectal adenoma and only less than 300 cases have been reported according to systematic reviews. So, have you ever encountered McKittrick-Wheelock syndrome in your clinical practice?
A 67-year-old male presented to the ED complaining of pain under the right costal arch, shortness of breath, repeated vomiting, and diarrhea over 6 months, with recent bloody stools. Key facts from the patients’ medical history: the patient is diagnosed with primary arterial hypertension but has recently experienced a decrease in blood pressure and stopped taking antihypertensives regularly. Upon physical examination, the abdomen was soft, tender, and painful under the right rib cage.
The patient complained of shortness of breath, which led to tests for cardiac-specific and infectious diseases markers. The patient tested positive for Respiratory Syncytial Virus (RSV) and elevated Troponin I (41 ng/l). An electrocardiogram was performed – the right bundle branch block and left anterior fascicular block were observed. As there were no signs of acute ischemia, acute coronary syndrome was excluded. In addition, a chest x-ray was performed, which showed no abnormalities.
Laboratory tests showed high creatinine (495 μmol/l), low glomerular filtration rate (>15 ml/min/1.73 m2) and elevated urea (31.5 mmol/l) levels which indicated acute kidney injury. Moreover, significant electrolyte disturbances such as hypokalemia (2.8 mmol/l), hyponatremia (124 mmol/l) and hypochloremia (78 mmol/l) were obtained. Abdominal ultrasonography showed a distended colon with isoechoic masses. The patient underwent an abdominal computed tomography (CT) which showed a dilated radius of the distal ileum and rectum with a villous adenoma. Based on the results, the patient was diagnosed with McKittrick-Wheelock syndrome.
Low CRP levels and the patient not meeting Rome IV criteria allowed to rule out infectious diarrhea and inflammatory bowel disease. The symptoms were typical of malabsorption, celiac disease, or pancreatic dysfunction, but the results of the laboratory tests and CT led to other conditions.
Based on laboratory and imaging findings, the case appears to be a typical manifestation of McKittrick-Wheelock syndrome. The syndrome is rare and the exact incidence is unknown. Moreover, less than 3 percent of villous adenoma is associated with secretory diarrhea. In conclusion, even if the symptoms strongly suggest McKittrick-Wheelock syndrome, more common conditions should be excluded first.
Ausrine ANUZYTE, Beatrice RASCIUTE (Vilnius, Lithuania), Renata JUKNEVICIENE, Pranas SERPYTIS
00:00 - 00:00
#42395 - Severe exacerbation of asthma in pediatric settings: Clinical and para-clinical aspects.
Severe exacerbation of asthma in pediatric settings: Clinical and para-clinical aspects.
Introduction : Severe asthma exacerbation (SAE) is a change in the patient's usual condition, which also does not respond to well-conducted medical treatment that can be life-threatening and requires urgent treatment.
Objective : Study the clinical and para-clinical characteristics of SAE in a pediatric department.
Methods : This is a retrospective, longitudinal and descriptive study, carried out within the pediatric department of the university hospital , which included children hospitalized for SAE, during a period of 1 year and 6 months.
Results : Thirty patients were identified. The average age was 47 months. Atopy was found in 43%. Six patients were previously hospitalized for asthma exacerbation. The average hospitalization time was 12.9±11 hours. The clinical severity criteria found were signs of intense respiratory struggle in 60% of cases, with auscultatory silence in 3.3% of cases, speech disorders in 46.7% of cases and 30% of patients had disorders of consciousness. The average respiratory rate was 52.80±10.2 cycles/minute, the average SpO2 was 90.93±2.7% on ambient air. On gas analysis, the average pH was 7.3±0.06 and the average capnia was 36.43±8 mm Hg. Biologically, hyponatremia was observed in 10% of cases. Hypokalemia was noted in 6.6% cases. Ventilatory disorders were noted in 36.3% of cases.
Conclusion : Strengthening therapeutic education for parents of asthmatic children represents a pillar of preventive management of these severe exacerbations.
Aucun cpnflit
A JELASSI, Olfa HAMMAMI, Manel KALLEL (Tunis, Tunisia), S BEN GUEBILA, I KHAMASSI
00:00 - 00:00
#42396 - Severe exacerbation of asthma in pediatric settings: Therapeutic and evolutionary aspects.
Severe exacerbation of asthma in pediatric settings: Therapeutic and evolutionary aspects.
Introduction : Severe asthma exacerbation (SAE) is a change in the patient's usual condition, which also does not respond to well-conducted medical treatment that can be life-threatening and requires urgent treatment.
Objective : Study the therapeutic and progressive aspects of SAE in a pediatric department.
Methods :This is a retrospective, longitudinal and descriptive study, carried out within the pediatric department of the university hospital of Bizerte, which included children hospitalized for ESA, during a period of 1 year and 6 months.
Results :Thirty patients were identified. The average age was 47 months. Six patients were previously hospitalized for asthma exacerbation. The average hospitalization time was 12.9±11 hours. Therapeutic management was based on terbutaline nebulizations, combined with anticholinergics in 90% of patients with intravenous corticosteroid therapy. Magnesium sulfate was administered in 70% children. Conventional oxygen therapy was necessary in 83.3% of cases with recourse to high flow oxygen therapy (OHD) in 5 patients. Hemodynamic support was necessary in four patients. The average duration of drug retention was 41 hours. Nineteen patients received antibiotic therapy. The average hospitalization lasted 4 ±1.2 days. In our study, we noted the occurrence of pneumothorax in 1 case, pneumomediastinum in 4 cases, atelectasis in 6 cases and hyponatremia in 3 cases. We also noted the occurrence of hyperglycemia in 8 cases and hypokalemia in 2 cases. There were no cases of healthcare-related infections or hypertension. No deaths were noted.
Conclusion : Strengthening therapeutic education for parents of asthmatic children represents a pillar of preventive management of these severe exacerbations.
AUCUN CONFLIT
Olfa HAMMAMI, Manel KALLEL (Tunis, Tunisia), A JELASSI, S GUEBLIA, I KHAMASSI
00:00 - 00:00
#42373 - Severe head trauma : situation in the emergency department.
Severe head trauma : situation in the emergency department.
Introduction:
Severe head trauma is a common reason for admission to the emergency room. This is a pathology associated with significant morbidity with a very high cost of care. In this perspective, we carried out a study whose objective was to describe the epidemiological characteristics and clinical findings of severe head trauma in emergency departments.
Methods:
Longitudinal study. Inclusion of patients aged over 14 years admitted to the emergency room for isolated severe head trauma from January 2021 until February 2024. Patients presenting with associated chest and abdominal trauma were excluded. Clinical, radiological and evolutionary data were collected. In-hospital mortality was researched.
Results:
Eighty patients were included. The gender ratio was 1/7. The average age was 43±19 years.
Medical History (%): hypertension (11), diabetes (8), stroke (4), epilepsy (3).
Current treatment (%): vitamin K antagonist (4), non-vitamin K dependent anticoagulant (2.5), aspirin (1).
The circumstances of the trauma (%): Public Road accident (69%), domestic accident (14), work accident (7.7), aggression (6.7).
The mode of prehospital transport (%): civil protection (91), MICU (6), own means (2.5).
The occurrence of trauma was (%): at night (44), on weekends (25).
The GCS (mean±SD) was 7±3. Spo2 (med [min-max]) was 92 [37-99]. SBP (mean±SD) (mmHg) was 117±49.
Examination of the pupils noted (%): anisocoria (21), non-reflective mydriasis (10.5), miosis (5). Only two patients did not have brain imaging. Brain lesions found (%): subdural hematoma (35), cerebral edema (33), extradural hematoma (28), deviation from the center line (21), jamb (7). Forty-eight of the patients were transferred to referral services. In-hospital mortality was 37%. The median length of stay was 6 days with extremes ranging from 0 to 64 days.
Conclusions:
Severe head trauma is a serious pathology with heavy morbidity and mortality, a sector should be established to organize the care of these patients and facilitate their transfer to a neuro-resuscitation unit to improve their survival.
Marouane SANAI, Asma JENDOUBI, Mouna JEMAI, Yassmine KARRAY (, Tunisia), Sarra JOUINI
00:00 - 00:00
#42387 - Severe head trauma: comparison between elderly and young.
Severe head trauma: comparison between elderly and young.
Introduction:
Head trauma in elderly people is a daily challenge given that they are less resistant to an aggressive situation than young people.
The objective of our study is to compare the epidemiological, clinical and prognostic parameters of severe head trauma between elderly and young subjects.
Methods:
This is a single-center prospective study carried out in the emergency room from January 2021 until February 2024. Patients aged over 14 years admitted for isolated GCT were included. Two groups were identified:
G1: severe head trauma in an elderly subject and G2: severe head trauma in a young subject.
An epidemiological, clinical and prognostic analysis was carried out.
Results:
We collected 80 patients. Sixteen patients were aged ≥65 years. Comparing the two groups in a univariate study, the population aged ≥65 years had a lower diastolic blood pressure with a statistically significant difference (p=0.013). In biology, group 1 had a higher CRP, INR and lactate level compared to group 2 with a significant difference (respectively 0.032, 0.02, 0.015). Intra-parenchymal hematoma was more frequent in group 1 with a significant difference (p=0.04). Complications were more pronounced in the G1 group with a significant difference (p=0.034).
Conclusion:
The elderly population was more at risk of developing intraparenchymal hematomas and more susceptible to developing complications.
Marouane SANAI, Asma JENDOUBI, Mouna JEMAI, Yassmine KARRAY (, Tunisia), Hana HEDHLI, Sarra JOUINI
00:00 - 00:00
#41333 - Severe sepsis due to psoas muscle abscess with iliac artery mycotic aneurysm.
Severe sepsis due to psoas muscle abscess with iliac artery mycotic aneurysm.
Introduction
: It is important for clinicians to find out the infection focus for patients with sepsis. History and physical examination, combined with timely, appropriate examination play a crucial role in early diagnosis. Here we would like to introduce a case of fever with severe flank pain.
Case Presentation
: This 59 year-old female with diabetes was admitted to the emergency department due to general malaise and anorexia for days. She complained of left flank pain when changing position. Initial vital signs displayed low grade fever (37.6 Celsius degree), tachycardia (113 bpm) and high blood pressure as 173/86 mmHg. Physical examination showed no icteric sclera, no abnormal breathing sound, no murmur in heart sound nor tender in abdomen. She had difficulty moving her back and walking due to severe left flank pain. Blood examination revealed leukocytosis (White blood count 25.14*10^3/uL) with N:L ratio as 96.4/1.8, C-reactive protein (CRP) 437.40 mg/L, glucose 821 mg/dL, ketone 3.3 mmol/L, creatinine 2.4 mg/dL, lactate 1.6 mmol/L. Urine analysis showed WBC 10-19/HPF with bacteria 2+/HPF and trace leukocyte esterase. In order to identify infection focus, computer tomography (CT) was performed that left psoas muscle and iliacus muscle air-forming abscess was found, with one round mass in the center of it. CT angiography displayed left common iliac artery aneurysm with surrounding abscess. Clinical condition progressed 4 hours later that her blood pressure dropped to 82/53 mmHg. Due to complicated psoas muscle abscess and diabetes ketoacidosis with ongoing septic shock, she was transferred to medical center. Blood culture revealed Salmonella bacteremia. The patient received left common iliac artery stent graft in the first place and CT-guided drainage thereafter. She is still under hospitalization due to drug-resistant bacterial infection and fungemia.
Conclusion
: Immunocompromise patients may encounter sepsis with uncommon origin. Proper image studying and reading is important for timely management.
Ya-Ching LIANG (Taipei City, Taiwan)
00:00 - 00:00
#41214 - Shared characteristics of rare diseases in the emergency department: a patient survey.
Shared characteristics of rare diseases in the emergency department: a patient survey.
Background
Rare diseases (RD) present a particular and altogether not so rare challenge in the emergency department (ED): RD and their management are often unfamiliar, presentation is nonspecific, awareness and knowledge are limited.
RD mean increased morbidity, mortality (overall and in the ED) and worse inpatient outcomes and therefore need to be addressed.
Since RD also present (as potentially life-threatening events) in the ED, but little is known about emergency care specific characteristics, this study aimed to characterize rare but treatable diseases in the ED.
Methods
Between July 2023 and June 2024, patients (>= 16 years, German-speaking) with known RD were invited to participate in a survey via outpatient departments of the Charité University Hospital and patient organizations. In the self-completed 30-40 min questionnaire, they were asked about their RD manifestation, RD related ED visits and diagnostic journey. The exemplarily considered set of RD combined rare but treatable diseases that can be seen and diagnosed in the ED in adolescents and adults with existing treatment options available, so timely diagnosis is essential: acute hepatic porphyria, fabry disease, familial mediterranean fever, fatty acid oxidation disorder, hereditary hemorrhagic telangiectasia, myasthenia gravis, paroxysmal nocturnal hemoglobinuria and thrombotic thrombocytopenic purpura and urea cycle defect. Median, mean, relative and absolute frequencies were used to analyze patient characteristics reported in the survey.
Preliminary Results
144 patients participated in the survey. Median age of RD onset was 22 years (IQR 22.5). The median time from symptom onset to diagnosis was 3 years (IQR 14.8).
59.7% had presented to an ED prior to diagnosis with symptoms related to their RD. Of those, only 8.1% reported that their RD had been diagnosed in the ED.
On average, RD patients described 13.8 (SD 8.6) different symptoms affecting 6.7 (SD 2.6) different organ systems. The two most common reported complaints across all RDs were general weakness/exhaustion (108/144) and abdominal pain (70/144). 77.1% reported that their symptoms had led them to give up certain activities (sport, travel, seeing friends and family, work). Factors that triggered or aggravated symptoms were present in 88.2%, with stress, infection and sleep withdrawal being the most common triggers (80.4%, 52.7%, 40.2%) and aggravators (85.5%, 52.7%, 48.2%).
Discussion & Conclusion
Our findings indicate that RD are frequently overlooked in the ED (59.7% of the survey participants had presented to the ED prior to diagnosis, only 8.1% of them reported being diagnosed in the ED) contributing to a diagnostic delay of several years. Shared characteristics of the surveyed RD patients were recurrent nonspecific presentation to the ED, multiple symptoms affecting various organ systems (5-8) and appointable trigger factors.
To prevent missing diagnosis of RD in the ED leading to increased morbidity and mortality despite available treatment options, strategies for identification of RD in the ED are needed. Most important, awareness among emergency professionals for rare but treatable diseases in the ED needs to be raised.
Trial Registration: The study has been registered in the German Clinical Trials Register (DRKS-ID: DRKS00033032).
Funding: This study did not receive any specific funding.
Ethical approval and informed consent: The Ethic Committee of the Charité University Berlin approved the study design (EA2/045/23). Informed consent of each participant was obtained.
Sandra PFLOCK (Berlin, Germany), Hannah Carolina MÜCKE, Rajan SOMASUNDARAM, Eva DIEHL-WIESENECKER
00:00 - 00:00
#42043 - SIC-score as a tool for assessing thromboembolic risk in COVID-19 patients.
SIC-score as a tool for assessing thromboembolic risk in COVID-19 patients.
Background : The COVID19 disease linked to the SarsCov2 Virus has been, in France, a major public health issue. Thromboembolic manifestations in patients with COVID-19 were quickly noted and the recommandations, made by many scientifical institution, of anticoagulation adapted to the thromboembolic risk was one of the key points of management.
Aim : The SIC-Score is a validated score for assessing thromboembolic risk in sepsis. Our objective was to assess its relevance to predict thromboembolic risk in COVID-19 patient.
Methods : We carried out a retrospective, single-center study in an adult emergency department. We analyzed data from patients admitted at the emergency department from 03/13/20 to 04/11/20 (first wave) and from 08/01/20 to 11/31/20 (second wave). The information collected lists clinical and paraclinical data of patients with COVID during their admission in order to calculate their SIC-Score.
Results: Of the 434 patients included, 30 (6.9%) presented a thromboembolic event. The relevance of the SIC-Score as a marker of thromboembolic risk was assessed by calculating the area under the ROC curve of 0.905 (95% CI = [0.823 - 0.910] - p< 0.001). In multivariate analysis, the increase of 1 point in the SIC-Score increases the probability of having a thromboembolic event by 2.11 (95% CI = [1.12 - 3.99]; p = 0.02). For the SIC-Score, a threshold below 2 shows a negative predictive value of 99.6% (Negative Likelihood Ratio at 0.047) and a threshold of 3 shows a positive predictive value at 34% (Positive Likelihood Ratio at 6.91).
Conclusion: The SIC-Score is an objective and relevant score in the assessment of thromboembolic risk in patients with COVID-19, making it possible to individualize patients at risk and therefore to initiate preventive anticoagulation adapted to them.
Felix MOSSE, Marine LORIDON, Sophie FLEURQUIN, Clément BONNET, Romain DURIF, Jeannot SCHMIDT, Dorian TEISSANDIER, Farès MOUSTAFA (Clermont-Ferrand)
00:00 - 00:00
#41301 - Sinus tachycardia and Diarrhea - Dehydratio?
Sinus tachycardia and Diarrhea - Dehydratio?
The differential diagnoses for diarrhea and sinus tachycardia are diverse. In everyday clinical practice, it is often difficult to recognize rarer etiologies. Thyrotoxic crisis is one of these more serious differential diagnoses, with a frequency of 0.8 to 1.4 cases per 100,000 inhabitants(1). Triggers of a thyrotoxic crisis with underlying hypothyroidism (e.g. as part of an autoimmune disease or an adenoma) include febrile infections, pregnancy, operations and a change in thyrostatic drug therapy. In addition to clinical symptoms such as tachycardia, fever, diarrhea, restlessness and much more, scoring systems such as the Burch Wartofski Score (BWS) or the Japanese Thyroid Association (JTA) score can be used for diagnosis(2,3). If clinical suspicion is high, therapy should be started before laboratory results arrive. ß.blockers, Thionamides and GCS are used for initial therapy(4). If therapy fails, plasmapheresis and surgical thyroidectomy can be considered(5).
Case presentation: We present the case of a 27-year-old female patient who presented to the ER complaining of a sore throat, abdominal cramps and diarrhea that had been present for a week. In the primary survey the patient was found to be: A: clear; B: tachypnic, C: HR 145/min, regular, RR 176/90mmHg; D:GCS 15, anxious, agitated. The neck was swollen & tender. Skin status: warm, dry. Resting ECG: Sinus tachycardia up to 140/min without ST-Changes. The BWS was:55. In cases of high suspicion of thyrotoxic crisis, 80mg thiamazole and 10mg propranolol were administered. Lab chemistry later showed a TSH of 0.01uIU/ml with an fT4 of 50 pIU/ml.
Discussion: In the case study, the diagnosis of a thyrotoxic crisis could be made with the help of the clinical symptoms and using the BWS. Knowledge of appropriate scoring systems is extremely important for ER-physicians. Therapy could then be initiated before Lab chemistry was obtained. The mortality from thyrotoxic crisis remains 10 to 25% despite modern therapies. Multi-organ failure is the most common cause of death from a thyrotoxic crisis. In addition to the medications described, GCS can also be used to inhibit the conversion of T4 to T3.
References 1. Galindo RJ, Hurtado CR, Pasquel FJ,García Tome R, Peng L,Umpierrez GE. National Trends in Incidence, Mortality and Clinical Outcomes of Patients Hospitalized for Thyrotoxicosis With and Without Thyroid Storm in the USA,2004-2013.Thyroid. 2019 Jan;29(1):36-43 2. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am. 1993 Jun;22(2):263-77 3. Akamizu T, Satoh T, Isozaki O, Suzuki A, Wakino S, Iburi T, Tsuboi K, Monden T, Kouki T, Otani H, Teramukai S, Uehara R, Nakamura Y, Nagai M, Mori M, Japan Thyroid Association. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid. 2012 Jul;22(7):661-79. 4. Jacobi J. Management of Endocrine Emergencies in the ICU. J Pharm Pract. 2019 Jun;32(3):314-326. May 5 Shinohara, Toyoyoshi Uchida, Takashi Funayama, Mika Watanabe, Makio Kusaoi, Ken Yamaji, Naoto Tamura, Hiromasa Goto, Hiroaki Satoh, Hirotaka Watada, Effect of Plasma Exchange in Thyroid Storm With Consideration of Its Distribution Into the Extravascular Space, Journal of the Endocrine Society, Volume 4, Issue 4,April 2020
Osama ALHUSSEIN (Hamburg, Germany), Dorothea SAUER
00:00 - 00:00
#41317 - Sirt6 overexpression in bone marrow mesenchymal stem cell-derived exosomes promotes wound healing and angiogenesis.
Sirt6 overexpression in bone marrow mesenchymal stem cell-derived exosomes promotes wound healing and angiogenesis.
Background
Wound repair is a huge challenge in clinical issue recently which requires advanced treatment strategies. In this study, we investigated the effects of Sirt6 over expression in bone marrow mesenchymal stem cell-derived exosomes (Sirt6-MSC-Exo) on angiogenesis and wound healing in vitro.
Methods
The mesenchymal stem cell (MSC) was obtained in C57BL/6 mouse bone marrow. Sirt6-overexpressed MSC (Sirt 6-MSC) was established. The exosomes were extracted and characterized, and the effect of Sirt 6-MSC exosomes on wound healing was examined by CCK8, immunofluorescence, wound scratch, Transwell, angiogenesis assays and Western blot.
Results
The MSC-Exo were harvested and identified successfully from MSC and sirt6-MSC. The ability of proliferation, migration and angiogenesis of HUVEC were enhanced under stimulation of sirt6-MSC-Exo when compared with that in the control group treated with MSC-Exo.
Conclusions
Sirt6-MSC-Exo could promote wound healing by enhancing proliferation, migration and angiogenesis. The current study showed the promise of exosome-based therapy for wound repair.
Funding
This research was funded by Key R&D Program Projects of Zhejiang Province (2021C03072).
Juan LONG, Zhongqiu LU (wenzhou, China, China)
00:00 - 00:00
#41013 - Skeletal radiograph interpretation discrepancies in the Emergency Department setting: a retrospective chart review.
Skeletal radiograph interpretation discrepancies in the Emergency Department setting: a retrospective chart review.
Background: The initial Emergency Department (ED) interpretation of a skeletal radiograph is an integral component of managing trauma-related presentations. These radiographs are subsequently read by radiologists to ensure they have been correctly assessed. With demand for radiology services continuing to increase, the provision of these reports may be delayed by hours to days. As a result, management decisions are often made based on the initial ED interpretation.
Objectives: To determine the frequency and clinical consequences of discrepancies in skeletal radiograph interpretation between emergency and radiology doctors in an Australian ED.
Methods: We reviewed the records of adult and paediatric patients assessed with skeletal radiography in an emergency department in Victoria, Australia over a three-month period (January to March 2022). Epidemiological data, the interpretation of the radiograph by ED and radiology doctors, and clinical management of the patient were recorded to determine interpretation discrepancies and the consequence of these.
Results: There were 2359 unique skeletal radiographs in 1576 patient presentations during the study period. Of these, 140 (6%) had a discrepancy. Where a discrepancy existed, in 47% the ED interpretation reported a fracture and/or dislocation which was not present in the radiology interpretation (false positive) whilst the remaining (53%) were attributed to a missed fracture and/or dislocation (false negative). Thirty-five discrepancies (2%) required a change in patient management and were therefore clinically significant. The most common affected body area was the elbow, where 15% of radiographs were discrepant. Pathology was more often missed when multiple abnormalities were present on the same radiograph (odds ratio 4.2, 95% confidence interval 2.5 to 6.8).
Conclusions: The rate of clinically significant discrepancies in the interpretation of skeletal radiographs by emergency physicians is low. This data supports using ED interpretation of radiographs to guide initial management as safe practice.
Jack KINNERSLY, Furqan AHMED, Chris SELMAN, Elyssia BOURKE (Melbourne, Australia)
00:00 - 00:00
#41207 - Small bowel intestinal obstruction with small bowel feces sign.
Small bowel intestinal obstruction with small bowel feces sign.
A 30-year-old male with a previous history of appendicectomy presented with severe abdominal pain and vomiting of one day duration. On examination he was in distress with periumbilical tenderness, there was no guarding or rebound tenderness. His vitals were stable otherwise. A contrasted CT scan of his abdomen and pelvis showed distended small bowel loops with diffuse wall edema and hypoenhancement, along with small bowel feces sign proximally. At least two transition points are seen raising the possibility of closed-loop obstruction. The diagnosis was that of small bowel obstruction with concerns of closed loops obstruction and ischemia. He was subsequently admitted to the General Surgery department and underwent exploratory laparotomy and limited right hemicolectomy. Intraoperative findings include closed-loop obstruction due to adhesion band arising from stapled base of appendix with 70cm of terminal ileum ischemic up to ileocolic valve. Small bowel feces sign may sometimes be seen on CT scan and is usually due to the presence of feculent material resembling colon content in the small intestine. This is thought to be due to delayed intestinal transit caused by incompletely digested food, bacterial overgrowth, or increased water absorption of distal small bowel contents due to obstruction. When seen with other findings on CT scan, it increases the reliability of diagnosing bowel ischemia in the presence of small bowel obstruction.
Benjamin WAN (Singapore, Singapore), Koh SHAO HUI
00:00 - 00:00
#41847 - Small extracellular vesicles derived from brain microvascular endothelial cells undergone cardiac arrest aggravate cerebral injury by promoting neuronal ferroptosis.
Small extracellular vesicles derived from brain microvascular endothelial cells undergone cardiac arrest aggravate cerebral injury by promoting neuronal ferroptosis.
BACKGROUND: As a common and frequently occurring disease, cardiac arrest (CA) has been paid more and more attention for its high mortality and high disability rates all around the world. Cerebral ischemic-reperfusion injury (CIRI) caused by CA- cardiopulmonary resuscitation - return of spontaneous circulation (CPR-ROSC) leads to neurons death, and prevention of neuron death is of great significance to protect neurological function after CIRI. Nevertheless, the mechanism of its occurrence and development is intricated and remains largely unknown. This study investigated that ferroptosis occurred in neurons after CIRI and its underlying mechanisms in vivo and in vitro.
METHODS: CA-CPR-ROSC mice in vivo models and oxygen glucose deprivation for 3 hours /reoxygenation for 3 hours (OGD3h/R3h) in vitro models were used, and ferroptosis level of neurons was detected. AAV-BR1-CD63-GFP was injected via lateral cerebral ventricle to proven that brain microvascular endothelial cells-derived small extracellular vesicles (BMEC-sEV) could be taken in by neurons, and AAV9-BR1- Rab27a-shRNA was used to reduce the production of BMEC-sEV. The effect of ferroptosis on ROSC rate and neurological prognosis in mice were confirmed by ferroptosis activators (RSL3, Erastin) and inhibitors (Fer-1, Lip-1). In order to discover the key molecules of ferroptosis in neurons, we conducted a proteome sequencing study using sEV acquired from the two groups of brain tissues. Overexpression/silencing methods and rescue experiments were utilized to demonstrate the important role of protein X and correlated mechanisms in CA-CPR-ROSC-induced CIRI.
RESULTS: In vivo, it was confirmed that the ferroptosis level of neurons in mice underwent CA-CPR-ROSC was superior to that of the sham operation group. In vitro experiments, it was found that the primary neurons had significant ferroptosis after OGD3h/R3h, which was mainly manifested by the changes of mitochondrial morphology under transmission electron microscopy (TEM), ferroptosis related proteins (TFR, ACSL4, SLC7ALL, GPX4, FTH1) and lipid peroxidation (4-HNE, MDA) levels. Immunofluorescence showed that BMEC-sEV labeled by green fluorescence protein (GFP) could be taken in by neurons. Compared with CPR group, ferroptosis level of neurons in the CPR+AAV-BR1-CD63-Rab27a-shRNA group was significantly reduced, indicating that CIRI induced by CA-CPR-ROSC was closely related to BMEC-sEV. In addition, CA-CPR-ROSC mice given Fer-1 and Lip-1 showed higher ROSC rates, neurological function scores, and 7-day survival rates, while, mice given RSL3 and Erastin manifested lower ROSC rates, poor neurological function and lower 7-day survival rates. Proteome sequencing indicated that there were 136 differentially expressed proteins in sEV from CPR group compared with that from sham group, of which 72 proteins were up-regulated and 64 proteins were down-regulated.
CONCLUSION: In general, our results demonstrate that BMEC-sEVCPR exacerbates CIRI by facilitating ferroptosis of neurons, suggesting that targeting this mechanism may be a feasible strategy to treat CIRI following CA-CPR-ROSC.
Trial registration: This study is a non-clinical work, so it is not registered.
Funding: This work was supported by grants from the National Natural Science Foundation of China (82272241).
Ethical approval and informed consent: The experimental design was approved by the Animal Care and Use Committee of West China Hospital, Sichuan University (Chengdu, China) (20231017006).
Mengyao JIAN, Gan LU, Pr Cao YU (Chengdu, China)
00:00 - 00:00
#41405 - Small or large bore chest drains in traumatic haemopneumothorax: a literature review.
Small or large bore chest drains in traumatic haemopneumothorax: a literature review.
Introduction
Thoracic injuries resulting from blunt or penetrating trauma constitute around 25% of global traumas, with haemothorax and pneumothorax being notable manifestations.
Current ATLS guidelines recommend a large bore chest tube (LCT) (28-40F) thoracostomy for the management of traumatic haemothorax and pneumothorax. On the other hand, an interest in small bore chest tube (SCT) (10-20F) use in trauma is gaining momentum as it is considered less invasive, safer and better tolerated by patients.
Method
To establish the benefit of using LCTs or SCTs in traumatic haemothorax and pneumothorax, we conducted a literature search using PubMed and Scopus databases. This resulted in 349 papers, but only six papers meeting our search criteria were included and appraised in our review.
Results:
Of the 6 papers: 2 were randomised control trials, 3 cohorts and 1 case report.
The main outcomes considered were drainage, failure rates and insertion-related complications.
In the assessment of insertion-related experience scores, SCT achieved a lower score, suggesting greater tolerability. Patients with an SCT inserted reported a lower IPE score when compared to LCT patients (1= can tolerate it vs 3= bad experience) (p 0.001) which supports the claims that LCTs have an unacceptably high rate of anxiety. Of the four papers that measured initial output, two produced a significantly increased initial output favouring the SCTs. For example, in Bauman’s study, the difference in initial output compared across all patients enrolled was significantly higher in SCTs (425mL) compared to LCTs (300mL) (p < 0.001).
The remaining studies showed no significant difference between the initial and then daily outputs.
There were no differences between failure rates and insertion related complications.
Conclusion:
Current ATLS guidelines favours the use of LCT (28-40F). However, these recommendations have never been subjected to evidence-based evaluation. From this review, it can be inferred that there is no discernible difference in the use of SCTs versus LCTs in stable, non-emergent patients with a traumatic haemothorax and pneumothorax, and possibly some benefit.
In summary, the present evidence is insufficient to advocate for any current guideline changes in the management of traumatic haemothorax and pneumothorax cases.
Not applicable
Charlotte GRAHAM, Abdo SATTOUT (Liverpool, )
00:00 - 00:00
#41602 - Smart Wristbands in Pre-hospital Emergency Care and Arrhythmia Monitoring.
Smart Wristbands in Pre-hospital Emergency Care and Arrhythmia Monitoring.
Introduction:
Arrhythmia is the leading cause of non-traumatic cardiac death, and early detection, along with prompt response to sudden cardiac arrest, could potentially save lives. Wearable watches are capable of continuously monitoring several cardiac parameters and providing instantaneous data upload for clinicians to review. Implementing this feature into emergency medical services (EMS) could reduce the medical burden and improve prognosis. This is because concerning cardiac rhythms or heart rates can alert the response team. Therefore, we conducted an observational study to assess the validity and effectiveness of wristbands in detecting arrhythmias and alerting the medical response team.
Methods:
This single-center observational study was conducted from January 2021 to December 2024 in collaboration with the New Taipei City Emergency Medical Services (EMS). Participants were recruited from the cardiovascular outpatient department, and those who did not wear provided wristbands or experienced data upload abnormalities were excluded from the study. A total of ninety-six patients with chronic diseases, including 61 with heart failure and 28 with atrial fibrillation, participated in this study. All participants wore wristbands developed by our team in collaboration with Acer, equipped with photoplethysmography (PPG) sensors. They wore these wristbands continuously for several days to several weeks. Whenever arrhythmia, defined by heart rates ≤ 40 beats per minute or ≥ 150 beats per minute, was detected, the dispatch center of the emergency medical services was alerted, and a dispatch call was made promptly to confirm the patient’s status. Data analysis was conducted and analyzed utilizing IBM SPSS Statistics 26 (IBM Corp., Armonk, NY, USA). We initially employed the Kolmogorov–Smirnov test to analyze the normal distribution of continuous variables. If the variable followed a normal distribution, we reported the mean; otherwise, we reported the median.
Results:
Sixteen patients were alerted to EMS: thirteen had a higher heart rate, while five had a lower heart rate. Among these alerts, three were false alarms, and three of the alerted patients actually reported feeling discomfort. Additionally, 68 participants took part in a satisfaction survey regarding their experience with the CareHeart App, wristband, and the service provided by educators/case managers. Overall, the average satisfaction score was 2 out of 5, with 1 representing the highest satisfaction and 5 the lowest. This score remained consistent across the three major factors. However, for minor factors such as the font size of the CareHeart App and wristband, appearance, battery life, and overall satisfaction, neutral opinions were expressed.
Conclusion:
The monitoring provided by the wristbands allows for the identification of the number of alarms triggered during the wearing period, which serves as a valuable reference for clinicians in making diagnoses. Furthermore, telephone visits to the service center of the fire station are deemed necessary, as they enable the identification of patients genuinely experiencing discomfort. While the future of this wristband appears promising, there remain numerous software and hardware issues that require improvement.
Far Eastern Memorial Hospital:PI20210003
Shy Yau ANG, Cheng CHIAO YIN, Li SHIH MIN, Tsai TSUNG HSIEN, Chu SHENG WEI, Pan KE HAN, Sun JEN TANG, Wu YEN WEN (New Taipei City, Taiwan)
00:00 - 00:00
#41722 - Smartphone use by young doctors training in emergency departments: a multicenter study.
Smartphone use by young doctors training in emergency departments: a multicenter study.
The healthcare sector is no exception to the trend towards digitalization and the use of artificial intelligence in today's digital age. Smartphones are set to become just as indispensable in the doctor's toolkit as stethoscopes. They are a veritable pocket computer with multiple functionalities, thanks to constantly evolving medical applications that can prove useful to doctors in the emergency room. We will describe the use of smartphones and medical applications by young doctors in training in the emergency department, including their frequency of use, advantages, and limitations. We will also assess their level of knowledge of the ethical and legal context of the use of these applications in medical practice. We will conduct a multicenter, cross-sectional descriptive study of young doctors in training in emergency departments between January 1, 2022 and June 30, 2022. 156 young doctors in training took part in the study. It's clear that almost all of them own a smartphone and use medical applications (97%). The most frequently used medical applications were score calculators, medication databases, and emergency guides. The main reasons for using applications were to help with diagnosis, prescribing, and self-training. It's evident that almost all young doctors with smartphones use them to exchange medical data, mainly photos and images. Exchanges are mainly with residents from other specialties (82%) and senior doctors (55%), to obtain diagnostic and therapeutic assistance. Most data and photos are stored on smartphones among personal data (67%) for academic, forensic, follow-up, and scientific purposes. Despite the fact that the majority of young doctors do not inform the patient of these exchanges (79%), do not ask for the patient's consent (87%), and do not trace these exchanges in the medical file (70%), 63% of them believe that these exchanges guarantee medical confidentiality. The smartphone is a valuable tool for young doctors in the emergency department, helping them to provide optimal patient care. Formal evaluation and training strategies for these medical applications should be developed to ensure their use with confidence. At the same time, young doctors in training must be aware of the legal framework for this practice.
Rabeb MBAREK, Haifa BRADAI, Chebbi NABIL (Tunisie-Sousse, Tunisia), Dorra LOGHMARI, Sondes LAAJIMI, Naoufel CHEBILI
00:00 - 00:00
#41546 - Socioeconomic inequality and mortality among acute patients with sepsis: A Danish cohort study.
Socioeconomic inequality and mortality among acute patients with sepsis: A Danish cohort study.
Introduction
Socioeconomic inequalities persist in infectious diseases and sepsis in high-income countries. We aimed to investigate if income disparities were associated with increased mortality among sepsis patients overall and among those treated in the intensive care unit (ICU) versus general ward.
Methods
A register-based cohort study including all adult patients (≥18 years) with an unplanned contact with a hospital in the Region of Southern Denmark from 1 January 2016 to 19 March 2018. Sepsis patients were identified based on the following criteria: (1) blood culture(s) performed within 48 hours of arrival, (2) antibiotic(s) administered within 48 hours of arrival, (3) a discharge diagnosis of infection, and (4) ≥1 organ failure(s) based on a SOFA-score. All criteria had to be fulfilled.
The cohort was divided into quartiles according to income. Cox proportional hazard was used to estimate the association between income groups and overall 90-days mortality, with a further subgroup analysis conducted to differentiate between patients treated in the general wards and those admitted to the ICU. The analyses were repeated with 7- and 365-days mortality as the outcome.
Results
We identified 7,813 first time visits with community-acquired sepsis, including 886 ICU-admissions (11.3%). The overall 90-days mortality rate was 21.6%, with the highest proportion of deaths in the lowest income group (25.4%). Being a patient with sepsis in the low-income group was associated with a hazard ratio (HR) of 1.63 (95% CI: 1.42-1.88) for 90-days all-cause mortality compared with the highest income quartile, which remained increased after adjustment for confounders: HR=1.19 (95% CI: 1.03-1.38). The effect was approximately the same for patients treated in the general wards, while no association was found between income group and mortality for the patients with an ICU-admission: adjusted HR=0.97 (95% CI: 0.69-1.36) for the lowest income group compared with the highest.
The crude HR for all-cause 7-days mortality was 1.62 (95% CI: 1.27-2.07) among the lowest income group compared with the highest, with an attenuated effect when adjusted for potential confounders: HR=1.17 (95% CI: 0.91-1.50). For a 365-days all-cause mortality, the crude HR was 1.72 (95% CI: 1.54-1.93), with patients in the lowest quartile having a significantly increased risk of mortality compared to those in the highest quartile. This remained the case even after adjusting for potential confounding factors, HR=1.28 (95% CI: 1.14-1.44).
Conclusion
Low income was associated with an increased mortality in patients with sepsis, with the strongest association observed at 365-days follow-up. The impact of income disparities was not observed among those admitted to the ICU following the control of confounding factors.
The study is founded by the University of Southern Denmark and Odense University Hospital.
Camilla SCHADE SKOV (Odense, Denmark), Bas DE GROOT, Mikkel BRABRAND, Christian BACKER MOGENSEN, Helene SKJØT-ARKIL, Flemming SCHØNNING ROSENVINGE, Isik SOMUNCU JOHANSEN, Annmarie LASSEN
00:00 - 00:00
#41792 - Special case: Rheumatoid purpura and intra-alveolar hemorrhage.
Special case: Rheumatoid purpura and intra-alveolar hemorrhage.
Introduction :
Rheumatoid purpura or Schönlein-Henoch syndrome is a systemic vasculitis of small vessels related to tissue deposits of immune complexes containing immunoglobulins A (IgA). It mainly affects children, the condition being rarer in adults. The disease is characterized by the association of cutaneous, joint and gastrointestinal signs, which can occur in flare-ups. Renal damage is sometimes associated with these signs. Pulmonary damage (intra-alveolar hemorrhage) is very rare, less than 5%, but often fatal. Intra-alveolar hemorrhage (IAH), characterized by the presence of blood at the level of the pulmonary acinus linked to a lesion of the alveolar capillary barrier (excluding flooding of bronchial origin), is a rare and severe disease involving the life-threatening. Mortality varies between 20 and 100%, with early mortality.
We report the case of a patient with a history of rheumatoid purpura who presented to our emergency room with severe intra-alveolar hemorrhage.
Observation :
We report the case of a young man aged 40, followed for two years in the nephrology department for chronic renal failure with preserved diuresis due to segmental and focal hyalinosis (diagnosed by a PBR carried out in the presence of an impure nephrotic syndrome in the face of arterial hypertension with organic renal failure) and for rheumatoid purpura with a digestive location causing occult bleeding and consequently deficiency anemia with occasional transfusion needs. The patient presented to our emergency department with a picture of severe acute respiratory failure with recurrent low-level hemoptysis, a picture which has been evolving for two days. The initial examination revealed polypnea at 40 cycles/min, marked signs of struggle, SpO2 at 70% on ambient air, crackling rales on pulmonary auscultation occupying both fields. The BP was 190/100 symmetrical in both limbs, HR at 120bpm, edema of the lower limbs significant soft white keeping the cup.
The immediate course of action was to condition him, monitor, oxygen therapy then he was put on NIV with FiO2 100%, aid at 12, PEEP at 5, two peripheral venous lines. The patient underwent an electrocardiogram, a chest X-ray, a complete assessment, and everything pointed us towards a diagnostic suspicion; intra-alveolar hemorrhage complicating rheumatoid purpura.
The patient was put on Solumedrol IV at high dose with a bolus dose of 15 mg/kg without exceeding 1 g (three days in a row), with a relay at a dose of 1 mg/kg at least during the first week. He was put on Nicardipine PES to control the high blood pressure levels.
A chest CT without injection of iodinated contrast product was performed after stabilizing the patient which confirmed our diagnostic suspicion, and the patient was transferred to the intensive care unit for further treatment.
Khouloud KHEMILI (Tunisia, Tunisia), Chaima MANAI, Bouhamed CHAFIAA, Sarra SOUA, Imen KETATA
00:00 - 00:00
#42402 - Special features of emergency admissions: elderly versus young patients.
Special features of emergency admissions: elderly versus young patients.
INTRODUCTION
The elderly are more likely to visit emergency departments and to be admitted to hospital because of their physical, psychological and socio-economic frailty.
The aim of our study was to describe the characteristics of admissions to emergency departments according to age.
METHODS
A prospective, descriptive, comparative, single-centre study conducted over a seven-month period from January to July 2023.
Patients over 18 years of age admitted to the emergency department were included.
We divided the population into two groups: subjects aged ≥ 65 years (G1) and young subjects (G2).
For each group, we compared the main diagnoses of hospitalisation, the length of stay of patients in the emergency department and their outcome.
Results
We enrolled 531 patients, 238 (45.2%) of whom were in G1.
The pathologies that were significantly more frequent in young subjects were traumatic pathologies (p=0.01), intoxications (p=0.03) and diabetic ketoacidosis (p<0.001).
Older subjects had a higher frequency of sepsis (p=0.001), pneumopathies (p=0.003), metabolic abnormalities (p=0.017) and cerebrovascular accidents (p=0.002).
There was no statistically significant difference for coronary heart disease or rhythm disorders. However, in G1, acute heart failure was more frequent (p=0.045).
he median length of stay in emergency departments was significantly higher in elderly subjects (G1), with a significant difference (p=0.006).
In-hospital mortality was higher in G1 with a rate of 13.7%, while it was 3.9% in G2 (p<0.001).
Conclusion
Elderly people are admitted to hospital more frequently and for longer periods. This is due to a number of factors (co-morbidities, diagnostic difficulties, atypical symptoms) and the lack of downstream services.
AUCUN
Khedija ZAOUCHE, Manel KALLEL (Tunis, Tunisia), Emna REZGUI, Emna KALLEL, Houssem BOUOMRANI, Sonia AISSA, Ramla BACCOUCHE
00:00 - 00:00
#42403 - Special features of emergency admissions: elderly versus young patients.
Special features of emergency admissions: elderly versus young patients.
INTRODUCTION
The elderly are more likely to visit emergency departments and to be admitted to hospital because of their physical, psychological and socio-economic frailty.
The aim of our study was to describe the characteristics of admissions to emergency departments according to age.
METHODS
A prospective, descriptive, comparative, single-centre study conducted over a seven-month period from January to July 2023.
Patients over 18 years of age admitted to the emergency department were included.
We divided the population into two groups: subjects aged ≥ 65 years (G1) and young subjects (G2).
For each group, we compared the main diagnoses of hospitalisation, the length of stay of patients in the emergency department and their outcome.
Results
We enrolled 531 patients, 238 (45.2%) of whom were in G1.
The pathologies that were significantly more frequent in young subjects were traumatic pathologies (p=0.01), intoxications (p=0.03) and diabetic ketoacidosis (p<0.001).
Older subjects had a higher frequency of sepsis (p=0.001), pneumopathies (p=0.003), metabolic abnormalities (p=0.017) and cerebrovascular accidents (p=0.002).
There was no statistically significant difference for coronary heart disease or rhythm disorders. However, in G1, acute heart failure was more frequent (p=0.045).
he median length of stay in emergency departments was significantly higher in elderly subjects (G1), with a significant difference (p=0.006).
In-hospital mortality was higher in G1 with a rate of 13.7%, while it was 3.9% in G2 (p<0.001).
Conclusion
Elderly people are admitted to hospital more frequently and for longer periods. This is due to a number of factors (co-morbidities, diagnostic difficulties, atypical symptoms) and the lack of downstream services.
AUCUN
Khedija ZAOUCHE, Manel KALLEL (Tunis, Tunisia), Emna REZGUI, Emna KALLEL, Houssem BOUOMRANI, Sonia AISSA, Ramla BACCOUCHE
00:00 - 00:00
#41654 - Spinal Anesthesia Complicated by Meningoencephalitis: A Case Report.
Spinal Anesthesia Complicated by Meningoencephalitis: A Case Report.
A 32-year-old male patient, previously healthy, presented to the emergency room for a one-day history of severe headache with phonophobia, photophobia, nuchal rigidity, and fever. One day before this presentation, he had a reconstructive ACL surgery, done under spinal anesthesia. He was discharged home on the same day on Inohep, anti-inflammatories, and paracetamol, and no reported complaints. However, on presentation, the patient was febrile, otherwise hemodynamically stable. On the physical exam, he had GCS 11, no cranial nerve deficit, pupils’ symmetrical and equally reactive, aphasia, no motor or sensory deficits in his extremities, and nuchal rigidity. His surgical wound was clean and non-infected. No infectious focus was apparent clinically. All clinical and neurological findings were suggestive of encephalopathy. Toxicological tests came back negative. Labs showed leukocytosis with neutrophilia. Computed tomography scans of the chest, to rule out infectious processes, and the brain, to rule out intracranial anomalies, were normal. The lumbar puncture however showed a cerebrospinal fluid that is: turbid, with 3200 WBC/mm2, 100% neutrophils, Gram-positive diplococci (Streptococcus Salivarius). Blood cultures were in addition positive for Streptococcus Salivarius. The admitting diagnosis was therefore meningoencephalitis contracted by spinal anesthesia as the only source of entry within the last hours.
Several processes are involved in the development of meningitis after lumbar puncture. Infection can arise during bacteremia due to a ''sudden drop in CSF pressure with a breakdown of the blood-brain barrier'' . Furthermore, organisms may be delivered into the CSF space by the needle when passing through tiny capillaries during bacteremia . Moreover, despite the use of appropriate precautions, bacteria may be dispersed after skin disinfection, onto the puncture area or puncture equipment, from the mouths of surrounding staff .
We conclude that extensive aseptic measures should be used to avoid lumbar puncture-associated meningitis. Although it is recognized in the literature that meningoencephalitis is a rare complication of spinal anesthesia, it can be prevented by adhering to guidelines and safe protocols. Early diagnosis and prompt management of bacterial meningoencephalitis is crucial as it can have detrimental effects on the patient.
Yara MOUAWAD (beirut, Lebanon), Mahmoud EL HUSSEIN, Patrick NASRALLAH, Cima HAMIEH, Eric REVUE
00:00 - 00:00
#42323 - Spinal cord compression or polyradiculoneuritis: two coexisting differential diagnoses. A case report.
Spinal cord compression or polyradiculoneuritis: two coexisting differential diagnoses. A case report.
Introduction:
Diagnosis of acute non-traumatic spinal cord injury includes spinal cord compression, acute
central nervous system infection and polyradiculoneuritis (PRN).
We report a clinical observation illustrating the association of two etiological conditions in the
same patient.
Clinical observation:
We report the case of a 70-year-old patient, with no notable pathological history, who
presented to the emergency department with five days' spinal pain, vesico-sphincter disorders
followed by heaviness in both lower limbs, for which he was treated with anti-inflammatory
drugs.
He had no history of trauma, influenza-like illness symptoms, fever, vaccinations or recent
travel.
On physical examination, he was 77% desaturated on room air, polypnoea, signs of
respiratory struggle, BP 155/88 mmHg, tachycardic at 120 bpm, GCS 15, flaccid tetraparesis
on side 0, ROT abolished, CPR indifferent on both sides, absence of Rossolimo, clonus and
Hoffman, no facial paralysis or swallowing disorders.
The patient underwent upper airway control with invasive ventilation. Biologically, the
ionogram was correct, and there was no biological inflammatory syndrome.
Given the suspicion of polyradiculoneuritis and the urgency of treatment, a course of
polyvalent immunoglobulin 0.4g/kg/d was started. The etiological work-up included a
cerebral sacnner, which was without abnormalities, and a negative lumbar puncture.
Spinal cord MRI, performed on the fourth day of treatment, showed anterior epidural
hematomas extending from D12 to L3 with spinal cord compression. Electromyography
confirmed peripheral neuronal damage.
Although the symptomatology presented was based on non-classical elements such as the
absence of influenza syndrome and trauma, it was considered a warning signal that we should
always focus on the etiological search for vital diagnoses requiring urgent treatment.
Conclusion:
Our observation illustrates the coexistence of two diagnostic emergencies in the same patient
during the same episode of acute spinal cord injury: PRN and spinal cord compression.
Mariem TLEMCENI, Khaireddine JEMAI (Tunis, Tunisia), Safia OTHMANI, Marouane SANAI, Dhekra HOSNI, Chaima TLAIES, Sarra JOUINI
00:00 - 00:00
#41432 - SPONTANEOUS CORONARY ARTERY DISSECTION.
SPONTANEOUS CORONARY ARTERY DISSECTION.
SPONTANEOUS CORONARY ARTERY DISSECTION
How does spontaneous coronary artery dissection present differently in patients compared to other forms of heart disease, and what are the implications for treatment?
Spontaneous coronary artery dissection (SCAD), causes myocardial injury as the result of coronary artery obstruction by formation of intramural hematoma or intimal disruption. Atherosclerotic plaque rupture or intraluminal thrombus, are excluded from this definition, as well as traumatic and iatrogenic dissection.
SCAD has emerged as an important cause of acute coronary syndrome, myocardial infarction and sudden death, particularly among young, middle-aged women without conventional atherosclerotic risk factors. It is the primary cause of postpartum myocardial infarction and these patients have more severe presentations and might be at higher risk for recurrent SCAD. Pathophysiology and treatment differs significantly from patients with plaque instability due to atherosclerosis. SCAD prevalence in patients presenting with acute coronary syndrome (ACS), is 1.7% to 4% on the basis of modern series. SCAD may be the cause of ACS in up to 35% of myocardial infarction in women younger than 50 years old. Several factors can trigger an episode of acute SCAD, such as emotional or physical stress. Long term survival for patients with SCAD is excellent, despite the risk of recurrent SCAD events is well recognized, and are certainly a justified concern in these patients.
Case report:40 years old female, with no cardiovascular risk factors, presents central thoracic pain
during moderate effort, irradiated to the neck and back. First electrocardiography was done before 10 minutes and has
sinus rhythm, narrow QRS, ST descent of 1 mm in II, III and aVF, ST elevation of 0.5mm in I, aVL. It also associates vomiting and minimal sudoration.
Arriving hemodynamically stable at the hospital, sublingual nitroglycerine as well as aspirin 250 mg and clopidogrel 600 mg oral.
Both the physical exploration and first complementary explorations are normal, except for troponin levels (max peak of 13436 ng/L).
Diagnosis was given by coronary angiography, that informed: total ostial occlusion of the first diagonal artery due to
spontaneous coronary artery dissection. To avoid the risk of coronary injury, IPC was not the elected procedure, and a conservative management was prioritised.
After discharge, aspirin and beta blocker therapy was prescribed, and also cardiovascular rehabilitation.
It is important do not forget differential diagnosis with the following entities:Atherosclerotic ACS, Coronary artery spasm, Takotsubo cardiomyopathy, Coronary thromboembolism, Myocardial infarction with no obstructed coronary artery
The final diagnosis was:
- Total ostial occlusion of the first diagonal artery due to spontaneous coronary
artery dissection.
- NSTEMI Killip I due to SCAD
The aim of this study is to improve the understanding and management of SCAD in the medical community. Do not underestimate differential diagnosis of SCAD, specially in those young female patients without cardiovascular risk factors, in order to apply the best acute and chronic therapy, by avoiding risky interventions or pharmacological treatments that can worsen the patient's clinical situation.
Elizabet VIDAL FOLCH (Puigcerdà, Spain), Iván TORRES FERNANDEZ
00:00 - 00:00
#41153 - Spontaneous pneumomediastinum in an agitated male adult after physical restraint.
Spontaneous pneumomediastinum in an agitated male adult after physical restraint.
Brief clinical history:
A 21-year-old male presented to the emergency department (ED) with a history of acute agitation for three days. He had been diagnosed with schizophrenia at the age of 13. One month prior to this admission, he reduced the drug dosage by himself. He eventually stopped all medications three days before this admission. He reported visual hallucinations of limbless apparitions and auditory hallucinations of profanity. He experienced insomnia and claimed that he was a prophet. Upon arrival at the ED, he was hyperactive. Due to aggressive behaviors, wrist and ankle restraints were applied, along with intramuscular injection of lorazepam and haloperidol for sedation.
Misleading elements:
Hours after observation and treatment, the patient had been stabilized. Fever with body temperature of 38.2℃ was detected. Heart rate was 115 beats/min, respiratory rate 18 breaths/min, oxygen saturation 98% on room air, and blood pressure 129/78 mmHg. He had mild cough with minimal sputum after admission.
Helpful details:
Heart sounds and breathing sounds were normal. There was no deviation of trachea. The complete blood count, electrolyte levels, liver and renal function tests were normal. Urine analysis and toxicologic panel were negative. Chest X-ray showed air streaks within upper mediastinum and the soft tissue of bilateral neck and shoulder. Chest computed tomography (CT) confirmed the diagnosis of pneumomediastinum and subcutaneous emphysema.
Differential and actual diagnosis:
Respiratory tract infection such as bronchopneumonia may be considered given the history of fever and cough. However, the diagnostic key for this case is the chest X-ray and chest CT. Chest X-ray may disclose radiolucent air outlining the mediastinum. CT can be useful in cases with uncertain diagnoses or underlying causes.
Educational and/or clinical relevance:
Spontaneous pneumomediastinum is a rare but self-limited condition in healthy individuals without an apparent cause such as surgery and trauma. It is predominantly seen between the age of 20-30 years, primarily among tall and thin males. Predisposing factors include asthma, tobacco, chronic obstructive pulmonary disease, and illicit drug use. Coughing, excessive vomiting, vigorous exercise, childbirth, and Valsava maneuver are common triggers. First-line treatment for spontaneous pneumomediastinum without cardiopulmonary compromise is usually conservative with oxygen therapy, analgesics, and rest. Physical restraint, in our case, is an extremely rare precipitating factor of spontaneous pneumomediastinum. Forceful resistance against restraints with Valsava maneuver may be the potential mechanism. This case report highlights that medical staff’s knowledge of de-escalation strategies and awareness of associated complications is important. Verbal de-escalation and pharmacotherapy should be incorporated into the management of agitated patients to minimize harm from physical restraint. Moreover, physical restraints should be removed at the earliest possible time to mitigate complications, which can vary from minor injuries to life-threatening asphyxia and even cardiac arrest.
Peng-Yu LEE (Taipei, Taiwan), Bo-Hwi KANG, Sheng-En CHU, Jen-Tang SUN, Chieh-Min FAN, Kuang-Chau TSAI, Shyh-Shyong SIM
00:00 - 00:00
#41109 - Squat: An Unusual Cause of Deep Vein Thrombosis and Acute Pulmonary Embolism.
Squat: An Unusual Cause of Deep Vein Thrombosis and Acute Pulmonary Embolism.
A 55-year-old man was evaluated in the chest clinic of the hospital because of hemoptysis that had begun three days earlier. He had also been experiencing persistent cough, chest tightness, and shortness of breath upon exertion for ten days. A new infiltrative lesion was found in his right middle lobe of the lung through a chest x-ray. As a result, he was referred to the emergency department for further evaluation.
He stated that he had not experienced any recent upper respiratory symptoms except for coughing. However, around three weeks ago, while performing squat training, he felt a sharp pain in his left lower leg, which was followed by gradual swelling. He believed it was a severe muscle strain and did not seek medical assistance at that time.
There was no fever, nausea, abdominal pain, back pain, palpitations, or syncope experience. Physical examination showed that the temperature was 36.1℃, the heart rate was 95 beats per minute, the blood pressure was 166/95 mm Hg, the respiratory rate was 18 breaths per minute, and the SpO2 level was 99% under room air. The conjunctivae were pink. Auscultation revealed clear breath sounds and absent heart murmurs. Swelling of the left lower limb below the thigh was noted. ECG showed normal sinus rhythm without evidence of right heart strain. Laboratory values demonstrated unremarkable complete blood count, markedly elevated D-dimer (5.62 mg/L), and elevated C-reactive protein (12.5 mg/dL).
CT angiography of the pulmonary was performed on the patient due to suspicion of an acute pulmonary embolism (PE), which was confirmed as expected. Thrombi were found in the right main, upper, middle, lower lobar, and segmental pulmonary arteries. Point-of-care ultrasound (POCUS) showed non-compressible left femoral and popliteal veins with intraluminal thrombi. The right ventricle was not dilated. The patient was diagnosed with less severe pulmonary embolism and deep vein thrombosis and was given enoxaparin. Further examination revealed that the patient had a positive lupus anticoagulant test but negative anti-β2-glycoprotein I and anticardiolipin antibodies. The patient was admitted and discharged several days later without any complications.
This case exhibited a typical presentation of an acute PE. Hemoptysis is a well-known symptom of PE and is included in different diagnostic scores for PE. The initial chest x-ray presented a Hampton hump sign, which represented local lung infarction. Pulmonary emboli were presented on the CT angiography, and deep venous emboli were presented on the POCUS. The normal ECG, cardiac enzyme and heart echo suggested a less severe process.
On the other hand, the triggering factor, squatting, a well-known and universal exercise, was an unusual cause of deep vein thrombosis and pulmonary embolism. Yim ES et al. reported a similar case of lower extremity deep vein thrombosis following an intense calf workout of a high-performance athlete in 2012. We recommend being cautious when it comes to extensive exercise in patients who may have hypercoagulative conditions.
Chung-Shiung WEN (Taipei, Taiwan), Mon-Rou LEE, Hung TZU-YAO
00:00 - 00:00
#41321 - SREBF1 attenuates dendrite cells immune function in lipopolysaccharide induced sepsis.
SREBF1 attenuates dendrite cells immune function in lipopolysaccharide induced sepsis.
Background:
The master lipogenesis regulator sterol regulatory element-binding transcription factor 1 (SREBF1) has potential pro-inflammatory effects, but its role in the immune function of dendritic cells has not yet been elucidated. Herein, we showed that increased lipid droplet production and lipid-related protein expression in dendritic cells after LPS stimulation. The immune function of septic dendritic cells was improved after silencing SREBF1.
Methods:
Bone marrow-derived dendritic cells (BMDCs) were treated with lipopolysaccharide (LPS), and lipid droplet content was detected by BODIPY 493/503 staining. Western blotting was applied to detect protein expression. Inflammatory factor levels were measured by qPCR. Flow cytometry was used to detect co-stimulatory phenotype expression levels. Carboxyl fluorescein succinimidyl ester (CFSE) was used to stain CD4 T cell to detect the proliferative capacity. Data were expressed as the mean ± SD. T-test was used to compare to the means of two groups. One-way analysis of variance (ANOVA) was used to compare the means of multiple groups. *P < 0.05, **P < 0.01, ***P < 0.001, and P < 0.05 was considered statistically significant.
Results:
Lipid droplets were increased in LPS-induced DCs. The expression of SREBF1, which was responsible for the regulation of fatty acids, and its downstream molecules FASN, ACACA, SCD1 were also elevated. We applied siRNA to silence SREBF1 in DCs and Western blotting to detect its knockout level. Silencing of SREBF1 gene resulted in some restoration of inflammatory factors and maturation phenotypes in DCs. To assess the T cell proliferation, we co-cultured pretreated DCs with CD4 T cells. The results showed elevated T cell proliferative activity after silencing SREBF1.
Discussion:
1. LPS induced the accumulation of lipid droplets and increased the protein expression levels of lipid-related proteins.
2. Silencing SREBF1 may improve the immune function of DCs under LPS stimulation.
Yaolu ZHANG (wenzhou, China, China)
00:00 - 00:00
#41891 - Steps for resilient society: Disasters & Animals.
Steps for resilient society: Disasters & Animals.
Steps for resilient society: Disasters & Animals
Disasters can be devastating not only for people but also for animals. Being prepared is vital for both people and animals to survive disasters. Most of the disaster preparedness plans do not include animals. Including animals in disaster preparedness plans is crucial for a resilient society. This poster is to attract all disaster management experts attention.
Important Issues That Affect Animals in Disasters:
Animal Injury and Illness:
Disasters can cause injury, illness, or even death to animals. It's important to have resources like emergency veterinary care and first aid kits on hand.
Loss and Displacement:
Disasters can cause animals to be separated from their homes. This can be quite stressful for both the animals and the people looking for them. It helps to keep identification information, such as microchips and ID tags, up to date and to create an emergency plan for your animals.
Shelter and Food:
Disasters can cause animals to lose their access to shelter and food sources. Therefore, it is important to provide emergency shelter and food.
Animal Health and Safety:
During disasters, the risk of animal diseases and zoonotic diseases (diseases that can be transmitted from animals to humans) increases. Therefore, it is important to make sure animals' vaccinations are up to date.
Psychological Impact:
Disasters can be traumatic that can cause stress and anxiety for animals. This needs to be kept in mind and plans before disasters is mandatory.
Protecting Animals in Disasters:
- Create an emergency plan. This plan should include important information such as emergency shelter and food, first aid kits, and identification information.
- Microchip tag your animals and keep identification information up to date.
- Make sure your animals' vaccinations are up to date.
- Identify resources for emergency veterinary care and first aid kits.
- Have an emergency shelter and food supply for your pets.
- Have resources to help your animals cope with stress and anxiety.
- Being planned and prepared in disasters can help keep both people and animals safe.
Benefits of Including Animals in Disaster Plans:
i) Reduces the Risk of Injury and Death to Animals: A disaster plan can reduce these risks by ensuring animals receive emergency shelter, food, and medical care.
ii) Reduces Loss and Displacement: A disaster plan can reduce the incidence of loss and displacement by keeping animals' identification information, such as microchips or identification tags, up to date and identifying ways to track them.
iii) A disaster plan can help reduce stress and anxiety levels by meeting animals' basic needs, such as shelter, food, and being with loved ones.
iv) Makes Society More Resilient: Including animals in disaster plans makes society more resilient by helping both people and animals recover from disasters faster and easier.
Ulkumen RODOPLU (Izmir, Turkey), Diana SILVA
00:00 - 00:00
#42041 - Steps for resilient society: Disasters & Autistic Individuals.
Steps for resilient society: Disasters & Autistic Individuals.
Disasters are challenging and traumatic for everyone, but for autistic individuals, these challenges can be greater. Autistic individuals may be more sensitive to sensory stimuli, causing them to become overwhelmed in an environment full of chaos and noise. Additionally, communication and socialization difficulties can make it difficult for them to get help or connect with loved ones during a disaster.
The purpose of this poster is to ensure that Autistic people and their families are protected from being a disadvantaged group in disaster preparedness and resilient society studies, and to increase the knowledge and attention of those working in disasters on this issue.
Some specific challenges that autistic individuals may face in disasters:
Sensory difficulties: Disasters are often associated with intense sensory stimuli such as loud noises, shaking, and bright lights. These stimuli can be very overwhelming for autistic individuals. This can lead to panic attacks, sleep disorders and other behavioral problems.
Communication difficulties: Autistic individuals may have difficulties in verbal and non-verbal communication. These difficulties can make it difficult for them to get help or express their needs during a disaster.
Social difficulties: Autistic individuals may have difficulty establishing relationships with other people. These challenges can make it difficult for them to find support or connect with new people during a disaster. They may also experience anxiety in crowds.
Changes in routine: Autistic individuals need routines and stability. Disasters can disrupt these routines, causing great stress and anxiety for autistic individuals.
Safety risks: During disasters, autistic individuals may be at risk of getting lost or injured. They may also have difficulty taking the necessary steps to protect themselves.
In disasters, it is important for officials to recognize autistic individuals and provide them with special support. Some common characteristics of autistic individuals:
-Avoiding eye contact
-Making repetitive movements or sounds.
-Having a limited range of languages.
-Difficulty understanding social cues.
-Hypersensitivity or insensitivity to sensory stimuli.
-Need for routines and stability.
Some behaviors shown by autistic individuals during disasters:
-Confusion.
-Anxiety.
-Agitation.
-Shutdown or self-isolation.
-Risk of loss.
-Difficulty protecting oneself.
Tips that can help officers identify autistic individuals during disasters:
-Look for an identification bracelet or card: Many autistic individuals wear an identification bracelet or card that can identify them in emergency situations.
-Be patient and understanding: Autistic individuals may have difficulty communicating or following instructions in stressful situations. Speak calmly and avoid eye contact.
-Consider sensory needs: Individuals with autism may be sensitive to loud noises, bright lights, or crowded environments.
-Use pictures or simple language: Instead of giving complex instructions, try communicating using pictures or gestures.
-Help establish routines: If possible, help autistic individuals maintain some elements of their daily routine.
-Get expert support if necessary: There are many organizations that offer psychological and social support to disaster victims. There may also be organizations that provide special services for autistic individuals.
Recognizing autistic individuals during disasters and providing them with special support can help them be less affected and recover faster during these difficult times.
Diana SILVA, Mariana HELOU, Ulkumen RODOPLU (Izmir, Turkey)
00:00 - 00:00
#40782 - Sternal haematoma infusion catheter: A novel technique for pain management in manubriosternal fractures in the emergency department.
Sternal haematoma infusion catheter: A novel technique for pain management in manubriosternal fractures in the emergency department.
Sternal fractures are associated with significant morbidity and mortality with some patients requiring admission for pain management, often through systemic analgesia, which may be ineffective. Regional anaesthetic techniques are more challenging for sternal fractures than in rib fractures and require experienced clinicians. Regional anaesthesia for pain management of manubrium sternum can be challenging due to its nerve supply and limited access to the first intercostal space. Local anaesthetic techniques are becoming recognised as a modality to improve pain control, and to reduce complications from opioid use, especially in the elderly.
We describe a case of a 70 year old female who sustained manubrium sternum fracture, rib fractures along with limb fractures. Her pain due to her sternum was not under control despite systemic analgesia and opioids and she was deteriorating with increasing oxygen demand. We delivered local anaesthetic haematoma infusion through an epidural catheter which relieved her pain. This technique enabled an improvement in pain scores, better engagement with physiotherapy, and reduced opioid use. She was discharged home after two months from the hospital. Local anaesthesia has been used previously to manage pain after coronary artery bypass graft surgery. Our experience demonstrated the safety, efficacy and tolerability of this approach to sternal fractures.
Salman NAEEM (Maidstone, ), Kyle FROWDE, Amir ALZARRAD, Donia ABDEL AZIZ
00:00 - 00:00
#41186 - Strengthening CBRN Emergency Capabilities: A Systematic Review Exploration of Health Sector Preparedness and Response Strategies.
Strengthening CBRN Emergency Capabilities: A Systematic Review Exploration of Health Sector Preparedness and Response Strategies.
Introduction
The evolving threats of the 21st century have led to an escalation in chemical, biological, radiological, and nuclear (CBRN) incidents, posing severe challenges to global health security. These natural, accidental, or deliberate events have far-reaching consequences that transcend geographical boundaries, necessitating robust preparedness and response mechanisms within the healthcare sector. This systematic review (SR) aims to synthesise the existing literature on strategies for enhancing the readiness and resilience of healthcare systems in managing CBRN emergencies.
Methods
This systematic review study adhered to the Preferred Reporting Items for guidelines and was registered in the International Prospective Register of Systematic Reviews registry under reference number CRD42022372815. A comprehensive literature search was conducted across multiple databases, including PubMed, Embase, and ScienceDirect, to identify relevant studies published until November 2022. Eligibility criteria included original qualitative and quantitative studies, commentaries, editorials, and case reports addressing healthcare system preparedness strategies for deliberate, accidental, and natural CBRN incidents. Two independent reviewers performed the study selection, data extraction, and quality assessment processes. A third reviewer interfered in case of disagreement. Al-Rayyan® software for SR was also utilised. Further, a thematic analysis was employed to synthesise the extracted data and identify recurring themes and strategies using Nvivo12® software.
Results
The SR identified 63 articles, including various study types, focusing on expert opinions and analytical studies. The analysis revealed ten key strategies for enhancing healthcare sector preparedness and response to CBRN emergencies: 1) Establishing a globally accepted definition of bioterrorism to foster international collaboration and align efforts. 2) Implement hospital-level initiatives to strengthen the psychological resilience of healthcare workers. 3) Engaging communities in preparedness efforts to build societal resilience and improve tactical responses. 4) Addressing geographical variability in response and preparedness through harmonised global approaches and knowledge-sharing. 5) Emphasising specialised training, including simulation-based exercises and blended learning methodologies. 6) Recognising bioterrorism as a persistent global threat and prioritising preparedness strategies accordingly. 7) Enhancing infrastructure and operational readiness for hazardous materials and CBRN incidents through integrated response plans and specialised expertise. 8) Promoting continuous research, capacity-building, and knowledge dissemination to develop innovative detection technologies and enhance response strategies. 9) Strengthening epidemic management and resilience through proactive measures, robust healthcare infrastructure, and adaptable response mechanisms. 10) Addressing radiological and nuclear threats through staff training, effective communication strategies, and coordinated response mechanisms.
Conclusion
This SR highlighted the complicated nature of CBRN emergencies and the need for coordinated preparedness and response strategies within the healthcare sector. The SR also highlighted the criticality of establishing a globally harmonised approach, fostering international collaboration, and prioritising specialised training, community engagement, and continuous research. The findings emphasise the importance of addressing geographical disparities, enhancing infrastructure readiness, and promoting responsible integration of emerging technologies in healthcare. Ultimately, this review contributes to the ongoing discourse on global health security, offering insights for policymakers, healthcare practitioners, and researchers to enhance the global health sector’s capacity to respond effectively to CBRN emergencies.
This study was registered in the International Prospective Register of Systematic Reviews registry under reference number CRD42022372815.
Hassan FARHAT, Guillaume ALINIER, Dr Mariana HELOU (Lebanon, Lebanon), James LAUGHTON, Walid ABOUJALALA, Mohamed BEN DHIAB
00:00 - 00:00
#40962 - STROKE AI-BASED DETECTION IN EMERGENCIES: DEVELOPING A VIRTUAL ASSISTANT BASED ON AI TOOLS FOR ACUTE STROKE (SAID-E).
STROKE AI-BASED DETECTION IN EMERGENCIES: DEVELOPING A VIRTUAL ASSISTANT BASED ON AI TOOLS FOR ACUTE STROKE (SAID-E).
Background and aims: In medical AI, stroke diagnosis and management are increasingly important. Quick and accurate diagnosis is key to effective treatment. Stroke care demands a coordinated, protocol-driven process from a skilled multidisciplinary team. Patient care is routed through HUB and SPOKE centers within a structured network, determined by case complexity and treatment needs. The emergency physician is crucial in initial stroke management, working with neurologists to follow established diagnostic and treatment pathways. This study aims to create a Virtual Assistant (VA) with software capable of recognizing ischemic stroke patients. The VA will undergo a learning process based on data collection and analysis to improve its accuracy in stroke patients in the emergency setting.
Methods: A prospective, longitudinal, interventional, non-profit, single-center study will be conducted. The study will last from 01/02/24 to 28/02/2025 and consists of five phases, from creating VA to validating SPOKE centers. Patient recruitment will span 12 months, beginning 01/03/2024, and will include consecutive patients presenting to the Emergency Department of the Perugia Hospital with suspected ischemic stroke. The VA utilizes advanced deep learning techniques through Tensorflow to analyze stroke-related symptoms specifically. It employs convolutional neural networks for detecting changes in facial symmetry and vocal patterns indicative of stroke events, enhancing classification accuracy with metadata.
Conclusions: The VA may be a new tool to support emergency physicians in recognizing and treating stroke more swiftly, improving patient outcomes.
Alessandro BUFI (Perugia, Italy), Valeria CASO
00:00 - 00:00
#42012 - Stroke caused by Basilar Artery Dolichoectasia.
Stroke caused by Basilar Artery Dolichoectasia.
Dolichoectasia, or the elongation, expansion, and bending of the basilar artery
As defined, it is. (1) Its effect frequently manifests as cerebral ischemia, hemorrhage, or mass compression symptoms in symptomatic situations. Additionally, developing trigeminal neuralgia is observed infrequently, at least as a result of fifth cranial nerve compression (2). Here
46-year-old left pontine with a complaint of left-sided weakness and a half-ischemic infarct region a patient who is female is shown.
46-year-old female patient was brought to our emergency service, weakness on the right side, speech emergency with complaints of facial disorder and facial asymmetry.She has a history of Diabetes, Hypertension and basilar artery dolichoectasia and there was a dissection flap in the dolichoectatic area.
On neurological examination, he was conscious, cooperative and Cognitive functions of the patient with full oriented. Cranial nerve examination was normal right lower and upper extremity muscle strength on examination was 4/5. DTRs are normoactive, on sensory examination no defect detected. Cerebellar tests were skillful.Plantar skin reflex right apathetic, left flexor. In laboratory examinations, LDL is 75 mg/dl (N 0-100 mg/dl), HBA1c 7% (N <6%).
In diffusion MRI imaging, the pontine midline acute diffusion in subcentimetric size on the left limitation was observed. (Picture 1)
CT angiography examination, left dolichoectatic course in the vertebral artery V4 segment shows. Basilar artery calibration evident increased and reaches up to 10 mm in diameter and dolichoectasia was observed. (Picture 2)
CT-MRI- cranial imaging:In addition to the right vertebral artery in the examinations, ıt has a dolichoectatic appearance with significant tortuosity and basilar artery appears ectatic, bulbus is on the right half, cerebellum inferior to the right half and pons middle A compression effect on the left half was observed in the cut. (Picture 3)
Vertebrobasilar dolichoectasia(VBD), vertebrobasilar marked dilation and elongation of the arteries and It is a rare disease characterized by tortuosity.Its etiology is primarily due to hypertension.Our patient had been smoking for many years and had hypertension.In a study conducted by Chen et al., patients with VBD risk of recurrence in patients with ischemic stroke They researched. During follow-up, 22 (19.1%) patients It was found that there was a recurrence of ischemic stroke.
In summary, individuals with VBD who have an ischemic stroke may be more susceptible to a recurrence. Diffuse intracranial dolichoectasia recurrence or basilar artery diameter may make comorbid diseases more likely.
It has also been demonstrated to raise the likelihood of recurrence. Consequently, give the patient regular antiplatelet and anticoagulant drugs.
In addition to its application, blood pressure control, avoiding hypertension, frequent exercise, and a balanced diet are advised.
Yaren AGAR, Kadir YENAL (Yenimahalle, Turkey), Ibrahim DILEKCAN
00:00 - 00:00
#42005 - Stroke caused by Basilar Artery Dolichoectasia.
Stroke caused by Basilar Artery Dolichoectasia.
Dolichoectasia, or the elongation, expansion, and bending of the basilar artery
As defined, it is. (1) Its effect frequently manifests as cerebral ischemia, hemorrhage, or mass compression symptoms in symptomatic situations. Additionally, developing trigeminal neuralgia is observed infrequently, at least as a result of fifth cranial nerve compression (2). Here
46-year-old left pontine with a complaint of left-sided weakness and a half-ischemic infarct region a patient who is female is shown.
46-year-old female patient was brought to our emergency service, weakness on the right side, speech emergency with complaints of facial disorder and facial asymmetry.She has a history of Diabetes, Hypertension and basilar artery dolichoectasia and there was a dissection flap in the dolichoectatic area.
On neurological examination, he was conscious, cooperative and Cognitive functions of the patient with full oriented. Cranial nerve examination was normal right lower and upper extremity muscle strength on examination was 4/5. DTRs are normoactive, on sensory examination no defect detected. Cerebellar tests were skillful.Plantar skin reflex right apathetic, left flexor. In laboratory examinations, LDL is 75 mg/dl (N 0-100 mg/dl), HBA1c 7% (N <6%).
In diffusion MRI imaging, the pontine midline acute diffusion in subcentimetric size on the left limitation was observed. (Picture 1)
CT angiography examination, left dolichoectatic course in the vertebral artery V4 segment shows. Basilar artery calibration evident increased and reaches up to 10 mm in diameter and dolichoectasia was observed. (Picture 2)
CT-MRI- cranial imaging:In addition to the right vertebral artery in the examinations, ıt has a dolichoectatic appearance with significant tortuosity and basilar artery appears ectatic, bulbus is on the right half, cerebellum inferior to the right half and pons middle A compression effect on the left half was observed in the cut. (Picture 3)
Vertebrobasilar dolichoectasia(VBD), vertebrobasilar marked dilation and elongation of the arteries and It is a rare disease characterized by tortuosity.Its etiology is primarily due to hypertension.Our patient had been smoking for many years and had hypertension.In a study conducted by Chen et al., patients with VBD risk of recurrence in patients with ischemic stroke They researched. During follow-up, 22 (19.1%) patients It was found that there was a recurrence of ischemic stroke.
In summary, individuals with VBD who have an ischemic stroke may be more susceptible to a recurrence. Diffuse intracranial dolichoectasia recurrence or basilar artery diameter may make comorbid diseases more likely.
It has also been demonstrated to raise the likelihood of recurrence. Consequently, give the patient regular antiplatelet and anticoagulant drugs.
In addition to its application, blood pressure control, avoiding hypertension, frequent exercise, and a balanced diet are advised.
Yaren AGAR, Kadir YENAL (Yenimahalle, Turkey), Ibrahim DILEKCAN
00:00 - 00:00
#42377 - Stroke in the emergency department: is there Difference between young and older adults?
Stroke in the emergency department: is there Difference between young and older adults?
Introduction:
Acute stroke is a public health scourge. It is a pathology that usually occurs in elderly people, but it is in a progressive increase among the young population.
Objective:
The aim of our work is to Study the epidemiological and clinical differences between two age groups; subjects aged less than 65 years and subjects aged over 65 years.
Method:
It is retrospective study conducted over a year in a regional emergency department . We included adult patients presenting with systematized neurological signs of sudden onset suggestive of stroke, those patients were then divided into two groups based on the age range.
Epidemiological and clinical differences were highlighted.
Results:
Eighty-three patients were included in the study with a mean age of 66 ±12 years, a minimum of 32 and a maximum of 92. The gender ratio was of 0,88.
Our study showed significant differences between older and young people in the following items:
* A Consultation time less than 60 minutes from the symptoms’ onset: p=0.049
*A history of diabetes: p=0.041
*The practice of CT scan in the emergency department: p=0.02
However, there were no significant differences in the other items in matter of past history, clinical presentation, ward orientation neither in prognosis.
No significant difference was observed between age and the nature of stroke weather it is an ischemic stroke or a haemorrhagic stroke (p=0.137).
There was also no significant difference in death rates among the two age groups (p=0.45).
Conclusion:
Our study showed no remarkable difference between young and older adults presenting to emergency department with stroke, this should conduct to the implementation of effective means to control risk factors regardless of age range.
aucun conflit d'interet
Khedija ZAOUCHE, Manel KALLEL (Tunis, Tunisia), Ibtissem BEN TAHER, Emna REZGUI, Sonia AISSA, Ramla BACCOUCHE
00:00 - 00:00
#41888 - Study protocol: early detection of delirium in the emergency department.
Study protocol: early detection of delirium in the emergency department.
Introduction: demographic changes associated with the growing number of people over 65 years of age have created the need to prepare health systems to care for this population, which is more vulnerable than the general population, with a higher degree of comorbidity, polypharmacy and frailty. Delirium is one of the most common complications in patients who attend the Emergency Department. Therefore, the detection, prevention and treatment of delirium in emergency departments has become a research objective.
Objective: to determine whether screening performed in emergency department triage using the 4AT scale allows for an early diagnosis of delirium and the possible avoidance of prolonged hospital stays.
Methodology: prospective cohort study during June 1, 2024 and May 31, 2025. In addition, a case-control study will be carried out nested in the cohort, which will be carried out on patients treated at the La Ribera University Hospital in the period between on January 1, 2023 and December 31, 2023. The target population will consist of all patients treated in emergency services over 65 years of age. The study variables will be: sociodemographic variables, the emergency episode, risk factors specific to the emergency department, the hospital stay, blood and urine samples, and risk factors for delirium.
Results: once the studied variables have been analyzed, the incidence of delirium will be quantified after the medical diagnosis at discharge from the emergency department. We will analyze whether the use of the 4AT scale in triage allows us to identify delirium early. We will observe the severity, chronicity, length of hospital stay, cerebral oximetry records and mortality in subjects admitted to hospitalization after discharge from the emergency department.
Conclusions: given the diagnostic accuracy of the 4AT scale to detect delirium in older patients, the implementation of its use in emergency department triage for the accurate, efficient and non-invasive detection of delirium could be promoted
Trial Registration: no appropriate register,
Funding: his study did not receive any specific funding
Ethical approval and informed consent: Not needed.
Immaculada TORMOS-MIÑANA (VALENCIA, Spain), Àngela SOLER-SANCHIS, Pilar PÉREZ-ROS, Francisco Miguel MARTÍNEZ-ARNAU, Begoña DE ROCHINA-RODRÍGUEZ, María CUENCA-TORRES
00:00 - 00:00
#42038 - Subcutaneous Emphysema Following Laser Assisted Dilation of Subglottic Stenosis.
Subcutaneous Emphysema Following Laser Assisted Dilation of Subglottic Stenosis.
ABSTRACT
Introduction: Subcutaneous emphysema is characterized by the accumulation of air beneath the dermal layers of the skin. We present a case of extensive
subcutaneous emphysema of the neck, face and arms in a patient who was two days post operative from laser assisted dilation of subglottic stenosis.
Case Presentation: A 71-year-old man with history of tracheal stenosis status post laser assisted subglottic dilation presented to the emergency department
two days post-operatively for progressively worsening swelling of the face, neck and arms. Physical exam was notable for crepitus of the face, neck and arms.
Oropharyngeal exam showed no edema to the posterior oropharynx or tongue. Breathing was non-labored without stridor. Imaging revealed extensive
subcutaneous emphysema without any obvious source. The otolaryngology (ENT) service evaluated the patient and admitted him to their service. Initially
he was managed conservatively via observation and supportive care however, on day two of hospitalization his respiratory status worsened. He required
intubation and tracheal stent placement. The tracheal defect was never found on exploration in the operating room, suggesting the defect was sub-centimeter
in size. He was extubated on hospital day four and discharged with a plan to have the tracheal stent in place for three months.
Conclusion: Subcutaneous emphysema secondary to a tracheobronchial tree defect is a known complication of laser dilatation of subglottic stenosis. Most
cases resolve spontaneously and can be managed conservatively. However, patients require close airway monitoring as some may require emergent airway
management. Clinicians should be aware of this complication and subsequent management.
Andrej URUMOV (Phoenix, AZ, USA, USA), Wayne MARTINI, Shari BRAND, Marcella TORRES, Douglas RAPPAPORT, Edmundo CHANTLER
00:00 - 00:00
#41768 - Subtalar Dislocations Demystified: A Case Report on Rapid Recognition and Effective Reduction.
Subtalar Dislocations Demystified: A Case Report on Rapid Recognition and Effective Reduction.
Background and Objective: Subtalar dislocations are exceedingly rare, accounting for less than 1% of all dislocations. Swift diagnosis and immediate reduction are crucial to preventing complications. This report presents a subtalar dislocation in a 23-year-old male, emphasizing the necessity of high suspicion and rapid management to avoid adverse outcomes.
Case Presentation: A 23-year-old male presented to the emergency department with a twisted right ankle after tripping on uneven ground. Physical examination revealed a deformed right foot with a lateral malleolus bruise, but no open wounds were noted, and neurovascular function remained intact. Initial X-rays confirmed a right talonavicular dislocation. Prompt reduction was performed under procedural sedation, followed by the application of a backslab for stabilization. A post-reduction CT scan identified a small avulsion fracture of the posterior malleolus and a small undisplaced cuboid fracture. Collaboration with the orthopedic team ensured that the reduction was stable, and the patient was admitted for observation. After one day, the patient was discharged with a physiotherapy referral for rehabilitation.
Discussion: Despite their rarity, subtalar dislocations require high clinical suspicion for timely diagnosis, as swift reduction prevents further complications. Imaging with X-rays and CT scans plays a crucial role in identifying associated fractures and ensuring reduction stability. Coordinating with orthopedic and physiotherapy teams enables comprehensive care and supports functional recovery.
Conclusion: Subtalar dislocations require immediate recognition and treatment by emergency physicians to minimize complications. Rapid imaging and prompt reduction under sedation are vital for effective treatment. Multidisciplinary collaboration ensures comprehensive management and optimal patient outcomes. Emergency physicians should remain vigilant for these uncommon injuries and act swiftly to provide high-quality care.
Kanu PRIYA (Birmingham UK, ), Ahmed ADNAN
00:00 - 00:00
#42316 - Sudden asphyxis asthma : a case report.
Sudden asphyxis asthma : a case report.
Introduction :The risk factors for severe acute asthma should be identified as soon as the patient is admitted to the emergency room. Alongside these risk factors, other situations are involved . Exposure to a triggering factor is obviously likely to induce an exacerbation, possibly serious.
Observation :
A 38-year-old patient with a history of asthma since young age, not followed up, withoutno asthma exacerbations during 10 years. She was brought to the emergency room of a district hospital for dyspnea of sudden onset and evolving 3 hours before admission. The initial examination found a patient in acute respiratory distress with polypnea at 36 cpm, SpO2 desaturation at 69% in ambient air and marked signs of respiratory struggle and wheezing. The cardiovascular examination showed a SBP of 150 mmHg and a DBP of 100 mmHg with a heart rate of 100 bpm. The diagnosis of a severe acute asthma attack was made. The initial therapeutic approach was oxygen therapy with face mask, nebulization of Salbutamol and Ipratropium Bromide continuously with 3 series of nebulization in the first hour. The patient received intravenous corticosteroid therapy with hydrocortisone hemisuccinate and a slow intravenous infusion of magnesium sulfate. The SMUR team was contacted to manage this serious acute asthma attack. When the team arrived, the clinical examination found upper airways at risk with polypnea at 35 cpm and marked signs of respiratory struggle. The SpO2 was at 87% under a face mask with an oxygen flow of 8L/min. On pulmonary auscultation, there were diffuse wheezing rales in both lung fields. Hemodynamically, the SBP is 152mmHg and the DBP is 74mmHg, with a tachycardia at 120 bpm. The neurological examination found a GCS of 8/15 with agitation and pupils in an intermediate reflective position, the blood sugar level on the fingertip was 1g/l. Faced with neurological and respiratory distress, the decision was to intubate the patient. Pre-oxygenation with the ambu was carried out, then orotracheal Intubation was performed after induction in rapid sequence. The patient was then sedated and transferred to intensive care unit. Faced with the persistence of bronchospasm, salbutamol was administered intraveinously and the patient was curarized. The evolution was favorable and the patient was extubated after 48 hours.
Conclusion: Sudden asphyxic asthma is very serious acute asthma occurring explosively.Early and adequate management of severe acute asthma is essential. This group was characterized by a rapidly favorable evolution with a duration of mechanical ventilation significantly shorter than patients ventilated for severe acute asthma. Therapeutic education as well as control of asthma are crucial.
Sirine KHABOUCHI, Khaireddine JEMAI (Tunis, Tunisia)
00:00 - 00:00
#41147 - Sufentanil for pain management in the pre-hospital emergency setting: an observational study Trentino, Italy.
Sufentanil for pain management in the pre-hospital emergency setting: an observational study Trentino, Italy.
Background:
The Trentino region is located within the Italian Alps, with approximately 600,000 residents, and seasonal variations up to threefold due to tourists mainly attracted by Trentino’s predisposition to extreme sports. Recreational skiing, freeskiing, mountaineering, paragliding, and water sports significantly increase the chances of trauma. Trentino's emergency medical service (EMS) dispatch center manages about 17,000 trauma calls annually. After-trauma pain is the most encountered symptom, which is often treated in harsh environmental conditions. Pain is currently considered a vital parameter whose evaluation and treatment are mainstays in prehospital trauma management. Among analgesics, sufentanil demonstrated a good profile, and its sublingual formulation makes it readily available without obtaining peripheral venous access and suitable for austere environments.
With this study, we evaluated the use of sufentanil after its introduction on all EMS vehicles, primarily to evaluate its effectiveness as a first-line analgesic, and secondarily to explore adherence to the established pre-hospital pain treatment protocol.
Material and Methods:
After a brief online training delivered to the personnel at the end of 2023, two tablets of sufentanil (30 mcg) were implemented to the drugs available to nurses and doctors on duty, starting from January 2024. This study retrospectively tracked and included patients aged ≥18 with one tablet of sublingual sufentanil administered as the first drug to treat pain between January 01 and April 10, 2024. Other data included the Numerical Rating Scale (NRS) at presentation, location, type of underlying event (illness or trauma), and any other drug administered after sufentanil as rescue doses. NRS after treatment was inconsistently reported; instead, “no need for further pain medications” after analgesic administration was selected as a surrogate endpoint and qualitatively interpreted as a successfully treated pain.
Results:
A total of 113 cases were included. A single dose of sufentanil successfully treated pain in 78.8% (89 patients). In the remaining 21.2%, a rescue dose with opioids (15; 13.3%), ketamine (5; 4.3%), paracetamol (2; 1.8%), or multiple associations (2; 1.8%) was needed to achieve the qualitative endpoint.
In 77% (87) of cases, sufentanil was administered to patients with an NRS ≥ 6, complying with the institution’s standard operating procedures.
Sublingual sufentanil was mostly used (75; 66,4%) in impervious and mountain terrains and predominantly (104; 92%) in trauma patients.
Conclusion and discussion:
Sublingual sufentanil seems to work well in resource-limited and harsh environments to treat moderate to severe pain in trauma patients. Only one-fifth of patients required rescue doses of painkillers, thus suggesting a good profile as a first-line drug to achieve pain control without the need to place peripheral venous accesses in such difficult terrains. In about one-quarter of patients, sufentanil was administered despite a NRS < 6, probably because of its practicality, but the exact reasons are not known and should be further investigated prospectively. The study confirms the established protocols for prehospital treatment of pain can be continued without major modifications. Also, the stratification of patients by adding an after-treatment NRS could add other insight and refine the protocol.
Enrico SCABARDI, Enrico SCABARDI (Trento, Italy), Stefania ARMANI, Andrea VENTURA, Matteo PAGANINI
00:00 - 00:00
#41650 - Suicidal attempt with sitagliptin and metformin overdose leading to severe metabolic acidosis: A case report.
Suicidal attempt with sitagliptin and metformin overdose leading to severe metabolic acidosis: A case report.
Introduction:
Sitagliptin and metformin are commonly used medications for managing type 2 diabetes mellitus (American Diabetes Association, 2022). Sitagliptin is a dipeptidyl peptidase-4 (DPP-4) inhibitor that increases insulin secretion and decreases glucagon levels, while metformin is a biguanide that reduces hepatic glucose production and improves insulin sensitivity. Overdose of these medications can lead to serious complications, including metabolic acidosis, hypoglycemia, and even death.
Background:
Metformin toxicity is characterized by the development of lactic acidosis, which is a rare but potentially life-threatening complication. Lactic acidosis occurs due to metformin-induced inhibition of mitochondrial respiratory chain complex I, leading to impaired lactate clearance. Patients with metformin toxicity typically present with nausea, vomiting, abdominal pain, hypotension, tachycardia, and altered mental status. Management includes aggressive fluid resuscitation, bicarbonate therapy to correct acidosis, and in severe cases, extracorporeal treatments such as hemodialysis to enhance metformin clearance.
Case Presentation:
A 21-year-old female with an unknown past medical illness, presented to the Emergency Department (ED) three hours after ingesting 60 tablets of Janumet 50/1000 mg (sitagliptin 50 mg and metformin 1000 mg) in a suicidal attempt. On presentation, she was tachycardic with a heart rate of 120 beats per minute, hypotensive with a blood pressure of 90/60 mmHg, and tachypneic with a respiratory rate of 28 breaths per minute. She was also diaphoretic and complained of nausea, vomiting, dizziness, and epigastric pain.
Initial laboratory tests revealed a venous blood gas (VBG) pH 7.1 and lactate of 4.6 mmol/L. The patient was started on IV fluids, but her condition continued to deteriorate, with a repeat VBG after one hour showing severe metabolic acidosis with a pH of 6.8 and lactate of 27 mmol/L. Despite aggressive IV fluid resuscitation, the patient developed recurrent hypoglycemia.
The medical intensive care unit (MICU), nephrology, and toxicology teams were consulted. Hemodialysis was initiated, and the patient's acidosis gradually improved. She was admitted to the MICU for further management and was eventually transferred to the psychiatry team for evaluation and management of her underlying psychiatric issues.
Discussion:
This case highlights the potential complications of sitagliptin and metformin overdose, including severe metabolic acidosis and hypoglycemia. Metformin toxicity should be suspected in patients with a history of metformin ingestion who present with lactic acidosis, even if they are normoglycemic. Early recognition and prompt treatment, including IV fluid resuscitation, bicarbonate therapy, and hemodialysis, are essential for a favorable outcome in these patients.
Learning Points:
• Metformin toxicity can lead to severe metabolic acidosis and should be suspected in patients with a history of metformin ingestion who present with lactic acidosis, even if they are normoglycemic.
• Prompt recognition and management of metformin toxicity, including supportive care, IV fluid resuscitation, and bicarbonate therapy, are crucial for a favorable outcome.
• In severe cases of metformin toxicity, hemodialysis may be required to remove metformin and correct acidosis.
Conclusion:
This case highlights the importance of considering metformin toxicity in patients presenting with lactic acidosis and the need for early recognition and management to prevent serious complications.
Shumaila Muhammad HANIF (Doha, Qatar), Amjad Ali GAUHER
00:00 - 00:00
#41903 - Suicide attempts of toxic origin in the emergency department : experience of a tunisian regional hospital.
Suicide attempts of toxic origin in the emergency department : experience of a tunisian regional hospital.
Introduction :
According to the WHO, suicide is the second leading cause of death among young people. In the Tunisian context, recent data has shown an amplification of the suicide phenomenon, especially since the 2011 revolution.
The objective of our work was to study the sociodemographic and epidemiological profile of suicide attempts of toxic origin consulting the emergency room of a tunisian hospital.
Methods :
This is a prospective observational longitudinal study which took place in the emergency department of the Béja regional hospital over a period of 12 months (from August 2022 to August 2023) including suicides aged 15 years old and more.
Results :
We included 55 patients with a mean age of 28±12 years with extremes ranging between 15 and 63 years. the highest incidence is that of 15 to 25 year olds (52.72%). A female predominance was noted with a sex ratio of 0.57. Fifty-eight percent of suicides reside in an urban environment and 80% come from their homes on their own (69%).
The socio-economic profile of the families of suicides was described as low or unfavorable in 12.8% of cases respectively, single status was predominant (76.4%) with a majority of primary and secondary education levels in 29.10% and 61.80% respectively.
The psychiatric history was the most common (47.3%). The recurrence of the suicide attempt was marked in 70.9% of patients. Among the reasons cited for resorting to a suicide attempt, family conflict (40%) and psychiatric disorders (22%) were noted.
Voluntary intoxication was caused by medication in 71.15% of cases. The average consultation time was 2.8 hours. Thirteen patients (23.63%) were in coma. Therapeutic management was symptomatic and specific.
The evolution of our suicides was marked by the occurrence of complications in 14.54% of cases and the death of a suicide following poisoning by aluminum phosphoride. After 3 month, only ten suicides were followed by a psychiatrist and 2 patient had suicide.
Conclusion :
It is necessary to strengthen studies on the risk factors of suicide attempts through multicenter, national, prospective and follow-up studies for suicides and to develop prevention strategies.
Amina JEBALI, Hanene MOUSSI (Tunis, Tunisia), Hend BEN KHALIFA, Soumaya BADRI, May ZNATI
00:00 - 00:00
#41824 - Survey assessing the agreement on the standard of new digital referrals to a children’s emergency department by primary care and emergency care physicians: a difference of opinion.
Survey assessing the agreement on the standard of new digital referrals to a children’s emergency department by primary care and emergency care physicians: a difference of opinion.
Background:
Globally, digital systems are increasingly integrated into the way we care for patients. In 2022 the UK government recommended that all trusts should have electronic health records (EHRs) by 2025. The Bristol Royal Hospital for Children recently adopted a new EHR. Previously referrals had only been possible by telelphone and not accurately recorded. The new system allowed digital processing of referrals sent to the Children’s Emergency department (CED) from community clinicians. Referrals were assessed by CED consultants and community General Practitioners (GPs) to understand the standard of referrals received.
Methods:
Referrals from the EHR were reviewed by CED consultants and GPs. Reviewers were asked to rate the standard of referrals on a visual analogue scale and provided with a free text box for further comments. The same referral was reviewed by two GP and two CED reviewers who were blinded to other responses. The visual analogue scale responses were converted to a 1-5 ordinal scale and statistically analysed to identify the level of agreement between reviewers using a weighted Cohen’s kappa. Comparisons were made of inter-rater agreement between all reviewers and results interpreted using the Landis and Koch guideline. This states that the closer the kappa value gets to 1, the better the agreement and <0.0 is poor agreement. The comments sections were analysed to identify common themes.
Results:
120 referrals were reviewed by consultants from the CED team with 240 total responses. 40 were reviewed by two GPs with 37 total responses. There was “poor” agreement between CED and community reviews (Kappa –0.2 to –0.006 with a Standard Error (SE) 0.10-0.24) on the standard of referral to CED. There was “slight” agreement on the standard between professionals from the same speciality (CED-CED Kappa =0.159 SE 0.15, Community-Community Kappa = 0.271 SE 0.23).
CED reviewers commented on a lack of a clear question or concern for CED to address. Other comments expressed opinions that the concern from the community team would be better managed by a direct conversation with an inpatient specialty team.
Discussion/Conclusion
Limitations in numbers of reviewers meant the statistics contain large standard errors but there was “poor” agreement between CED and community reviewers on the standard of referrals to CED. It cannot be said why this disagreement exists as this was not investigated in this survey.
The results demonstrate a disconnect in perceived standard of referrals between CED and primary care clinicians. More work is needed to increase dialogue about what high standard of referral between these two specialities contains.
The digital referral form utilised was generic and built by the EHR supplier without local clinician input. This survey suggests the importance of building referral forms according to local demands to aid clear communication between CED and community teams. Furthermore, their digitisation has the potential to allow improvements in information governance and to gain insights into the patterns and reasons behind referrals. This is increasingly valuable during this period of ever-increasing demand on emergency services.
Michael CONNELLY (Bristol, ), Elizabeth LEDGER, Mark LYTTLE
00:00 - 00:00
#41528 - Survey of current state and response in crowd crush injury.
Survey of current state and response in crowd crush injury.
1. OBJECTIVE
The objective of this study is to identify the characteristics and appropriate response of the crowd crush disaster.
2. BACKGROUND
On October 29, 2022, a crowd gathered for a spontaneous Halloween event in the Itaewon area of Seoul, South Korea, where a crowd crush accident occurred. At least 158 people were killed and at least 196 people were injured. The victims were mostly young adults. The victims were mostly young adults. In this study, the authors tried to learn a lesson by investigating the worldwide crowd crush disaster and analyzing the differences and results.
3. METHOD
First, the current crowd crush disasters were investigated and summarized through literature and internet searches. Based on this, we secondarily conducted a survey of experts to derive the prevention, management, emergency medical response of crowd crush disasters and the research contents needed in the future.
4. RESULT
Our research shows that crowd crush disasters have occurred in both developed and developing countries since the 1800s. Common characteristics include high crowd density due to crowds being concentrated in a specific location, a crowd collapse occurring at a certain point after a sustained period of crowd movement, a narrow section of the crowd that becomes a bottleneck, or a large number of people suddenly converging in a certain space. The largest loss of life occurred in 2015 during the Hajj pilgrimage in Mecca, Saudi Arabia, but the events varied from concerts, sporting events to funerals. It is important for organizers to ensure that crowd density does not exceed certain limits, and that efforts are made to maintain order and prevent accidents. While it is important to adhere to the principles of disaster medicine, such as rapid and dispersed transportation, crowd management may be more important due to the difficulty of accessing patients during a crowd crush. In the future, crowd management guidelines and a real-time crowd density monitoring system using CCTV or drones can be established.
5. CONCLUSION
Crowd crush disasters can occur in any type of crowd gathering where crowd density increases, and should be prevented through crowd management and managed through real-time crowd density monitoring.
This work was supported by the National Research Foundation of Korea(NRF) grant funded by the Korea government(MSIT) (No. NRF-2023R1A2C1002938).
Soon-Joo WANG (Hwaseong city, Republic of Korea), Phil S YANG
00:00 - 00:00
#41850 - Sympathetic electrical storm caused by coronary spasm due to hypokalemia: a case report.
Sympathetic electrical storm caused by coronary spasm due to hypokalemia: a case report.
A 32-year-old male was admitted to the emergency department with acute symptoms of worsening substernal chest pain over the course of nearly 5 hours. He had been experiencing these symptoms intermittently since 3 days ago. In the afternoon of the day before this visit, he had similar chest pain and went to a nearby hospital. When he arrived at the hospital, the symptoms disappeared, and no detailed abnormalities were found in electrocardiogram and chest CT and then he went home. However, 5 hours later, the chest pain came back, he rushed to the emergency department of another nearby hospital, this time the ECG revealed sinus ST-segment elevation in the inferior wall leads (II, III, aVF). At the same time, he began to sweat profusely and felt an increase in precordial discomfort. After loaded with aspirin (300mg), ticagrelor (180 mg), and atorvastatin (20mg), the patient was emergently taken for coronary catheterization and developed ventricular fibrillation (VF). Cardiopulmonary resuscitation(CPR) was initiated and defibrillation with 200 joules was administered on the stretcher which was effective in returning the biphasic rhythm to sinus rhythm. Conorary angiography revealed normal right coronary aterty and other coronary vessels with the decreased ejection fraction (EF) of about 45%. Biochemical test results showed that the patient had severe hypokalemia with the blood potassium of 2.8mmol/L. At the same time myocardial injury markers showed increased troponin and CKMB, indicating that the patient had experienced acute myocardial infarction. In the CCU, the patient experienced recurrent syncope events and ECG monitoring revealed ventricular tachycardia and ventricular fibrillation, multiple electrical cardioversion and defibrillation were given. The patient's symptoms did not improve after administration of amiodarone, but ventricular arrhythmias occurred more frequently. Multiple ECG analyses found that each episode of ventricular tachycardia and or subsequent ventricular fibrillation were induced by an R-ON-T premature beat. Although the patient's basic heart rate was not so slow, fluctuating between 60-70 beats/min, however, the corrected QT(QTc) of patients was relatively long, around 460ms. Given the absence of obstructive lesions in the patient's right coronary artery, the elevation of the II III AVF was due to the presence of coronary spasm and the occurrence of acute myocardial infarction due to the longer duration of the spasm. To correct hypokalemia as soon as possible, the patient was given intravenous and oral potassium and magnesium supplementation. Despite the concern that the use of beta blockers might induce coronary spasm, we still cautiously administered esmolol intravenously and Alprazolam orally in view of the patient's recurrent sympathetic storms. We were pleased to note that no malignant arrhythmia events occurred and the patient's condition stabilized after the administration of the above drugs. Both troponin levels and ECGs normalized on hospital day 5 and the patient remained stable until discharge.
Zhao XIANGMEI (Zhengzhou, China), Qin LIJIE
00:00 - 00:00
#41628 - Syphilitic Aortic Aneurysm: An Unveiled Menace in Emergency Medicine.
Syphilitic Aortic Aneurysm: An Unveiled Menace in Emergency Medicine.
Syphilis resurgence presents a formidable challenge in emergency medicine, with its potential to manifest in diverse and deceptive ways. This abstract delves into the clinically relevant aspect of syphilitic aortic aneurysms, offering brief clinical insights, highlighting pertinent abnormalities, and elucidating its critical significance in emergency medicine practice and education. Through concise clinical vignettes, we outline the stealthy progression and diagnostic nuances of syphilitic aortic aneurysms, emphasizing key abnormalities such as thoracic aortic dilatation and associated cardiovascular complications. This presentation aims to underscore the urgent need for heightened awareness among emergency medicine practitioners regarding syphilis-related vascular sequelae, given their potentially catastrophic consequences if overlooked. By illuminating the link between syphilis and aortic pathology, this abstract serves as a pivotal educational resource, equipping emergency medicine professionals with the requisite knowledge to expedite accurate diagnosis and implement timely interventions, thereby safeguarding patient well-being and averting dire outcomes in the emergency setting.
Martina CERMAKOVA (Hradec Králové, Czech Republic)
00:00 - 00:00
#42064 - System for Anticipating and Forecasting Emergency Department Crowding (SAFED-C) Capacities Using Artificial Intelligence and Developing Interventions with Machine Learning Operations (MLOPs).
System for Anticipating and Forecasting Emergency Department Crowding (SAFED-C) Capacities Using Artificial Intelligence and Developing Interventions with Machine Learning Operations (MLOPs).
Aim: Pediatric Emergency Departments are critical medical units responding to unforeseen health conditions. Fluctuations in patient admissions directly affect the workload and management of these services. This study aims to predict patient admission numbers using artificial intelligence, intending to enhance service quality through the optimization of workload by forecasting unexpected patient volumes.
Material and Method: This study conducted a comprehensive analysis of the records from 321,672 patients who visited the Pediatric Emergency Department between 2018 and 2023. The research was retrospective and simulated within an MLOps architecture, with the assumption that new data were added to the existing dataset weekly. After processing the data, the most stationary time interval was identified as hourly aggregation, leading to an examination of data on an hourly basis. In this process, twenty different models were evaluated, and the N-HiTS, N-BEATS, TCN, and TiDE-RIN models were selected due to their superior performance. These models were retrained weekly with newly incoming data, and their performances were assessed using metrics such as R², SMAPE, RMSE, and MAE. The model with the highest R2 performance in a given week was selected for deployment. Forecasts were generated monthly based on the predictions from the higher-performing models, and physician shifts were optimized accordingly, taking into account patient admission trends.
Results:According to inferential analyses, statistically significant distinctions (p<0.001) were observed in the number of admissions based on historical periods, weather conditions, air pollution, age groups, and types of admissions. Throughout the simulation, it was observed that the median R2 score for all models (n=80) was 44 [IQR: -2.5 - 60]. During the prediction phase, the median R2 score for models selected based (n=20) on the highest R2 score monitoring was 63 [IQR: 58 - 69.5]. For the forecasting phase (n=20), the median R2 score of the selected models was 60 [IQR: 57 - 67.2]. The performance of these models over a five-month period, selected based on forecasting performance throughout the simulation and therefore representing a dynamic model choice, was superior to all other developed models, highlighting the value of continuous new model development (p<0.001). Based on these trends, physicians in emergency service shifts were assigned to groups of three, four, or five, according to the predicted workload.
Conclusions: In conclusion, this study demonstrates that advanced data analysis techniques, specifically artificial intelligence, can generate realistic dynamic weekly forecasts for pediatric emergency services. These forecasts have potential to optimize workforce distribution in managing overcrowding, thereby enhancing the quality of patient care.
Izzet Turkalp AKBASLI (, Turkey), Ahmet Ziya BIRBILEN, Ozlem TEKSAM
00:00 - 00:00
#41748 - Targeted treatment of recurrent ventricular fibrillation in patient with myocardial infarction after pre-hospital point-of-care arterial blood testing: case report.
Targeted treatment of recurrent ventricular fibrillation in patient with myocardial infarction after pre-hospital point-of-care arterial blood testing: case report.
Brief clinical history
A 48-year-old male patient with no relevant past medical history alerted emergency medical services because of severe chest pain for 30 minutes. At arrival of the ambulance team after 15 minutes, the patient presented alert, pale and sweating with ongoing complaints. Within two minutes, before a diagnostic ECG could be acquired, the patient went into ventricular fibrillation (VF). An immediate defibrillation was performed, restoring organised rhythm. In total, 13 shocks were necessary to treat recurrently occurring VF, without need for chest compressions as shocks delivered after witnessed recurrence of VF (up to three at a time, including vector change to anterior-posterior placement) were continuously successful in restoring an organised rhythm. The 12-lead ECG showed an atrial rate of 60/min with premature ventricular complexes (ventricular bigemini) resulting in a ventricular rate of 110/min. The ECG showed significant ST elevation in V1-V5 in physiological conduction, with excessive discordant ST elevation after premature ventricular complexes in LBBB configuration.
Misleading elements and helpful details
While repetitively delivering shocks, intravenous access was established, 300mg amiodarone, 250mg acetylsalicylic acid, 5000 IU heparin, 3mg midazolam and 0.1mg fentanyl were administered. An arterial line was established for continuous blood pressure measurement and point of care arterial blood (gas) testing, revealing mild hypokalemia (3.3 mmol/l) and lactatemia (4.01 mmol/l.) After intravenous application of magnesium and potassium (initially faster, then targeting 20 mmol/h) the ECG rhythm stabilised, and premature complexes disappeared. The patient was, except for short no-flow intervals lasting a few seconds until a shock was applied after VF recurrence, hemodynamically stable, slightly hypertensive with adequate peripheral perfusion and alert until sedation with midazolam.
Differential and actual diagnosis
While congenital or acquired syndromes causing malignant tachyarrhythmias were considered, the typical presentation made occluding myocardial infarction the most likely diagnosis. The ECG showing regional ST elevation almost confirmed the diagnosis even before angiographic visualisation of LAD occlusion.
Educational and clinical relevance
This case report highlights two important learning points: Point of care blood (gas) testing (including electrolytes) should be performed for patients with recurrent ventricular fibrillation, even after a diagnosis that can (partially) explain the predisposition for occurrence of tachyarrhythmias, as it can reveal reversible co-factors. Pre-hospital services should consider making this available as experience from Graz, Austria has shown that it is feasible.
The second main learning point for future research is that algorithms for recurrent VF, which is more common than refractory VF, should be reconsidered. If the ambulance team didn’t witness the primary occurrence of VF, the ERC ALS algorithm would have mandated immediate chest compressions, only analysing the rhythm every two minutes, most likely always showing VF as the interval between recurrences of VF was less than two minutes. This would have led to the patient being in a state that is presumed to be low flow (VF and chest compressions) for a significantly longer duration. ECG filters allowing manual or artificial intelligence augmented ECG analysis during chest compressions might allow creating and following tailored algorithms for patients in recurrent ventricular fibrillation.
David PURKARTHOFER (Graz, Austria), Marco LERCHER, Moritz MISSMANN, Valentina BACHNER
00:00 - 00:00
#40415 - Temporal analysis of the prehospital time Intervals among out-of-hospital cardiac arrest patients.
Temporal analysis of the prehospital time Intervals among out-of-hospital cardiac arrest patients.
Objectives
In out-of-hospital cardiac arrest (OHCA), prehospital time for each stage is critical. This study conducted temporal analysis of the prehospital time intervals among OHCA patients.
Methods
Retrospective observational study using Korea OHCA registry was conducted. From January 2016 to December 2021, adult OHCA patients were enrolled. The trend of the total emergency medical services (EMS) time intervals (the time from emergency calls to hospital arrival) were analyzed. Additionally, to identify the conducted Dispatcher assistant cardiopulmonary resuscitation (DA-CPR), we excluded witnessed cardiac arrest by EMS provider cardiac arrest, dispatcher unawareness of cardiac arrest, bystander cardiopulmonary resuscitation initiation before dispatcher instruction, Dispatcher did not instruct CPR and No DA-CPR initiation. The trend of the total DA-CPR initiation time intervals (the time from emergency calls to the initiation of DA-CPR) were analyzed.
Results
Total 179,096 patients were enrolled during the study period: (2016: 28,349, 2017: 28,028, 2018: 29,598, 2019: 29,716, 2020: 30,885, and 2021: 32,520, respectively.). The median (Q1-Q3) total EMS time was increasing over the years (2016: 28 [23-37] minutes, 2017: 29 [23-37] minutes, 2018: 29 [23-37] minutes, 2019: 29 [24-37] minutes, 2020: 32 [26-40] minutes and 2021: 32 [26-40] minutes, respectively.). The number of conducted DA-CPR patients was 63,032 during the study period. The median (Q1-Q3) total DA-CPR initiation time was decreasing over the years (2016: 171 [128-230] seconds, 2017: 162 [120-221] seconds, 2018: 154 [116-209] seconds, 2019: 119 [94-171] seconds, 2020: 115 [90-161] seconds and 2021: 114 [86-160] seconds, respectively.).
Conclusions
The prehospital time intervals are changing dynamically. Further researches are needed on how to effectively use the prehospital time intervals.
So Ra SONG (seoul, Republic of Korea), Jeong Ho PARK, Ki Hong KIM, Kyoung Jun SONG, Sang Do SHIN
00:00 - 00:00
#41893 - That's An Orful Rash!
That's An Orful Rash!
Orf disease is an enzootic among small ruminants in Asia, Africa, and some other parts of the world. It is caused by the orf virus the parapoxvirus, double DNA stranded is highly contagious and causes mucocutaneous disease in sheep and other farm animals. Orf disease is characterized by localized proliferative and persistent skin nodule lesions. Morbidity and mortality rates of orf are higher especially in newly infected kids and lambs. It can cause huge cumulative financial losses in livestock farming. Farmers and farm hands apply of antibiotics together with antipyretic and/or analgesic is highly recommended as a supportive disease management strategy for prevention of subsequent secondary microbial invasion. Vaccinations are sometimes also given but offer limited protection. Despite failures to contain the spread of orf virus by the use of conventional vaccines, vaccination of animals with live orf virus is still considered as one of the best choice.
Cases of zoonosis from infected animals to animal handler are therefore not uncommon. This a case report presents a case of a part-time farmer referred by her general practitioner to the Emergency Department for an infected thumb and generalised itchy rash. She was treated with multiple antibiotics and the practitioner had attempted to incised the lump with no relief , however making it worse. She had a generalised rash that affected her body, back, buttock and legs. After a thorough history and examination, she was diagnosed with Erythema Multiforme following Orf disease.
Orf also known as sheep pox; ecthyma contagiosum and contagious pustular dermatitis can occasionally affect humans when broken skin comes into contact with contaminated saliva of infected animals. Varying from 3-10 days single or multiple papules and later nodular lesions evolve mostly on the hands and face. the later become crusted and can complicate to lymphangitis and by becoming secondarily infected. Systemic complications such as erythema multiforme and maculopapular rash and generalised lymphadenopathy are rare. Diagnosis is difficult if it is not suspected.
Enda JENNINGS, Kiren GOVENDER (Galway, Ireland)
00:00 - 00:00
#40866 - The Acute Basic Palliation Concept evaluated by relatives and healthcare professionals: An observational study of 40 dying patients without specialized palliative needs who were discharged from a Department of Emergency Medicine.
The Acute Basic Palliation Concept evaluated by relatives and healthcare professionals: An observational study of 40 dying patients without specialized palliative needs who were discharged from a Department of Emergency Medicine.
Background: Many individuals prefer to pass away in the comfort of their own homes, yet logistical
obstacles often result in their admission to hospitals for End-of-Life care.
Objectives: To measure effectiveness assessed by relatives and staff of End-of-Life care according to the
Acute Basic Palliation Concept (ABPC) for patients discharged from an Emergency Department.
Methods: An observational study of 40 consecutive actively dying patients who were discharged using the
ABPC. Effectiveness of End-of-Life care was measured by questionnaires to relatives, discharging doctors
and nurses, and municipality health staff. The ABPC comprised of a physician checklist, instructions for
medical professionals, a medication template to be personalized, an added standardized text to discharge
papers, information pamphlets for patients and relatives, and a box of medicine and utensils.
Results: Among the 40 included patients (mean age 84 (Standard deviation 7.7)), four experienced
improvements at home and resumed active treatment. The patients who died had an average survival time
of 3.8 days (standard deviation 7.5). According to relatives, 90% of patients died a dignified death without
suffering. Municipality nurses rated the usefulness of the ABPC at 96 (Inter Quartile Range 88;100) on a 0-
100 scale, and all healthcare staff wanted to use the ABPC again.
Conclusion: The ABPC showed great potential as a tool for discharging dying patients without specialized
palliative needs to good-quality End-of-Life care at home. The ABPC was widely accepted by relatives and
all health staff. The ABCP is ready for large scale testing with patient subgroups and economic analysis.
Development and quality testing of the Concept has been supported by:
The Innovation foundation in the North Denmark Region, the BETA.HEALTH Innovation Foundation by the Novo Nordic Foundation, The Health Hub by Spar Foundation, The Svend Andersens Foundation, The Health Science Foundation of the North Denmark Region
Dorte MELGAARD, Mike ASTORP, Johannes RIIS, Inez Madeleine JENSEN, Anne Louise Hartvig SKALBORG, Matilde Alida Arendt ERIKSEN, Camilla LY, Bensu IZGI, Anne Lund KRARUP (Aalborg, Denmark)
00:00 - 00:00
#41389 - The added value of first responders: What’s real?
The added value of first responders: What’s real?
Aim
First responder [FR] systems are associated with improved outcomes. The evidence is, however, of very low certainty. Some regions are still exploring the implementation of a FR system. We wanted to inform this process and explore the reality of out-of-hospital cardiac arrest [OHCA] in a Belgian municipal region.
Methods
We evaluated all cases of OHCA attended by the physician-staffed EMS team of Ghent University Hospital [07/2020-07/2021] and explored the potential for a FR in each.
Results
During the study period, we attended 200 OHCA cases. In 62.5%, we considered a FR obsolete from start (due to e.g. irreversible death, resourceful setting, EMS arrival within 5 minutes…). In another 17%, the added value was considered minimal after evaluation (because of e.g. delayed recognition, frailty, trauma…). Although it is not possible to truly identify those cases from the remaining 20.5% that would benefit, we presume this to be true in only about half (for various reasons e.g. high-quality bystander CPR, complicating contexts…). Even then, many of the latter are unwitnessed arrests in a residential setting.
Conclusion
There might be added value for a FR system but the number-needed-to-treat, the associated cost-effectiveness ratios and the risks of harm should not be ignored. A better identification at the system point of entry of victims for whom CPR likely provides more benefit than harm is crucial.
none
Patrick VAN DE VOORDE (Ghent, Belgium), Thomas TACKAERT, Margo DUBOIS, Kim TO, Nicolas MPOTOS
00:00 - 00:00
#40730 - The Ambulatory Chest Pain Patient.
The Ambulatory Chest Pain Patient.
Brief clinical history
A female in her 70s presented to the Emergency Department (ED) overnight with chest pain. She had had a dual-chamber pacemaker inserted the previous day. On examination she looked well at rest and was pain free at the time of assessment. Normal breath sounds were heard bilaterally. Saturations were 98% on room air and respiratory rate was 18. Her pulse rate was 88 and she had normal heart sounds. Her blood pressure on arrival was 102/63. She was alert and orientated. Temperature was 35.8. She was tender on palpation around the pacemaker site, with nil infective signs.
Helpful details
Initial troponin was 26 (elevated) and her ECG showed sinus rhythm with premature ventricular complexes. Chest X-ray showed, the leads of the pacemaker remained intact and the position unchanged compared to the post-procedural film, chronic right-sided pleural effusion, chronic left basal atelectasis, and pulmonary congestion. A repeat troponin level showed a dynamic rise to 46.
Differential and actual diagnosis
Initially differential diagnoses were musculoskeletal chest wall pain or acute coronary syndrome (ACS). Due to the dynamic rise in troponin levels, she was treated as ACS and given the appropriate treatment protocol (Aspirin & Clopidogrel loading dose, and Fondaparinux treatment dose). Thirty minutes after the initial treatment she had a hypotensive episode that normalised with IV crystalloid infusion.
The patient had a further haemodynamic compromise 4 hours later that did not respond to fluids, and was escalated to the day ED senior team. She was moved from the ambulatory waiting room to a monitored bed where Point of Care Ultrasound (POCUS) was performed. The findings were consistent with haemopericardium and clot formation, with echographic features of cardiac tamponade.
Further anticoagulation doses were withheld and an urgent cardiology review was requested. Her blood pressure stabilised and no further haemodynamic compromise occurred. Upon discussion with the cardiothoracic team, she underwent a CT Chest to check for lead placement. This revealed that the tip of the RV lead had perforated the RV causing haemopericardium. The patient was transferred to a cardio-thoracic centre for device explantation and pericardiocentesis.
She made a complete recovery and was discharged.
What is the educational and/or clinical relevance of the case(s)?
The ambulatory chest pain patient is an incredibly common presentation in the ED, accounting for anywhere between 5-20% of ED presentations. This, combined with a wide differential that encompasses all levels of clinical severity, make it a challenging condition to manage. This case is an example of how early use of POCUS can enable clinicians to make better informed decisions that deliver specific and optimised care, and even dramatically alter the trajectory of patients. With the ever increasing long waits and overcrowding in the ED, the use of POCUS ensured this patient received early definitive treatment with an excellent outcome. Had she endured the long waits for specialties while receiving further IV fluids and anticoagulation doses, the outcome may have been far worse.
Daniel RAJAN (Liverpool, ), Ann CURRAN
00:00 - 00:00
#41541 - The association between demographic, economic, and medical resource factors and the inflow and outflow of severe emergency patients by medical service districts in South Korea.
The association between demographic, economic, and medical resource factors and the inflow and outflow of severe emergency patients by medical service districts in South Korea.
This study identified the in and outflow of severe emergency patients by 70 medical service districts, categorized them into regional types, and analyzed their association with demographics, economy, and medical resources in South Korea. This study analyzed 922,108 emergency department visits for severe diseases using National Emergency Department Information System data from January 1 to December 31, 2021. The relevance index (RI) and commitment index (CI) were calculated, and a cluster analysis was performed to categorize the types of regions for critical care. Demographic, economic, and medical resource factors were compared and analyzed for each type of district. Finally, a correlation analysis and multiple linear regression analysis were conducted to compare the association of demographic, economic, and medical resources with RI and CI. The districts types of the 70 medical service districts were divided into 21 outflow and 49 inflow districts. In addition, RI was associated with the number of primary clinics (β=-0.805), the average number of Computed Tomography (CT) (β=1.320), the average number of Magnetic Resonance Imaging (MRI) (β=-1.125), and the average number of dedicated specialists in the Emergency Department (ED) (β=1.176) (p<0.01). The CI was associated with the financial autonomy rate (β=0.366), the number of primary clinics (β=0.708), the number of Intensive Care Units (ICUs) (β=-1.290), the number of vulnerable areas for emergency medicine (β=0.395), the average number of dedicated specialists in the ED (β=-0.512), and the number of beds in the ED (β=0.915) (p<0.01). The lower the average number of MRIs and the number of primary clinics, the greater the outflow of severe emergency patients from the central region. The higher the number of ICUs and the average number of dedicated specialists in the ED, the greater the inflow of severe emergency patients from other districts.
Tag HEO (Gwangju, Republic of Korea), Seongmin LEE
00:00 - 00:00
#41194 - The association between emergency department length of stay and relevant clinical outcomes depends on age and triage urgency: an observational multi-centre cohort study.
The association between emergency department length of stay and relevant clinical outcomes depends on age and triage urgency: an observational multi-centre cohort study.
Background: Prolonged emergency department (ED) length of stay (LOS) is associated with ED crowding, typically linked to adverse outcomes in healthcare systems with relatively long ED LOS. We hypothesized that even in systems with shorter ED LOS, prolonged LOS leads to adverse outcomes, particularly in older and urgently triaged patients. This study assesses the association between ED LOS, in-hospital mortality, and hospital LOS ≥3 days in patients older and younger than 70 years, categorized by triage urgency.
Methods: Observational multicentre cohort study including all hospitalized ED patients from the Netherlands Emergency department Evaluation Database, stratified by age and triage category. Multivariable logistic regression analyses were employed to calculate Adjusted Odds Ratios (AOR) for the association between ED LOS and outcomes, adjusting for confounders.
Results: Among 718,358 patients, the median ED LOS was 2.6 (95% CI: 2.59-2.61) hours, while median hospital LOS was 3.0 (95% CI: 2.98-3.02) days; 14,666 patients (2%) died. Patients with ED LOS of 4-8 and >8 hours had AORs for in-hospital mortality of 1.16 (95% CI: 1.12-1.21) and 1.06 (95% CI: 0.95-1.18) respectively, compared to those with ED LOS <4 hours. For hospital LOS ≥3 days, AORs for ED LOS 4-8 and >8 hours were 1.72 (95% CI: 1.69-1.75) and 2.07 (95% CI: 1.97-2.18), respectively. Younger, non-urgently triaged patients had higher AORs for adverse outcomes.
Conclusion: In the Dutch healthcare system which relatively short ED LOS, prolonged ED LOS is associated with adverse outcomes, especially in younger, non-urgently triaged patients, contrary to our hypothesis.
Not aplicable
Bas DE GROOT (AMSTERDAM, The Netherlands)
00:00 - 00:00
#41708 - The Association Between the 20-minute Whole Blood Clotting Test and the Fibrinogen Level in Green Pit Viper Envenomation in Bangkok.
The Association Between the 20-minute Whole Blood Clotting Test and the Fibrinogen Level in Green Pit Viper Envenomation in Bangkok.
Background: The venom of green pit viper (GPV) causes hypofibrinogenemia. A fibrinogen level of < 100 mg/dL has been used to indicate the administration of antivenom in GPV envenomation. However, assessing fibrinogen levels can be challenging in most hospitals. The 20-minute whole blood clotting test (20WBCT) is a bedside test with minimal resource requirements. This study aimed to determine an association between fibrinogen levels and 20WBCT and assess the diagnostic parameters of 20WBCT.
Methods: This was a prospective diagnostic study. Patients aged 18 years or older presenting to the Emergency Department (ED) due to a GPV bite between September 1st, 2022, and November 30th, 2023 were enrolled.
Results: A total of 39 patients were enrolled in this study, contributing to 188 blood samples. The results of 20WBCT, interpreted as completely clotted (CC), majorly clotted (MJ), minorly clotted (MN) and unclotted (UC), had median fibrinogen levels at 259.1, 223.5, 226.1, and 48.7 mg/dL, respectively. A significant difference was observed between the unclotted group and the others (CC: p=0.001, MJ: p<0.001, MN: p = 0.002), while no significant differences were found among the CC, MJ, and MN groups. The unclotted 20WBCT had a sensitivity of 28.6% and a specificity of 99.4%. When interpreting 20WBCT with UC and MN as test positive, we found a higher sensitivity at 42.9% but lower specificity at 90.9%. A fibrinogen level < 83 mg/dl demonstrated the highest performance in detecting unclotted 20WBCT.
Conclusion: The fibrinogen level in the unclotted 20WBCT group was significantly lower than that in the partially and completely clotted groups. Interpretating partially clotted 20WBCT as majorly clotted and minorly clotted showed no statistically significant difference. We recommend interpreting the partially clotted group, whether minorly or majorly clotted, as completely clotted and initiating antivenom only in unclotted 20WBCT.
Trial Registration: no appropriate register
Funding: Navamindradhiraj University Research fund
Supa NIRUNTARAI (Bangkok, Thailand), Rittirak OTHONG, Sivilai HENGTRAKUL
00:00 - 00:00
#41277 - The challenge of suspicion in the Emergency Department: Speed and diagnostic tests.
The challenge of suspicion in the Emergency Department: Speed and diagnostic tests.
90-year-old woman, independent for basic activities of daily living and with a history of arterial hypertension under pharmacological treatment and cholecystectomy. Institutionalized.
She came to the emergency department referring48 hours of abdominal pain associated with vomiting and intermittent diarrheal stools. Afebrile at home, in the Emergency Department peak of fever up to 38º.
The physical exam shows fair general condition, alert, oriented and cooperative, with an acute globular abdomen, distended and tympanic, painful on palpation with the point of greatest pain in the right iliac fossa being Blumberg test positive.
Complementary tests include elevated acute phase reactants with leukocytosis with left shift, elevated CRP and lactate. Tendency to hypotension since his arrival that improves after administration of serum therapy. Analgesia was prescribed with regular pain control.
An abdominal CT scan with intravenous contrast was performed, showing parietal thickening at the level of the cecum, with dilatation of small bowel loops and gastric chamber. As well as loco-regional inflammatory changes at the level of the cecum and presence of intra-abdominal and pelvic free liquid and extraluminal air bubbles adjacent to the colic frame suggestive of pneumoperitoneum, which could be the origin of the cecum. Final clinical judgment suspects intestinal perforation. Urgent surgery was performed under antibiotic prophylaxis with favorable outcome and evolution. Intraoperative findings of perforation of the cecum towards retroperitoneum, with inflammatory plastron including ascending colon and terminal ileum. Purulent peritonitis in lower quadrants, with fibrin between loops. Release of right parietocolic and distal ileum to release inflammatory plastron from retroperitoneum. Right hemicolectomy. Antibiotherapy during admission with wide coverage with meropenem, amikacin and linezolid. After that, good clinical and hemodynamic evolution during hospitalization being discharged after 18 days of admission. Review by surgery within one month.
Conclusions The exploration and clinical suspicion of an acute abdomen in the ED should indicate an early attitude of requesting complementary imaging tests to complete the study as well as initiating early medical support measures (hemodynamic monitoring, diuresis, antibiotic coverage, fluid therapy and analgesia). In senile patients it is important to take into account the previous quality of life and to consider the surgical option versus support measures given the probability of not being fit for surgery.
Vanesa YAÑEZ BERMEJO, Álvaro MARTÍN PÉREZ (Badajoz, Spain), Rafael ROLDÁN JIMÉNEZ
00:00 - 00:00
#41683 - The consequences.
The consequences.
A 55 years old woman came to our emergency center, CUE el Molar, due to pain and functional impotence in the right proximal tibia with previous minor trauma in a car accident, without fever or other symptoms. The patient came in a wheelchair with a pain score of 9 out of 10. She had personal history of breast cancer a year ago, treated with bilateral mastectomy and posterior reconstructive surgery. After these two surgical procedures, she started treatment with tamoxifen and anastrozole (an aromatase inhibitor). She had healthy habits, good nutrition and has body mass index of 21%. She reported doing sports 5/6 days a week.
The patient reported continuing to do impact sports, until she was diagnosed with a pathological fracture, first in the calcaneus and later in the left tibia, in relation to treatment with tamoxifen and anastrozole.
After the evaluation of the patient and the realization of an X-ray in two projections, the X-ray of our emergency center showed a dubious new fracture, diagnosed a posteriori by magnetic resonance imaging. The patient was concerned about the possibility to continue doing sport during the treatment with tamoxifen and anastrozole knowing the risk of pathological fractures.
Regarding this case, we will review the differential diagnosis of pathological fractures. On the differential diagnosis of pathological fractures, we have tumors, osteoporosis, bone metastases, cystic lesions, dysplasia, and medication (i.e. tamoxifen).
The most widely used hormonal therapy drug in hormone receptor-positive breast cancer is tamoxifen. Treatment with tamoxifen can reduce breast cancer recurrence by 40-50% in postmenopausal women and by 30-50% in premenopausal women, depending on the study. There exists a personal variability. The toxicity of tamoxifen in most studies is minimal and only 1% of patients have to quit the treatment because of the side effects. Between the side effect of tamoxifen, we have amenorrhea (the most frequent), vaginal dryness, thrombophlebitis/deep vein thrombosis/pulmonary embolism, increased bone pain, dizziness, depression, headache, weight loss, etc. In most studies, the treatment only with tamoxifen does not produce osteopenia. But in some studies, the association of inhibition of aromatases and tamoxifen does increase the risk of pathological fractures in 34 - 59%, depending on the study.
The interest of this case is not only to review the differential diagnosis, but also from out of hospital setting, to take this type of personal history into account since it leads to a great risk of serious fractures such as those of the pelvis and femur, as and as described by Melton LJ 3rd.
From the pre-hospital medical emergency system, such as SUMMA 112, it is important not to lose sight of the primary objective of our work, which is the patient, and therefore take into account all the risk factors and conditions that may affect our patient, especially all in a scenario of serious pathology, in order to give detailed attention. Fortunately, this was not the case for our patient, her personal history should be taken into account much more, in case it was a potential trauma.
Maria REDONDO LOZANO, Varela García PILAR, Miriam UZURIAGA MARTIN (Madrid, Spain), Vanesa Natalia ISAAC, Cristina BARREIRO MARTÍNEZ, Blanca GUERRERO MOÑUS, Noemi SOTO TOSTADO, Marta HUEDO JIMENEZ
00:00 - 00:00
#41197 - The eCREAM project: enabling Clinical Research in Emergency and Acute care Medicine through automated data extraction.
The eCREAM project: enabling Clinical Research in Emergency and Acute care Medicine through automated data extraction.
Background:
Doing research in emergency departments (EDs) clashes with sustainability issues for the vast number of patients involved and the staff shortages that chronically afflict these departments. The only way to make research possible is to automatically extract valuable data from ED applications.
Aims:
eCREAM (enabling Clinical Research in Emergency and Acute-care Medicine) is an EU-funded project with three main aims:
1) to develop new technical solutions to extract reliable clinical information from structured and unstructured data contained in different electronic health records (EHRs);
2) to exploit the databases created in two relevant use cases: the assessment of ED propensity to hospitalise patients (use case 1), and the development of a dashboard to be used by citizens, healthcare providers, and policymakers to improve the quality of care in ED (use case 2);
3) to FAIRify (i.e., make data Findable, Accessible, Interoperable, and Reusable) the established databases, respecting the European and national legislations.
Methodology
eCREAM involves 11 partners in 8 countries (France, Greece, Italy, Poland, Slovakia, Slovenia, Switzerland, and the United Kingdom); it started in 2022 and will last 5 years.
1. We are following two approaches to extracting data from electronic records. First, the development of an IT platform to extract information from EHRs used in the different EDs. Second, the development of a new ED EHR specifically designed to meet the needs of clinical practice and research.
A common tool for these two solutions will be a large language model capable of interpreting the free text in medical records to extract structured, valuable information for research purposes.
2. The propensity to hospitalise patients in the different EDs is being studied in the first use case. Using multivariable models, the hospitalisation rate between the participating centres will be compared in order to study how this affects patient outcomes. Guidance will thus be provided to the participating EDs on how to improve the quality of their care.
In the second use case, we are developing dashboards to inform practitioners, health policymakers, and citizens about the real-time characteristics of EDs.
3. eCREAM adheres to the Open Science movement and is committed to implementing FAIR principles, recognising the importance of data as a public good. The different databases created during the project will be integrated into the Medical Informatics Platform (MIP). The MIP is a unique open-source GDPR-compliant platform that enables remote and federated analyses from datasets physically distributed in various sites without moving the data outside their original storage.
Expected impact
eCREAM will produce several impacts in the short, medium and long term. The databases collected will be made available to the scientific community for secondary uses in various research areas, from those on developing artificial intelligence-based language models to those studying ED functioning. It will produce results useful in understanding and improving the decision to admit or discharge patients from the ED. Most importantly, it will develop tools to enable the implementation of research in emergency medicine, which is chronically excluded from large international scientific production.
Funding
The eCREAM project was funded by the European Commission under the Horizon Europe programme (Grant Agreement no. 101057726) and by UKRI (UK Research and Innovation) and SERI (Swiss State Secretariat for Education, Research and Innovation).
Disclaimer: the opinions expressed are solely those of the authors and do not express the views or opinions of their employer.
Vicky RUBINI (BERGAMO, Italy), Giulia GHILARDI, Chiara PANDOLFINI, Felice CATANIA, Bernardo MAGNINI, Peter MITRO, Federica MORETTI, George NOTAS, Gregor PROSEN, Maria RUJANO, Birgit SCHAFFHAUSER, Pankaj SHARMA, Jacek GORKA, Guido BERTOLINI
00:00 - 00:00
#42004 - The effect of calcium administration following pre-hospital blood transfusion in major trauma patients between 2019 and 2023.
The effect of calcium administration following pre-hospital blood transfusion in major trauma patients between 2019 and 2023.
Background
Pre-hospital blood transfusion has become a more widely practiced intervention in UK major trauma patients. Whilst it makes pathophysiological sense to replace lost blood, there are risks. Hypocalcaemia is one such concern as it is associated with increased mortality in trauma patients and contributes to the trauma diamond of death. There’s currently no consensus across UK pre-hospital services on the amount of supplemental calcium to be given alongside blood for prevention. At NWAA, 10ml of Calcium Chloride is given with every two units of blood product.
This study aims to look at the first blood gas from a series of patients who were treated by NWAA and delivered to a Major Trauma Centre following blood transfusion. The objective is to establish the relationship between blood products, calcium levels and the current calcium replacement protocol .
Methods
We identified major trauma patients who had received blood products from NWAA between 16/01/2019 and 20/042023 using HEMSBASE records. The number of units of blood product and calcium given was identified and linked to TARN outcomes. The first blood gas upon hospital admission determined whether calcium levels were abnormal following transfusion.
Results
117 patients received blood products from the North West Air Ambulance Service between 16/01/2019 and 20/04/2023. Of these, 53.0% (n=62) had a blood gas identified. 45 patients received calcium pre-hospital: 44.4% (n=20) were hypercalcaemic, 13.3% (n=6) were hypocalcaemic and 42.2% (n=19) had normal calcium levels. For the 17 patients that didn’t receive calcium pre-hospital, 5.9% (n=1) were hypercalcaemic, 70.6% (n=12) were hypocalcaemic and 23.5% (n=4) had normal calcium levels.
Conclusion
In conclusion, patients who received calcium were significantly less likely to be hypocalcaemic (13.3%) than those that did not receive calcium (70.6%). The NWAA supplementary calcium regime led to a significant number of patients with hypercalcaemia on first hospital gas.
Completed with the help of the North West Air Ambulance Service but did not receive funding to go ahead as this project used data that was already available.
Georgia CLARKE (Huddersfield, ), Simon CARLEY, Megan PODE, Scott BEATTIE, Polly HAYWOOD, Robert EVANS
00:00 - 00:00
#41622 - The effect of smart watch use on cardiopulmonary resuscitation.
The effect of smart watch use on cardiopulmonary resuscitation.
Introduction: Smart watches can be used as a feedback device in cardiopulmonary resuscitation with the sensors they contain and applicable mobile software. In our study, we investigated the effect of smartwatch use on chest compressions applied during resuscitation.
Materials and Methods: 40 paramedics were asked to perform 2-min chest compressions on a computer-assisted resuscitation manikin in accordance with current guidelines. Paramedics performed the application by wearing a classical watch in the first cycle and a smart watch in the second cycle. Compression values of each cycle were recorded on the computer. They were asked to mark the degree of fatigue on a scale ranging from 1 to 10.
Results: The mean depth of chest compressions was 56.33 mm in round 1 and 53.93 mm in round 2 (P<0.05).The median number of compressions per minute was 124/min in round 1 and 110.5/min in round 2 (P<0.05). Effective compression percentages; the median value of the 1st round was 72%, the median value of the 2nd round was 87% (P<0.05). The median values of fatigue levels were 4 in the 1st round and 2 in the 2nd round (P<0.05).
Conclusion: The use of a smart watch improves resuscitation quality and reduces practitioner fatigue.
Bahadir CAGLAR (Balikesir, Turkey), Suha SERIN
00:00 - 00:00
#41404 - THE EFFECT OF STRETCHER ANGLES OF STROKE SUSPECTED PATIENTS BROUGHT TO THE EMERGENCY DEPARTMENT BY AMBULANCE ON VITAL SIGNS AND OPTIC NERVE SHEATH DIAMETER.
THE EFFECT OF STRETCHER ANGLES OF STROKE SUSPECTED PATIENTS BROUGHT TO THE EMERGENCY DEPARTMENT BY AMBULANCE ON VITAL SIGNS AND OPTIC NERVE SHEATH DIAMETER.
Aim: Stroke is the second leading cause of death and the third leading cause of disability worldwide. Post-stroke hypoperfusion of brain tissue often results from an increase in intracranial pressure (ICP), endangering cerebral blood flow. The diameter of the optic nerve sheath (ONSD) is continuously related to the intracranial space. When ICP increases, the diameter of this sheath will expand. Recently, ONSD ultrasonography has emerged as an alternative non-invasive, fast, and easy-to-use method for diagnosing increased ICP. This study aims to evaluate the potential effects of stretcher angles of stroke-suspected patients brought to the emergency department by ambulance on ONSD, which is an indicator of ICP increase, and vital signs.
Materials and Methods: This prospective, cross-sectional (observational), single-center study was conducted at Ankara Bilkent City Hospital Emergency Department, which receives an average of 150 ambulances and 2000 patient admissions daily. The study included individuals over 18 years of age suspected of stroke according to the Cincinnati Stroke Scale. Patients' age, gender, time to hospital arrival with ambulance, ONSD, vital signs, clinical findings, stretcher angle, and Glasgow Coma Scale (GCS), diagnoses were recorded.
Results: The study included 82 patients, of whom 42.7% were maleand the average age was 74 years. Patients were divided into four groups according to stretcher angles: Group 1 (0-30°) had 16 patients, Group 2 (31-45°) had 27 patients, Group 3 (46-60°) had 22 patients, and Group 4 (61-90°) had 17 patients. The average stretcher angle was 44 ± 17°, mean systolic blood pressure (SKB) 163 ± 35 mmHg, mean diastolic blood pressure (DBP) was 91 ± 17 mmHg, mean ONSD was 0.36 ± 0.07 cm on the right and 0.37 ± 0.07 cm on the left. In our study, GCS was lower in Group 1 compared to Group 3 (p=0.002), DBP values were higher in Group 4 compared to Group 3 (0.023), and ONSD values were wider in Group 4 compared to Group 2 (p=0.007).
Conclusion: The findings of our study demonstrate the impact of stretcher head height on GCS, ONSD, DBP among patients transported by ambulance. Therefore, It is important for healthcare personnel working in pre-hospital and post-hospital emergency healthcare services to pay more attention to the height of the stretcher head and be informed about it when transporting patients with suspected stroke.
Bektaş BAKIRCI (Ankara, Turkey), Ayhan ÖZHASENEKLER, Habibe Selmin OZENSOY, Burak BEKGÖZ, Alp ŞENER
00:00 - 00:00
#41638 - The effect of therapeutic hypothermia on ischemic brain injury assessed by 18F-FDG PET in a rat model of cardiac arrest.
The effect of therapeutic hypothermia on ischemic brain injury assessed by 18F-FDG PET in a rat model of cardiac arrest.
Therapeutic hypothermia (TH) is recognized as one of the key interventions that are effective in preventing hypoxic-ischemic brain injury in comatose patients following cardiac arrest (CA). However, there is recent controversy regarding its effectiveness. In this preclinical study, we evaluated the effect of TH on brain glucose metabolism, as measured by fluorine-18-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) in a rat model of CA. Asphyxia CA was induced using vecuronium in Sprague-Dawley rats. 18F-FDG brain PET images were acquired from 21 CA rats, with or without TH intervention, by randomization. Of the 21 CA rats, 9 rats in the TH group underwent mechanical ventilation under general anesthesia during the application of hypothermia for 8 hours, while the remaining 12 rats in the non-TH group were simply observed without anesthesia. Between-group regional and voxel-based analyses of standardized uptake values relative to the pons (SUVRpons) were performed. The survival rates in the TH and non-TH groups were the same (67 %). The SUVRpons of each brain cortical region on the PET scan did not show any difference according to the application of TH intervention. In a subgroup analysis of non-survived rats (n = 7), across most brain cortical regions, 3 rats in the TH group exhibited a significantly higher SUVRpons compared to the 4 rats in the non-TH group (FDR-corrected p < 0.05). Overall, an improvement in the SUVRpons according to TH intervention was observed only in the cortical regions of the severe encephalopathy group that died. The effect of TH on brain glucose metabolism in the asphyxia CA model appears to be limited to groups with severe ischemic encephalopathy.
Hyunsoon KIM (Incheon, Republic of Korea), Daehee KIM, Hae-Jeon YOON
00:00 - 00:00
#41800 - The epidemiology of thoracic trauma at SAMU 03.
The epidemiology of thoracic trauma at SAMU 03.
Introduction:
Thoracic trauma is the result of a significant force acting on the thorax, which presents a significant management challenge. It is therefore of paramount importance to ascertain the clinical and paraclinical data associated with this type of trauma.
The objective of this study was to determine the clinical characteristics and the complementary examinations of thoracic trauma initially managed by SAMU 03.
The study employed a retrospective analysis of medical records of patients initially managed by SAMU 03 for thoracic trauma.
A comprehensive analysis of the medical records of patients treated for thoracic trauma by SAMU 03 was conducted. A comprehensive review of the clinical data, including vital signs, presenting symptoms, and initial assessments, was conducted. Furthermore, paraclinical data, including medical imaging findings (radiographs and scans), were analyzed.
The results of the study are as follows:
A total of 64 patients were included in the study, with 89.1% of them being male.
The medical examination revealed a mean blood pressure of 118/68 mm Hg. The mean heart rate was 97 beats per minute (bpm), with extremes ranging from 55 to 180 bpm. The results of the electrocardiogram (ECG) examination indicated that 59.4% of patients exhibited a normal electrical pattern. With regard to the respiratory system, 20.3% of patients exhibited a saturation between 65% and 94%, while 31% were polypneic. Upon arrival, patients frequently exhibited altered vital signs, with 68% demonstrating tachycardia and 45% respiratory distress. A neurological examination revealed that 23.4% of patients exhibited a score between 9 and 14, and nine patients were found to be comatose. Paraclinical examinations, including e-FAST ultrasound and CT scans, revealed the presence of lesions, including rib fractures (76.56%), pulmonary contusions (64.06%), hemothorax (39.06%), and pneumothorax (37.5%). A significant correlation was observed between the presence of specific symptoms and the severity of lesions.
Biological results indicated the presence of anemia in 11.6% of patients, deglobulation in 13.9%, and renal failure in seven patients. Fluid and electrolyte imbalances were observed in 13 patients. Approximately ten patients exhibited a low total protein (TP) level of less than 70%.
Conclusion :
This comprehensive examination of clinical and paraclinical data expands our comprehension of thoracic trauma. This information is of the utmost importance for the accurate assessment, rapid intervention, and continuous improvement of clinical practice.
Dorra LOGHMARI, Sondes LAAJIMI, Chebbi NABIL (Tunisie-Sousse, Tunisia), Rabeb MBAREK, Haifa BRADAI, Naoufel CHEBILI
00:00 - 00:00
#41837 - The Fenice Project to Evaluate and Improve the Quality of Healthcare in High-Dependency Care Units: Results after the First Year.
The Fenice Project to Evaluate and Improve the Quality of Healthcare in High-Dependency Care Units: Results after the First Year.
Abstract
High-Dependency care Units (HDUs) have been introduced worldwide as intermediate wards between Intensive Care Units (ICUs) and general wards. Performing a comparative assessment of the quality of care in HDU is challenging because there are no uniform standards and heterogeneity among centers is wide.
Objective:
The Fenice network promoted a prospective cohort study to assess the quality of care provided by HDUs in Italy. This work aims at describing the structural characteristics and the clinical characteristic of admitted patients of Italian HDUs to develop a framework to evaluate quality.
Methods:
All Italian HDUs affiliated to emergency departments (ED) were eligible to participate in the study. Participating centers reported detailed structural information and prospectively collected data on all admitted adult patients in 2022. Patients’ data are presented overall and analysed to evaluate the heterogeneity across the participating centers. Structural characteristics of the HDU and clinical characteristics of admitted patients were collected, together with HDU and hospital outcomes.
Results:
A total of 12 HDUs participated in the study, 2/3 located in Northern Italy, with a median of 8.8 beds each: overall 3670 patients were enrolled. 81% of patients were admitted from the ED, 7% transferred from ICU and 10% transferred from other wards. Patients were aged 68 years on average, had multiple comorbidities and were on major chronic therapies. Several admitted patients had at least one organ failure (39%). 44% of patients had an infection at admission, 14% had trauma in the previous 7 days. The majority of patients underwent one or several procedures and 18% underwent non-invasive ventilation during HDU stay. Mortality in HDU was 8.4%, raising to 16.6% in hospital. Median length of stay was 5 days, while most patients were transferred to general wards, a small proportion required ICU transfer (3.9%) and a large group was discharged directly home from the HDU (31%).
A wide heterogeneity was observed in the proportion of traumatic patients admitted (3,5 to 33,5%), in the rate of patients with at least one organ failure at HDU admission (25.2% to 61.9%), in length of stay (range of medians: 2.0 – 7.0) and in HDU and hospital mortality (2.2% - 20.7% and 10.1% - 25.7%, respectively).
Discussion:
The expertise of HDUs in managing complex and fragile patients is supported by both the available equipment and the characteristics of admitted patients. The limited proportion of patients transferred to ICUs supports the hypothesis of preventing of ICU admissions. The heterogeneity of HDU admissions requires further research to define meaningful patients’ outcomes to be used by quality-of-care assessment programs.
The Fenice working group :
Angela Beltrame5, Riccardo Boverio6, Mario Calci7, Ersilia Castaldo8, Michele Covella9, Patrizia Cuppini10, Enrico Mirante8, Paola Noto11, Lucia Pierpaoli12, Paolo Pinna Parpaglia13, Alberto Ricchiardi14,
5 Pronto Soccorso e Medicina d’Urgenza, Ca Foncello ULSS9, Treviso, Italy
6 Department of Emergency Medicine, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
7 Pronto Soccorso e Medicina d’Urgenza, Azienda Sanitaria Universitaria Friuli Centrale, Presidio Ospedaliero Universitario “Santa Maria della Misericordia” di Udine, Udine, Italy
8 Emergency Department, S. Eugenio Hospital, Rome, Italy
9 Emergency Medicine Unit, A.O. Parini, Aosta, Italy
10 Emergency Medicine, Bufalini Hospital, Cesena, Italy
11 Department of Emergency Medicine, Azienda Ospedaliero Universitario Policlinico " G. Rodolico - San Marco", Catania, Italy
12 Emergency Medicine, S. Maria Delle Croci Hospital, Ravenna, Italy
13 Emergency Medicine, A.O.U. Sassari, Sassari, Italy
14 Emergency Medicine, Edoardo Agnelli Hospital, Pinerolo, Torino, Italy
Giovanni PORTA, Dr Valeria CARAMELLO (TORINO, Italy), Adriana BOCCUZZI, Fabiola SIGNORINI, Carlotta ROSSI, Giovanni NATTINO, Marcella CONVERSO, Giulia CAVALOT, Franco APRA', Daniela ZATELLI, Giulia Irene GHILARDI, Guido BERTOLINI
00:00 - 00:00
#41858 - The first mission of the Tuscan U.S.A.R. (Urban Search And Rescue). team for the earthquake in Turkey: the perception of work in a mixed team and nursing assistance directly under the rubble in the red zone.
The first mission of the Tuscan U.S.A.R. (Urban Search And Rescue). team for the earthquake in Turkey: the perception of work in a mixed team and nursing assistance directly under the rubble in the red zone.
The study focuses on emergency response in urban settings, with particular attention to integrating Firefighters and Medical Components into a single team, known as U.S.A.R. (Urban Search And Rescue). After the team's training in Tuscany, there was an opportunity to apply the skills acquired during the earthquake in Turkey in February 2023. A specific questionnaire was used to assess the perception of work within a multidisciplinary team and the benefits of advanced healthcare in rescuing people trapped under rubble. Additionally, the questionnaire investigated the need for improvements after the first experience of the Tuscan U.S.A.R. team in Turkey.
The results of the study highlighted the importance of the role of nurses within the U.S.A.R. team and the psychological support provided during stressful and uncertain situations. Furthermore, the group benefited from the communication skills of emergency nurses, which contributed to concentration and efficiency. It was also observed that less experienced members of the team showed a greater predisposition to burnout syndrome, emphasizing the importance of ongoing training and skill development.
In conclusion, the healthcare operator with U.S.A.R. training was considered crucial in rescuing people trapped under rubble. However, deficiencies in the preparation of the U.S.A.R. team and the need for further training to address extreme scenarios emerged. Additionally, psychological support and non-technical skills of emergency nurses were found to be fundamental.
No funding was received for this study.
Vittorio BOCCIERO (Florence, Italy, Italy), Barbara BRUNO, Nadia MATTALIANO, Niccolò SALVADORI
00:00 - 00:00
#41345 - The impact of ambulance clinicians’ well-being on occupational and patient safety in prehospital emergency medical services: a scoping review.
The impact of ambulance clinicians’ well-being on occupational and patient safety in prehospital emergency medical services: a scoping review.
BAKGROUND: Working in prehospital Emergency Medical Services (EMS) can be unpredictable and emotionally demanding for the Ambulance Clinicians (ACs). Burnout, high level of stress, sleeping deprivations, fatigue and mental health issues potentially increase the risk of injuries and adverse events in occupational and patient safety. The aim was to identify and map the existing literature on the current state of impact of Ambulance Clinicians’ well-being on occupational or patient safety risks in prehospital EMS. Review question was How is Ambulance Clinicians’ well-being related to occupational or patient safety risks in prehospital EMS missions based on existing literature?
METHODS: A scoping review with a structured search was conducted in databases CINAHL Plus, PubMed, Scopus, Web of Science, and Mednar in March 2024. Published and unpublished studies were searched. English, Finnish and Swedish data was included without limitations regarding to timeline. Studies on ACs working in prehospital EMS and reporting their physical, mental and social well-being with an impact to occupational or patient safety risks were eligible for inclusion. Numerical and thematic analysis were used.
RESULTS: After the screening of the studies (n=3559) for titles and abstracts, 135 studies were included in full text phase. Three themes were identified: 1) Deficiencies in mental well-being related to occupational safety risks, 2) Deficiencies in mental well-being related to patient safety risks, and 3) Deficiencies in physical well-being related to occupational safety risks. According to preliminary results of this study, ACs having deficiencies in mental or physical well-being were probably more often exposed to occupational safety risks and contributed to negative impact on patient safety in prehospital EMS. The most important deficiencies in mental well-being were fatigue and stress, having a negative impact to occupational safety, such as vehicle crashes, injuries, and exposures. A slight majority of studies linked the deficiencies in mental well-being to patient safety risks, such as medical errors and deviations from the treatment instructions. Deficiencies in physical well-being, potentially leading to occupational safety risks, were identified in a minority of the studies. A link between deficiencies in physical well-being and patient safety risks was not found. ACs’ Social well-being was not discussed in any of the studies.
DISCUSSION & CONCLUSIONS: According to existing literature, poor well-being among the ACs can be a threat to high-quality job performance, and lead to occupational and patient safety risks in prehospital EMS. Results of this study support the previous knowledge and give a deeper understanding of how different well-being components among the ACs are related to occupational and patient safety risks. Deficiencies in mental well-being, especially fatigue and stress, seem to be the most significant predictor of occupational safety risks. Patient safety risks are less usual. Similarities can be found with existing literature; however, the sleep-related problems are often more emphasized. Solutions that reduce ACs’ stress and fatigue, and occupational and patient safety risks, need to be prioritized to ensure that ACs maintain good well-being and can deliver high-quality care.
Ethical approval and informed consent: Not needed.
Trial Registration: Not needed.
Funding: This study did not receive any specific funding.
Viivi TIKKANEN, Viivi TIKKANEN (Flen, Sweden), Maria KÄÄRIÄINEN, Roivainen PETRI
00:00 - 00:00
#41461 - The Impact of Apparent Temperature on Return of Spontaneous Circulation Outcomes in Out-of-Hospital Cardiac Arrest Patients.
The Impact of Apparent Temperature on Return of Spontaneous Circulation Outcomes in Out-of-Hospital Cardiac Arrest Patients.
Objective
Substantial evidence links temperature variations to the incidence of out-of-hospital cardiac arrest (OHCA), and targeted temperature management has demonstrated improved outcomes in OHCA patients. This study aimed to investigate whether environmental conditions, serving as a natural thermoregulatory mechanism, could influence the outcomes of OHCA patients across different apparent temperature.
Method
This is a retrospective cohort study conducted between January 2015 and December 2016, utilizing data from the OHCA registry of the Fire Bureau of Kaohsiung City Government and following the Utstein resuscitation registry template. Additionally, data from the Environmental Protection Administration's environmental monitoring network was utilized to calculate the average apparent temperature recorded at the nearest station during the four-hour period preceding each event. High and low temperature conditions were defined using a cutoff of 33 degrees Celsius. A multivariate logistic regression model was constructed to analyze the likelihood of achieving return of spontaneous circulation (ROSC), adjusting for patient age, response time, and whether defibrillation was performed. The effects of high and low 4-hour average apparent temperature on ROSC were estimated and compared.
Result
Excluding 507 trauma-related events and 28 pediatric events (age < 18 years), the study comprised 4,600 non-traumatic, adult out-of-hospital cardiac arrest (OHCA) events during the study period. The cohort consisted predominantly of males (84.8%), with a mean age of 69.3 ± 16.3 years, and a defibrillation rate of 17.7%. In the multivariate logistic regression analysis for return of spontaneous circulation (ROSC), the adjusted odds ratios (95% confidence intervals) were: 0.84 (0.73-0.98) for age over 70 years compared to 70 years or younger, 0.79 (0.68-0.91) for response time exceeding 6 minutes compared to 6 minutes or less, 1.87 (1.54-2.27) for defibrillation performed compared to no defibrillation, and 0.41 (0.19-0.86) for 4-hour average apparent temperature above 32°C compared to 32°C or below.
Conclusion
These findings suggest that higher ambient temperatures may adversely impact the resuscitation success of out-of-hospital cardiac arrest (OHCA) patients. The observed temperature effects on return of spontaneous circulation (ROSC) outcomes could be attributed to environmental conditions acting as a natural thermoregulatory influence. Further research is warranted to elucidate the underlying mechanisms and develop targeted strategies. Exploring prehospital targeted temperature management approaches might yield insights into improving OHCA patient resuscitation and survival outcomes.
Shih-Chiang HUNG (Kaohsiung City, Taiwan), Jyun-Bin HUANG, Kuan-Han WU
00:00 - 00:00
#42206 - The Impact of Artificial Intelligence-Enhanced Medical Applications on Patient Health Education.
The Impact of Artificial Intelligence-Enhanced Medical Applications on Patient Health Education.
Objective: The integration of artificial intelligence (AI) in healthcare has profound implications for patient health education. This study aimed to assess the effectiveness of medical applications in delivering health information, treatment steps, and guidance on healthy lifestyle to patients in emergency departments, where time for patient education is limited.
Methods: The study was conducted on a sample of 2000 patients to evaluate the impact of AI support using the MedAssistAI application developed by AssistAI. The frequency and types of queries submitted to the application were tracked. Additionally, a survey was conducted to gather qualitative feedback on patient satisfaction and perceived impact of the application.
Results: The use of AI-enhanced diagnostic tools had a significant impact on patient health education, increasing the level of understanding of information provided by medical staff. Patients reported better understanding of the diagnostic and treatment process, as well as guidance on treatment and healthy lifestyle when using the MedAssistAI application. The utilization of the application was perceived by patients as convenient and comfortable. Our study is in its final data collection phase. Specific results will be presented in the final publication. Present conclusions are based on preliminary analysis and feedback obtained during the ongoing research period.
Conclusion: This study contributes to understanding the role of artificial intelligence in patient health education, particularly in emergency departments. The value of the MedAssistAI application as a tool supporting the delivery of comprehensive health information and treatment guidelines has been confirmed, suggesting its potential to improve the effectiveness of patient education processes in high-pressure healthcare settings. Patients demonstrated greater confidence in their knowledge and were not hesitant to ask additional questions, positively influencing communication between patients and medical staff. These observations underscore the need for further research on the use of artificial intelligence-based applications to improve communication and effectiveness of patient health education in emergency departments.
No fundings
Aleksandra SZYMCZYK (, Poland), Robert KRION, Klaudia KRZYZANIAK, Dominik PLAZA, Mariusz SIEMINSKI
00:00 - 00:00
#41134 - The impact of Beirut explosion on the mental health of Lebanese healthcare providers. A scoping review.
The impact of Beirut explosion on the mental health of Lebanese healthcare providers. A scoping review.
Introduction. Lebanon has been struggling with repetitive crisis, starting with the economic collapse in 2019, then the Covid-19 outbreak, and the August 4 Beirut Blast. This has made the population susceptible to psychological consequences. Our study aims to assess the psychological disturbances of the Lebanese healthcare providers in response to Beirut blast. Methods. Electronic databases search was conducted. A total of 21 manuscripts were included in this report. Results. Different psychological presentations were reported among the healthcare workers. The prevalence rates of burnout are 37.2% as disengagement and 51.5% as exhaustion. Similarly, feelings of heaviness, fear, exhaustion, and anxiety were reported. Around 60% of healthcare workers had moderate to severe stress and half of them had moderate to severe anxiety and depression. In addition, 44% were at high risk of developing post-traumatic stress symptoms. Discussion. Lebanese healthcare workers have endured major psychological traumas in the last years. Awareness campaigns about mental health is needed and training sessions should be conducted among healthcare workers.
Dr Mariana HELOU (Lebanon, Lebanon), Fadi EL TERS, Kaissar YAMMINE
00:00 - 00:00
#41712 - The impact of early use of echocardiography performed by non-cardiologist in patients with chest pain - the ENDEMIC study.
The impact of early use of echocardiography performed by non-cardiologist in patients with chest pain - the ENDEMIC study.
Background: Echocardiography is well-established method in management of chest pain at Emergencydepartment (ED). However, evidence on the optimal scope of the examination and the education of the examiner is scarce. Early point of care echocardiography (POCE) by ED physician can speed up the diagnostic process compared to echocardiography performed by dedicated specialist, at the cost of a higher risk of misdiagnosis.
Purpose: Primary objective was to assess the impact of POCE on length of stay on emergency department (ED). Secondary objectives were to evaluate the impact of POCE on time to revascularization and on the accuracy of the diagnosis at the initial examination.
Methods: ENDEMIC study is a prospective, randomised, open-label single centre study. Prior to enrolment, physicians without any previous experiences with POCE were educated according to BSE standard level 1. Patients examined for chest pain of uncertain etiology were enrolled into the study and randomised in even-odd manner for POCE within 90 minutes or for usual management. In all patients the length of ED stay, time to coronary angiography and accuracy of working diagnosis.
Length of ED stay was defined as time form first contact of the patient with ED to the moment when the patient physically leaved the ward. Time to revascularization was retrieved from patient´s medical records and confirmed by telephonic visit. A working diagnosis was considered accurate if it shared both pathophysiological mechanism
and diagnostic criteria with the final diagnosis. All POCE examinations were recorded and revised by certified echocardiography specialist for errors.
Results: The study was early terminated after enrolment of 150 patients, because main objectives were met. The use of POCE resulted in a significant shortening of both time of decision (138.0 [68.5−230.5] min vs. 252.0 [165.5−304.0], p=0.000004) and length of ED stay (209.0 [143.5−260.0] min vs. 271.0 [206.5−336.0],
p=0.0002. Moreover, in patients indicated for further follow-up, utilisation of POCE resulted in better concordance of working and final diagnosis: 91,6 % vs. 50 %; RR = 1.83 (1.104-2.565); p = 0.0063. Benefits of POCE were most pronounced in patients requiring hospitalization.
Conclusion: The study showed that echocardiography performed by sufficiently educated physician in patients with acute chest pain results in significant shortening of ED stay along with improved diagnostic accuracy.
Type of funding sources: Public grant(s) – National budget only - The work was supported by the Ministry of Defence of the Czech Republic “Long Term Organization Development Plan 1011” – Clinical Disciplines II of the Military Faculty of Medicine Hradec Kralove, University of Defence, Czech Republic (Project No: DZRO-FVZ22-KLINIKA II) - I
agree that this information can be used as submitted and made available online within the context of ESC research projects
TrialRegistrationNumber : Echocardiography by Non-cardiologist in Early Management of Patients With Chest Pain (ENDEMIC); NCT05306730
Martin JAKL (Hradec Králové, Czech Republic), Karel MĚDÍLEK, Jiří NOVÝ, Radek PUDIL, Petr GRENAR, Jaromir KOCI, Jan VANEK
00:00 - 00:00
#42016 - The impact of iron deficiency on hemodynamic status in patients with acute heart failure: a preliminary study via USCOM device.
The impact of iron deficiency on hemodynamic status in patients with acute heart failure: a preliminary study via USCOM device.
INTRODUCTION:
Iron deficiency (ID) is one of the major causes of anaemia, particularly in patients with heart failure (HF). It is estimated that more than 80% of patients with acute heart failure (AHF) have an ID condition.
Considering this strong correlation between ID and HF and the possibility of improving patient’s clinical conditions through the intravenous administration of ferric carboxymaltose, the latest ESC (European Society of Cardiology) guidelines (2021) underline the need to evaluate periodically the state of anaemia and ID in patients with HF.
The monitoring of laboratory parameters goes hand in hand with the need for an appropriate hemodynamic evaluation. Until now, pulmonary artery catheterization (PAC) remains the gold standard for assessing cardiac output (CO), although its placement is complex and not without risk. In this context, a new non-invasive monitoring system is introduced, the USCOM (UltraSound Cardiac Output Monitor), which allows for rapid estimation of CO and parameters of preload, afterload, cardiac inotropism and systemic perfusion.
METHODS:
The adopted methodology consists of two steps: a first one for validating the USCOM device, and a second one aiming to assess a possible correlation between the USCOM parameters and the value of transferrin saturation (TSAT), the main parameter to define the ID condition. For this purpose, two populations were enrolled: fifteen left-ventricular-assist device (LVAD) patients for validating the USCOM device, and further fifty-five AHF patients for testing the correlation between their ID condition and hemodynamic status.
RESULTS:
The results of the validation of the USCOM device in LVAD patients showed a good correlation between the cardiac output (CO) value measured with USCOM and that detected by the LVAD, with a statistical significance of less than 0.01 (p-value: 0.00033).
In the next step, fifty-five AHF patients were divided in two different groups depending on the USCOM data acquisition method (aortic or pulmonary). Then, the hemodynamic data of each group were analysed in function of their TSAT value (adopted cut-off: 12%). In the aortic acquisition group, patients with TSAT ≥ 12% showed a reduction in preload, CO, contractility, and oxygen delivery (DO2) parameters, with an increase in afterload parameters compared to patients with lower TSAT. In the pulmonary acquisition group, no significant differences in hemodynamic status related to TSAT were observed.
CONCLUSION:
Analysing our data, the USCOM device represents a good system for CO monitoring. Furthermore, the device provides some parameters that allow to study the hemodynamic status changing of patients in function of their TSAT level that one is often not easily available in all emergency departments.
Future evaluations include increased statistical sampling and predictive studies of TSAT values based on USCOM parameters.
Claudia CARELLI (Naples, Italy), Riccardo CANDIDO, Flavio CESARO, Paola IERANÒ, Maria Paola URSI, Cristiano AMARELLI, Claudio MARRA, Mario GUARINO
00:00 - 00:00
#42139 - The Impact of the Frailty at the Front Door Service in the Emergency Department.
The Impact of the Frailty at the Front Door Service in the Emergency Department.
Integrated Care promotes new ways of working together to improve the quality of care delivered by people who work in our health care system. The Integrated Care Programme for Older Persons (ICPOP) is works with Acute Hospitals and Community Healthcare Organisations at local to drive a coordinated patient centred approach. Frailty at the Front Door is in keeping with Slaintecare, provides right care, in the right place, at the right time. Frailty is defined as a medical syndrome with multiple causes and contributors; characterised by diminished strength, endurance and reduced physiological function that increases an individual’s vulnerability for developing increased dependency and/or death. The Irish Longitudinal Study on Ageing (TILDA) suggests that up to 25% of older people in Ireland are living with frailty while a further 45% are at risk of being pre-frail when a frailty index measure is applied.
The Frailty Front Door (FFD) service at Portiuncula University Hospital (PUH) commenced in September 2021 as part of the Enhanced Community Care programme (ECC) to improve and expand community health services and reduce pressure on hospital services. The team is a multidisciplinary team in the ED. Following a holistic assessment, factors contributing to falls and frailty are identified and measures are put in place to promote a safe recovery.
This retrospective study reviewed the impact of the FFD service in ED at PUH in 2023. A total of 1568 patients were identified for assessments by the FFD within weekday working hours on the patient information system. 731(282 GCA’s, 449 ISARS) patients were assessed by the team. 837 were not assessed; 224 unwell, 216 unable to assess due to a lack of space, 114 were robust, 95 could not be assessed when there was FFD staff shortage, 52 had their needs met and another 45 were recently assessed by the FFD team whilst 18 others awaited in patient assessments. 362 patients presented with a history of more than 2 falls in the last 12 months, 317 lived alone, 256 were on more than 10 medications, 139 were known to have cognitive impairments and 132 had a 4AT score of greater than 4. Patients had Clinical frailty scores of CFS 4(190), CFS 6(153), CFS 5(144), CFS 3(132), CFS 7(67) were recorded. Patient were assessed in the context of home help at presentation; 338 were not in receipt of it/did not require it, 204 had sufficient help, 83 had insufficient, 19 had approved help but not in place, 69 were not in receipt of help/required it. Patients were subsequently referred along the integrated pathway: 47 to public health nurse, 40 to community physiotherapist, 39 ICPOP team, 13 community OT, others to the community diabetic, interventional, memory and podiatry clinics.
Front Door (FFD) Team has supported discharge of patients assessed, by referring them to community services. For a service to be consistent adequate staffing is required. Overcrowding of ED impact valuable services like FFD. It was noteworthy that the service recognised those patients at risk and directed community services to them.
Lisa OLOONEY (Galway, Ireland), Stella HANNON, Tracy MCCARTHY, Kiren GOVENDER
00:00 - 00:00
#42299 - The impact of transportation mode on STEMI patients in Emergency Department: A retrospective single- center analysis.
The impact of transportation mode on STEMI patients in Emergency Department: A retrospective single- center analysis.
Abstract:
Background
In patients with ST elevation myocardial infarction (STEMI), timely management is critical in the Emergency Department (ED). Emergency Medical Services (EMS) have a pivotal role in facilitating access to care and reducing the rate of mortality among STEMI patients. Therefore, the present study aimed to evaluate the mortality rate among STEMI patients underwent percutaneous coronary intervention (PCI) and its association with the mode of transportation.
Methods
This retrospective, observational cohort study included all STEMI patients who presented to ED at KSUMC and underwent PCI from July 2020 to February 2024. Data collection focused on socio-demographic information, risk factors, comorbidities, mode of arrival, key performance indicators and 30 days mortality rate. Kolmogorov-Smirnov test, Mann-Whitney Test, Cox-proportional hazard regression were used to examine difference in variables. A p value ≤ 0.05 was considered statistically significant.
Results
A total of 234 STEMI patients were included, categorized based on their mode of transportation. Of these, 81 (34.6%) arrived by ambulance, while 153 (65.3%) arrived by private car. The 30-day mortality rate was 14.8% among ambulance-transported patients. The median length of stay in the ED was 38.0 minutes (range: 15-73) for the ambulance group and 44.0 minutes (range: 20-77) for the private car group.
Conclusion
No statistically significant difference was observed in the mortality rate between the ambulance and private car groups (P = 0.158). Ambulance transportation significantly reduced the time to first ED physician contact. However, it did not correlate significantly with a shorter Door-to-cath time compared to private vehicle transport.
N/A
Reema ALHUSSEIN (Saudi Arabia, Saudi Arabia)
00:00 - 00:00
#41358 - The Impact of variants on effective cause of death in SARS-CoV- 2 positive patients admitted to hospital from the Emergency Room.
The Impact of variants on effective cause of death in SARS-CoV- 2 positive patients admitted to hospital from the Emergency Room.
The Impact of variants on effective cause of death in SARS-CoV- 2 positive patients admitted to hospital from the Emergency Room
Background: The evolution of SARS-CoV-2 has led to the emergence of various variants, each with a distinct influence on patient outcomes, influencing both disease progression and mortality rates. Variants such as Alpha, Delta, and Omicron have drawn significant attention due to their heightened transmissibility and clinical consequences. Nonetheless, the advent of vaccines has been crucial in mitigating the severity of COVID-19 complications. This study examines the intricate interplay between SARS-CoV-2 variants and the cause of death in patients admitted to the hospital via the emergency room (ER).
Aim of the study: The primary outcome was to assess whether the Omicron viral variant affected the number of patients who died from Covid-19 among patients admitted to the hospital positive for SARS-CoV-2. The secondary outcome was to analyse the clinical, laboratory, and demographic characteristics of individuals who died with SARS-CoV-2 infection in different waves of the pandemic.
Materials and Methods: A monocentric observational study was conducted on a retrospective cohort of 228 patients who were admitted through the ER of Policlinico Agostino Gemelli Hospital between March 2021 and January 2022 and subsequently died with confirmed SARS-CoV-2 positivity. Patients were categorized into three groups based on the prevalent SARS-CoV-2 variant during their admission: pre-Delta (March to June 2021), Delta (July to December 2021), and Omicron (January 2022). We ascertained whether the cause of death was directly attributable to the SARS-CoV-2 infection or not. Clinical, laboratory, and radiological data were collected using the hospital's electronic health records.
Results: The cohort (mean age 78 ± 12 years; 54% male) included 112 individuals who had been in the intensive care unit for at least one day, 16 patients (7.04%) without comorbidities, and 75 of them (33%) with more than four chronic conditions, such as diabetes, hypertension, ischemic heart disease, atrial fibrillation, cancer, and neurological disorders. All patients required oxygen therapy, with 109 patients (48%) needing orotracheal intubation. Deaths attributed to COVID-19 involved respiratory failure, multiorgan failure (MOF), or acute respiratory distress syndrome (ARDS). Furthermore, 38 patients (16.6%) passed away from non-COVID-19 illnesses, including cancer, myocardial infarction, intestinal occlusion and perforation, various forms of shock (haemorrhagic, cardiogenic, or septic from non-pulmonary sources), cerebral haemorrhages, and hepatorenal syndrome.
Conclusions: A marked increase in non-viral causes of death was observed among patients with the Omicron variant and confirmed SARS-CoV-2 diagnosis compared to those infected with other variants.
Michela NOVELLI (Roma, Italy), Francesco FRANCESCHI, Gloria ROZZI, Giacomo SPAZIANI, Gianluca TULLO, Giulia PIGNATARO, Giuseppe MERRA, Andrea PICCIONI, Veronica OJETTI, Marcello CANDELLI
00:00 - 00:00
#42155 - The importance of interprofessional education via simulation for students on placement in the emergency department.
The importance of interprofessional education via simulation for students on placement in the emergency department.
Background
‘Interprofessional education (IPE) occurs when two or more professionals learn about, from and with each other to enable effective collaboration and improve health outcomes’ (Framework for action on IPE and collaborative practice, World Health Organisation). Whilst multidisciplinary team (MDT) practice is advocated by university courses, actually partaking in IPE whilst at university is very rare, and doing it with simulation is a new concept in medical education. Interprofessional relationships are especially important when looking after an acutely unwell patient. The aim of this study was to explore the impact of introducing IPE via simulation with medical and nursing students on their placements in the Emergency Department (ED).
Methods
In October 2023 we began a pilot study to introduce IPE in the ED for third year medical and nursing students. Sessions involved introducing the concept of IPE and why it is important, and also highlighted the roles of people within the MDT and different communication methods. We then ran a simulation scenario with the students and afterwards reflected on the importance of interprofessional relationships.
We gave the students a questionnaire to fill in before and after the session to grade the following four aspects; their understanding of the role of others in the MDT when looking after an acutely unwell patient, their understand of their own role within the MDT when looking after an acutely unwell patient, how comfortable they felt communicating with people from the MDT with different roles and levels of experience, and whether they had a realistic understanding of what it will be like to work in an MDT looking after an acutely unwell patient. We used this feedback to calculate whether students found the session useful or not.
Results
The results from the questionnaire showed that all of the students who took part had a better understanding of both their role and the role of others in the MDT when looking after an acutely unwell patient, they were more comfortable communicating with people from the MDT with different roles and levels of experience, and gained a more realistic understanding of what it will be like to work in an MDT looking after an acutely unwell patient. 100% of students agreed or strongly agreed that more sessions like this would be valuable in preparing them to work with other health care professionals in an acute setting.
Discussion and Conclusions
The results from this study show how beneficial IPE is for students whilst on their placement in the ED. Students feel it gives them a better understanding of the roles withing the MDT and improves their communication with different health care professionals. There is also a desire for there to be more sessions like this to improve interprofessional relationships further. Our aim is to involve both universities to make IPE training a compulsory part of the curriculum for nursing and medical students. We also want to expand this further by including colleagues training to be paramedics and pharmacists.
Trial Registration: non-clinical work and no patients involved
Funding: This study did not receive any specific funding
Ethical Approval and informed consent: Not needed.
Emily STOKES (, Virgin Islands, British), Ashok VAGHELA, Debra PAISLEY-BRIGHT, Emma EDWARDS
00:00 - 00:00
#41376 - The importance of mental health in out-of-hospital care.
The importance of mental health in out-of-hospital care.
We were called to SUMMA 112 for a 56-year-old patient who had suffered a cardiorespiratory arrest with no apparent precipitant. On arrival, advanced cardiopulmonary resuscitation protocol was performed on the patient, but to no avail and a judicial commission was activated. Husband and son at home. It was decided to activate the SUMMA 112 emergency psychologist.
SUMMA112 of the Community of Madrid has the only Unit of Psychologists for first intervention in out-of-hospital emergencies and emergencies in the National Health System. When they are activated, they go to the place of the intervention as an emergency. On arrival, they already know by telephone all the data obtained about the: number of patients to be attended, age, situation generated, emotional impact and added dangers.
Their activation criteria are:
1. ATTENTION TO THE ALERTER OR PERSONS PRESENT AT THE INTERVENTION.
• Attention to bereavement and support in communicating bad news:
• Self-mythical behaviour and/or Suicide in progress.
• Multiple Victim Incidents (MVI).
• Violence or mistreatment (especially of vulnerable groups: minors, the elderly, physical or intellectual disability and/or criteria of dependency).
• Person with a decompensated mental disorder.
• In all those cases that the Duty Manager so requires.
2. CARE FOR INTERVIEWING STAFF: Provide on-site psychological support intervention for intervening staff in the following situations:
• Aggression or violence towards professionals during the intervention.
• Accident in a SUMMA112 care resource.
• Individual or group psychological effects following highly emotional or particularly difficult incidents.
In the case of intervening personnel, contact with all members of the team is always considered. Contact can be made by telephone and then the presence of the psychologist on site can be assessed.
We wanted to find out whether this service exists in other European countries, and if so, how it works and how it differs from ours.
We have been struck by the fact that it is not widely used, especially outside hospitals, although it is true that in the wake of the COVID-19 pandemic it is spreading to the rest of Europe.
In the event of an emergency, the first responders are usually the police, community leaders, religious leaders and social workers nearby (Manaois et al., 2020; Stene et al., 2022). However, in most cases, these individuals are unable to provide the necessary psychological care (Stene et al., 2022). Mental health specialists, including medical psychologists, psychiatrists, nurses, social workers and counsellors, often intervene later (Ha, 2020).
In this regard, in China, a study was conducted to train emergency psychologists (Wang).
And we find it remarkable that in Portugal (Cunha, 2008) however, emergency psychologists go further by following up with them up to 3 months after the incident.
We believe that this is a very useful tool in the mental health of our patients that we must promote and continue to promote in SUMMA 112.
Miriam UZURIAGA MARTIN (Madrid, Spain), Vanesa Natalia ISAAC, Cristina BARREIRO MARTINEZ, Blanca GUERRERO MOÑÚS, Noemi SOTO TOSTADO, Marta HUEDO JIMÉNEZ, Maria REDONDO LOZANO, Pilar VARELA GARCÍA
00:00 - 00:00
#42343 - The Incidence And Prognosis Of Stroke In Young Subjects Admitted To Emergency Departments.
The Incidence And Prognosis Of Stroke In Young Subjects Admitted To Emergency Departments.
Introduction: The incidence of stroke among young adults has increased since the 1980s, which has occurred alongside increasing prevalence of vascular risk factors and substance abuse among youth. Behavioral risk factors such as physical inactivity, excessive alcohol consumption and smoking.
Objective: The objective of this study was to analyze the incidence and prognosis of stroke in people under 55 years of age.
Materials and methods: This is a prospective study, including 453 patients whose age is less than 55 years, admitted to 22 Tunisian centers for treatment of a stroke. Patient evaluation was done on day 30 after inclusion by telephone call in order to note the rate of patients who had complete follow-up, complications and mortality occurring within one month and the modified RANKIN score.
Results: Among the 453 patients included, a male predominance was observed. The average age of the patients included was 43.7 ± 9.3 years (41.1 ± 7.2 in women and 46.3 ± 4.9 in men). More than eighty percent of patients were diagnosed as ischemic stroke, 8.3% as intracerebral hemorrhage, and 3.9% as transient ischemic attacks. Smoking was the main risk factor linked to poor prognosis and higher mortality.
Conclusion: The identification of risk factors encourages patients to modify their lifestyle for long-term prevention in order to improve their prognosis.
Achraf KOOLI, Rym YOUSSEF (SOUSSE, Tunisia), Hajer YAAKOUBI, Rahma JABALLAH, Nada BOUJELBENE, Wael ZOUARA, Imen TRABELSI, Houda BEN SALAH, Asma ZORGATI, Lotfi BOUKADIDA, Riadh BOUKEF
00:00 - 00:00
#40947 - The interactions predictability of halogenated anesthetics with myoglobin and hemoglobin in fire smoke poisoning patients.
The interactions predictability of halogenated anesthetics with myoglobin and hemoglobin in fire smoke poisoning patients.
Background: smoke intoxication is a central event in mass burn incidents, and toxic smoke acts at different levels of the body, blocking breathing and oxygenation. The majority of these patients require early induction of anesthesia to preserve vital functions. Methods: We applied quantum chemical calculations with optimized molecular geometries to obtain the molecular electrostatic potential and the vibrational spectrum of myoglobin and hemoglobin as essential elements of their binding to hydrochloric acid from fire smoke. In the second stage, we studied the influence of hemoglobin and myoglobin blockade by hydrochloric acid in an interaction model with gaseous anesthetics. Results: Through docking analysis, we observed that hemoglobin creates more stable complexes with anesthetic gases than myoglobin. Intoxication with gaseous hydrochloric acid produces conformational and binding energy changes of anesthetic gases to the substrate (both the pathway and the binding site), the most significant being recorded in the case of desflurane and sevoflurane, while for halothane and isoflurane, they remain unchanged. Conclusions: According to our theoretical model, the selection of anesthetic agents for patients affected by fire smoke containing hydrochloric acid is critical to ensure optimal anesthetic effects. In this regard, our model suggests that halothane and isoflurane are the most suitable choices for predicting the anesthetic effects in such patients when compared to sevoflurane and desflurane.
No applied
Luciana ROTARU, Flavius Nicusor TRUICU (Craiova, Romania), Mihai Alexandru BUTOI, Diana Carmen CIMPOEȘU
00:00 - 00:00
#40774 - The Leser-Trélat sign.
The Leser-Trélat sign.
A 61 year old Chinese lady with a background of a spinal cord tumour that was resected in 1982 presented to the Emergency Department and was diagnosed with severe pneumonia requiring ventilatory support.
On examination, multiple eruptive seborrheic keratoses were incidentally noted over her back, which had suddenly developed 3 years ago.
Computed Tomography noted a suspicious heterogenous 5.9cm uterine mass which correlated with raised serum CA-125.
These findings were suggestive of the Leser-Trélat sign in association with a gynaecological malignancy.
The Leser-Trélat sign is a rare dermatological phenomenon characterized by sudden, rapid onset of multiple seborrheic keratoses, which are non-cancerous skin tumors.
They occur in areas where seborrheic keratoses are not commonly found.
It is a red flag for underlying malignancy, and anyone who exhibits this should seek medical evaluation.
Anissa LYE, Anissa LYE (Singapore, Singapore)
00:00 - 00:00
#40273 - The management of anticoagulated patients with severe bleeding at the emergency department.
The management of anticoagulated patients with severe bleeding at the emergency department.
This EMCREG-International Europe Multidisciplinary Consensus Paper provides a systematic approach to the management of anticoagulated patients with severe bleeding at the emergency department. This Multidisciplinary Consensus Paper contains input from experts in Emergency Cardiovascular Care, Trauma Surgery, Hematology and Vascular Medicine, Neurology and Neurocritical Care, and Gastroenterology. When a patient treated with anticoagulants, such as warfarin, Factor IIa, and Factor Xa inhibitors, presents to the Emergency Department with life-threatening bleeding, achieving rapid and controlled haemostasis is critically important to save the patient’s life. Repletion and reversal management of the specific anticoagulants is described in detail. For patients on vitamin K antagonists the administration of vitamin K and repletion of clotting factors with Four-Factor Prothrombin Complex Concentrate (4F-PCCs) provides real time ability to stop the bleeding. For patients using a direct oral anticoagulant, specific antidote are necessary to reverse the anticoagulative effect. For patients receiving the thrombin inhibitor dabigatran, treatment with idarucizamab has been demonstrated to reverse the hypocoagulable state resulting in hemostasis. For patients receiving a factor Xa inhibitor (apixaban or rivaroxaban), Andexanet alfa is the indicated antidote in patients with major bleeding. Furthermore specific treatment strategies are discussed in patients using anticoagulants with a major traumatic bleeding, intracranial haemorrhage or gastrointestinal bleeding.
Barbra BACKUS, Barbra BACKUS (Rotterdam, The Netherlands)
00:00 - 00:00
#41519 - The medical mystery behind rats or reaction.
The medical mystery behind rats or reaction.
A 24 year-old male presented to the Emergency Department on a Monday afternoon with fever and swelling of his left elbow, forearm and thigh down to his foot which developed over 1 day. He was previously fit and well until 3 nights ago when he had diarrhoea and vomiting lasting 1 day before settling over the weekend. However, on Sunday afternoon he started feeling more lethargic and noted redness and swelling over his left elbow and forearm before having a 'tense' feeling spreading down his left thigh and calf in the evening. Upon waking up in the morning he felt numb in his left foot and was in severe pain all over his body. He now noticed a developing red rash and swelling over his right elbow when sitting in the Emergency Department. He is a builder who has been working on a farm the last few weeks with two more builders who were well in themselves.
On examination, he had generalised oedema, flushed appearance, a red tongue with a white streaks, **clear** lung fields and his abdomen was soft with mild suprapubic tenderness. Apart from a slight tachycardia of ***, all other vital signs were within normal range with a temperature of *** and a pain score of ***. His left lower limb was more swollen than the right and tender from mid thigh downwards with reduced sensation in his foot despite a palpable dorsalis pedis pulse.
The differentials considered at this point included **((sepsis, MOF))**, reactive arthritis, scarlet fever, septic arthritis and leptospirosis. He was started on broad-spectrum intravenous antibiotics, fluids and admitted. His bloods on Day 1 showed thrombocytopenia, acutely deranged liver functions, stage 1 acute kidney injury (AKI) and a CRP of 289. During his inward stay his platelet count picked up and CRP dropped to *****. He initially progressed to AKI stage 2 before eventually resolving completely. His skin had started peeling away at his palms and soles and he was commenced on Benzylpenicillin and Clindamycin for possible Streptococcus pyogenes following blood culture results ad consultation with Microbiology.
He had exploration and wound debridement done for his left arm by the Orthopaedic team. Ultrasound scans were done twice for his left leg which showed subcutaneous oedema, liquified complex collections and no signs of deep vein thrombosis so no interventions were done acutely. He was seen by Rheumatology for **** which were negative. He was screened and tested negative for HIV. **PCR for Lepto*** was sent.
Dodiy HERMAN, Sankhavi SATHIYAMOORTHIE (Shrewsbury, )
00:00 - 00:00
#41339 - The Prognostic Value of Serum Levels of Lactate Acid on Outcomes in Out-of-Hospital Cardiac Arrest Patients Undergoing Coronary Angiography.
The Prognostic Value of Serum Levels of Lactate Acid on Outcomes in Out-of-Hospital Cardiac Arrest Patients Undergoing Coronary Angiography.
Background: In out-of-hospital cardiac arrests (OHCA), prolonged systemic ischemia and subsequent low perfusion are linked to adverse outcomes. Elevated initial lactate levels often reflect ischemic injury, including myocardial ischemia. While coronary angiography (CAG) has shown to improve survival rates in patients with suspected cardiogenic etiology, predicting outcomes in these patients remains a challenge. This study investigates the prognostic significance of initial serum lactate levels during CPR on outcomes in patients undergoing CAG following OHCA.
Methods: We conducted a retrospective analysis of non-traumatic adult patients aged over 20 who underwent CAG post-OHCA at National Taiwan University Hospital and its affiliates from January 2017 to December 2023. We collected data from medical records, including demographics, pre-arrest conditions, EMS details, resuscitation events, and laboratory tests. Outcomes measured were survival and neurological status at hospital discharge. We evaluated prediction capabilities using the area under the receiver operating characteristic (AUROC) curve, with the optimal cutoff value determined by Youden's index. Multivariate logistic regression was used to assess if initial lactate levels during CPR were significantly associated with mortality and poor neurological outcomes (Cerebral Performance Category scale 3-5), with adjusted odds ratios (aOR) and 95% confidence intervals (CI) calculated.
Results: Out of 1,258 initially presumed cardiac-origin OHCAs, 390 were eligible for analysis after excluding those without CAG (n = 772) and those with incomplete blood data (n = 96). The mean age was 61 years, and 81% were male. Significant differences in serum lactate levels were observed between the survival (n = 208, 53.3%) and mortality (n = 182, 46.7%) groups (8.96 mmol/L vs 10.48 mmol/L), and between the favorable (n = 163, 41.8%) and unfavorable (n = 227, 58.2%) neurological outcome groups (8.64 mmol/L vs 10.41 mmol/L). Higher serum lactate levels during resuscitation were significantly associated with increased in-hospital mortality (aOR: 2.22, 95% CI: 1.29–3.76; p = 0.004) and unfavorable neurological outcomes (aOR: 2.67, 95% CI: 1.59–4.48; p < 0.001). The AUROC for predicting mortality was 0.64 (95% CI, 0.59–0.70), with a sensitivity of 0.58 and a specificity of 0.69. For predicting unfavorable neurological outcomes, the AUROC was 0.63 (95% CI, 0.57–0.68), with a sensitivity of 0.69 and a specificity of 0.57.
Discussion & Conclusions: Hyperlactatemia during CPR can be a prognostic indicator of both increased mortality risk and poor neurological outcomes in post-OHCA patients with presumed cardiac origin undergoing CAG. Measuring serum lactate levels may aid in early identification of patients at risk of poor outcomes and could potentially guide medical decisions during post-arrest care. Further large-scale external validation studies are warranted to confirm these findings.
Funding: This work was funded by the National Science and Technology Council (grant number: 112-2314-B-002-324).
Chun-Ju LIEN (Hsin-Chu, Taiwan, Taiwan), Yi-Ju HO, Jia-How CHANG, Jiun-Wei CHEN, Wen‑Chu CHIANG, Chien-Hua HUANG, Edward Pei-Chuan HUANG, Chih-Wei SUNG
00:00 - 00:00
#41848 - The Pulseless Disease: A Case Report and Review.
The Pulseless Disease: A Case Report and Review.
Takayasu’s arteritis is a rare autoimmune inflammatory disease of the large arteries and whilst it affects the aorta and its branches like the subclavian arteries that supply the arms, renal arteries to the kidneys, coronary arteries in the heart and carotid arteries in the head and brain. These arteries may become narrowed or blocked and is often referred to as “the Pulseless disease”.
This case report and literature review is of a 53 yr. old female patient immigrant from Pakistan with little English who self-presented to the ED with a productive cough with chest pains. She also complained of progressive dyspnoea at rest, fever tiredness and diffuse myalgia. Although she had been treated at a hospital previously for a rare disease and was on multiple medications, her medical records were not readily available. On examination she had no peripheral radial pulses and was systemically unwell
It mostly affects young people, primarily between the ages of 10 and 40 years. Although both sexes may be affected, 80-90 per cent of patients are female. It has worldwide prevalence, affecting all races and is thought to be more common in patients originating from the Far East, Japan and the Asian sub-continent. The initial symptoms are typically non-specific and may include one or more of malaise profound fatigue, fever, night sweats, weight loss, myalgia, arthralgia, rash. Other symptoms can include light headedness, shortness of breath, cramping pain in the arms, legs or chest on exertion. Carotidynia is found in approximately 25 per cent of patients. clinical examination most commonly detects decreased or absent pulses in the arms and less frequently in the legs. Bruits are heard over the neck, chest or kidneys indicating narrowed arteries. High blood pressure is commonly found.
As an autoimmune disease patient have an acute presentation of the disease process itself, side effects of the long-term medication or infections. Clinicians are often confounded by the constitutional symptoms, lack of peripheral pulses and bruits.
Treatment is aimed at improving symptoms and preventing further damage and scarring to the blood vessels and any acute disease. When there is active inflammation in the arteries, treatment is started with steroids, usually prednisolone, and often in combination with an immunosuppressant drugs. Those commonly used include methotrexate, azathioprine or mycophenolate. These drugs increase the effectiveness of steroid therapy and help to reduce the dose of steroids required. In patients with persistent or very severe disease, cyclophosphamide may be recommended. In recent years, for refractory disease, biologic therapies, including tumour necrosis factor inhibitors such as etanercept and infliximab have been used successfully, as has tocilizumab which targets interleukin-6. Drugs to lower blood pressure are often recommended. Statins are commonly prescribed to lower cholesterol and reduce the risk of heart disease. Low-dose aspirin may be prescribed to reduce the risk of a blood clot developing. The long-term prognosis is good. Approximately 20 per cent of patients will have a monophasic self-limiting disease however the disease follows a relapsing and remitting course.
Jasdev Singh Sra SOVINDER SINGH, Kiren GOVENDER (Galway, Ireland)
00:00 - 00:00
#40768 - The Relationship Between Focused Cardiac USG and Pro BNP in the Diagnosis of Acute Heart Failure.
The Relationship Between Focused Cardiac USG and Pro BNP in the Diagnosis of Acute Heart Failure.
Heart failure and its complications are a serious health problem with an increasing frequency of admission to the emergency department (ED), resulting in significant permanent damage and death. Rapid and differential diagnosis in the emergency department is very important in effective treatment and reduction of complications. With this study, we aimed to determine the place of FOCUS in the diagnosis of heart failure and it’s effectiveness in early diagnosis of heart failure in emergency room and to compare the effectiveness of FOCUS, serum proBNP levels and other diagnostic methods in diagnosis of heart failure and aimed to reduce the time in the emergency room by ensuring that patients with heart failure are diagnosed early in ED.
Material and Method: This study was planned as a cross-sectional, prospective clinical study, and after the approval of the Çukurova University Faculty of Medicine Ethics Committee, patients aged 18 years and older, who applied to the critical care unit of the ED of our university and were diagnosed with left heart failure, were included in the study. The heart failure classification according to the left ventricular ejection fraction in the ESC 2016 guideline was used to classify the patients. Sociodemographic data, vital findings and medical history of the patients, the signs and symptoms, laboratory findings, ECHO, ultrasonography (USG), electrocardiography (ECG) and radiographic findings were collected and recorded in the previously prepared study sheat. In this study,. Ejection fractions, left atrial diameters, left ventricular dilatations and inferior vena cava diameters were measured by focused cardiac ultrasonography.
Results: 38 patients were included in the study. The average age of the patients evaluated in the study was 70.34 ± 8.67 years, 26 of the patients (68.4%) were male and 12 were female (31.6%). Chronic medication was used in 97% (n = 37) of the patients. The most common complaint for admitting the emergency room was shortness of breath in 71.1% (n = 27) of patients. The most common physical examination finding in patients was 92.1% (n = 35) ral in the lungs. When the correlation relationship between the proBNP values and ECHO findings of the patients included in the study was examined, it was found that there was a statistically significant negative relationship between the ejection fraction and the proBNP values . When the ECHO findings of the patients included in the study were compared according to their BMI values, it was found that there was a statistically significant positive relationship between the body mass index (BMI) and the vena cava inferior (VCI) diameter. There was no statistically significant relationship between VCI diameter and collapse rates and proBNP values but statistically significant levels of VCI collapse rates were found to be <50% in patients with chronic renal disease or asthma / COPD.
Conclussion: Despite the presence of important findings in the diagnosis of heart failure such as wall motion disorder, right ventricular dilatation or VCI collapsibility, the lack of a significant relationship between proBNP level and these findings suggests that ECHO findings are our priority in diagnosis.
Fuat BELLI, Zeynep KEKEC (ADANA TURKIYE, Turkey), Ömer TASKIN
00:00 - 00:00
#41578 - The Rise in Glucagon-Like Peptide-1 Receptor Agonist Related Calls to Poison Centers: A Review of the National Poison Data System 2005-2023.
The Rise in Glucagon-Like Peptide-1 Receptor Agonist Related Calls to Poison Centers: A Review of the National Poison Data System 2005-2023.
Background
In 2005, the United States (U.S.) Food and Drug Administration (FDA) approved the first Glucagon-Like Peptide-1 Receptor Agonist (GLP-1RA) as adjunctive therapy to improve glycemic control in type 2 diabetes. In 2021, the FDA approved semaglutide for chronic weight management. We aim to characterize GLP-1RAs related calls to all U.S poison centers (PCs).
Methods
We conducted a retrospective review of the U.S. National Poison Data System (NPDS) between 2005 and 2023 for all GLP-1RA exposures. All 55 PCs covering the entire U.S. population submit, in near real-time, de-identified case data to NPDS after providing poison exposure management to callers from the general public and health care providers.
Results
During the study period, U.S. PCs handled 13,692 GLP-1RAs related calls, of which 12,451 were a GLP-1RA single substance exposures. In 2023, PCs received 4,414 GLP-1RA related calls, compared to 234 in 2014 (a twenty-fold increase over 10 years). Seventy three percent of exposures involved females (n=10,017). The main reasons for exposure were therapeutic errors (n=10,213; 75%), adverse drug reactions (n=1,222; 9%) and suspected suicide (n=557; 4%). Gastrointestinal symptoms, such as nausea (n=2,913; 23%), vomiting (n=2,515; 20%), and abdominal pain (n=593; 5%), and neurological symptoms, including central nervous system depression (n=191; 1.5%), dizziness (n= 563; 5%) and headache (n=495; 4%) were the most commonly reported clinical effects in single substance exposures. Hypoglycemia was reported in 431 cases (3.5%), Most single substance exposures were managed outside a healthcare facility (n=8.573; 69%), and hospital admission was reported in 5% of exposures (n=601).
Conclusions
PCs are well positioned to monitor trends in GLP-1RAs human exposures and associated adverse events and therapeutic errors. Based on available data, PCs can manage specific cases-types without referral to the hospital, preventing unnecessary healthcare utilization.
Rita FARAH, Abigail KERNS, Conner T. MCDONALD (Charlottesville, USA), Christopher HOLSTEGE
00:00 - 00:00
#42333 - The role of dispatcher in recognizing cerebrovascular incident.
The role of dispatcher in recognizing cerebrovascular incident.
The role of dispatcher in recognizing cerebrovascular incident
Introduction:
Working process in Medical Dispatch Unit (MDI) in Croatia is based on criteria based dispatch – Croatian Index of Emergency Call Receipt. All despatchers are proffessional healthwork employees. When answering the call dispatcher has to determine appropriate card, criteria and priority, and to rationally dispatch an appropriate medical team. Croatian emergency medical service EMS has two tier system – T1 (with doctor of medicine, emergency medicine technician and driver) and T2 ( two emergency medicine technicians).
In Croatia, as well as in Europe and the world, stroke is the second cause of death. Patient with transitory ischaemic attack (TIA) and easier stroke ( without consequential disability) have higher risk of reccurent stroke so the suspicion on TIA should be considered as emergency. TIA should be recognized so the treatment could be started as soon as possible.
Aim:
We wanted to find out the correlation between working diagnosis in field made by T1 and recognition of possible cerebrovascular incident ( TIA, stroke) by the dispatcher during received emergency call. We also wanted to find out correlation between field diagnosis and diagnosis in emergency department.
Methods:
We have retrospectively searched eDatabase Rinels in three month period in 2023 in Institute for Emergency Medicine Split Dalmatian County for International Disease Classification (IDC) Cerebrovascular Diseases I60-I64 and Transitory Cerebral Ischaemic Attack G45 as well as under what criteria in Index teams were dispatched to the field intervention, especially considering the use of Index card 25 – Consciousness Disturbances/Paralysis.
Results:
There were 215 patients with I60-I64 and G45 diagnosis, and dispatcher applied Index card 25 at 138 patients ( sensitivity 68,37%). Next criteria after card 25 where the field diagnosis was cerebrovascular incidence was card 05 – Unclear problem. They were all transported to Emergency Department (ED)in Clinical Hospital Centre Split. We analyzed 195 records of ED, data on 20 patients were not available. The diagnosis was confirmed at 77,43% . Better confirmation was at I60-I64 than at G45. Among 44 non-hospitalized patients we found 40,90% with I60-I64 and G45 ICD leaving ED.
Conclusion:
Dispatcher recognized possible cerebrovascular incident at 68,37% of later established working diagnosis I60- I64 and G45 ICD by emergency physician in field. The time from first call to transfer to ED was not significantly different at patients who were discharged alive or had a lethal outcome. Dispatcher training with re-listening of phone calls might improve sensitivity in recognition of possible cerebrovascular incidence with better adherence to standardized questions in Index.
Radmila MAJHEN UJEVIC, Ivan BRDAR (Split, Croatia)
00:00 - 00:00
#41873 - The role of point-of-care ultrasound at a rural hospital in northwest Tanzania: An ethnographic field study.
The role of point-of-care ultrasound at a rural hospital in northwest Tanzania: An ethnographic field study.
Background:
Access to medical imaging remains a significant challenge in resource-limited settings. According to the World Health Organization, one-half to two-thirds of the world’s population lacks access to diagnostic imaging. Point-of-care ultrasound (POCUS) is a growing field in high-income countries, with emerging evidence that it improves time to diagnosis and changes patient management in high-resource settings. Low- and middle-income countries currently using POCUS have also shown a positive impact on clinical care, but the quality of current evidence is low.
This study aimed to gain insight into the current use of POCUS and its future potential at a rural hospital in northwest Tanzania.
Methods:
Design: A six-week ethnographic fieldwork. We used participant observation to gain insight into the clinical setting, current POCUS use, local needs, barriers, and perspectives. The researcher actively engaged in daily hospital activities, observing and interacting with the participants.
Dates: September 13 to October 27, 2023.
Study setting: A rural hospital in northwest Tanzania. The hospital is one of the largest in the region, annually treating an average of 35,000 patients with 3,500 admissions.
Participants: Local medical doctors, assistant medical doctors, and clinical officers.
Researcher: The participant observation was conducted by a 6th year Danish medical student.
Results:
The hospital had an outdated, stationary ultrasound machine in the maternity ward. Two doctors performed basic obstetric and abdominal ultrasound examinations. The remaining medical imaging included an old X-ray machine.
We found great potential to further implement POCUS and improve the local doctors’ skills. However, we also identified several barriers to a POCUS implementation, including limited training resources, equipment costs, difficulty of maintaining skills, and a lack of a sustainable method to achieve quality assurance. Furthermore, we found a lack of local initiative and prioritization.
In addition to limited access to medical imaging, we observed multiple other challenges at the hospital. These included limited access to neonatal care, insufficient expertise in basic airway management, and inadequate interhospital transport services.
Finally, at the hospital we observed several failed charitable projects, including a new unused intensive care unit. These projects were all donated by high-income countries but were implemented without consideration for local needs and perspectives. None of the projects were initiated by the local staff.
Discussion and conclusion:
While there was great potential to further implement POCUS, several barriers were identified. These included limited financial and training resources, challenges in maintaining skills and ensuring quality assurance, as well as a lack of local initiative and prioritization. A successful implementation would require strong motivation and active engagement from the local staff. Furthermore, future POCUS initiatives should carefully consider local perspectives and address local needs without overshadowing other critical healthcare challenges. While the study was conducted at a single hospital, the findings are likely applicable to other hospitals within the region.
Trial registration: Not applicable.
Funding: The project received funding from a Danish commercial foundation (Poul Due Jensen’s Foundation). They had no role in designing or executing the study or interpreting, writing, or submitting the manuscript.
Ethical approval and informed consent: Ethical approvement not needed. An invitation letter from the hospital was obtained.
Camilla ULSØE (Aarhus, Denmark), Rasmus HERLØW, Joas John KYABONAKI, Stig Holm OVESEN, Søren Helbo SKAARUP, Jesper WEILE
00:00 - 00:00
#42178 - The role of the hacor score in determining the disposition of patients treated with non-invasive ventilation in the emergency department: a retrospective study.
The role of the hacor score in determining the disposition of patients treated with non-invasive ventilation in the emergency department: a retrospective study.
Introduction
Non-invasive ventilation (NIV) is routinely used to treat patients with acute respiratory failure (ARF) in the Emergency Department (ED) and outside the ICU. Several works list minimum standards for the use of NIV in a non-intensive setting, but we do not have established criteria to define where NIV can be safely performed after the initial management in the ED. The HACOR score is an easy-to-calculate tool and could be used to guide the disposition of patients treated with NIV in the ED. Our primary aim was to verify whether a HACOR score≤2 could identify patients treated with NIV who could safely receive ventilatory support in the general ward.
Materials and methods
This is a retrospective study, which included all non-COVID patients treated with NIV in the High Dependency Unit (HDU) of the University Hospital Careggi, from July 2021 to December 2022. Clinical and blood gas parameters were recorded upon admission and at least daily, selecting the worst respiratory performance during the 24 hours. The admission to the general ward was considered appropriate if, at the moment of the discharge from the ED, the HACOR score was ≤2 and it was possible to alternate NIV with conventional oxygen treatment or High-Flow Nasal Cannula (HFNC).
Results
We included 320 patients, mean age of 79 ± 11 years, 57% female; the average length of stay in our HDU was 2.8±3.0 days, median of 2 days. The most frequent presenting diagnoses were pneumonia (55%), heart failure/pulmonary oedema (48%), COPD exacerbation (39%), sepsis (14%), sometimes coexisting. Thirty-one percent of patients had hypoxemic respiratory failure, and 69% had hypercapnic respiratory failure. The disposition from our HDU was as follows: 10 patients (3%) were discharged to home, 13 (4%) deaths in HDU, 235 (79%) were transferred to the general ward, and 62 (21%) were transferred to the critical setting. At the moment of discharge from the ED, NIV was alternated with conventional oxygen in 81% of patients and one-third of patients employed HFNC to promote weaning from NIV.
Among the 62 patients admitted to the critical care setting, 19% underwent orotracheal intubation and 31% died. Among those transferred to the ordinary ward with an appropriate admission, no patient underwent orotracheal intubation and the in-hospital mortality rate was 7%. Among patients transferred to the ordinary settings with an inappropriate admission, none underwent intubation, and the mortality rate was 21% (vs 7% in appropriate admissions, p=0.004).
Based on our criteria, one-third of patients who spent 3 or more days in HDU could have been safely transferred to a general ward after only 48 hours.
Discussion and conclusions
Our criteria identified a population that, once transferred to a general ward, showed a low prevalence of adverse events. Based on the same criteria, a consistent proportion of patients could have been transferred to the ordinary ward within the first 48 hours. The HACOR score could represent a feasible tool to identify the most appropriate setting for patients treated with NIV in the ED.
This study did not receive any specific funding.
Ethical approval and informed consent: not needed.
Mattia VERSACE (Negrar di Valpolicella, Italy), Rudy MARCHETTI, Zaccaria GIANPIERO, Marta SILVESTRI, Rosarita LOFFREDO, Francesca FERRETTO, Bruna LUPO, Carolina COGOZZO, Francesca INNOCENTI
00:00 - 00:00
#41770 - The structure of civilian injured as a result of missile attacks in Ukraine.
The structure of civilian injured as a result of missile attacks in Ukraine.
Background: The full-scale war in Ukraine is characterized by constant rocket attacks on populated areas by the Russian military. This fact definitely indicates a violation of the rules of conventional warfare and is frankly terrorist in nature. As a result of missile attacks by ballistic and cruise missiles, the number of injured among the civilian population of Ukraine has increased significantly. In the first quarter of 2024, according to the regional Centers for Emergency and Disaster Medicine reports, the total number of victims among the civilian population was 3,114; 265 people died, including 16 children. Understanding the structure of the injured in combat will provide an opportunity to improve the work of the emergency medical care system.
Methods: The analysis was based on data obtained from statistical forms (110/o) filled out at the pre-hospital stage. The cases of rocket attacks in 2024, during which the number of victims was 10 or more civilians, were selected for analysis. In total, 234 forms where the information was filled in completely and correctly were selected. In addition to general data, the values of the Shock index were analyzed to understand the volume of blood loss and the level of the Revised Trauma Score (RTS) scale. The data obtained were statistically processed. We used STATISTICA software (“StatSoft, Inc.”, USA).
Results: The average age of the victims was 43.5±2.7 years (min - 4 months, max - 96 years). Among all the injured, 53% were women, 47% were men. The victims' average stay at the scene was 49.9±6.2 minutes (min – 1, max - 201). Among the group of victims, 23 people (9.7%) had an acute reaction to stress, 25 people (10.7%) had isolated injuries, and 186 (79.6%) had combined injuries.
The average value of the shock index was 0.92±0.07: up to 1 - 179 victims (76.6%), 1 to 1.5 - 26 victims (10.9%), and more than 1.5 - 29 victims (12, 5%). In the group of victims with a value of the shock index greater than 1, in 48 (86.7%), the cause of bleeding was penetrating injuries and open fractures (only in one case was recorded an isolated penetrating injury of the thigh, in others a combined injury), in 7 (13.3%) internal bleeding.
The average value of the RTS scale was 10.6±0.3: a value of 12 was determined in 159 victims (67.8%), a value of 11 in 15 victims (6.4), a value from 3 to 10 in 12 victims (19, 4%) and less than 3 in 15 victims (6.4%). All victims with a value of less than three had a combined injury with a craniocerebral component.
Discussion & Conclusions: The obtained data generally provide an understanding of the structure of trauma in civilians as a result of missile attacks. At the same time, it should be noted that the research group included victims who were in cities. We do not rule out that the data may change when analyzing the general array.
Vitaliy KRYLYUK, Halyna TSYMBALIUK (Ternopil, Ukraine), Maksym MAKSYMENKO
00:00 - 00:00
#42270 - The training of emergency medicine physicians in Greece regarding pediatric emergencies. A quality questionnaire filled out greek emergency medicine physicians through various hospitals in Greece.
The training of emergency medicine physicians in Greece regarding pediatric emergencies. A quality questionnaire filled out greek emergency medicine physicians through various hospitals in Greece.
ABSTRACT
Abstract
The purpose of this quality questionnaire is to assess the training of emergency physicians in pediatric emergencies, evaluate their ability to manage pediatric patients, and seek suggestions or desires for optimizing training in this area.
In Greece, emergency medicine has been a supraspecialty since 2020 and doctors can become emergency medicine physicians after two years of training and final examination or by completing the board-certified examinations regardless the official training process of emergency medicine.
Until present, there is a small population of emergency medicine physicians in Greece. Among them, the majority do not feel confident dealing with neither urgent nor critically ill pediatric patients and would like to participate in more educational and training programs specified on pediatric population.
Introduction
Emergency Medicine is a new concept in Greece. Since 2020, it has started as a supraspecialty of two years. Pediatric rotation is usually one to two months. Moreover, most of the doctors missed their pediatric training due to Covid era.
Greek doctors who have supraspecialised at emergency medicine often have to assess and treat pediatric patients, but in Greeks emergency departments the final consult and disposal are made by pediatricians.
Object
This is the first questionnaire that aims to appraise the level of training, expertise and needs of emergency medicine physicians in Greece with respect to pediatric emergencies.
Method
This questionnaire was sent by email to various emergency physicians who had accomplished their training in emergency medicine or were board certified emergency medicine physicians. The response rate was relatively high (70-80%). Participation in the survey was anonymous.
Results
Twenty one emergency medicine physicians participated in the survey.
Among other answers, it is of great interest that 90% stated that in the emergency department that they work, pediatricians are the primary doctors who assess and deal with the non critically pediatric patients, while they tend to participate more when the child is at a critical state (47,6%).
Additionally, there were various percentages and levels of confidence regarding the management of both critically and non-critically ill pediatric population among them. It is noteworthy that 9% feel very confident when the patient is critically ill and nearly 20% when the patient is more stable and non-urgent.
62% (n 13) of the doctors had additional training through various private seminars and only one of them did not had to pay for those but it was through the institution that worked at the present moment. All the participants expressed that if the seminars were free or compensated by the hospital or the government of health they would have participated at more or more frequently.
Finally, all the participants proposed and wished for more seminars, simulation labs, hands on courses and others in order to gain more skills, confidence and knowledge concerning pediatric emergencies.
Conclusions
Even though this questionnaire had a few participants, we can conclude that the training at pediatric emergencies for the emergency medicine in Greece has to be improved on multisectoral levels.
Anna DROKOU (Athens, Greece)
00:00 - 00:00
#41570 - The use of adenosine in ventricular tachycardia.
The use of adenosine in ventricular tachycardia.
SUMMA 112 was notified by a 67-year-old male, who came from the health centre with palpitations, sweating and sternal/epigastric tightness of one hour's duration. The health centre alerted SUMMA 112 due to an alteration in the ECG, tachycardia at 190 bpm. On arrival, the patient was pale, sweaty and generally unwell. Personal history of type II DM, dyslipidaemia, hypertension, ex-smoker (12 years ago).
We proceeded to explore and monitor the patient, blood pressure 134/88, two peripheral venous lines were cannulated. An electrocardiogram was performed showing regular tachycardia with wide QRS at 190 bpm, with LBBB morphology, good haemodynamic tolerance. Given the ECG of regular tachycardia with wide QRS, there was a doubt as to whether to cardiovert the patient electrically or pharmacologically, and given the haemodynamic stability we opted for adenosine. We doubted whether it was VT or pre-excited AF. We administered 6 mg of adenosine, and after administration of the medication we observed reversion to sinus rhythm at 110 bpm with narrow QRS, without alteration of repolarisation, some ventricular extrasystoles were observed, with parallel improvement of symptoms. On arrival at the hospital, the patient was asymptomatic, without chest pain, stable HD. No syncope, dyspnoea or symptoms compatible with CHF.
Following a literature review, it is known that there are different ventricular tachycardias and there are studies indicating that there is a type of adenosine-sensitive ventricular tachycardia (VT) that is due to cAMP-mediated triggered activity. It originates in the RVOT and occurs in patients with apparently normal hearts. Although according to Markowit's study using magnetic resonance imaging, they tested the hypothesis that adenosine-sensitive VT occurs in patients without structural or mild heart disease. Patients with idiopathic adenosine-sensitive VT comprise a heterogeneous group as assessed by MRI, with 70% demonstrating mild structural abnormalities. However, these findings are unlikely to be causally related to the tachycardia and the functional significance of these anatomical abnormalities is uncertain. On the other hand, according to Yeh SJ, right ventricular tachycardia is characterised by a QRS configuration of left bundle branch block, as was the case here.
According to Gupta , as most VTs are insensitive to adenosine. This is because adenosine does not affect VTs due to microreentry, macroreentry and increased automaticity. An exception to this, where adenosine is very effective, is VT due to cAMP-mediated triggered activity due to afterdepolarisations. These tachycardias originate in the outflow tracts and are induced by exercise or sympathetic arousal. Adenosine interrupts these tachycardias due to its antiadrenergic (cAMP-dependent) effects. In this case the patient described that he was exercising when the pain started.
In conclusion, this case would fall into this type of ventricular tachycardia that is sensitive to adenosine.
Noemi SOTO TOSTADO, Marta HUEDO JIMÉNEZ, María REDONDO LOZANO, Pilar VARELA GARCIA, Miriam UZURIAGA MARTÍN (Madrid, Spain), Vanesa NATALIA ISAAC, Cristina BARREIRO MARTÍNEZ, Blanca GUERRERO MOÑUS
00:00 - 00:00
#41550 - The value of Point-of-Care ultrasound in the early identification of post-MI mechanical complications. A case report of ventricular septal rupture/dissection.
The value of Point-of-Care ultrasound in the early identification of post-MI mechanical complications. A case report of ventricular septal rupture/dissection.
It is an indisputable fact that cardiovascular diseases (CVDs) are the leading cause of both morbidity and mortality worldwide, with the incidence of acute myocardial infarction (AMI) consistently increasing over time. Mechanical complications are one of the most severe complications of AMI; the ventricular septal rupture (VSR) even though it's rare, remains a devastating postinfarction complication. In the setting of AMI, the use of point-of-care ultrasound (POCUS) provides a non-invasive, real-time assessment of cardiac function as well as the benefit of early identification of VSR.
Patient presentation. A 63-year-old male, with a history of smoking, was presented to a primary health care facility due to chest pain started 7 days ago. The electrocardiogram revealed inferior myocardial infarction (MI) and he was transferred to a tertiary hospital for primary percutaneous coronary intervention (PPCI). Upon presentation to the ED, the patient looked critically-ill with clinical signs of hypoperfusion (cold, sweated extremities, oliguria, tachycardia and hypotension).
Initial work up. Repeated electrocardiogram confirmed the diagnosis of inferior MI. Bedside focused cardiac echocardiography was performed within the first 5 minutes of ED presentation. The findings were as follows: no pericardial effusion, left ventricular ejection fraction (LVEF) 40-45%, right ventricle dilatation and findings consistent with interventricular septum rupture/dissection. Sonographic findings of lung congestion were present. Initial lactate levels were 9.1 mmol/l.
Diagnosis and Management. Clinical presentation and echocardiographic findings were consistent with cardiogenic shock. Hemodynamic support with vasopressor infusion of noradrenaline at 10 mcg/minute intravenously was started. The Shock Team (emergency physician, interventional cardiologist and cardiac surgeon) was activated immediately and the patient was transferred directly to the cardiac catheterization laboratory within 20 minutes of ED presentation. Coronary Angiography revealed flush occlusion of the right coronary artery (RCA). Placement of intra-aortic balloon pump (IABP) was decided for short-term mechanical circulatory support. The patient died two hours later, during transportation to the operating room.
Conclusion.
Even though, VSR is a post-MI mechanical complication with high mortality, prompt identification can be life-saving and time-saving. In those patients, who are usually hemodynamically unstable, bedside point-of-care ultrasound performed by the treating physician, during ongoing resuscitation, is of paramount importance. Focused sonographic evaluation can add crucial information in order to facilitate immediate and targeted therapeutic interventions.
Christos VERRAS (ATHENS, Greece), Evmorfili DIALETI, Grigoris KARAMASIS, John PARISSIS, Effie POLYZOGOPOULOU
00:00 - 00:00
#41077 - THEY ARE IGNORING ME.
THEY ARE IGNORING ME.
Woman 55 years old independent for basic activities of daily living ap. diabetic.
She calls 112 complaining of general body pain, which has been going on for 1 hour and 30 minutes.
From the emergency and emergency coordination center we advise you to go to the health center by their own means.
After a short time he reiterates the call indicating that he cannot go to the health center. We suggest that the doctor from the health center go to the home and he tells us that he cannot because he has many patients waiting. Observing the delay, it is decided to send an ambulance to transfer to health center.
Upon the arrival of the ambulance they request help since they cannot see the patient well, the closest resource is the SVAE (advanced nursing life support).
Upon arrival at the SVAE patient with poor physical appearance, o2 saturation 95% BP 70/40 ECG regular rhythm narrow QRS heart rate 37 bpm, complete AV block ST elevation in II, III and AVF and in precordials from V3 to V6.
Advanced nursing life support requests the emergency coordination center by isochronous medical helicopter.
medical helicopter activates heart attack code for transfer to the nearest useful hospital by isochrons.
Upon arrival by helicopter of a hermodynamically unstable patient, a decision was made to perfuse norepinephrine and an external pacemaker.
Prior notice is given to hemodynamics and transfer to hemodynamics is accepted.
Conclusions
Anterior and inferior infarction with anterior descending and right coronary stenting.
Pilar VARELA GARCIA, Miriam UZURIAGA MARTIN (Madrid, Spain), Vanesa NATALIA ISAAC, Cristina BARREIRO MARTINEZ, Blanca GUERRERO MOÑUS, Noemi SOTO TOSTADO, Marta HUEDO JIMENEZ, Maria REDONDO LOZANO
00:00 - 00:00
#40878 - Thigh collection with septic shock and Point of Care Ultrasound.
Thigh collection with septic shock and Point of Care Ultrasound.
A 57 years old male who was a transit passenger presented with left posterior thigh pain and swelling for few weeks .He did not have any fever nor any other associated symptoms. His past medical history is relevant for Diabetes Melitus not on medication. He had a history of trauma where he slipped and fell on his back around 2 months ago, after which he developed multiple lower back and gluteal collections that were operated and drained .On examination, patient was found to be hypotensive and tachycardic. There was a large fluctuant, tender left posterior thigh swelling with no overlying skin changes, there was anothere right posterior thigh open wound from previous drainage with minimal pus at the edge, no pus discharge expressed on milking of wound. Relevant laboratory work-up revealed raised C-reactive protein (CRP) (299.4 mg/L), high white cell counts (20.2 x 103/mL ) with predominant neutrophilia (18.2x 109/L) and elevated creatinine (217 micromol/L).
Due to prolonged symptoms and unstable condition of the patient , point of care ultrasound (POCUS) was used to assess the nature of the swelling quickly.POCUS showed deep-seated intramuscular fluid collection with dense internal echoes within the deep tissue of the left posterior thigh and was thought to represent either an abscess or a hematoma likely. Following this, the surgical team was alerted and got involved in the care. Who took him to OR the same day for Insicion and drainage and found ‘’Large pocket of abscess extending from the greater trochanter down to a level above the knee. Pocket is deep to the hamstring muscle with no muscle necrosis.
POCUS is a valuable and convenient equipment to use in ambiguous cases. It is non invasive , extremely safe and does not use radiation. It provides real time imaging , which makes it a good tool for reassessing if there is any change in patient’s condition. POCUS facilitates early diagnosis of cases which are unstable to be sent to CTs .
Ghazala FAHEEM (Doha, Qatar), Tahir SHAHZAD
00:00 - 00:00
#40718 - This disease is killing our diabetic youth and most clinician don't know about it.
This disease is killing our diabetic youth and most clinician don't know about it.
Background / Introduction:
Diabulimia (DB) is the intentional omission or reduction of insulin administration in a patient with insulin-dependent diabetes mellitus (IDDM) and coexisting eating disorder in the attempt to reduce or avoid weight gain. It is a disease almost exclusively of young women with a high mortality rate. Many of these patients go undiagnosed despite of multiple contacts with the healthcare system, mainly in the Emergency Department (ED). Without adequate treatment, patients go in an accelerated path to suffer all the consequences of poorly controlled IDDM & the eating disorder, leading to significant morbidity and premature death.
Objectives:
Case presentations to raise awareness of this disorder in the emergency medicine and critical care community by providing clinicians the necessary tools to identify these patients early in their disease course, so they can be promptly referred and thus prevent complications and improve outcomes.
Method / Description:
Medical literature search using the keywords: Diabulimia, eating disorder, anorexia, bulimia, insulin dependent diabetes, diabetic ketoacidosis and refeeding syndrome. Social medial survey of emergency clinicians with more than 1500 responses.
Result / Outcomes:
It is estimated that between 20-30% of girls and up to 40% young women with IDDM have experienced diabulimia since their diagnosis was made. The combined mortality rate of IDDM with an eating disorder can be as high as 35% annually. Despite of its high mortality, diabulimia remains underdiagnosed. When surveyed, only 1% of emergency physicians have heard the term, treated a patient with or had a lecture on Diabulimia; and just 3% feel comfortable or somewhat comfortable diagnosing or screening for eating disorders.
Conclusion:
Diabulemia has the highest mortality of any psychiatric disorder, and higher than many conditions we treat in the ED including acute coronary syndrome and pulmonary embolism, and yet we are missing the opportunity to help these patients. Our job is to cast a wide net and refer patients with IDDM for psychological evaluation who are suspected of having an eating disorder, anxiety or depression, especially after their first episode of diabetes related complications, regardless of BMI or prior psychiatric diagnoses. The old mantra still applies: The fact that you haven’t seen it, doesn’t mean it hasn’t seen you!
N/A
Dr Adan ATRIHAM (Houston Texas - USA, USA)
00:00 - 00:00
#42194 - Three Unusual Presentations of Infectious Spondylodiscitis.
Three Unusual Presentations of Infectious Spondylodiscitis.
Introduction: Infectious spondylodiscitis is an infection of the intervertebral disc and vertebral bodies. It can be associated with epidural involvement or paravertebral abscess. The most isolated pathogen is Staphylococcus aureus. We present three cases illustrating diagnostic challenges.
Case 1: A 58-year-old diabetic patient with a 30-year previous pulmonary tuberculosis presented to the emergency department with a five-day history of back pain treated with corticosteroids. On examination, the patient complained of burning sensation during urination, fever, and paravertebral muscle spasm in the lumbar spine. He had elevated inflammatory markers, and urine cytobacteriological examination was negative. Abdominal CT scan revealed bilateral perirenal fat infiltration. Given the negative findings, magnetic resonance imaging (MRI) showed infectious spondylodiscitis at L5-S1. Blood culture and vertebral biopsy were positive for Streptococcus spp. The patient responded favorably to antibiotics.
Case 2: A 72-year-old patient with a history of adenocarcinoma of the lower rectum treated for two years presented with fever and torticollis. He had elevated inflammatory markers. MRI revealed cervical spondylodiscitis at C4-C5, C5-C6, and C6-C7 with epidural involvement and micro-epidural abscesses. Infection workup isolated Streptococcus agalactiae from vertebral biopsy. The patient responded well to antibiotics.
Case 3: A 68-year-old patient with a history of diabetes, coronary artery disease, and cholecystectomy presented with right hypochondrial pain and fever. Laboratory tests showed elevated inflammatory markers. Abdominal CT scan did not reveal any intra-abdominal infectious focus but showed bone lysis at the ninth and tenth dorsal vertebrae. MRI revealed extensive dorsal spondylodiscitis from the sixth to the tenth dorsal vertebrae. Despite an exhaustive infectious workup, including discal-vertebral biopsy, bacterial documentation was inconclusive. The decision was made to initiate anti-tuberculosis and anti-staphylococcal antibiotics based on presumptive evidence: positive tuberculin skin test and lymphocytic exudative pleural fluid. The patient showed favorable clinical and laboratory evolution.
Conclusion Spondylodiscitis is a rare and challenging diagnosis. It should be suspected in cases of vertebral pain even in the absence of fever. These cases highlight the complexity of the diagnostic process and the importance of MRI in diagnosis.
Saloua HOUIMLI (la Marsa, Tunisia), Sarra AKKARI, Nessrine YAHYAOUI, Wiem DERBALA, Mohamed ASSADI, Fatma HEBAIEB
00:00 - 00:00
#40330 - Thrombotic Storm Presenting with Synchronous Myocardial Infarction, Stroke and Bowel Ischaemia: A Review of Management Strategy.
Thrombotic Storm Presenting with Synchronous Myocardial Infarction, Stroke and Bowel Ischaemia: A Review of Management Strategy.
We describe the first known case of a simultaneous myocardial infarction, stroke, and bowel infarction, likely precipitated by a thrombotic crisis. A 72-year-old was found drowsy and unresponsive in his parked car. An electrocardiogram done on presentation revealed an acute inferoposterior ST-elevation myocardial infarction (STEMI) and slow atrial fibrillation (AF). A Computed Tomography Brain (CT Brain) was done to rule out a stroke which returned normal. The preliminary diagnosis was cardiogenic shock and slow AF secondary to a Killip 4 acute inferoposterior STEMI and sinoatrial node infarction, complicated by lactic acidosis and hypoactive delirium. The patient was intubated and sent for catheterisation which revealed a complete occlusion of his right coronary artery. Post-procedure, he suffered from two episodes of pulseless electrical activity but managed to obtain return of spontaneous circulation (ROSC). Post-ROSC, the patient was noted to have a blown right pupil and underwent a repeat CT Brain which revealed an acute left insula and M2 ischemic stroke. On retrospective review, it was noted that subtle findings of the stroke were already present in the initial CT scan. Repeat blood tests showed an uptrending serum lactate. A CT Mesenteric Angiogram was done in view of concerns of ischemic bowel, which revealed multiple infarcts in his spleen, kidney, and intestines. A degree of bowel infarction was likely to have been present on presentation as well, explaining the initial raised lactate levels. The patient subsequently passed away approximately two days after initial presentation. Cases of thrombotic storm often present critically unwell and are challenging to diagnose and treat. It is essential that physicians be cognizant of the possible presentations, clinical considerations, and management considerations. In this paper, we present recommended management for such patients, based on time of presentation. Further research is recommended to design a robust, evidence-based management strategy.
Wenjian CHAN (Singapore, Singapore), Timothy Xin Zhong TAN, Arjun THOMPSON, Ponampalam R
00:00 - 00:00
#41454 - Thrombotic thrombocytopenic purpura - the great masquerader.
Thrombotic thrombocytopenic purpura - the great masquerader.
Brief clinical history
A 50-year-old female initially presented to our emergency department with right sided facial, arm and leg weakness and numbness. On examination she was found to have no objective neurological signs. CT head was normal and a TIA clinic referral done as advised by the tertiary centre stroke team. She was safety netted and discharged. She reattended the following night, now with left arm and leg weakness, blurred vision, husky voice, headache, and vomiting. A CT venogram was normal, ruling out venous sinus thrombosis given the new headache and visual disturbance.
Initial blood results showed platelet count of 19, haemoglobin (Hb) of 100, LDH 673, reticulocyte count 172.5. Coagulation profile was normal. Blood film also showed reduced platelets. A diagnosis of thrombotic thrombocytopaenic purpura (TTP) was made. No other bleeding or bruising was identified. She was transferred to a local tertiary centre where she underwent a total of three plasma exchanges and started on high dose methylprednisolone. She recovered well and was discharged on a tapering dose of oral prednisolone.
Misleading elements
A common presentation in the emergency department of stroke like symptoms with limb weakness, slurring of speech and visual disturbance but no initial discernible weakness to examination in the first instance.
No blood test reports during the first attendance as the sample haemolysed and discarded, likely due to the extremely low platelets.
Absence of classical TTP symptoms like bruising or bleeding resulting in an atypical presentation of a rare, life-threatening haematological condition.
Helpful details
Repeat bloods were taken which showed a further drop in platelets to 13 whilst in the department. Blood tests should always be checked before a final management plan.
High index of suspicion with presentation of episodes of neurological dysfunction not consistent with specific stoke regions and negative imaging, especially in younger patients.
Differential and actual diagnosis
Actual - Thrombotic thrombocytopenic purpura (TTP)
Differential – Stroke, hemiplegic migraine, ITP, DIC
Educational and/or clinical relevance
TTP is an acute life-threatening haematological disorder caused by disseminated microthrombosis of the microvasculature, utilising the platelets inappropriately leading to consumption thrombocytopaenia as well as end-organ ischaemia. The classic pentad of Thrombotic thrombocytopenic purpura (TTP) characterised by microangiopathic haemolytic anaemia, thrombocytopenia, neurological symptoms, renal failure and fever; but is seen in less than 5% of patients. The most common presenting symptoms are in fact GI upset (69%), weakness (63%), bleeding or purpura (54%), major neurological finding (stroke, seizure or coma, 41%), minor neurological finding (headache or confusion, 26%), fevers (10%). The overall incidence rate is 2.2 per million per year, frequently in women with median age at presentation being 43 years. If left untreated, it will have an almost 100% mortality rate but with treatment through plasma exchange this can be reduced to 4-7%. TTP is a rare but important differential to consider in younger patients presenting with stroke like symptoms and negative radiology. This case therefore highlights the importance of a comprehensive analysis of the presenting symptom as well as all investigations provided to reach a definitive diagnosis.
Rajesh THANASINGH, Abbie RANDALL (London, United Kingdom), Abbie RANDALL
00:00 - 00:00
#41443 - Thyroid Breathtaking.
Thyroid Breathtaking.
Woman, 90 years old, with history of toxic multinodular goiter under propylthiouracil, presented with dyspnea and dysphagia for solids
and liquids. On objective examination, no nodules were palpated, but multiples of these confluents were identified on ultrasound.
Computed tomography of the neck was performed for anatomical characterization, showing a large multinodular goiter
diving with several nodular formations. The largest nodule located in the upper third of the left lobe measuring 8 cm. The same caused
marked compression and deviation of the esophagus, trachea and larynx. After multidisciplinary discussion, it was considered that there was no
surgical conditions, so comfort measures were initiated with the support of the palliative care team.
Mariana FARINHA (Torres Novas, Portugal), Eduardo CARDOSO, Vila Nova CARLOS, Ricardo GOMES, Maria Isabel BESSA, Ana Sofia MARAVILHA, Rita CORREIA, Abílio GONÇALVES
00:00 - 00:00
#41401 - Time for a reality check! - A tale of mismatch between salary and inflation for Emergency Physicians.
Time for a reality check! - A tale of mismatch between salary and inflation for Emergency Physicians.
Background:
Doctors’ salaries in UK have not kept up with inflation over the last decade. This in fact had prompted the unprecedented extreme step of industrial action by medical workforce with multiple strikes over the winter period of 2023-24. We wanted to see what the salary matched to inflation is in comparable health systems.
Methods: This is a survey of six countries comparing the existing Emergency Physician (EP) salaries to those from about a decade back. We calculated the % change and obtained the inflation figures over same period in respective countries to show the net effect.
Results:
Country Average EM consultant pay 2012 (US dollars) Average EM consultant pay 2022 (US dollars) Change% Inflation
2012-2022 Net Gain
USA 250,000 373,000 33% 36% -3%
Canada 220,000 298,000 26% 21% +5%
UK 124,000 148,000 16% 37% -21%
Australia 154,000 260,000 41% 26% +15%
New Zealand 160000 180,000 11% 20% -9%
Republic of Ireland 200,000 273,000 27% 8% +19%
Discussion: Salary is one of the most important factors that form part of the work compensation, and this is often a major predictor of career and sustainability choices. This has been ignored over time in UK for a considerable period impacting the medical workforce. It is clear that EP consultant salaries have increased in comparable economies, but the most significant mismatch seems to have been taken by the UK EP’s. Although consultants in UK have agreed recently to Government proposal of up to 12% equivalent rise in their salaries over 2 year (2023-24) that would still leave us 9% worst off factoring in inflation.
Conclusion: It is evident that medical workforce shortage is compounding the increasing demand on the already strained healthcare which is overheating the system towards a melting point. Drastic steps must be taken now to implement innovative and non-orthodox ideas for a long overdue catch-up with market forces i.e., workforce planning and renumeration. It is time for a reality check!
NA
Imran ZAKRIA (Manchester, ), Thomas CHERI
00:00 - 00:00
#41431 - Timely management of patients with suspected neutropenic sepsis in emergency department.
Timely management of patients with suspected neutropenic sepsis in emergency department.
Background: Neutropenic sepsis is a potentially fatal condition and requires immediate treatment before further deterioration occurs. The main aim was to analyse the time frame in management of neutropenic sepsis in Oncology patients presenting to Emergency care to identify delays which can be remedied.
Methods: This retrospective study was carried out in two district general hospitals in the Shropshire county of United Kingdom of which 10% of the total population are living with and beyond cancer. One of the hospitals has an on-site Oncology unit and physical inpatient reviews can be arranged. Patients above the age of eighteen attending the Emergency Departments between 1 April 2023 and 31 July 2023 were identified and triaged following which they were streamlined for prompt clinical assessment. The timelines for an emergency clinician review, prescription of treatment after identifying the possible focus, administration of treatment and referral to Oncology services were assessed to identify points of delay.
Results: Of the 66 symptomatic patients who were triaged over the four months, 29% were seen by a clinician, 24% were prescribed antibiotics and 9% received antibiotics within an hour. 18% were seen by a clinician, 20% were prescribed antibiotics and 27% received the antibiotics within one to two hours of being triaged. 20% were reviewed by a clinician, 24% had antibiotics prescribed and 26% had them administered within two to four hours of triage. In 17% of the overall presentations, the oncology nurse was contacted for further review directly from emergency care. Of the total cohort who received treatment as suspected neutropenic sepsis, 14% were truly neutropenic with an absolute neutrophil count of less than 0.5 x 10^9/litre.
Discussion and Conclusions: As per national (NICE) guidelines, the 'Sepsis Six' care bundle should be initiated within the first hour of presentation to medical care in patients undergoing anticancer treatments and having fever as their main, and sometimes only, symptom. Our research showed that one-third of such patients received treatment as per the national guidelines and one-sixth of them were referred directly to specialist services from the emergency care. Some limitations identified in our research were the lack of documentation of timings of prescription and administration of antibiotics, the considerably large numbers of patients attending these emergency departments, the lack of isolated treatment spaces which are crucial in managing patients with suspected neutropenic sepsis as well as deficiency of in-department availability of broad-spectrum antibiotics needed in the context of Penicillin allergy, like Aztreonam.
In conclusion, we recommend educating key staff members (triage team) in addition to placing a dependable trust protocol to ensure that patients arriving at the emergency department are risk-stratified using a focused checklist, reviewed promptly by a clinician and commenced on treatment early to ensure they receive antibiotics within one hour of their presentation. A multidisciplinary stakeholder meeting will take place with the relevant specialities to discuss the implementation of this local policy. This will be continually reviewed at trust clinical governance meetings to assess its impact on patient management and outcome.
Our study is registered with the Shrewsbury and Telford Hospital NHS Trust and the audit number is 5578. This study did not receive any specific funding and ethical approval was not required.
Sankhavi SATHIYAMOORTHIE (Shrewsbury, ), Nabina BHATTARAI, Dodiy HERMAN
00:00 - 00:00
#41963 - Timely troponin test for chest pain patients - the red troponin card.
Timely troponin test for chest pain patients - the red troponin card.
Background
Worcester Royal Hospital ED experiences trolley occupancy of over 400% daily with chest pain as a common presenting symptom. Given the potential for ACS to cause significant morbidity and mortality, ensuring a high level of suspicion for this diagnosis and performing timely Troponin-I tests is imperative to ensure prompt treatment. In addition to the diagnostic benefits, this test also plays a crucial role in reducing the time from a patient's arrival to their disposition. Subsequently reducing the number of patients breaching the 4hr ED waiting time target. This project was also triggered by a previous Troponin-I audit in 2022 which revealed an average discharge time of 14hr 07mins.
Material and Methods
We conducted a quality improvement project involving two PDSA cycles. Data from each cycle was collected through clinical audits of patients presenting with chest pain requiring Troponin-I. The parameters assessed included the time from assessment to first troponin, second troponin, and the time of discharge. In cycle 1 the audit was carried out following the education of ED staff members on the 1-hour troponin test guideline. In cycle 2 the Red Troponin Card was given to patients in the ED waiting room and for patients attending via Ambulance, it was handed-over to the staff managing them. Following patient assessment, collaboration between patients and staff was encouraged to record the time of the 1st and 2nd Troponin-I. The data from this was collected between 24/04/23 – 10/06/23.
Results
Post implementation of the first intervention; Education in PDSA1. The data collected showed an average discharge time of 7hrs. Once the red troponin card was introduced in PDSA2, the discharge times for patients progressively decreased to an average of 5hrs 54mins at the end of the 7th week.
Conclusions
The red troponin card is an easy but effective tool in utilizing highly sensitive Troponin-I in investigating and management of patients with chest pain. As a result, it can reduce overcrowding and increase bed availability within the ED. Finally, it also promotes good collaboration between staff and patients, and for the patients, active involvement in their healthcare helped alleviate anxieties whilst waiting.
Angel ACHESE (Worcester, United Kingdom), Raja IQBAL, Urooj MUSTAFA, Sachin SEKHSARIA
00:00 - 00:00
#42028 - To err is Human to learn is Excellence.
To err is Human to learn is Excellence.
Harm from medication errors occurs in all countries. Much can be learned from the analysis of medication errors with the support of confidential error-reporting and learning systems. Organisations with these systems are better placed to protect patients, educate healthcare professionals and support institutions to prevent medication errors and implement safer medication practices as noted in the Salamanca Declaration. The Irish Medication Safety Network was established in 2007, with the principal aim of improving patient safety with regard to the use of medicines. The National Medication Safety Programme is one of the priority safety programmes within the HSE Quality Improvement Division for improving quality works with patients, healthcare professionals and organisations to reduce patient harm associated with medicines or their omission.
This study is a qualitative review of reported medication safety incidents at Portiuncula University Hospital in 2023 on the National Incident Management System (NIMS). These incidents were then compared to 2022 and analysed to the medical type error groups antimicrobials, central nervous system medicines, anti-thrombotic and analgesics. Incidents were analysed for root cause and then provided recommendations for quality improvement.
366 medication incidents reported in 2023, similar to 373 incidents reported in 2022. Whilst reporting was consistent in 2022, there was a high level of reporting in Q1 of 2023 and dropped significantly in Q4. The most common problem documented was omitted/delayed dose(90); wrong dose/strength(78); incomplete/ inadequate medication(60); wrong frequency(40) and wrong drug(38). The ratio of near miss incidents for 2023 was 1:1.1 compared to 1:1.2 in Q4 of 2022, 1:1.8 in Q3 2022 and 1:3.5 in Q2 of 2022. There were three incidents of errors leading to injury requiring medical treatment. These included the administration of penicillin to a patient with documented penicillin allergy, an adverse drug reaction post intravenous administration of a proton pump inhibitor and penicillin and the delay in therapy initiated for a patient due to a change in the prescribing system. The most common incidents by medication type for 2023 were antimicrobials; CNS drugs; Anti-thrombotic and analgesia. The stage at which medication errors were noted mostly in prescribing 69%; administration 28%; supply/ordering/transport 1%; preparation/Dispensing 1% and storage 0.5%. Incidences of high risk included clozapine omission, the administration of penicillin to a patient with documented allergy status and the omission of oral anticoagulants on discharge. The ratio of near miss reporting to actual incidents was 1: 1.1. Incidents analysed to root cause included lack of Prescriber knowledge of treatment regimes and dosing variations, lack of clear communication within teams where drug and doses were not clarified, the lack of access to a complete medical record, duplicate prescribing and pharmacodynamic interactions, not reviewing the drug durations, incomplete documentation, administration times and allergy documentation.
There was a high level of incident reporting at PUH including good near miss: incident ratio, indicating a good safety culture. The medication safety programme and results should be used to inform and educate all stakeholders. The programme at PUH is effective and highlights areas for improvement and addressed in a multidisciplinary manner.
David WALSH, Kiren GOVENDER (Galway, Ireland)
00:00 - 00:00
#42050 - Tokyo Guidelines’s performance with acute cholangitis among Emergency Department patients.
Tokyo Guidelines’s performance with acute cholangitis among Emergency Department patients.
Background and importance:
Acute cholangitis is a disease with a high mortality rate. It is important to start the right treatment quickly to improve prognosis. The Tokyo Guidelines 2018 have in selected populations proved a high diagnostic accurancy to identify patients with cholangitis but the diagnostic accuracy among unselected patients in the Emergency Department is unknown.
Objectives:
This study investigates the diagnostic discriminatory ability of the Tokyo Guidelines 2018 criteria regarding presence of inflammation and affected liver parameters as a guide to proceed with imaging diagnostics to diagnose acute cholangitis among unselected adult ED patients.
Design, settings, and participants:
This study was a register-based, multicenter, cohort study of all ED patient visits in the Region of Southern Denmark. The cohort included patient visits collected from five EDs between January 1, 2016, and March 20, 2018. Identified inflammation ( fewer and/or increased CRP) and affected liver parameters ( at least one) was used as the diagnostic exposure, and a hospital discharge diagnosis of acute cholangitis was used as gold standard.
We calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive and negative log likelihood ratios.
Results:
We investigated 202.881 ED patient visits who had blood test performed at arrival to the EDs, median age 65 years.
We found 19.816 patient visits, who fulfilled the two basic Tokyo Criteria, and a total of 440 (2,22%) patient visits with a cholangitis hospital discharge diagnosis. The two Tokyo Criteria had a sensitivity of 85,1%, specificity of 90,4%, PPV of 2,2%, and a NPV of 99,96%. The positive likelihood ratio was 8,9. The negative likelihood ratio was 0,16.
The 30-day mortality for patients with cholangitis was 15%.
Conclusion:
The two basic Tokyo Criteria have a high diagnostic accuracy among unselected adult ED patients, which makes it relevant to use in the ED as guidance for further imaging diagnostic to confirm a diagnosis of acute cholangitis. The high negative diagnostic value provides a safe rule out strategy regarding a diagnosis of acute cholangitis.
Christina WILLUMSEN, Amalie SCHNELL, Annmarie LASSEN (Odense, Denmark), Stig LAURSEN
00:00 - 00:00
#41734 - Toll-like receptors: biomarkers to discriminate bacterial and viral infection in ED patients.
Toll-like receptors: biomarkers to discriminate bacterial and viral infection in ED patients.
Background:
Toll-like receptors (TLRs) are a class of proteins that play a key role in the innate immune system by early recognition of pathogen invasion. Expression patterns of TLRs have the potential to discriminate between bacterial and viral infection. Thus, we aim to study the characteristics of circulating TLR mRNA levels in patients presenting to the ED with infection.
Methods:
Patients aged 18 years or above, presenting to the ED with infection were recruited in the Prince of Wales Hospital in Hong Kong. Blood samples were collected and buffy coat was extracted. Circulating mRNA levels of TLR2,3,4,5,7,8 and 9 in the buffy coat were measured by real-time PCR. Area Under the Curve (AUC) of Receiver Operating Characteristic (ROC) analyses were performed for predicting the presence or absence of bacterial infection.
Results:
Among 37 patients recruited (median age 70 years old, 51.4% male), 29 had confirmed pathogens. Of 29 patients with detected pathogens, 17 had bacterial infections and 12 had viral infections. Higher mRNA levels of TLR3 and TLR7 were found in patients with viral infection than those with bacterial infection. No differences were observed in TLR2, 4, 5 and 9 mRNA levels between bacterial and viral infections. However, TLR8 mRNA levels in buffy coat were very low. The Areas Under the Curve (AUC) of TLR2, 3, 4, 5, 7 and 9 to discriminate bacterial and viral infection was 0.73, 0.74, 0.59, 0.60, 0.89 and 0.58 respectively. The combination of TLR3, 7 and 9 showed a promising AUC of 0.93 (0.75 to 0.99).
Discussion and Conclusions:
Our results suggest that TLR expression patterns can potentially discriminate between bacterial and viral infection. TLR expression profiles could provide information to help physicians to decide whether to initiate antibiotic treatment or not.
Trial Registration: No intervention
Funding: This study did not receive any specific funding
Ly LEUNG, Kkc HUNG, C CHO, Ca GRAHAM (Hong Kong, Hong Kong)
00:00 - 00:00
#41870 - Torticollis mimicking a spinal epidural abscess: a booby trap to remain vigilant for.
Torticollis mimicking a spinal epidural abscess: a booby trap to remain vigilant for.
Brief clinical history:
A 55-year-old male, without significant medical history, presented himself at the Emergency Department (ED) with complaints of neck pain for two days. The clinical exam did not withhold red flags and the patient was diagnosed with torticollis and discharged with adequate analgesia. Despite treatment, the pain intensified. He consulted his general physician 6 days later who performed a full blood analysis and ordered a CT of the cervical spine. Ct scan could not identify any pathology, but blood results showed an inflammatory blood panel. He was referred back to the ED.
The patient’s vital parameters were within normal limits, his cervicalgia was still present with questionable nuchal rigidity without any neurologic deficit. Viral testing yielded negative results, while inflammatory blood markers were confirmed. Additionally, urinary analysis showed pyuria. A comprehensive Ct scan of the thorax and abdomen did not reveal any definitive source of infection.
After re-evaluating the cervical CT, the emergency physician noticed miniscule air bubbles in the epidural space at the C3-C4 level dorsally. These findings raised suspicion for a spinal epidural abscess (SEA) measuring 5,6 mm. The radiologist confirmed this diagnosis and treatment was started with Ceftriaxone and Metronidazole. Subsequently, the patient was admitted to the department of neurosurgery.
An MRI scan confirmed the presence of the abscess and showed a skip lesion at the T8-T10 level, with adjacent spondylodiscitis on both levels. After a thorough neurosurgical evaluation, a conservative approach utilizing antibiotics was chosen and in coordination with the in-hospital infectiologist a switch to Cefazolin and Vancomycin was made. Cardiac ultrasound and PET CT ruled out hematogenous spread. The patient remained hospitalized for 17 days.
At discharge, a complete clinical and biochemical remission was obtained, without neurological deficit. A six-week course of Moxifloxacin was initiated. Blood culture identified multi-sensible Staphylococcus Aureus. Despite extensive investigation, no definitive infectious source could be identified.
Discussion:
A SEA is a rare but potentially devastating infection with an insidious presentation. SEA can result from hematogenous dissemination (50%), contiguous spread (30%), direct inoculation (15%) or idiopathic factors (20%). Neurological decline can occur rapidly, emphasizing the importance of early diagnosis. Delayed treatment (seen in up to 75% of cases requiring multiple presentations) may lead to paralysis or even death (1-15%). SEA’s clinical presentation can be insidious, and early diagnosis is challenging. Classical features include back pain, fever, and neurological deficit. However, only a minority of patients exhibit all three features.
Surgical exploration is considered the benchmark treatment for SEA. Non-surgical management can be attempted selectively. Controversy exists regarding whether SEA should be managed as a surgical emergency due to its uncertain course. Surgery combined with antibiotics is recommended for cases with neurological impairment. Nonoperative management carries a risk of failure, especially in cervical spine involvement (failure rate 10-49%, morbidity to 22%).
Conclusion:
Prompt diagnosis and proper management are crucial to prevent complications and achieve a cure. As an emergency physician, maintaining a broad perspective and carefully assessing all aspects of the clinical and biochemical puzzle is essential for successful management.
Herbert MERTENS (Aalst, Belgium), Katleen DEVUE, Katrien VAN LIERDE, Dewolf PHILIPPE
00:00 - 00:00
#41959 - Toxic epidermal necrolysis (Lyell's syndrome) : case report.
Toxic epidermal necrolysis (Lyell's syndrome) : case report.
INTRODUCTION : Lyell syndrome, also known as toxic epidermal necrolysis, is a very rare but potentially fatal skin condition. It is characterized by a severe skin reaction that can result in significant loss of the epidermis, the top layer of the skin, as well as damage to the mucous membrane. This condition is often triggered by an allergic reaction to a drug, although in rare cases it can be caused by a bacterial or viral infection. Symptoms may include a severe rash, redness and pain, as well as high fever. Hospitalization in an intensive care unit seems to be necessary in the majority of cases as the prognosis is life-threatening.
CLINICAL CASE : We report the case of Mrs. MS, 56 years old, who presented to the emergency room for a generalized tonic-clonic seizure that lasted 5 minutes and gave way spontaneously. After eliminating a metabolic and organic cause, the patient was put on an anticonvulsant treatment with carbamazepine as the drug of choice. The patient started to develop skin lesions on the face, thorax, upper and lower limbs, she was reconsulted after 15 days for extension of the lesions with installation of a brutal dyspnea. At the initial examination: a temperature of 38.7 on the respiratory level: arterial oxygen saturation was 86% on room air The respiratory frequency was 16 cycles per minute, auscultation : free she had an oedema of the uvula with a hoarse voice. On the hemodynamic level: blood pressure at 11/07 heart rate at 110 bpm and warm extremities. on the neurological level: a Glasgow score of 15/15 intermittent pupils with no sensory-motor deficit. the patient had erythematous lesions on the forehead, both cheeks, both legs and feet. echymottic lesions on both forearms and hands. purpuric spots on the neck and abdomen. on the biological level : leukocytes: 15160 hemoglobin: 10,2 platelets: 157000 glycemia: urea: 10 creatinine: 98 natremia: 127 kalemia: 3,7 chloremia:102 CRP :56 cbeu : negative ECG: no abnormalities. chest x-ray: no abnormalities. the diagnosis of lyell's syndrome was made in view of the fever, the recent medication, the extensive skin lesions and the respiratory and hemodynamic repercussions without the presence of another etiology. The patient was put in an intensive care unit, oxygen therapy via a nasal mask, refilling with lactated ringer, repeated nebulizations of adrenaline, hydrocortisone intravenous with a dressing of the lesions with a monitoring every hour. The evolution was marked by the weaning of the oxygen after 3 days, a disappearance of the odema of the uvula after 7 days with stability of the lesions and stop of the extension.
DISCUSSION: A study carried out at the Sfax University Hospital (1) on 34 cases of toxidermia following carbamazepine intake showed an average age of 46 years in these patients, with a predominance of females, a symptom onset period of between 15 and 120 days and an average hospitalisation period of 15 days, with only one case developing a lyell's syndrome, the outcome of which was fatal following septic shock.
Neila MAAROUFI, Youssef ZOUAGHI, Houcem ZAMIT (Sousse, Tunisia)
00:00 - 00:00
#41819 - Toxicokinetics, in Vivo Metabolic Profiling, and Tissue Distribution of Chlorfenapyr in Mice.
Toxicokinetics, in Vivo Metabolic Profiling, and Tissue Distribution of Chlorfenapyr in Mice.
Background
Chlorfenapyr is a novel broad-spectrum insecticide widely used in China, derived from natural pyrroles derivative produced by Streptomyces app.. It acts as a pro-insecticide and is converted to the active metabolite, tralopyril, wich is a mitochondrial oxidative phosphorylation uncoupler in insects and experimental animals, leading to disruption of ATP synthesis and subsequent death. Clinical understanding of chlorfenapyr poisoning comes mainly from case reports describing its insidious, delayed and highly lethal nature. Unfortunately, there is a lack of information on the toxicokinetics, metabolism and tissue distribution of orally administered chlorfenapyr, as well as measurements of tralopyril.
Method
In this study, we investigated the metabolic profile, toxicokinetics and tissue distribution of chlorfenapyr and tralopyril after oral administration (45 mg/kg) in mice using ultra-high performance liquid chromatography (UPLC), Q-Exactive plus mass spectrometry and tandem mass spectrometry (MS/MS). The UPLC-Q-Exactive plus-MS data revealed 23 metabolites in plasma, urine and faeces, which were mainly formed by dealkylation, oxidative dechlorination and methylation.
Results
Toxicokinetic results demonstrated the rapid conversion of chlorfenapyr to tralopyril after administration, and the half-life (t1/2), area under the curve (AUC) and the peak concentration (Cmax) values of tralopyril were significantly higher than those of chlorfenapyr (P＜0.05) in vivo. The AUC for chlorfenapyr and tralopyril in plasma after administration were 322.58 ± 93.00 μg/L*h and 15912.77 ± 3891.94 μg/L*h, respectively. The t1/2 was 2.35 ± 1.63 h and 5.39 ± 0.75 h and the Cmax was 223.04 ± 39.43 μg/L and 4212.48 ± 795.81 μg/L for chlorfenapyr and tralopyril, respectively.
Discussion & Conclusions
Tissue distribution experiments confirmed that, compared to chlorfenapyr, the metabolite tralopyril had a longer half-life, a lower clearance and a wider distribution in different organs and tissues. It was also able to cross the blood-brain barrier, suggesting a potential association with brain lesions. In conclusion, a sensitive and rapid UPLC-MS/MS analytical method was established for the detection of chlorfenapyr and tralopyril. This study provided valuable metabolism, toxicokinetics and tissue distribution information, contributing to future risk assessment and forensic identification in cases of chlorfenapyr poisoning.
This is a fundamental study, thus, trial registration free.
Aihua PENG, Yu CAO, Xinjie XIANG (Chengdu, China, China)
00:00 - 00:00
#42007 - Tracheal Rupture After Trauma: A Successful Surgical Management.
Tracheal Rupture After Trauma: A Successful Surgical Management.
Blunt or penetrating trauma can cause tracheobronchial injury (TBI), an uncommon and potentially fatal injury. There is a lack of data to support the optimal course of treatment, which can involve surgery or conservative measures. The surgical care of a 40-year-old male patient who had a severe tracheal laceration is described in this case study as being successful. This section includes information on the warning signs and symptoms, preferred imaging modalities, treatment plan reasoning, and common complications. The authors hope to raise awareness about how to appropriately manage these patients and draw attention to the characteristics that should trigger suspicions of this potentially deadly traumatic injury through this case study.
A 40-year-old male was brought to the Our Emergency Department after a blunt trauma, in which he hit the bough accidentally. On admission, the airway was patent, respiratory and hemodynamic parameters were normal and the Glasgow Coma Scale was 15. Bilateral cervical and thoracic subcutaneous emphysema and a tracheal midline blunt injury with air leak stood out in the physical examination.
On his laboratory examination,only leukocytes level was high,13,000 g/dl, other parameters were normal.
Thoracic CT(Figures 1-2) revealed In the skin-subcutaneous regions and next to the muscle planes, subcutaneous emphysema spreads to the lower abdomen, measuring about 2 cm in width. There's a suspicious appearance of tracheal rupture in the trachea at the T2-T3 level anteriorly and at the 9 o'clock position right before the tracheal bifurcation, together with a broad pneumomediastinum appearance.
The right hemithorax displayed a broad pneumothorax line that was seen to stretch the mediastinum and lung parenchyma quite a bit (tension pneumothorax?).
A chest tube was placed by Thoracic Surgery but it wasnt enough expansion on control X-Ray.Thoracic Surgery decide to urgent bronchoscopy in ER.Bronchoscopy showed us ıntraluminal hemorrhage until carina level und there is a ruptured area approximately 1.5 centimeter.After all thoracic surgeons decided to perform urgent surgery.After surgery the patient was admitted to an Intensive Care Unit (ICU) for close monitoring.
Trauma to the neck and chest that is blunt or penetrating may result in tracheobronchial damage.There are no differences between the initial diagnostic workout and other trauma tests. The function of CT is not well understood, nevertheless. CT is not as specific in identifying airway injury as it is in detecting symptoms of airway trauma, such as pneumothorax and pneumomediastinum. A negative CT scan does not, therefore, rule out the possibility of airway damage.The preferred examination for identifying and characterizing airway injuries is a bronchoscopy.
Finally, it is important to address late sequelae including recurrent pulmonary infections and airway constriction. Within one to four weeks following airway damage, granulation tissue and stenosis appear, resulting in long-term problems. It's critical to perform a bronchoscopy assessment to identify this late involvement.
Kadir YENAL (Yenimahalle, Turkey), Ahmet KESKIN, Ufuk YILDIZ
00:00 - 00:00
#41814 - Tragic Dualities: Exploring Fatal Accidental Deaths Linked to Carbon Monoxide Poisoning in Two Cases.
Tragic Dualities: Exploring Fatal Accidental Deaths Linked to Carbon Monoxide Poisoning in Two Cases.
Introduction:
Carbon monoxide (CO) poisoning remains a critical global health concern with persistently high rates of mortality and morbidity. In numerous countries, it accounts for over 50% of reported fatal poisonings, underscoring its significant impact on public health. Carbon monoxide, often referred to as "CO," is a stealthy and lethal gas that lacks color, odor, taste, and irritant properties. Originating as a by-product of incomplete combustion, a common culprit is the fuel utilized for heating water in residential settings.
In Tunisia, CO poisoning stands as the predominant cause of intoxication-related deaths, particularly prevalent during the winter months. The clinical spectrum of CO poisoning varies from mild to moderate and, in severe cases, can be life-threatening. This underscores the pressing need for heightened awareness, preventive measures, and enhanced medical interventions to mitigate the adverse consequences associated with CO exposure.
Case report:
In November 2023, at 9 p.m., our emergency department received a distressing case involving a 26-year-old female with no prior medical history and her 70-year-old father. Both were discovered unconscious on the floor of their living room, displaying alarming symptoms including urine incontinence and a cyanotic (bluish) complexion. The presence of a censer or "Kanoun" nearby raised suspicions of carbon monoxide (CO) exposure.
Upon arrival, the initial presentation was severe. The 26-year-old female and her elderly father were hypothermic, with a Glasgow Coma Score of 3. They exhibited hypotension and cold, cyanotic skin. Swift action was taken as both patients were admitted to the intensive care room, where they underwent immediate conditioning and continuous monitoring. In light of their critical condition, intubation through rapid sequence, and ventilation with 100% of O2 were initiated to ensure adequate oxygenation.
Tragically, within the first hour of admission, the father experienced a cardiac arrest, and despite extensive efforts, including CPR, he did not respond.
In a parallel and equally intense scenario, the 26-year-old female also went into cardiac arrest. A sinus rhythm was restored within 10 minutes of CPR. Subsequently, she was transferred to the reanimation department for further specialized care. Regrettably, despite every effort, she succumbed to the critical nature of the situation before receiving hyperbaric oxygen therapy.
This harrowing incident emphasizes the urgency of recognizing and responding to potential carbon monoxide exposure. The outcome serves as a poignant reminder of the devastating consequences associated with delayed intervention in cases of severe poisoning.
Conclusion
Carbon monoxide poisoning is associated with significant mortality and morbidity. The mere notion of exposure to risk should evoke the diagnosis of carbon monoxide poisoning in an emergency. Complications, essentially neurological and cardiorespiratory, can be life-threatening in the short term, and require urgent treatment, of which oxygen is the cornerstone.
Khouloud KHEMILI (Tunisia, Tunisia), Sarra SOUA, Imen KETATA, Chaima MANAI, Yahya SALHI, Bouhamed CHAFIAA
00:00 - 00:00
#41854 - Transcription factor POU2F2 identified as a novel biomarker for aortic dissection diagnosis.
Transcription factor POU2F2 identified as a novel biomarker for aortic dissection diagnosis.
Background
Aortic dissection (AD), characterized by the tearing of the intimal layer of the aorta, is a critical cardiovascular emergency requiring prompt diagnosis. Currently, AD diagnosis primarily relies on imaging techniques, lacking specific biomarkers for timely detection. This study aims to identify biomarkers for early AD diagnosis by analyzing gene expression profiling data from the Gene Expression Omnibus (GEO) database and utilizing machine learning algorithms.
Methods
A publicly available gene set (GSE147026) from the GEO database was used to identify differentially expressed genes (DEGs) between AD patients and healthy individuals and perform functional enrichment analysis. The Least Absolute Shrinkage and Selection Operator (LASSO) regression model machine learning algorithm was employed to select candidate gene biomarkers. The expression levels and diagnostic effectiveness of the identified biomarkers were further validated using the GSE190635 dataset.
Results
A total of 969 DEGs were identified between AD and healthy control samples. Gene Ontology (GO) analysis shows that these DEGs enriched pathways are mainly involved in inflammatory responses, and similarly, Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis shows that pathways related to inflammatory responses are mainly involved. Finally, the transcription factor POU2F2 was identified as a potential biomarker for efficient AD diagnosis, with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.75 (95% CI 0.349 - 0.968) in the validation cohort. Similarly, the expression of POU2F2 was significantly higher in AD samples compared to healthy controls.
Conclusion
This study identifies POU2F2 as a novel biomarker for AD diagnosis, providing potential clinical implications for early detection and management of this life-threatening condition. The findings warrant further investigation to validate the diagnostic value of POU2F2 in larger clinical cohorts.
This work was supported by the National Natural Science Foundation of China (NSFC, 82241060).
Fulin WANG (chengdu, China)
00:00 - 00:00
#41756 - Transforming care using standardized electronic handovers to improve nursing efficiency and productivity.
Transforming care using standardized electronic handovers to improve nursing efficiency and productivity.
Background
Nursing handover is defined as the transfer of professional responsibility and accountability of patients, facilitating the exchange of crucial information between care teams to ensure consistency of patient care. Studies suggested interdepartmental transfer increases nursing load and diminish available nursing manpower to provide nursing care. Through internal review, physical nursing handover process consumes an average of 30 to 45 minutes, as Emergency Department(ED) nurses are required to leave the department to handover to inpatient team. In recent implementation of Next Generation Electronic Medical Records(NGEMR) integrated system using EPIC Hyperspace which synchronises patient’s records across restructured institutions in Singapore, the team has reviewed to explore an alternative handover process to improve nursing efficiency.
Aim
To assess feasibility of transforming patient care using only electronic handovers documentation template via NGEMR-EPIC Hyperspace system for ED admissions to general wards with the following targets to improve:
• Nursing efficiency and productivity
• Nursing manpower utilization
• Effective interdepartmental transfer of patient care
Methods
A time-motion study was conducted following a quality improvement project, in an acute restructured hospital in Singapore, with a bed capacity of 795, spanning five days(17th to 20th October 2023). Nursing champions from both inpatient and ED collaborated to establish exclusion criteria, focusing on patients deemed unstable or unfit for wheelchair transfer. This initiative aimed to assess the suitability of wheelchair transfer facilitated by one non-nursing trained staff, including portering staff, Care Support Associate(CSAs) and Patient Care Officers(PCOs). Additionally, the team has standardised a handover documentation template within the electronic healthcare system, encompassing significant snapshot of patients' conditions and care plans.
The outcomes of the study include:
• The weightage of patients requiring transfer by trolley versus by wheelchair
• The percentage of patients transferred by Nurses/CSA/PCO/Porters
• The average handover time with the implementation of electronic handover
Results
165 patients being transferred to general wards from the ED over the 5-day period. The total percentage of patients transfer via trolley and wheelchair were 73% and 27% respectively. Out of the total transfer amount, 3-20% are nurses and 80-96% are other non-nursing trained staffs. The average duration used to handover is 18 minutes.
Discussion & Conclusion
Despite the introduction of electronic handover, a significant portion (73%) of patients still necessitated trolley transfers by one PCOs, CSAs, or ED nurse, along with a porter. However, the nursing involvement is remarkably low. In addition, the average transfer and handover duration has shown a significant time saving ranging from 12 to 27 mins. This implementation has helped to improve better utilization of nursing manpower, efficiency and productivity.
The effort has been widely accepted by the inpatient nurses and it is timely especially for the ED as the nursing manpower is challenged to provide care under overcrowding situation.
Implication
As most restructured hospitals in Singapore is transiting into EPIC Hyperspace system, electronic handover can potentially revolutionise EDs and inpatient settings. This intervention offers a breakthrough in saving time and resources while ensuring seamless continuity of care for the patients.
Soon Huat CHUA (Singapore, Singapore), Ratnasari YAWIERIIN
00:00 - 00:00
#41184 - Transforming CBRN readiness through artifical intelligence enhanced Delphi method in a cross-sectional study: An innovative approach to regional cooperation in the Middle East and North Africa.
Transforming CBRN readiness through artifical intelligence enhanced Delphi method in a cross-sectional study: An innovative approach to regional cooperation in the Middle East and North Africa.
Introduction
Chemical, biological, radiological, and nuclear (CBRN) incidents pose a significant threat globally, particularly in the Middle East and North Africa (MENA) region due to its complex geopolitical differences and fragile health infrastructure in most countries. Despite notable efforts to enhance CBRN preparedness in MENA countries, these initiatives are often dispersed and need more sustainability. This study aimed to develop a region-specific assessment tool, operational response guidelines, and simulation tabletop exercises for healthcare professionals to improve CBRN preparedness and response in the MENA region.
Methods
A Delphi study was performed electronically with a panel of 40 globally recognised experts in disaster medicine, mostly from MENA. To establish the validity of the survey questions, we calculated content validity indices (CVIs). Consensus measures, including Kendall’s coefficient of concordance (Kendall’s W), were utilised to evaluate the degree of agreement among the experts. Further, artificial intelligence (AI) analytics techniques such as sentiment analysis were used to assess the emotional tendency of responses, t-distributed stochastic neighbour embedding (t-SNE) to visualise high-dimensional data, and k-means clustering to group similar experts’ opinions together. The Ethical Committees of the Faculty of Medicine “Ibn Eljazzar” of Sousse in Tunisia and of the Hamad Medical Corporation’s Medical Research Center in Qatar (under references CEFMS 110/2022 and MRC-01-22-258, respectively)
Results
The CBRN response flowcharts, preparedness assessment tool, and table-top scenarios survey’s items were validated with an overall item-level CVI average of 0.88, respectively, indicating strong content validity. Consensus analysis demonstrated a strong Kendall’s W coefficient of an average of 0.83 for the overall items’ tools, indicating high agreement among panellists. The t-SNE revealed four clusters with varying perspectives: 1) mid-career MENA professionals, 2) young Australasian experts, with ten experts for each cluster, 3) highly experienced MENA-Canadian representatives (seven experts), and 4) well-established European-North African experts (twelve experts), a more cohesive cluster in opinions.
Conclusions
This study employed a Delphi survey reinforced with advanced AI statistical computing techniques to establish consensus among international disaster medicine experts on essential CBRN preparedness and response tools. The AI analyses revealed strong convergence on crucial elements forming the core of the proposed risk assessment tool, validating its applicability across different geographic regions. Further, the AI computing techniques uncovered larger, more cohesive clusters among European-North African experts, suggesting a higher consensus among regional experts than others. This finding highlights the importance of considering regional variations when developing and implementing CBRN strategies. The study’s outcomes, including response flowcharts and scenario-based exercises, should be integrated into a comprehensive, immersive training program, potentially enhanced by technologies like virtual reality. By expanding expert engagement and deploying the consensus AI algorithm developed in this study, Worldwide healthcare policymakers, including those in MENA, can develop more robust, adaptable, and geographically customised CBRN preparedness and response strategies and enhance their capacity to mitigate the impacts of CBRN incidents, protect populations, and foster resilience considering evolving threats. Future research should focus on refining AI methodologies to incorporate broader expert input.
The Ethical Committees of the Faculty of Medicine “Ibn Eljazzar” of Sousse in Tunisia and of the Hamad Medical Corporation’s Medical Research Center in Qatar (under references CEFMS 110/2022 and MRC-01-22-258, respectively)
Hassan FARHAT, Dr Mariana HELOU (Lebanon, Lebanon), Gregory CIOTTONE, Roberto MUGAVERO, Luc MORTELMANS, Guillaume ALINIER, Nidaa BAJOW, Alan M.BATT, Heejun SHIN, Craig CAMPBELL, Arezoo DEHGHANI, Carolyn DUMBECK, Walid ABOUJALALA, Zelfani SAIDA, Mohamed BEN DHIAB
00:00 - 00:00
#42002 - Translational simulation: strengthening major incident response and building staff confidence.
Translational simulation: strengthening major incident response and building staff confidence.
Background and aims:
Paediatric major incidents are rare events but when they occur they cause devastating morbidity and mortality. A well-tested major incident plan allows for optimal management and improved outcomes for the maximum number of patients. Our aim has been to develop a translational major incident in-situ simulation 6-monthly programme. We sought to identify strengths and challenges in our plan, develop changes to strengthen it and build on staff confidence in their role.
Methods:
Through a major incident small working group at a paediatric major trauma centre, we identified an experienced faculty to plan, write and facilitate simulation. We have run 6-monthly major incident in-situ simulation for over 2 years with over 50 participants taking part in a single simulation. Each time different parts of our plan have been tested. Following each simulation, we run a hot and organisational debrief in order to build staff confidence whilst also identifying areas of the plan to be strengthened. Participants completed a questionnaire to detail any changes in their knowledge and confidence.
Results:
Consistently we have demonstrated an increase in confidence on the Iikert scale comparing before and after the simulation: cohort 1 - average 6.3 to 7.1, cohort 2 - 5.6 to 7.8 and cohort 3 - 5.2 to 7.5.
The sims have resulted in the implementation of a clinical record, changes to systems such as the major haemorrhage response and the addition of new action cards for new roles identified.
Conclusions:
Translational major incident in-situ simulation facilitates strengthening your major incident plans whilst building staff confidence.
Natalie BEE, Kilpatrick KIRSTY (Glasgow, United Kingdom)
00:00 - 00:00
#40911 - Transport of the Critically Ill Paediatric Patient – As Simple As ABCDE or More than ABCDE?
Transport of the Critically Ill Paediatric Patient – As Simple As ABCDE or More than ABCDE?
Background/ Aim: The transport of critically ill paediatric patients is a daunting task. In a mobile environment with limited capacity and capability, the transport team has to assess and monitor patients, perform interventions, and communicate with each other. We aimed to describe the patient characteristics, clinical progress and outcomes of critically ill paediatric patients transferred from a general Emergency Department (ED) to a paediatric hospital.
Methods: A retrospective study was carried out from August 2018 to July 2023. Critically ill paediatric patients were defined as patients who were less than 16 years old and admitted to High Dependency Unit (HDU) or Intensive Care Unit (ICU) following ED management. Transfer of these patients would be performed by the ED team but patients with more critical conditions would be transferred by the transport team from the paediatric hospital. Information including patient demographics, triage category, diagnosis, ED management and disposition, transfer process, and clinical outcome were collected and analyzed.
Results: There were 31,960 paediatric cases – 1218 cases were triaged as emergent (P1). After ED management, 568 were transferred to the paediatric hospital for further inpatient management. Among these, 481 (84.7%) patients were admitted to the general ward, while 87 were critically ill and admitted to HDU (n=59, 10.4%) or ICU (n=28, 4.9%). The median age of the critically ill paediatric patients was 4.4 years old [interquartile range (IQR) 1.3-10.6) and 54 (62.1%) of them were males. The top three diagnostic categories for these patients were neurology (n=45, 51.7%), respiratory (n=18, 20.7%) and infectious disease (n=7, 8.0%). The ED team carried out 56 (64.4%) transfers and the transport team from the paediatric hospital carried out 31 (35.6%). The most common clinical concern among these patients was disability related such as reduced Glasgow Coma Scale score (n=46, 52.9%). During the transfer, eight (9.2%) patients deteriorated with desaturation (n=6) occurring most commonly. There were two mortalities but these were due to their clinical conditions rather than deterioration during transfer.
Discussion and Conclusions: To optimise transport of the critically ill paediatric patients in a challenging space, the staff should be aware of their roles and responsibilities, and have the knowledge, skill, expertise and experience. The stuff should consist of key equipment, drugs and consumables for assessment, monitoring and intervention. The selection of transport team should consider the clinical conditions of the patients, and be discussed between the referring ED and receiving paediatric hospital. Simulation training and clinical protocols for common scenarios encountered can improve response and decision making. Ultimately, it is about making transport of the critically ill paediatric patient a safe process, thereby reducing morbidity and mortality.
Trial registration: Not applicable.
Funding: This study did not receive any specific funding.
Yin Ting LIAU (Singapore, Singapore), Jen Heng PEK, Shun Yee LOW, Chee Yun Eunice CHAN
00:00 - 00:00
#42219 - Traumatic brain injury induced coagulopathy.
Traumatic brain injury induced coagulopathy.
Traumatic brain injury induced coagulopathy
ABSTRACT :
INTRODUCTION :
Traumatic brain injury ranks among the primary causes of both death and disability globally. Trauma-induced coagulopathy describes abnormal coagulation processes attributed to trauma. Despite individuals with isolated traumatic brain injury (TBI) experiencing less bleeding and receiving limited fluid volume compared to those with trauma to the limbs or trunks, the prevalence of coagulopathy is notably higher in TBI patients. The aim of this study was to investigate the mortality and prognostic factors of traumatic brain injury-induced coagulopathy.
METHODS :
This prospective study includes all severe traumatic brain injuries in individuals aged over 15 years, with a focus on the first 48 hours post-injury. Clinical, biological, and radiological data were collected upon admission.
Trauma-induced coagulopathy was defined by thrombocytopenia (< 120,000/mm³), a Prothrombin rate (PT) below 70%, an International Normalized Ratio (INR) exceeding 1.5, or an Activated Partial Thromboplastin Time (APTT) exceeding 40 seconds.
RESULTS :
We enrolled 110 patients diagnosed with traumatic brain injury. Preliminary results indicated a male predominance in 86.36% of cases, comprising 95 patients. Mortality within 48 hours was observed in 18.18% of cases (20 patients).
Variables correlating with mortality included the duration to treatment, presence of acute subdural hematoma, midline shift, Glasgow Coma Scale (GCS) score, initial pupil reactivity, as well as the presence of trauma-induced coagulopathy.
CONCLUSION :
Improving the prognosis of these patients relies essentially on advancing pre-hospital medicine .
Anas ALAOUI (, Morocco), Mohamed Anass FEHDI, Asmae DAFIR, Badria AGGOUG, Mohammed MOUSSAOUI, Mohammed MOUHAOUI
00:00 - 00:00
#42110 - Traumatic Brain Injury presentation at the Emergency Department: a multicenter prospective study in France.
Traumatic Brain Injury presentation at the Emergency Department: a multicenter prospective study in France.
Purpose
The main objective of this study is to describe the profile of Traumatic Brain Injury (TBI) patients consulting in the Emergency Department (ED) in France. The secondary objectives were to describe and assess i) TBI severity across age groups; ii) the delay between the occurrence of TBI and ED arrival; iii) the prevalence of traumatic Intracranial Hemorrhages (ICHs)
Methods
This prospective cohort study collected patient data over a three-day period in March 2023 across 71 French EDs. All adult patients (≥18 years old) admitted to the ED with a TBI (defined as a trauma to the head) were included. Patients were followed in the first 24 hours after ED presentation.
Results
Among the 71 participating EDs: 27(38.0%) were university-affiliated teaching hospitals and 1070 patients presented a TBI were included in the study, with a median age of 68.5 [37-85] years old. Ground-level falls were the leading cause of TBI (60.3%) and mild TBIs were the most prevalent presentation (98.4%). The median time from TBI to ED visit was 2 hours [1.0 – 5.5], with 59.2% of patients visiting the ED within three hours of their trauma. CT head scans were performed for 636 patients (59.6%), of which 56 were positive. ICH prevalence was 5.2% [95% CI: 4.0-6.7]) and three patients (0.3%) required a neurosurgical intervention.
Conclusion
One TBI patient out of two presenting in the ED is aged over 65 years and ground-level falls have become the overwhelming majority of TBI causes.
Xavier DUBUCS (Toulouse), Thomas LAFON, Romain ADAM, Solene LOTH, Florian NEGRELLO, Mustapha SEBBANE, Valérie BOUCHER, Marcel EMOND, Sandrine CHARPENTIER, Frederic BALEN
00:00 - 00:00
#41538 - Traumatic Shoulder Dislocation with Axillary Artery Injury in an Elderly Patient: A Case Report.
Traumatic Shoulder Dislocation with Axillary Artery Injury in an Elderly Patient: A Case Report.
Objective: This case report aims to highlight the risk of axillary artery injury following traumatic anterior shoulder dislocation in elderly patients. Emphasizing the importance of early recognition and reduction to control haemorrhage.
Introduction: Shoulder dislocations are common in the Emergency Department, they represent approximately 50% of all major joint dislocations. The most common complications would be nerve injury (brachial plexus and axillary nerve), followed by rotator cuff ruptures. Arterial injury following a shoulder dislocation is rare. They are usually due to penetrating trauma with only 6% due to blunt trauma. However, injury to the axillary artery following a shoulder dislocation is more common than expected in the elderly population, with an incidence rate as high as 1-2%. This is likely due to the artery being less elastic from atherosclerosis making it easier to injure and transect.
Case Summary: This case involves a 76-year-old Caucasian man who presented to our Emergency Department following a fall from standing height after an alcoholic binge. He was brought in by paramedics who found him on lying in a large pool (at least 500mls) of fresh blood. He was in haemorrhagic shock when he arrived in the resuscitation room. The left shoulder was held abducted with a weak radial pulse and there was a 1cm wound over the axilla with a large underlying hematoma but no active bleeding. A decision was made to perform an anterior-posterior (AP) X-ray of the shoulder almost immediately with a view for reduction for haemorrhage control. The X-ray showed an inferior glenohumeral dislocation. Sedation was given with intravenous (IV) ketamine and reduction was performed with gentle traction. Following reduction, there was a large gush of blood and clots from the wound that stopped bleeding after a few minutes of manual compression. The patient’s hemodynamics subsequently improved after compression and reduction. The patient was eventually able to be brought for a computed topographic (CT) angiogram which showed a hematoma that lies posterior and superior to the left axillary artery, with active arterial bleeding at the third part of the axillary artery. Left sixth and seventh rib fractures were also found on imaging which could explain the puncture wound. The patient was brought to the emergency operating theatre where a left axillary wound exploration was performed. The entire third part and distal half of second part of the axillary artery was dissected out and no active bleeding was noted. The patient was observed in the high-dependency unit for a day where his hemodynamic continued to be stable and subsequently opted for an against medical advice discharge 4 days into admission.
Conclusion: This case underscores the importance of maintaining a high index of suspicion for axillary artery injury in patients presenting with traumatic shoulder dislocations, especially in the elderly population with associated risk factors. Timely diagnosis, early reduction and surgical repair are essential to mitigate potential morbidity and mortality associated with this rare but serious complication.
Darren Zhi-Yang LOW (Singapore, Singapore), Jia Hao LIM, Pei Yi Geraldine KOO, Boon Kiat Kenneth TAN
00:00 - 00:00
#41984 - Treatment administered in the emergency department in patients with delirium.
Treatment administered in the emergency department in patients with delirium.
Introduction: delirium is a prevalent syndrome in older people who attend emergency services and has negative consequences such as loss of quality of life and increased dependency, morbidity and mortality. It is underdiagnosed and undertreated, but screening for delirium in older people at risk would allow early identification and treatment, thus minimizing its consequences.
Objective: to know which pharmacotherapeutic groups are used in the emergency department in patients diagnosed with delirium and if there are differences in patients who have been screened using the 4AT scale in triage.
Material and methods: this cross-sectional study examined a population of individuals aged 65 years or older who attended the emergency department (ED) during the period between November 2021 and June 2022. Randomly and adjusting to the load care at the time, some participants were previously screened by the nursing staff in triage to detect delirium using the 4AT scale. All patients who were diagnosed with delirium according to DSM-V were included and patients without informed consent and delirium due to pharmacological causes or alcohol consumption were excluded. A descriptive and bivariate analysis was carried out through t-student and Chi square.
Results: a total of 153 patients were included. 50.3% (n=77) were female with a mean age of 85 (SD 7.68) years. The mean number of drugs administered was 2.12 (SD 1.98). The most administered pharmacotherapeutic groups were analgesics 51.6% (n=79) followed by antibiotics 35.3% (n=54) and antipsychotics 27.5% (n=42). Of the total sample, 66% (n=101) of the patients were screened with the 4AT scale by the triage nursing staff. There was a higher average of drug administration in the screened group compared to the non-screened group (2.25 (2.09) vs 1.88 (1.73); p= 0.44)
Conclusions: the pharmacotherapeutic groups most administered in patients who come to the emergency services with delirium are the analgesic group, followed by antibiotics and antipsychotics. More drugs are administered to patients who have previously been screened using the 4AT scale in triage. Screening for delirium through the 4AT scale could help in the detection and subsequent diagnosis, allowing early treatment of the organic cause and delirium.
Ethical approval and informed consent: committee approval date October 11, 2021 (Hospital Francesc de Borja, Gandia – Valencia – Spain)
Immaculada TORMOS-MIÑANA (VALENCIA, Spain), Àngela SOLER-SANCHIS, María CUENCA-TORRES, Francisco Miguel MARTÍNEZ-ARNAU, Pilar PÉREZ-ROS
00:00 - 00:00
#40943 - Trend of prehospital mechanical cardiopulmonary resuscitation among out-of-hospital cardiac arrest: Nationwide observational study.
Trend of prehospital mechanical cardiopulmonary resuscitation among out-of-hospital cardiac arrest: Nationwide observational study.
Prehospital mechanical cardiopulmonary resuscitation (CPR) in Korea has increased further since COVID-19. This study aims to determine the trend of prehospital mechanical CPR practice over a 10-year period in Korea. Retrospective analysis using Korean Out-of-Hospital Cardiac Arrest (OHCA) registry was conducted. From 2012 to 2021, we enrolled adult OHCA patients who received prehospital mechanical CPR. Study groups were categorized into 5 groups according to every two years. The effect of multiple dispatch among patients with prehospital M-CPR on survival outcomes was analyzed by multivariable logistic regression. Total 31,077 patients were enrolled. Prehospital mechanical CPR continued to increase [178 in 2012-2013; 204 in 2014-2015; 3,038 in 2016-2017; 10,277 in 2018-2019, and 17,380 in 2020-2021]. The survival rate of prehospital mechanical CPR were 5 (2.8%) in 12-13, 13 (6.4%) in 14-15, 162 (5.3%) in 16-17, 410 (4.0%) in 18-19 and 558 (3.2%) in 20-21. The proportion of multiple dispatch among study population was also increased [0 (0%) in 12-13 25 (12.3%) in 14-15, 1,802 (59.3%) in 16-17, 8,116 (79%) in 18-19 an 14,576 (83.9 %) in 20-21]. The survival rate by multiple-dispatch were 263 (4.0%) in single dispatch group and 885 (3.6%) in multiple dispatch group. Multiple-dispatch was positively associated with prehospital ROSC (AOR [95% CI] 1.27 [1.10-1.47]), but inversely associated with survival to discharge (AOR [95% CI] 0.78 [0.66-0.93]). Prehospital mechanical CPR continues to increase in Korea. Further research is needed to effectively apply prehospital M-CPR.
Jae Hyun KIM (, Republic of Korea), Jung Ho PARK, Ki Hong KIM, Sang Do SHIN, Kyoung Jun SONG
00:00 - 00:00
#40944 - Trend of prehospital mechanical cardiopulmonary resuscitation among out-of-hospital cardiac arrest: Nationwide observational study.
Trend of prehospital mechanical cardiopulmonary resuscitation among out-of-hospital cardiac arrest: Nationwide observational study.
Prehospital mechanical cardiopulmonary resuscitation (CPR) in Korea has increased further since COVID-19. This study aims to determine the trend of prehospital mechanical CPR practice over a 10-year period in Korea. Retrospective analysis using Korean Out-of-Hospital Cardiac Arrest (OHCA) registry was conducted. From 2012 to 2021, we enrolled adult OHCA patients who received prehospital mechanical CPR. Study groups were categorized into 5 groups according to every two years. The effect of multiple dispatch among patients with prehospital M-CPR on survival outcomes was analyzed by multivariable logistic regression. Total 31,077 patients were enrolled. Prehospital mechanical CPR continued to increase [178 in 2012-2013; 204 in 2014-2015; 3,038 in 2016-2017; 10,277 in 2018-2019, and 17,380 in 2020-2021]. The survival rate of prehospital mechanical CPR were 5 (2.8%) in 12-13, 13 (6.4%) in 14-15, 162 (5.3%) in 16-17, 410 (4.0%) in 18-19 and 558 (3.2%) in 20-21. The proportion of multiple dispatch among study population was also increased [0 (0%) in 12-13 25 (12.3%) in 14-15, 1,802 (59.3%) in 16-17, 8,116 (79%) in 18-19 an 14,576 (83.9 %) in 20-21]. The survival rate by multiple-dispatch were 263 (4.0%) in single dispatch group and 885 (3.6%) in multiple dispatch group. Multiple-dispatch was positively associated with prehospital ROSC (AOR [95% CI] 1.27 [1.10-1.47]), but inversely associated with survival to discharge (AOR [95% CI] 0.78 [0.66-0.93]). Prehospital mechanical CPR continues to increase in Korea. Further research is needed to effectively apply prehospital M-CPR.
Jae Hyun KIM (, Republic of Korea), Jung Ho PARK, Ki Hong KIM, Sang Do SHIN, Kyoung Jun SONG
00:00 - 00:00
#42293 - Trends in Older Adult Exposures Reported to the Poison Centers.
Trends in Older Adult Exposures Reported to the Poison Centers.
Background: The National Poison Data System (NPDS) is a robust surveillance system containing approximately 2.2 million deidentified poison exposures reported to the Poison Centers (PCs) in the United States (U.S.) each year. A high proportion of older adults use over-the-counter medications, take multiple drugs for various medical conditions, and undergo significant physical and biological changes that affect drug metabolism. The present study sought to evaluate the recent trends in toxic exposures among older adults reported to the U.S. (PCs).
Methods: The NPDS was queried for all closed, older adult exposures (OAE) (60 years and above) from January 1st, 2019 through December 31st 2023 using America’s Poison Centers generic code identifiers. We identified and descriptively assessed the relevant demographic and clinical characteristics. Reasons for exposures and medical outcomes were particularly highlighted. Reports from acute care hospitals and hospital based EDs (ACHs) were evaluated as a subset. Trends in exposure frequencies and rates (per 100,000 human exposures) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2019) were reported with the corresponding 95% confidence intervals (95% CI).
Results: During the study period, there were over 1 million toxic exposures among older adults that were reported to the PCs. The frequency of exposures increased by approximately 8% (95% CI: 5.5%, 10.4%; p<0.001), and the rate of exposures significantly increased by 9% (95% CI: 4.2%, 11.7%; p<0.001). Of the total OAE calls, the proportion of calls from ACHs was approximately 23%, with this trend remaining constant through the study period. Multiple substance exposures accounted for 18.1% of the overall calls and 31.5% of calls from ACHs. Approximately 6% of the older adult patients reporting exposures were admitted to the critical care unit (CCU), with 2% of patients being admitted to a psychiatric facility. Residence was the most common site of exposure (92.2%), and most cases were enroute to the hospital when the PC was notified. Cases were predominantly female (63.1%), with the most common age group being 60-69 years (47.6%) followed by 70 – 79 years (32.9%). Therapeutic error (38.8%) was the most common reason for exposure, followed by other unintentional reasons (37.1%). Suspected suicide was the most common reason for exposure in cases reported by ACH. The proportion of cases reporting therapeutic error as the reason for exposure increased significantly during the study (17%). Major effects and moderate effects were seen in 2.9% and 10.6% cases, respectively. The case fatality rate was 0.4% and the frequency of fatalities increased significantly during the study period (696 to 824). Ingestion was the most common route of exposure. Beta blockers and benzodiazepines were the most reported substances.
Conclusion: Older adult exposures reported to U.S. PCs during the study period increased significantly. Severe outcomes (major outcome and death) also demonstrated increases. Therapeutic errors were the most common reason for calls and represent a modifiable cause of exposure. This study can guide efforts on how to prevent further rise of toxic exposures in older adult populations.
n/a
Saumitra REGE, Rita FARAH, Scott SCHMALZRIED (Charlottesville, USA), Conner MCDONALD, Christopher HOLSTEGE
00:00 - 00:00
#42226 - Trends in symptom and diagnostic patterns and mortality in emergency Ambulance Patients, 2017-2023: a comparison of older versus younger patients.
Trends in symptom and diagnostic patterns and mortality in emergency Ambulance Patients, 2017-2023: a comparison of older versus younger patients.
Background:
Demand for ambulances has increased over the past decade and various factors are associated with this trend, including accessibility of primary care and ageing populations. We aimed to investigate trends over the years with special focus on old patients calling for an ambulance, including contact prevalence, symptoms, contact to hospital, hospital diagnoses and 1 and 30-day mortality in a seven-year period from 2017-2023
Methods:
A historical population-based observational cohort study from the North Denmark Region. We included all emergency call patients with known civil registration number. Symptoms were categorized according to the Danish Index for Emergency Care (DI) assessed by healthcare professionals at the call. Hospital diagnoses were classified according to the WHO ICD-10 system. The patients were divided into two separate groups: patients aged 65 and older (old group) and patients from 0-64 years old (the others). We defined 1 day mortality as death within the same or the following day from the emergency call, and 30-day mortality to include all patients who died within 30 days, including 1-day mortality patients.
Descriptive statistics in terms of numbers and percentages were used to compare changes over time and changes between the two groups.
Results:
The study showed an increase in emergency call patients of nearly 20 % from 30,347 patients in 2017 to 36,283 patients in 2023. The largest increase was found for the old group with an 34% increase compared to 8% in the others. The percentages of patients with contact to the hospital decreased for both groups; from 87% - 82% for the old group and from 84% - 75% for the others.
The symptom unclear problem decreased with 9% compared to 6%. There was a 9% increase in stroke-symptoms for the old group compared to 5% for the others.
Overall, the hospital diagnoses were approximately equally distributed between the two years for both groups. However, the diagnoses circulatory diseases and respiratory diseases decreased 3% for the old group. The opposite was found for the non-specific diagnoses with a 3% increase for both groups.
Overall, the changes in 1 and 30-day mortality showed a minor decline for both groups.
Discussion & Conclusions:
The study showed an increased demand for ambulances from 2017- 2023. This was mainly due to an increase in patients over 65 years. The fall in DI unclear problem can possible be explained by a targeted attention to reduce use of the criteria at the Emergency Medical Coordination Centre. There have been campaigns to increase the awareness of stroke which might affect the increase in DI possible stroke. It would be relevant to investigate comorbidity and the severity of diseases, which is expected to increase due to an ageing population.
Funding:
This study did not receive any specific funding.
Ethical approval and informed consent:
Not needed.
Stine IBSEN (Aalborg, Denmark), Torben KLØJGÅRD, Tim LINDSKOU, Morten Breinholt SØVSØ, Erik ZAKARIASSEN, Erika CHRISTENSEN
00:00 - 00:00
#41500 - Triage in Mass Casualty Incidents: An application of discrete event simulations.
Triage in Mass Casualty Incidents: An application of discrete event simulations.
Background
Planning for Mass Casualty Incidents (MCIs) is an essential part of emergency preparedness. Globally a diverse set of triage tools are in use with few designed and validated for use in MCIs. One example of a triage protocol is taught in the WHO Mass Casualty Management course (MCM), where primary triage separates walking and non-walking patients and directs them to green and red zones respectively.
We hypothesise that an additional physiological triage step by a healthcare professional at the entrance to the red zone could increase queues but may also effect time to life saving intervention, flow of patients and staffing requirements. To test this, we developed a process map of both scenarios and developed a discrete event simulation (DES).
Methods
We developed a process map based on the principles of a single point of triage prior to the red/green zones. We then created an alternate process map, with the additional physiological triage step at the entry to the red zone to allow movement to the green zone if determined to not need life-saving treatment.
We created a patient cohort based on real-life mass casualty events including mechanism of injury, injuries sustained and interventions required. A list of life-saving interventions was supplied with estimated time and resources to perform based on expert group consensus.
Using process mapping at key decision points, we stress tested the two methods of triage to look for: 1) Bottlenecks due to increased patient volume, 2) Staffing limitations and 3) Time to life saving intervention.
A DES was created using Anylogic software, utilising the process maps with one scenario (blast - 1000 patients, arrivals within 8 hours, 3 patient sub-cohorts) to test the two triaging options. The three personas had different characteristics - walking/non-walking, lengths of stay at each step, ultimate destination - and the delays were modelled with triangular functions to represent the variations in length of stay at each step through the system.
Results
With one triage step prior to entry into either zone, the green zone quickly became overwhelmed. This is to be expected, as the walking patients (predicted 80% of casualties in a MCI) do not require life saving interventions. If a significant proportion of patients are designated non-walking the red zone develops capacity problems. This is partly remedied by diverting flow back to the green zone for less severely injured patients using a second triage step, however this has implications for the triage staffing required and diverts clinicians from delivery of life saving intervention. The preliminary results showed a strong dependence on patient cohort (arrival speed and distribution of red/green) and staffing - both numbers and level of training.
Discussion and Conclusion
Use of in-silico simulation offers an opportunity to evaluate MCI protocols, compare triage processes and how the protocols perform in different settings and across different scenarios. Using DES enables manipulation of resources to understand where bottlenecks and delays may develop, where to focus resources to improve preparedness and time to life saving intervention for those critically injured.
LH and TB are funded by the NIHR Global Health Research Group on Acquired Brain and Spinal Injury NIHR 132455.
Laura HOBBS (Cambridge, ), Laura WALKER, Kuldeep KAUR, Orla MANTLE, Nelson PITA DE OLIM, Katharina KOHLER, Thomas BASHFORD
00:00 - 00:00
#41844 - Triage in the Croatian Emergency Departments.
Triage in the Croatian Emergency Departments.
Triage nurses in every hospital Emergency Department (ED) in Croatia assess the patient’s main health concern using the Australasian triage scale with five triage categories. Triage nurses determine the triage category for each patient bearing in mind the main health concern, short medical history and physiological parameters. The Australasian triage scale is a clinical tool used to prioritize patients in ED according to patient's acuity and to establish the maximum waiting time for medical assessment and treatment of every patient. Triage assessment generally takes no more than two to five minutes. In every ED in Croatia Australasian triage scale has been used since 2012. Croatian hospital EDs are facing the problem of an increasing number of patients with problems and difficulties of various degrees of urgency. A significant number of patients in the hospital EDs are patients with chronic illnesses seeking treatment for non-emergency conditions. Every triage nurse in Croatia undergoes a mandatory triage course. Their correct medical assessment and determining the triage category are of extreme importance in the triage process and may affect the treatment outcome of patients.
Marina FRISCIC (ZAGREB, Croatia), Kata IVANIŠEVIĆ, Saša BALIJA
00:00 - 00:00
#41868 - Trusting Clinical Intuition: a vital component in diagnostic decision-making.
Trusting Clinical Intuition: a vital component in diagnostic decision-making.
A 59 year-old women was brought to the emergency department unconscious. ABCDE approach showed a patent airway. Her respiratory rate is low at 7 breaths per minute, with oxygen levels of 80%. And a blood pressure of 140mmHg/70mmHg with normal Capillary refill time (CRT). The Glasgow Coma Scale score is 4 (E2V1M1) with pinpoint pupils, but without neck stiffness. There is no fever, no external trauma or petechiae, however a mild blanchable erythema on the thorax warrants further investigation. The patient history includes an opiate allergy (although the specific type of reaction remains unclear) and an intrathecal pain pump (Syncromed II-40 with bupivacaine) following a failed back surgery. Additionally, the pump was refilled the day before. The night before ED presentation the patient experienced symptoms of redness under the eyes, itchy nose, nausea, and vomiting later that evening. It appears that the patient self-administered cetirizine before going to sleep, attributed these symptoms to a possible allergic reaction.
Further investigation with arterial blood gas showed hypercapnia, hypoxia, metabolic acidosis and elevated lactate levels (pH: 7.04; pO2 65.4mmHg; pCO2 78.2mmHg, sat 80%, lactate 7.50 mmol/L). Urine analysis was positive for opiates. Other laboratory findings were within normal limits.
An empirical dose of naloxone 0.4mg was administered, resulting in some response (Glasgow Coma Scale 8, E2V2M4). The neurosurgeon who prescribed the pain pump was contacted and confirmed that the prescribed medication was indeed bupivacaine. Additionally, the pharmacy who prepared the medication was contacted, and they also confirmed that the correct medication (bupivacaine) had been administered.
Extensive cerebral CT examination, including angiography and perfusion studies, revealed no abnormal findings that could explain the symptoms. Consequently, stroke has been excluded as a possible diagnosis.
In the context of persistent hypercapnia and reduced consciousness, the patient was intubated and mechanically ventilated upon admission to the intensive care unit. No clear diagnosis was established at admission, prompting a differential diagnosis including intoxication (CO, opiates, sedatives), metabolic causes of decreased consciousness, among others…
Given the initially non-persistent erythema, pruritus, and allergic symptoms in a patient with a known opioid allergy and positive urine analysis for opiates, the emergency physician insisted on further analyzing the content of the intrathecal pump. This decision was made despite declarations by both the neurosurgeon and the pharmacist regarding the pump’s content. The subsequent analysis revealed a positive result for opioids!
In the field of medicine, clinical intuition-often referred to as ‘gut feeling’-plays a vital role in diagnostic processes. This abstract emphasizes the importance of recognizing and incorporating clinicians' intuitive insights into diagnostic frameworks. While evidence-based medicine provides a strong foundation for clinical decision-making, there are scenarios where the patients' symptoms deviate from expected patterns. When somethings doesn’t quite add up, healthcare professionals must trust their intuition and dig deeper into diagnostic investigations.
The abstract highlights the need for a proactive approach when clinical presentations do not align with initial diagnosis.
Lukas MATHUIS, Lukas MATHUIS (Aalst, Belgium), Femke KNAPEN, Katleen DEVUE, Ives HUBLOUE
00:00 - 00:00
#41246 - Turmeric - not just health benefits. A case report on Turmeric related Drug Induced Liver Injury (DILI).
Turmeric - not just health benefits. A case report on Turmeric related Drug Induced Liver Injury (DILI).
The easy access and intensive promotion of herbal and dietary supplements, which are marketed with various health benefits, are commonly used around-the-world. Unfortunately, the consumers are not informed of their side effects, since products often available in over-the-counter or bought by internet, and often lacking table of contents. These molecules are not considered as a treatment by the patient, and hence not declared or asked for when medical history and ongoing treatment is assessed in patients consulting in the ED. We would like to present a patient with Drug Induced Liver Injury (DILI) after consuming ‘health shots’ containing ginger and turmeric/curcuma.
Case report
28-year-old female with PMHx of colon irritable with simethicone and trimebutine if needed treatment, and oral contraception. She did not smoke, use alcohol or recreational drugs. Her last trip abroad had been to Mexico 6 months prior seeking ED care. She sought ED care for 10 days history of feeling unwell with abdominal discomfort after meals, itchiness without skin lesions, and she found her urines to be more dark than usual and stool more pale than usual. She reported to not have taken paracetamol containing products. On clinical examination her GCS 15/15, temp 36.5, BP 131/102, HR 100/min, SaO2 100%. She had jaundice, her cardiopulmonary examination was normal, the abdomen as soft with normal bowel sounds, she had some URQ tenderness, no guarding or mass was found. Her bloods showed normal NFS, RFT and coagulation with TP 95%, but abnormal LFT with minor cytolysis with ALAT 247 U/l (ref <35 ) and ALT 407 U/l (ref <35), ALP 142 U/I (ref 35-105), Bil T 65.6 mcmol ( <21), Bil C 61.3 mcmol/l (< 3.4). The work out was completed with viral serologies which came back negative, and auto-immune screening with ANA which was weakly positive at 1/80, anti-mitochondrial ab/anti-smooth muscle ab/ anti LKM1/anticytosolic-ab were negative.
Abdominal US was normal
She was discharged with follow-up in the hepatology out-patient-clinic (OPC) with weekly LFT test control and advised against use of simethicone which can have deranged LFT as a side effect.
The OPC follow-up the blood tests showed normalisation of the LFTs, but the bilirubin remained elevated Bil T 123 mcmol/l, Bil C 117. The MRI of biliary tract was normal. The patient reported having taken 2 ‘herbal shots’ in 60 ml bottles, marketed as immune booster, and to fight against tiredness, containing turmeric and ginger, bought from an online supplier, 2 days before starting to feel unwell. No table of content was provided on the bottles
Discussion
There are several case reports related to turmeric related DILI from Europe and US, which may come after short term use, and the turmeric induced DILI may be idiosyncratic. In the US DILI is suspected in 13% of acute liver failure cases, in which the herbal/dietary supplements accounting for 9% of the cases. The research of the use of these supplements is essential in the work-up of patients with abnormal liver function tests.
Capucine GOUVERNEUR, Hanna OVASKA (CRETEIL), Vincent NGUYEN KHAC, Lola MULATIE-GACHET, Mehdi KHELLAF
00:00 - 00:00
#41354 - TWIDDLER syndrome; an exceptional cause of discomfort.
TWIDDLER syndrome; an exceptional cause of discomfort.
A 78-year-old female patient was admitted to the emergency room for assessment of discomfort. Her main history was rhythmic heart disease for which the patient had benefited from implantation of a dual-chamber pacemaker (6 months previously). The clinical examination at admission was unremarkable. The patient was conscious, oriented and showed no signs of trauma. The biological assessment did not reveal any notable abnormalities. The electrocardiogram showed inappropriate ventricular spikes (Fig. 1A). The chest x-ray (Fig. 1B) showed a coiling of the probes around the housing having undergone numerous rotations around its central axis, making it possible to confirm the diagnosis of Twiddler syndrome. The patient underwent surgical revision which consisted of repositioning the probes as well as the housing in the retropectoral space. Twiddler syndrome represents an exceptional and often surprising cause of pacemaker dysfunction. Its frequency is around 7% [1]. It was first described in 1968 by Bayliss et al. He willingly touches patients with a psychiatric history, who “play” with their subcutaneous casing (twiddle meaning “to fiddle” in English), by making it turn on itself, then causing a movement of the probes which wrap around the pacemaker and a malfunction thereof by default of capture. The syndrome can present with unusual symptoms [2], in addition to those leading to the first implantation of the pacemaker (syncope, dyspnea, etc.), such as hiccups in the event of stimulation of the phrenic nerve, or the pectoral muscles or even abdominal muscles responsible for abdominal pain, or abnormal movements of the limbs by stimulation of the brachial plexus.
1- Tonino W.A, Winter J.B (2006): Images in clinical medicine. The Twiddler syndrome. N Engl J Med ; 354: 956
2- Benezet-Mazuecos J, Benezet J, Ortega-Carnicer J (2007). Pacemaker Twiddlersyndrome. Eur Heart J ;28(16): 2000.
Hakim SLIMANI (Colmar)
00:00 - 00:00
#42179 - Ultrasound-guided regional anesthesia - they say mistakes make you wiser, which basically makes me a genius.
Ultrasound-guided regional anesthesia - they say mistakes make you wiser, which basically makes me a genius.
My interest in ultrasound-guided regional anesthesia began in Milan in 2022 at YEMD refresher course. Ultrasound-guided regional anesthesia has gained increasing attention in emergency medicine for its potential to provide rapid and effective pain management. This abstract explores the benefits and even more the pitfalls associated with the integration of UGRA into the practice and experiences in our emergency department. Key themes identified include patient outcomes, procedural success rates, resource utilization, and provider training.
The utilization of UGRA in the ED has demonstrated numerous benefits, including improved pain control, reduced opioid use, shorter procedural times, and enhanced patient satisfaction. Additionally, UGRA offers the advantage of real-time visualization, facilitating accurate needle placement and reducing the risk of complications. However, challenges such as limited time in overcrowded emergency departments and equipment availability remain significant hurdles to widespread adoption.
Ultrasound-guided regional anesthesia represents a valuable adjunct to pain management in the emergency department, offering numerous benefits for patients and providers alike. While its integration may present challenges, addressing these barriers through comprehensive training programs, resource allocation, and workflow optimization can maximize the potential of UGRA to enhance emergency care delivery.
Matea BINGULA (Zagreb, Croatia), Bojana RADULOVIĆ
00:00 - 00:00
#40973 - Umbilical cord mesenchymal stem cell-derived small extracellular vesicles modulate IL-6/NF-κb/NLRP3/GSDMD axis via IL-6st to alleviate pyroptosis in sepsis acute lung injury.
Umbilical cord mesenchymal stem cell-derived small extracellular vesicles modulate IL-6/NF-κb/NLRP3/GSDMD axis via IL-6st to alleviate pyroptosis in sepsis acute lung injury.
Objective: To investigate the protective effects and mechanisms of human umbilical cord mesenchymal stem cell-derived small extracellular vesicles (hucMSC-sEV) against sepsis acute lung injury (S-ALI).
Methods: The hucMSC-sEV was obtained by differential ultracentrifugation and size chromatography, and then characterized by transmission electron microscopy, nanoparticle tracking analysis, nano-flow cytometry and western blotting. S-ALI model was established by cecal ligation and puncture (CLP) and LPS, and was intervened with hucMSC-sEV. Firstly, the biodistribution of hucMSC-sEV in CLP mouse was analyzed using IVIS spectral imaging system. In vitro, the uptake of hucMSC-sEV by LPS-induced BEAS-2B cells was observed by confocal microscopy, and quantified by flow cytometry. ELISA was used to detect the levels of serum inflammatory factors, LD and LDH. MDA, SOD and ATP levels in lung tissues were measured. HE staining was used to detect the pathological changes of lung tissue. Functional molecules and differentially expressed genes of hucMSC-sEV were analyzed by proteomics and RNA sequencing. qRT-PCR, Western blot and immunohistochemical/fluorescence techniques were applied to assess the activation levels of inflammatory factors and signaling pathways. Inhibition assay were validated by cell transfection.
Results: Through a series of experiments, we found that hucMSC-sEV significantly ameliorated sepsis acute lung injury in vitro and in vivo. In vivo, IVIS showed that the number of hucMSC-sEV distributed in lung increased significantly after CLP. In the hucMSC-sEV intervention group, mice showed less body weight loss, higher survival rate, and less pathological lung tissue damage; lower serum LD, LDH, IL-1β, IL-6, TNF-a, and IL-18 levels; and lower lung tissue MDA and SOD levels and higher ATP. Similarly, in vitro, confocal microscopy and flow cytometry showed increased uptake of hucMSC-sEV by LPS-stimulated BEAS-2B cells, and the inflammatory response was suppressed. Mechanistically, RNA sequencing revealed that CLP-induced upregulated genes were mainly associated with inflammatory response, and the signal pathway was enriched in NLRs-like receptor signaling pathway, which was significantly inhibited after hucMSC-sEV intervention. Combined with exosomal proteomics sequencing analysis and qRT-PCR validation, it was confirmed that IL-6st was highly enriched in hucMSC-sEV, which could regulate the NF-κb/NLRP3/GSDMD signaling pathway by competitive binding to IL-6, thereby inhibiting pyroptosis and ameliorating lung injury. In contrast, after knocking down IL-6st in hucMSC, the protective effect of hucMSC-sEV against S-ALI was reduced.
Conclusion: hucMSC-sEV carries IL-6st to competitively bind IL-6, thereby inhibiting NF-κb/NLRP3/GSDMD signaling pathway-induced pyroptosis and alleviating sepsis acute lung injury.
Feng CHEN (Beijing, China), Tang TAO-TAO, Chen ZHI-QING, Liu BI-CHENG, Wang ZHONG
00:00 - 00:00
#41115 - Underlying Clinical Domains of Frailty in Older Acutely Admitted Patients.
Underlying Clinical Domains of Frailty in Older Acutely Admitted Patients.
Background: When assessing frailty in older patients using the Clinical Frailty Scale (CFS), the score gives information about the patient’s overall functional ability and risk of adverse outcomes. However, the score does not provide information on how and when to intervene to prevent or potentially reverse the progression of frailty. Underlying causes of frailty, specifying disabilities, health-related problems, and cognitive problems are important in defining different frailty domains and allowing for individualized interventions for acute older patients. We investigated the occurrence of five underlying frailty domains (cognition, malnutrition, multimorbidity, low muscle strength, inflammation) in older, acutely admitted medical patients and explored the domain’s association with the degree of frailty.
Methods: Analyses were based on 632 acutely admitted patients (aged ≥65 years) enrolled in the Copenhagen PROTECT Study. Frailty was evaluated by the CFS and divided into three groups: Non-frail (CFS: 0-3), frail (CFS: 4-5), and severely frail (CFS ≥6). The domains were assessed within 24H of the admission: cognition by “Orientation-Memory-Concentration test”, malnutrition by “Short Nutritional Assessment Questionnaire”, multimorbidity by “Charlson Comorbidity Index”, low muscle strength by hand grip strength, and inflammation by C-Reactive protein. Relative Risks (RR) with 95% confidence interval (95% CI) were analyzed between the domains and the clinical frailty groups. Moreover, logistic regression analysis was performed to calculate the Odds Ratio (OR) with 95% CI between the domains and the clinical frailty groups in both a crude and adjusted model (age, sex, and the other domains).
Results: The patients had a mean age of 78.8 years (±7.5), and 54.6% were female. Patients with low muscle strength, cognitive impairment, multimorbidity, and malnutrition had a RR (95% CI) of 2.4 (1.8-3.2), 2.0 (1.4-3.0), 1.8 (1.4-2.3), and 1.5 (1.2-2.1) of frailty, respectively, compared to the non-frail. Correspondingly, the same domains had RR of 2.7 (2.1-3.6), 2.4 (1.7-3.4), 1.7 (1.4-2.1), and 1.7 (1.4-2.2), respectively, for severe frailty. Regarding inflammation, the frail and the severely frail groups did not differ significantly from the non-frail group. For cognitive impairment, malnutrition, multimorbidity, and low muscle strength, the logistic regression analysis revealed an OR (95%CI) when adjusted for age, sex, and the other significant domains for frailty of 2.3 (1.3-3.8), 1.6 (1.0-2.5), 2.0 (1.3-3.1), and 2.6 (1.7-4.0), respectively. For the severely frail, these domains presented an OR (95%CI) with similar adjustments of 3.7 (1.9-7.3), 2.2 (1.2-4.0), 2.7 (1.5-5.0), and 7.1 (3.9-12.8), respectively.
Discussion and conclusion: Abnormal assessments in the majority of our defined domains were significantly more frequent among frail and severely frail compared to the non-frail. The underlying domains of frailty occurred with different impacts across the levels of frailty. Muscle strength marked the largest difference, followed by cognitive impairment, multimorbidity, and malnutrition in both comparisons. This underlines the importance of assessing these different domains across the spectrum of frail patients to offer individualized treatment and care.
Clinical Trial Registry: Clinicaltrials.gov ID: NCT04151108
Funding: The Novo Nordisk Foundation - Grant ID: NNF18OC0052826.
Hanne NYGAARD (Copenhagen, Denmark), Rasmus GREGERSEN, Rikke KAMPER, Anette EKMANN, Sofie HANSEN, Pernille HANSEN, Martin SCHULTZ, Eckart PRESSEL, Charlotte SUETTA
00:00 - 00:00
#42215 - Unexpected sepsis.
Unexpected sepsis.
Methods. Patient was consulted in Emergency Department of Vilnius University Hospital Santaros Klinikos (VUHSK) by emergency medicine doctor. Patient gave written consent to use his data anonymously.
Clinical history. A 77 year-old woman was sent to the Emergency Department of VUHSK by a cardiologist after coronarography. Procedure was done in other medical facility. No damage to coronary arteries was found. After the procedure the patient felt weakness, blood pressure was a bit lower so additional infusion of crystalloids was given. After about 1 hour the patient felt worse, started to shake, blood pressure remained lower and a tachycardia was registered (HR 130 bpm). Diazepam 5 mg p/os, Clemastinum 2 mg į/r and Dexamethasone 8 mg į/r was given in fear of anaphylaxis. Decision to transportate patient to VUHSK Emergency department was made. While waiting for transportation, the patient had febrile fever ( 39°C). Tablet of Paracetamol 500 mg was given.
Patient’s condition was worse in VUHSK Emergency department. Blood pressure of 66/44 mmHg was measured, tachypnea and tachycardia was present. Patient was transported to the Emergency department’s ICU. Maculopapular rash was seen on patients knees, patient complained of pain in the abdomen. Abdominal ultrasound was done - general lymphadenopathy was found. Thinking it might be anaphylaxis fluid therapy was continued, additional 8 mg of dexamethasone and 2 mg of Clemastine was given, also intravenous epinephrine therapy was started. Despite the treatment patient’s condition remained the same, the rash turned pale. Procalcitonin (PCT) level was 40,50 mcg/l, c-reactive peptide (CRP) - 52,2 mg/l in blood analysis. Empiric antibiotic treatment by Co-amoxiclav was started (after two days inflammatory proteins lowered). Patient was hospitalized in the ICU. Tryptase test was taken that rule-out anaphylaxis (4,95 ng/ml). In blood culture Corynebacterium imitans was present. Biopsy of lymph node was taken - aggressive T-cell nodal lymphoma, also T-cell lymphocytic infiltration was found in skin biopsy. Patient was discharged after CRP and PCT levels were normal and prephase with prednisolone was done (CTP protocol was recommended).
Relevance. Differential diagnosis is often a big challenge in the Emergency Room (ER). While anaphylactic and septic shock can look the same. Though it is very important to differentiate between these two conditions because of what treatment should be administered in the long run.
Kristina ŠULSKUTĖ (Vilnius, Lithuania), Julius JARAMAVIČIUS, Tomas JABLONSKAS
00:00 - 00:00
#41791 - Unprecedented Self-Harm: A Case of a fatal throat Injury in Schizophrenia.
Unprecedented Self-Harm: A Case of a fatal throat Injury in Schizophrenia.
Introduction:
Self-mutilation, a deliberate act of self-destruction, manifests in various psychiatric disorders. Numerous methods of self-harm have been documented in literature. Individuals with schizophrenia are known to engage in self-destructive behaviors driven by command hallucinations, catatonic excitement, or depression. This is a unique case of Throat self-injury through inserting a sharp metal object in a patient with schizophrenia and discusses treatment and management considerations.
Case report:
A 25-year-old male with a long-standing diagnosis of schizophrenia, was admitted to our emergency department following an alarming episode of inserting an iron wire and a firewood into his throat.
He presented with a history of auditory hallucinations instructing him to inflict harm upon himself. During a state of heightened agitation and distress, he resorted to inserting forcedly an iron wire and a firewood into his throat. 3 days after His brother brought him to the emergency room complaining of sudden onset of shortness of breath, chest pain, and difficulty swallowing.
Upon examination, the patient appeared anxious and was in mild respiratory distress. Vital signs were within normal limits, except for tachycardia (heart rate of 120 beats per minute), moderated hypoxia Spo2 90% in room air and Fever 38,5°C. Lung examination revealed bilateral inspiratory crackles, and chest auscultation was not significant for abnormalities. The patient's neck was supple, and there was no jugular venous distention or tracheal deviation. His electrocardiogram as well as Chest X ray were normal. Arterial Blood Gaz showed: pH=7,34 paO2=69 pcO2=45 Hco3-=20 Sa02=89% lactate=4, and the rest of biology was normal.
The patient was admitted for more investigation and suspecting Pneumothorax regarding the mechanism of injury. Accordingly, the patient underwent a thoracic CT angiography that revealed bilateral pneumothorax, associated with a left-sided hemothorax, with findings suggestive of mediastinitis.
Soon after the CT scan, he presented a cardiorespiratory arrest, resuscitated for 45 minutes with no success. Autopsy revealed mediastinitis with pus discharge. Diagnosis established as septic shock due to mediastinitis resulting from self-mutilation.
Conclusion:
Self-harm behaviors in individuals with psychiatric disorders are multifaceted, and extreme cases such as inserting sharp harmful objects, though rare, require careful evaluation and intervention. However, in all cases, it can potentially be fatal. A holistic treatment approach involving collaboration between psychiatric and medical professionals, along with support from family and caregivers, is essential in promoting the well-being and recovery of individuals facing such challenging circumstances.
Khouloud KHEMILI (Tunisia, Tunisia), Chaima MANAI, Bouhamed CHAFIAA, Sarra SOUA, Imen KETATA
00:00 - 00:00
#41803 - Unrecognised a Perfect Storm can be Catastrophic: Thyroid Storm.
Unrecognised a Perfect Storm can be Catastrophic: Thyroid Storm.
Thyroid Storm is a rare life threatening hyperadrenergic state that if unrecognised and left untreated 80% or more can be fatal. It can be anticipated in patient’s with Graves’ disease with thyrotoxicosis and in other rare instances although self-limiting associated with viral illness. Transient hyperthyroidism is common in subacute thyroiditis however thyroid storm is a rare complication of it. Some viruses like the Epstein Barr, Influenza and the recent SARS-COVID-19 and in rarer cases even an aspirin overdose have been associated with acute onset thyrotoxicosis and subsequently Thyroid Storm.It isn’t always recognised and can be challenging especially in the emergency department where it is important to consider other critical differentials in the acutely ill patient.
This case report describes a presentation of a 41yr old female patient who had been acutely unwell for the past 8 weeks after an infection. She had sought treatment prior to the Emergency department. She was very short of breath and was exhausted from coughing and not sleeping.
The symptoms and signs of a rapid heart rate, very high blood pressure, and extremely high body temperature may be noted but also are consistent with other differential’s like sepsis. A good history and examination considering the potential of an underlying thyroid disorder to cause thyroid storm is important. However, it must be noted that a thyroid storm may not occur in all patients with thyrotoxicosis as only 16% of those hospitalized with thyrotoxicosis have a thyroid storm. Those with thyrotoxicosis and a thyroid storm have higher mortality rates than those with just thyrotoxicosis. Emergent treatment is the key as the mortality rate in those in which thyroid storm goes untreated ranges from 80% to 100%. When treated, thyroid storms prove fatal in less 10%. When treating thyroid storm multiple interventions that interfere with the excessive thyroid hormone levels causing it. Treatment includes blocking the synthesis of thyroid hormone using antithyroid drugs. In patients who can't tolerate antithyroid drugs, lithium is sometimes used. Blocking the release of thyroid hormone using a potassium iodide preparation. This is usually given after the antithyroid drugs. Blocking T4 to T3 conversion using a corticosteroid drug, such as hydrocortisone. Use of a beta-blocker drug, such as propranolol, to reduce blood pressure and heart rate. Supportive treatment may also include cooling to help reduce body temperature, fluids to combat dehydration, and treatment of any other infections. Improvement will be seen within 48 hours. Prognosis however depends on the patient’s age and health. Poor outcomes are associated in patients with multisystem complications and those with complex co-morbidities.
Jasdev Singh Sra SOVINDER SINGH, Kiren GOVENDER (Galway, Ireland)
00:00 - 00:00
#42094 - Unusual presentation of acute hepatic failure secondary to chronic herbal consumption with a fatal outcome: a novel approach.
Unusual presentation of acute hepatic failure secondary to chronic herbal consumption with a fatal outcome: a novel approach.
This case is interesting because it presents an intriguing scenario, as an acute liver injury resulting from herbal consumption. This is not typically among the primary considerations for emergency department admission diagnosis during physicians initial assessment, despite its potential for fatal outcomes. We emphasize that diagnosis of a disease is contingent upon awareness and consideration of its existence.
This case encompasses a rare presentation because patient presents with jaundice syndrome and abdominal pain, initially suspected to be due to obstructive biliary or hepatic infectious disease. However, subsequent investigations ruled out these etiologies. The patient's condition deteriorated rapidly, manifesting increased jaundice, acute renal failure with dialysis requirement, and prolonged coagulation times, yet an elusive etiology persisted. Consequently, routine inquiry regarding xenobiotic consumption for managing gout crisis pain was on mind. The patient confirmed regular ingestion of these agents and herbal supplements.
Learning points:
The need to remember the initial approach, proper initial medical history collection, high clinical suspicion, and conduct thorough medical history taking in order to avoid wasting time and prevent fatal outcomes for the patient.
Early suspicion leads to cost reduction and increased diagnostic accuracy.
Results:
Upon admission, ALT levels were within normal limits, while bilirubin and alkaline phosphatase were elevated. Hepatocellular profile indicated no evidence of viral infections. Renal function revealed rapidly progressive acute kidney injury. Coagulation times were prolonged. Moderate hypovolemic hyponatremia was noted. Ultrasound findings revealed a liver with typical contour and shape, but increased echogenicity, nodular and diffuse appearance, and apparent gallbladder wall calcification, suggestive of possible chronic hepatopathy and porcelain gallbladder.
Brief Clinical History:
We present a 58-year-old man with a history of hyperuricemia, currently on allopurinol therapy, admitted to our emergency department due to a one-week history of generalized jaundice, right hypochondrium abdominal pain, adynamia, and food-containing emesis. On admission, he showed signs of dehydration (grade II), jaundiced sclerae, tender distended abdomen, bilateral arm ecchymosis and hand nodular lesions, as well as knee nodules and grade II lower limb edema. Neurologically intact, he deteriorated after 24 hours, developing drowsiness, respiratory distress, and oliguria. Laboratory findings indicated multiorgan failure, necessitating ICU admission with vasoactive, ventilatory, and dialytic support, ending in a fatal outcome.
Missleading elements during the case inluded: accurate clinical approach, detailed interrogation, comprehensive system review and acquiring disease-specific knowledge.
Unfortunately, re-interrogation and necropsy reveal that the patient suffered from hepatic failure of unknown etiology; however, hepatic damage related to intoxication by exogenous substances is established.
Differential Diagnosis:
Obstructive biliary pathology
Viral hepatitis
Abdominal sepsis
Actual Diagnosis:
Acute Hepatic Failure Secondary to chronic herbal consumption
Educational and clinical relevance include the importance of training physicians about this particular case, considering it's an unusual clinical presentation, which may lead to underdiagnosis, increasing costs and hospital stay, as well as a potentially preventable fatal outcome. Early diagnosis, along with timely treatment or intervention, could prevent such outcomes.
Cristian Camilo ORTIZ BUITRAGO, Valentina VILLARREAL (, Colombia), Camilo NOY, Oscar WALTEROS, Miguel Angel SAAVEDRA
00:00 - 00:00
#41627 - Unveiling Meningioma in the Emergency Department: Clinical Insights.
Unveiling Meningioma in the Emergency Department: Clinical Insights.
Meningiomas, representing a significant portion of primary brain tumors, pose diagnostic challenges in emergency medicine due to their diverse clinical presentations. This abstract provides a concise clinical overview, focusing on relevant abnormalities and highlighting the clinical and educational significance of meningiomas in the emergency department (ED).
Meningiomas commonly present with nonspecific symptoms such as headaches, seizures, focal neurological deficits, and cognitive impairments. Behavioral changes, including personality alterations and mood disturbances, can also occur, adding complexity to the diagnostic process. Moreover, meningiomas can manifest acutely with intracranial hemorrhage or mass effect leading to raised intracranial pressure, necessitating prompt recognition amidst various differential diagnoses.
Neuroimaging, particularly MRI and CT scans, plays a crucial role in diagnosing meningiomas. Key radiological features include extra-axial location, dural attachment, and variable enhancement patterns, aiding in delineating the extent of the lesion and predicting its clinical course.
Understanding meningioma's clinical spectrum and imaging characteristics is essential for timely diagnosis and appropriate triage in the ED. Failure to recognize meningiomas can lead to delays in management and life-threatening complications. Emphasizing meningiomas in differential diagnoses enhances diagnostic acumen among emergency medicine practitioners, fostering a culture of continuous learning and vigilance in the ED. Improved recognition and management of meningiomas through interdisciplinary collaboration ultimately enhance emergency care delivery.
Martina CERMAKOVA (Hradec Králové, Czech Republic)
00:00 - 00:00
#41930 - Unveiling Rare Bacterial Culprit in Flexor Sheath Phlegmon: A Case Report Following a Cat Bite.
Unveiling Rare Bacterial Culprit in Flexor Sheath Phlegmon: A Case Report Following a Cat Bite.
Aim: The emergence of flexor sheath phlegmon represents an inevitable surgical emergency due to its local and functional repercussions. A frequently identified cause is a seemingly minor wound, often resulting from an animal bite, with Pasteurella multocida being the predominant pathogen. In this context, we present a unique case of flexor sheath phlegmon following a cat bite, featuring a notable bacteriological characteristic: the presence of Pasteurella canis.
Case presentation: A 57-year-old woman presented to the emergency department with scratches from a stray cat on her right hand. No significant medical history was reported. She promptly received treatment, including wound dressing, tetanus immunoglobulin, and a rabies vaccination protocol. However, the patient returned two days later due to worsening symptoms. Initial vital signs were as follows: temperature of 39 ℃, heart rate of 88/min, respiratory rate of 18/min, and blood pressure of 118/75 mmHg. Wounds were located on the dorsal aspect of the right index, exhibiting redness, swelling, and intense pain, particularly during extension of the ipsilateral index finger (Painful palpation of the anterior aspect of the right index finger, extending from the distal interphalangeal joint (P3) to the metacarpophalangeal joint), and discharge of pus. No abnormalities were detected on standard radiographs.
Initial blood test results were as follows: white blood cells (WBC) at 15.4 × 10^9/L (neutrophils at 85.5%), hemoglobin at 12 g/dL, and platelets at 250 × 10^9/L. No significant abnormalities were noted in routine blood chemistry, except for an elevation in acute-phase reactants (C-reactive protein [CRP] at 100 mg/dL). Given the clinical presentation, the diagnosis of flexor sheath phlegmon of the index finger (right hand) was established. The patient was admitted to our service and underwent synovectomy with lavage, confirmed intraoperatively: Stage 2 phlegmon of the flexor sheaths, accompanied by perioperative bacteriological sampling. Amoxicillin/clavulanic acid therapy was initiated immediately and continued throughout hospitalization. Microbiological examination of the samples revealed the presence of Gram-negative coccobacilli on a direct Gram-stained smear, ultimately identifying Pasteurella canis. The pathogen demonstrated susceptibility to amoxicillin/clavulanic acid. Therefore, antibiotic therapy was continued, dressings were changed every two days, and clinical and biological monitoring was ensured.
Conclusion: This report marks the first identification of P. canis from a wound caused by a cat bite. The findings of this study underscore the importance of early management and bacteriological sampling for the diagnosis and treatment of infections resulting from animal bites.
Khouloud KHEMILI (Tunisia, Tunisia), Jacem SAADANA, Firas CHAOUECH, Moez JELLALI, Amine SIOUD, Bilel FAIZI, Said ABID, Insaf BEN MESSAOUD, Ahmed MDAOUKHI, Hatem BELGACEM, Abderrazek ABID
00:00 - 00:00
#42119 - Unveiling the impact of Virtual Reality simulation on cardiopulmonary resuscitation: a literature review.
Unveiling the impact of Virtual Reality simulation on cardiopulmonary resuscitation: a literature review.
Background: Virtual reality (VR) is a new method for training different medical groups. Based on this technology, professionals and students of various medical sciences can determine their level of competence for medical treatment before any performance on the patient. This paper outlines what VR is, its strengths, its weaknesses for simulation in cardiopulmonary resuscitation (CPR) the evidence behind it, its use in practice and where the future lies.
Methods: Using the following key word composition in the PubMed database: "Simulation" AND "CPR" AND "Virtual Reality." The window for publishing was set to run from 2019 until 2024. Only works published in English were chosen. Fifty-eight research papers were found during this search. A review of the four papers were done after comprehensive selection.
Results: In experimental research with 241 first-year health science students who were trained in CPR using VR versus traditional methods. It revealed that the two approaches acquired skills in a comparable way both immediately following and six months after training with no statistically significant difference (1). Moreover, a randomized, single-blinded VR simulation-based pilot study of CPR training was compared to a traditional course. The study involved 26 participants who were recruited based on specific inclusion criteria such as being adults over 18 years old and either never having taken a CPR course or not having taken one for over a year. The participants were randomly divided into two groups: one group underwent the traditional CPR training and the other the VR-based training. The results showed no visible changes in skill gaining, but the VR course was well-liked, indicating that it could be a possible option for CPR instruction (2). Furthermore, a comparative experimental research specifically comparing VR-assisted CPR training to traditional mannequin-based training included 43 first-year medical students. The VR system was equipped with motion detection technology that assessed the quality of chest compressions. VR methodology for CPR training showed a positive effect on knowledge and manual skills, with as well as without the physical mannequin (3). Last paper is controlled experimental research. The study involved 30 participants. The intervention included VR-based CPR training. Participants performed CPR in a VR environment, with some using a VR setup alone and others using VR combined with a physical mannequin. Experimental study looked at compression depths and frequency and found no difference between VR group and standard CPR training group (4). Overall, in 4 studies there were 340 participants. 2 studies had evaluated knowledge of CPR and it did not differ between groups. All participants who trained with VR versus standard training did not differ in compression frequency or depth (p>0.05).
Discussion & Conclusions: This literature review suggests that VR teaching could deliver CPR skills in an attractive, cheaper, and game-like manner, with no inferiority in acquisition of these skills compared to traditional methods. Further and more similar designed studies need to be done to compare those two methods.
Kasparas ASOKLIS, Beatrice RASCIUTE (Vilnius, Lithuania), Renata JUKNEVICIENE, Pranas SERPYTIS
00:00 - 00:00
#41569 - Use of ketamine in emergencies.
Use of ketamine in emergencies.
SUMMA 112 was notified by a 75-year-old woman who had fallen to the ground from her own height and was unable to move. An ambulance was on the scene and reported that the patient was in a lot of pain and that analgesia would be necessary to mobilize her in the most comfortable way.
We proceed to monitor the patient, cannulate venous line and perform a physical examination. The patient was 157/96, saturation 96%. The examination showed shortening and internal rotation of the right lower limb, functional impotence, with mobilization of the foot and distal coldness of the limb. The patient was given analgesia.
We doubted which type of analgesic would be the best choice for our patient, since the patient was in a lot of pain, and required manipulation to immobilize and bring her down from her home. We opted for ketamine, at a dose of 0.3 mg/kg, weight 70 kg. A total dose of 21 mg of ketamine IV was administered, with this dose she had the desired effect, 128/88 after administering medication. With this dose, the patient was in a correct state for immobilization of the leg and subsequent mobilization of the home. She maintained a good level of consciousness, responded to the call and had no pain throughout the journey to the ambulance.
The question we had in this case was whether to use fentanyl or ketamine to control the patient's pain. Although the use of ketamine for acute pain control is relatively new, there are several studies that encourage the use of ketamine in the management of pain in emergencies. Currently there is a problem with the abuse of fentalin and the dependence it generates, an effective and safe alternative according to the literature review I have performed is ketamine.
According to Balzer low doses of ketamine and morphine had similar analgesic efficacy within 60 minutes after administration with comparable safety profiles, suggesting that ketamine is an effective alternative analgesic for acute pain control in the emergency department. According to Pourmand ketamine has a favorable adverse effect profile when administered in subdisociative doses, less respiratory depression, and less extensive abuse potential. Pourmand also discusses the use of ketamine at use below 1 mg/kg for desired effects. On the other hand Mengyao Ying speaks of doses below 0.5 mg/kg. And Aun Nam Lee, speaks of ketamine in low doses at 0.3 mg/kg, as we did, with good results.
One of the main challenges limiting the use of ketamine in many emergency departments is the familiarity and comfort level of not only the physicians, but also the nursing staff. The use of low-dose ketamine has been shown to be safe and effective for the treatment of acute pain.
Therefore, the dose we used with this patient would be indicated for the control of acute pain, a dose 0.3 mg/kg, where we obtained the desired effects of ketamine, a good control of acute pain, without side effects.
Noemi SOTO TOSTADO, Marta HUEDO JIMÉNEZ, María REDONDO LOZANO, Pilar VARELA GARCIA, Miriam UZURIAGA MARTÍN (Madrid, Spain), Vanesa NATALIA ISAAC, Cristina BARREIRO MARTÍNEZ, Blanca GUERRERO MOÑUS
00:00 - 00:00
#42330 - Use of NIV in treatment of drowning: a case study.
Use of NIV in treatment of drowning: a case study.
We are presenting the case of a 27 years old male, who was brought to Emergency Department (ED) by ambulance service following drowning into a swimming pool. Patient was intoxicated by alcohol and fell accidentally into the pool and was submerged for an estimated time of 1 to 2 minutes. Bystanders performed Cardiopulmonary resuscitation manoeuvres briefly until patient coughed. Saturation (SpO2) was initially 89%, so paramedics started oxygen therapy.
On arrival in ED, the patient was alert, mildly tachycardic with heart rate (HR) of 110 beats per minute, normotensive and was maintaining a SpO2 of 98% on 15 l/min of oxygen on non-rebreathe mask (NRB), but was becoming dyspnoeic and more tachycardic when it was tried to wean him off high flow oxygen. On examination patient had bilateral rhonchi on lung fields.
Arterial blood gas (ABG) was performed and showed pH 7.312, pO2 20.2, sO2 99.2, HCO3- 20.0 and Be -5.5. The calculated Horowitz Index (pO2/FiO2 ratio) was 179, in keeping with picture of moderate Acute Respiratory Distress Syndrome (ARDS). Chest Xray was performed and showed bilateral opacifications with mild pulmonary oedema.
ED clinician then decided to initiate Non Invasive ventilation (NIV) support with BiPAP modality. Initial setting were IPAP 12, EPAP 4, FiO2 40% Tidal Volume of 500 with pressure support modality.
Intensive Care team was involved along with respiratory team.
After 2 hours of NIV patient was stepped down on Venturi mask and repeated ABG showed significant improvement in all parameters with normalised pO2/FiO2 ratio.
After 24 hours of admission patient was discharged and did not suffer with any further complications.
DISCUSSION
Drowning is a relevant medical problem, leading to approximately 500,000 deaths per year. Hypoxia is leading cause of mortality and morbidity, but recently more and more focus has been put on Acute Lung Injury (ALI) and ARDS caused by liquid aspiration.
The pathophysiological mechanism is based on disruption of the integrity of alveolar surfactant, leading to alveolar collapse, atelectasis and pulmonary oedema with shunting and ventilation/perfusion mismatch, resulting in ARDS.
Hence it is necessary to break this cycle to restore ad adequate lung function in order to prevent death, usually caused by hypoxia and acidosis.
The use of NIV in treatment of drowning has been described only in last few years, with limited amount of studies to establish definite protocols of use. Nevertheless the results are promising in terms of good recovery and reduced length of admission in patients treated with NIV. Moreover, less complications are associated with NIV in comparison with intubation.
Lastly, setting and management of NIV is more immediate than intubation and ventilation, making this technique more accessible in pre-hospital ad ED settings.
CONCLUSION
Drowning is an event often associated with high mortality and morbidity, due to respiratory complications. Despite lack of studies, early use of NIV seems to be very effective in achieving positive outcomes in terms of surviving and recovery. Thus, we advocate its use and further studies should be encouraged.
None of the authors has any conflict of interest.
Dr Mattia KOLLETZEK (Colchester, ), Daniel STANCIU, Rupa CHATTERJEE, Yagmur NURAYDIN
00:00 - 00:00
#41643 - Use of Quantitative Metagenomics Next-Generation Sequencing to confirm leishmaniasis in a non-endemic area: case report and literature review.
Use of Quantitative Metagenomics Next-Generation Sequencing to confirm leishmaniasis in a non-endemic area: case report and literature review.
Abstract
A body temperature >38.3°C that lasts ≥3 weeks and lacks a clear diagnosis after 1 week of standard hospital examination and treatment is called “fever of unknown origin” (FUO). The main causes of fever of unknown origin are infections, hematological diseases, autoimmune diseases, and other noninfectious inflammatory diseases. In recent years, quantitative metagenomics next-generation sequencing (Q-mNGS) has been used widely to detect pathogenic microorganisms, especially in the contribution of rare or new (e.g., severe acute respiratory syndrome-coronavirus-2) pathogens. We describe a patient who had a 1-month history of fever. We made a diagnosis of leishmaniasis in a non-endemic area by utilizing Q-mNGS. Here, as well as discussion of the patient, the applicability of Q-mNGS for an undetermined cause of fever is discussed.
CASE REPORT
A 53-year-old man attended our hospital due to a 1-month history of high fever (≤40°C) and 10-day history of muscle soreness. Previously, he had been fit and well. He lives in a village in Shanxi Province (China) and is a truck driver. Before he came to our hospital, he had been treated with ceftriaxone sodium, oseltamivir, and various antipyretic drugs, but to no avail.
Upon hospital admission, physical examination revealed an enlarged spleen (thickness of 46 mm on ultrasound), swollen lymph nodes (neck, axillary, bilateral groin) and a body temperature of 39.4°C: other abnormalities were not found. We documented a reduced white blood cell (WBC) count of 3.91×109/L, red blood cell (RBC) count of 3.36×109/L, hemoglobin concentration of 105 g/L, platelet count of 64×109/L, interleukin (IL)-6 level of 136.36 ng/mL, ESR of 40 mm/h, and D-dimer level >5 µg/mL. An increased concentration of IL-6, D-dimer, and ESR suggested that an infectious disease could not be ruled out.
In consideration of pathogens that may not have been detected by laboratory tests, we carried out Q-mNGS on his peripheral blood. We documented 28802 sequence readings of Leishmania species (which accounted for 69.82% of genome coverage) and 8404 sequence readings of Leishmania donovani species complex (which accounted for 20.37% of genome coverage) in peripheral blood within 24 h. The L. donovani found in this case belonged to the Pasteur strain.
Next, we undertook a real-time fluorescence-quantitative polymerase chain reaction (qPCR) to detect the DNA of Leishmania species. Our Q-mNGS finding was validated by qPCR.
After being diagnosed with visceral leishmaniasis, he was started on sodium antimony gluconate (1.9-g daily, i.m.). His fever subsided after 1 day of medication. At 7-day follow-up, fever, fatigue, and muscle soreness had resolved fully. The WBC count was 4.10×109/L (normal range = 3.5–9.5×109/L), RBC was 4.26×109/L (normal range = 4.09–5.71×109/L), hemoglobin concentration was 136 g/L (normal range = 131–172 g/L), platelet count was 291×109/L (normal range = 125–350×109/L), absolute neutrophil count was 2.37×109/L (normal range = 1.8-6.3×109/L), and albumin concentration was 40 g/L (normal range = 35–55 g/L).
Junyi DENG (Tianjin，China, China)
00:00 - 00:00
#40847 - Utilization of Micro-debriefing in Medical Student Simulation: An Emergency Department Experience.
Utilization of Micro-debriefing in Medical Student Simulation: An Emergency Department Experience.
Background
Simulation-based education among novice learners such as medical students emphasizes effective debriefing modalities which has been one of the most important component of promoting technical and/or non-technical skills as well as knowledge acquisition; and the purpose of this mix-method study is to evaluate the efficacy of micro-debriefing as a subtype of reflection-on-action technique which occurs “in-simulation”. Using this method, the facilitator can adjourn the session any time an error or uncertainty occurs and uses a “pause-(rewind)-proceed again” approach to allow the learners to repeat specific technical skills or cognitive tasks after simplified guided feedback has been provided.
Methods
This was conducted at the largest tertiary academic centre affiliated with SingHealth Duke-NUS Institute of Medical Simulation, from October 2021 to December 2022 with Year-4 undergraduate medical students in a high-fidelity simulation laboratory. During the approximately two-hour session, the senior simulation faculty would conduct pre-briefing which included mannequin orientation, learning objectives, ground rules and expectations followed by "in-simulation" micro-debrief. An anonymous Debriefing Assessment for Simulation in Healthcare and free-text responses on 6 questions related to the simulation and debriefing experience were collated electronically after 4 pre-planned emergency scenarios (ACLS, ATLS, respiratory failure and metabolic derangement). Cross-sectional descriptive statistics were calculated to summarise as quantitative data using Microsoft Excel for Microsoft 365 Version 2211. Free-text responses were analysed by two independent observers. They identified themes and tabulated the frequency of their occurrence.
Results
A total of 61 Year-4 undergraduate medical students on their 3-week emergency medicine core posting participated in the simulation sessions.There was a 100% response rate for the DASH element survey. Micro-debriefing faculties were rated well on all 6 elements (mean = 6.86-6.92). Thematic analysis of 95 free-text responses revealed key themes surrounding the guided nature of micro-debrief, exemplary learning experiences and sufficient psychological safety with drawbacks such as lacking more simulation opportunities and preference for more scenarios.
Discussion & Conclusion
Micro-debrief is not only time-efficient but it allows for just-in-time learning for novice learners who lack simulation knowledge as well as inadequate medical foundation on acute presentations. This in theory allows scaffolding of the learning experience and helps progress the simulation scenario to achieve deliberate learning. For micro-debriefing, the general principles still apply such as debriefing with good judgement, etc. and appropriate pauses to prevent any disruption to cognitive flow, but just appropriate to share bitesize information which are relevant and targeted. The interaction during these stops should also be dual direction between the learners and facilitator, as well as timely and focused in order to clarify doubts instantaneously. Students valued micro-debriefing as good guidance from the facilitator during stops, practical application of clinical knowledge, and was able to achieve desired outcomes as per all simulation activities. They also felt psychologically safe to perform during the scenario without any detract from realism and were comfortable with the pace and flow of the scenarios. Therefore micro-debriefing as part of simulation-based education does provide an effective alternative to reinforce positive learning experience and strengthen clinical reasoning skills especially for novice learners.
Yuan Helen ZHANG (SINGAPORE, Singapore)
00:00 - 00:00
#41560 - Utilizing CFIR to Investigate Factors Influencing the SurgeCon Implementation across Four Canadian Emergency Departments.
Utilizing CFIR to Investigate Factors Influencing the SurgeCon Implementation across Four Canadian Emergency Departments.
Abstract
Context: The extended wait times and overcrowding experienced in emergency departments (EDs) pose substantial national challenges in Canada. In response to this issue, SurgeCon, a quality improvement program designed to improve wait times, elevate patient satisfaction, and foster communication among clinicians, was developed and deployed. Objective: The objective of this study is to pinpoint the factors that facilitate or hinder the implementation of SurgeCon in four EDs, employing the Consolidated Framework for Implementation Research (CFIR). CFIR is a widely utilized implementation framework that facilitates the design, assessment, and execution of evidence-based interventions. It encompasses 38 constructs categorized into five domains: innovation, outer setting, inner setting, individual, and process. Setting: Two rural and two urban Canadian EDs with 24/7 on-site physician support. Study Design: A longitudinal process evaluation was utilized, spanning from before implementation to after. Forty-two semi-structured interviews were conducted with healthcare providers (physicians and nurses), decision-makers, and software developers. CFIR guided the interviews. A deductive approach, guided by CFIR, was utilized to formulate pertinent codes and themes for analyzing the data. Results: Among the CFIR domains, SurgeCon implementation was facilitated by factors from the innovation domain, such as adaptability (e.g., configuring software for each ED), complexity (e.g., simple data entry), and design (e.g., training sessions). Additionally, factors from the individual domain, such as other implementation support (e.g., champions), played a significant role. Barriers stemmed from the outer setting domain, including critical incidents (e.g., the impact of COVID-19), and the inner setting domain, comprising structural characteristics (e.g., physical infrastructure) and available resources (e.g., admission space and human resources). Various constructs from diverse domains received mixed feedback, acting as both facilitators and barriers. These encompassed relative advantage, relational connections, communication, organizational culture, tension for change, compatibility, relative priority, access to knowledge and information, and engaging. Conclusions: While factors that enabled the successful implementations frequently originated from innovative characteristics and the individual domain, barriers linked to the inner and outer settings presented considerable challenges. Furthermore, the dual role of specific constructs underscored the complexity of implementing initiatives like SurgeCon. Using CFIR to analyze the implementation enabled stakeholders to evaluate the facilitators and barriers to implementing SurgeCon the quality improvement program and develop flexible strategies to mitigate them.
Trial Registration:
• Name of the registry: ClinicalTrials.gov
• Trial registration number: NCT04789902
• Date of registration: 03/10/2021
• URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT04789902?cond=surgecon&draw=2&rank=1
Funding:
Funding agencies providing financial support for the SurgeCon study include:
-Canadian Institutes of Health Research
-Newfoundland and Labrador Provincial Government (Department of Industry, Energy and Technology)
-Eastern Health (NL Eastern Regional Health Authority)
-Trinity Conception Placentia Health Foundation
Among the funding agencies providing financial support, only Eastern Health is assisting with the collection of data. The design of the study, analysis, interpretation of data and manuscript preparation is/will be completed independently by the research team.
Ethical approval and informed consent:
Ethical approval for the SurgeCon study was granted on March 19, 2020 by the Newfoundland and Labrador Health Research Ethics Board. Ethics approval will be renewed annually until the end of the study. This study includes consent forms for patients and healthcare staff participating in the study. HREB Reference #: 2019.264
Nahid RAHIMIPOUR ANARAKI (St.John's, Canada), Meghraj MUKHOPADHYAY, Jennifer JEWER, Christopher PATEY, Paul NORMAN, Holly ETCHEGARY, Oliver HURLEY, Shabnam ASGHARI
00:00 - 00:00
#41667 - Validating the Emergency Team Competencies Score for the briefing and debriefing activities of emergency healthcare providers: A Delphi Method Approach.
Validating the Emergency Team Competencies Score for the briefing and debriefing activities of emergency healthcare providers: A Delphi Method Approach.
Non-technical skills (NTS) are pivotal for healthcare professionals to ensure an efficient and safe, performance. Global patient safety data indicate a concerning prevalence of adverse events, leading to substantial increases in healthcare costs [1] [2]. Despite heightened awareness, adverse events persist, necessitating enhanced training and support for healthcare professionals [3]. Addressing the absence of validated tools for assessing technical and non-technical competencies during emergencies, this study seeks to validate an assessment and monitoring system tailored to healthcare professionals' competencies. Using a qualitative-quantitative approach, the study used the Delphi method to develop and validate Emergency Team Competency (ETC) scores. Key Performance Indicators (KPIs) were identified in collaboration with healthcare professionals experienced in non-technical competencies. Using the Delphi technique, expert consensus on the relevance and necessity of each KPI was sought through online questionnaires and videoconferencing, in addition to validation of the scoring method implemented to address patient safety risks. Statistical analyses were performed to assess construct validity, including the calculation of the content validity index (CVI). 30 healthcare professionals participated in 3 Delphi rounds, with response rates ranging from 68% to 75%. Participants identified areas for improvement, particularly in the areas of 'communication', 'decision making' and 'stress management'. Assessment of Key Performance Indicators (KPIs) on various parameters showed that S-CVI/Ave scores ranged from 0.81 to 0.78 for some areas, while others were below the proposed thresholds.
Analysis of the S-CVI/Ave for the items proposed showed scores above 0.80 for relevance, clarity, accessibility, applicability, with scores between 0.62-0.73 for effectiveness, simplicity and objectivity. The re-verification of the change in the assessment model, the introduction of observation facilitation tables and post-simulation debriefing supported assessment achieved S-CVIs above 0.96. In the final round, thephi was administered and assessed for appropriateness. All items exceeded S-CVI/Ave values of 0.90. In 5 areas the S-CVI/Ave was equal to 1.This study demonstrates good construct, content and face validity with regard to the design of the Emergency Team Competencies score at a theoretical level. By highlighting the importance of non-technical skills in healthcare, the study supports the need to align training with safety standards observed in sectors such as aviation to improve patient safety and optimise healthcare delivery. It will be necessary to apply the tool to simulation activities to perform statistical validity tests to verify the reliability and sensitivity of the tool in detecting unsafe behaviour of emergency teams.
Ethics Committee request not necessary.
Gabriele LORENZINI, Alberto DI MARTINO, Alberto PELLACANI, Alberto ZAMBONI (Olbia, Italy), Nicolo BARBIERI
00:00 - 00:00
#41554 - Validation of Automated VIDAS® TBI (GFAP, UCH-L1) Test for Prediction of Absence of Intracranial Lesions in Adult Mild Trauma Brain Injury Patients.
Validation of Automated VIDAS® TBI (GFAP, UCH-L1) Test for Prediction of Absence of Intracranial Lesions in Adult Mild Trauma Brain Injury Patients.
INTRODUCTION:
A combination of blood-based brain biomarkers, glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1), have been shown to accurately identify mild traumatic brain injury (mTBI) patients who have intracranial lesions (ICLs) on head computed tomography (CT).
OBJECTIVE:
To evaluate the clinical and key analytical performances of the GFAP and UCH-L1 assay performed on the automated VIDAS® platform in identifying ICLs on CT Scan.
METHODS:
Biomarker analysis using the VIDAS® TBI (GFAP, UCH-L1) test was conducted on samples from the multicenter ALERT-TBI trial. Patients included adult blunt head injury with an initial Glasgow Coma Scale (GCS) score of 13-15 with blood obtained within 12 hours of injury meeting the criteria. Test characteristics were determined relative to the CT status of each subject (CT-positive or CT-negative), as defined by the presence or absence of acute ICLs.
Final qualitative interpretation of the VIDAS® TBI test is obtained by combining the results of the two assays, where the test is positive if at least one protein concentration is above its respective cut-off value. Cutoff values for positive tests were 22pg/ ml for GFAP and 327 pg/ ml for UCH-L1. Analytical performances of VIDAS® assays were defined according to respective applicable CLSI.
RESULTS:
Of the 1911 patients/samples included, mean (sd) age was 49.1 (20.0) years, 56.5% males, and 94.1% has an initial GCS score of 15. A positive CT was noted in 120 patients (6.3%). Analytical Measuring Interval (AMI) is 10.0-320.0 pg/ mL for VIDAS® GFAP assay, and 80.0-2560.0 pg/mL for VIDAS® UCH-L1 assay. The two assays are linear over their AMI. Limits of quantitation are 5.4 pg/mL for GFAP and 48.1 pg/mL for UCH-L1 assays and for each assay, the coefficients of variations are below 8 %.
The VIDAS® TBI test had the following test characteristics: Sensitivity 96,7% (95% CI 91,7-99,1%), Specificity 41,2% (38,9-43,5%) and Negative Predictive Value (NPV) 99,5% (98,6-99,9%). All five patients with neurosurgical manageable lesions had a positive test.
CONCLUSION:
VIDAS® TBI test is a new automated test for simultaneous measurement of GFAP & UCH-L1. High sensitivity (96.7%) and NPV (99.5%) of VIDAS® test support its clinical utility as an aid in determining the need for a head CT by predicting the absence of acute lesions on CT up to 12 h following injury.
This study was funded by bioMérieux
Robert D WELCH (Detroit, USA), Valdislav PAVLOL, Pierre-Géraud CLARET, Louise LEFEBVRE, Sandrine MICHEL BUSSERET, Hélène BRIAND, Sarah LACHEREZ, Alexandra WERLE, Linda PAPA, Bazarian JEFF
00:00 - 00:00
#41704 - Validation of the PECARN rule in febrile infants below 60 days visiting European Emergency Departments: a multicenter study.
Validation of the PECARN rule in febrile infants below 60 days visiting European Emergency Departments: a multicenter study.
Background
Fever is a common cause for infants visiting the Emergency Department (ED), with 10-20% suffering from a serious bacterial infection (SBI). Distinguishing between viral and bacterial infections remains challenging. Various prediction rules exist to support the challenge of identifying SBIs in febrile infants. The Pediatric Emergency Care Applied Research Network (PECARN) published a prediction rule for febrile infants aged≤60 days to support the identification of SBI, using urinalysis, absolute neutrophil count, and procalcitonin (PCT) without routine lumbar puncture and antibiotics. This study aimed to externally validate the PECARN rule in a multicenter European cohort.
Methods
This multicenter observational cohort study combined data from two large cohort studies in febrile children, i.e. the MOFICHE and a Swedish multicenter study. MOFICHE included data from febrile children aged 0-18 years from 2017 to 2018 across twelve EDs in eight European countries. The Swedish study included previously healthy febrile infants aged ≤60 days from 2014 to 2020 in four EDs. The outcome measure SBI was defined as infants with a urinary tract infection (UTI), meningitis, or bacteremia. We aimed to validate the original rule in both cohorts, but due to missing PCT values (92% and 79.9%, respectively) we validated the original rule (sensitivity/specificity) in a 2018-onward sub-cohort of the Swedish cohort (with presence PCT 63.1% n=338). Additionally, we adapted the PECARN rule by using C-Reactive Protein (CRP) with a cut-off value of ≥20 mg/L and assessed validity in both the MOFICHE and Swedish full-cohort. Finally, a sensitivity analysis assessed the accuracy of the selected and different CPR cut-off values.
Results
The MOFICHE and Swedish cohort together included 2749 febrile infants, of which 323 (11.7%) were diagnosed with SBIs, comprising 284 UTIs and 39 invasive bacterial infections. Only 375 (13.6%) infants had values for all the parameters of the original PECARN rule. In the Swedish cohort, more infants had fever <24 hours (92% vs. 69% in MOFICHE), and fewer were assessed as ill-appearing (9% vs. 27% in MOFICHE). In the Swedish post-2018 sub-cohort, sensitivity of the original PECARN rule was 96.6% (95% CI 88.1-99.6) with specificity of 61.9% (95% CI 57.4-66.3). The adapted PECARN rule with CRP showed a sensitivity of 92.2% (95% CI 81.1-97.8) MOFICHE and 97.8% (95% CI 95.3 - 99.2) Swedish full-cohort and a specificity of 50.5% (95%CI 45.9-55.2) MOFICHE and 52.2% (95% CI 49.9-54.4) Swedish full-cohort. False-negative results were 4 infants, all with UTI in the MOFICHE cohort and 6 infants (0.3%) in the Swedish cohort. Sensitivity analysis with CRP cutoffs of 10, 20, 30 and 40 mg/L showed almost consistent sensitivity (92.2%-90.2%, MOFICHE and 97.8%-97.1%, Swedish full-cohort) and a limited gain in specificity (43.7%-54.2%, MOFICHE and 47.4%-54.6%, Swedish full-cohort).
Discussion and Conclusion
The original PECARN rule in our study showed comparable performance to its internal validation study. Adapting the PECARN rule by replacing PCT with CRP (cut off ≥20 mg/l) showed similar validity and could be considered using in settings lacking PCT to improve feasibility. Nonetheless, the adapted rule shows better performance in settings featuring fewer ill pediatric patients.
Trial Registration: Secondary analysis on existing cohorts.
Funding: PERFORM: This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 668303.
Sanne VRIJLANDT (Rotterdam, The Netherlands), Ioannis ORFANOS, Daan NIEBOER, Eline VAN DER WALLE, Chantal TAN, Henriette MOLL, Rianne OOSTENBRINK
00:00 - 00:00
#41721 - Validation of the reduced Vittel score in pre-hospital trauma patients.
Validation of the reduced Vittel score in pre-hospital trauma patients.
Pre-hospital triage is an initial clinical assessment conducted in the field to direct an injured patient to the most appropriate center based on the patient's clinical condition. A number of studies have demonstrated that referring trauma patients to specialized trauma centers (TCs) reduces mortality. Consequently, there is a clear need for useful and accurate pre-hospital triage tools, such as the Vittel criteria and the Injury Severity Score (ISS), which can be employed to ensure that the most appropriate center is selected for each patient. The objective of this study was to validate a reduced score of the French Vittel score in pre-hospital trauma patients in the SAMU03 territory between November 2020 and 2022. The objective of this study was to validate a reduced score of the French Vittel score in pre-hospital trauma patients in the SAMU03 territory between November 2020 and 2022. A longitudinal analytic study was conducted on polytraumatized patients transported by SMUR teams of the Tunisian eastern center SAMU 03's emergency medical assistance service over a two-year period from November 2020 to November 2022. The patients' socio-demographic and clinical data were collected using a pre-established questionnaire, after which the Vittel score and ISS score were calculated for each patient. The statistical tests were completed, leading to the formation of three alternative algorithms. The Vittel algorithm was then compared with the three alternative algorithms in accordance with the method of Delong et al. Men in their thirties were particularly susceptible to trauma, with a sex ratio of 5.3. Road traffic accidents were the primary cause of injury, affecting 77.2% of males. Blunt trauma was the most common lesion mechanism, accounting for 47.3% of cases, followed by penetrating trauma (15.6%). Of the 461 polytrauma patients included in the study, 41% had an Injury Severity Score (ISS) greater than 15, 25% were admitted to intensive care units, and 23.9% died within 30 days of transfer. In the context of multivariate analysis, no criteria related to kinetic elements demonstrated a statistically significant correlation with ISS 15, 30-day mortality, or ICU admission. Conversely, three categories of the French Vittel score, namely physiological variables, prehospital resuscitation, and physical injuries, were identified as significant predictors of major trauma (ISS 15), whereas kinetic elements did not exhibit this predictive capacity. Our study highlights the necessity for coordination between hospitals. A new reduced Vittel score effectively predicts severe trauma (ISS 15) based on physiological criteria, accident mechanism, and prehospital resuscitation. Although different algorithms perform similarly, challenges remain in prehospital triage criteria.
Rabeb MBAREK, Chebbi NABIL (Tunisie-Sousse, Tunisia), Haifa BRADAI, Sondes LAAJIMI, Dorra LOGHMARI, Naoufel CHEBILI
00:00 - 00:00
#42301 - VALUE OF OPTIC NERVE SHEATH DIAMETER ULTRASOUND FOR THE NON-INVASIVE DETECTION OF ELEVATED INTRACRANIAL PRESSURE IN AN EMERGENCY DEPARTEMENT.
VALUE OF OPTIC NERVE SHEATH DIAMETER ULTRASOUND FOR THE NON-INVASIVE DETECTION OF ELEVATED INTRACRANIAL PRESSURE IN AN EMERGENCY DEPARTEMENT.
Ultrasound measurement of the diameter of the optic nerve sheath is used to detect the elevation of intracranial pressure (ICP) in brain-injured patients , when it is greater than 5.5mm.
Changes in cerebral blood flow during refractory intracranial hypertension can be monitored by transcranial Doppler ultrasound , wich spectrum evolution in patients progressing towards encephalic death is known.
It is a simple, reproducible and non-invasive test.
In this study, our aim was to compare the optic nerve sheath diameter (ONSD) measurements with those of transcranial Doppler ultrasound in order to deduce their sensitivity and usefulness.
This is a prospective study including patients identified in refractory elevated intracranial pressure in the department over a 45-day period between September and mid-October 2023.
When a patient in the department presented with hight ICP that was refractory to all the therapies used, regular ultrasound monitoring was required.
As part of this study, we combined the ICP monitoring protocol with the measurement of patients' ONSD until the angioscanner was performed if necessary.
transcranial doppler ultrasound spectra were classified as grade 0: indicative of severe elevated ICP; grade 1: bilateral reverse flow (RF) with negative area less than positive area; grade 2: bilateral RF with negative area greater than positive area; and grade 3: protosystolic peak and/or disappearance of flow.
We analysed the value of the ONSD at inclusion, at the diagnosis of brain death, and in relation to the grades of transcranial doppler ultrasound.
15 patients were included
48% of our patients were men with an average age of 56.
The mean ONSD at diagnosis of intracranial hypertension was 6.76±0.67mm, significantly higher than at inclusion (6.3±0.54mm), p<0.01. Values in brain dead patients were relatively higher at 6.93±0.46 (4 patients included).
In correlation with trans-cranial Doppler, there was a significant difference between grade 1 and 2 and between grade 1 and 3.
In our study, ONSD appears to be increased during intracranial hypertension and progression to brain death. This study is preliminary and requires confirmation.
Determining the diagnostic value of the ONSD during the transition to brain death could be of interest.
Hamza TOBI (RABAT, Morocco), Aziz BERTUL, Tahir NEBHANI, Naoufel CHOUAIB, Ahmed BELKOUCH, Saad ZIDOUH, Lahcen BELYAMANI
00:00 - 00:00
#42113 - Variation in the use of head CT scan in patients presenting at the emergency department following ground-level fall-related minor head trauma: a prospective multicenter study.
Variation in the use of head CT scan in patients presenting at the emergency department following ground-level fall-related minor head trauma: a prospective multicenter study.
Objective
To assess the variation in the use of head CT scan in patients visiting Emergency Department (ED) following ground-level fall-related minor head trauma and identify patient and ED characteristics associated with use of head CT scan.
Methods
This was a planned sub-analysis of a prospective multicentric study performed in 63 EDs in France. Only patients sustaining ground-level fall-related with minor head trauma (defined as Glasgow Coma Scale (GCS) score ≥13 upon arrival) were included in this sub-analysis. The main outcome was head CT scan performed during ED stay. Variations in the use of head CT head were described at the ED and the region level. The dependent variable was the use of head CT at the patient level. A multiple fixed effects mixed logistic regression model (random intercepts were modeled per region and per ED) was performed to identify factors associated with head CT scan use.
Results
A total of 631 patients admitted for head injury following a ground-level fall were included in this sub-analysis. Median age was 79 years (63-88). A head CT scan was performed in 409 patients (64.8%) and 29 (4.6%) of them showed a traumatic intracranial hemorrhage of which two patients requiring urgent neurosurgery. At region level, head CT scan prescription rates ranged from 45.5% to 84.6%. In multivariable analysis, preinjury antiplatelets (OR 29.2, CI95%: 12.2-69.9), anticoagulants (OR 69.9, CI95%: 20.0-243.9), syncope (OR 6.9, CI95%: 2.0-24.2), post-trauma amnesia (3.2, CI95%: 1.0-10.5) and post-trauma loss of consciousness (OR 5.6, CI95%: 2.0-15.9) were associated with head CT scan use.
Conclusion
In EDs, the prescription of head CT scans in patients with head trauma following ground-level fall is highly variable. The need to develop a decision rule dedicated to this population and to update our recommendations seems necessary to homogenize our practices.
Xavier DUBUCS (Toulouse), Frederic BALEN, Thomas LAFON, Pierre-Hugues CORMICAEL, Axel BENHAMED, Valérie BOUCHER, Eric MERCIER, Sandrine CHARPENTIER, Marcel EMOND
00:00 - 00:00
#42349 - Variation of biological parameters in patients with upper digestive bleeding: prognostic value.
Variation of biological parameters in patients with upper digestive bleeding: prognostic value.
Introduction: Digestive bleeding is a frequent and potentially serious reason for consultation in the Emergency Department, which is associated with significant morbidity and mortality. The incidence of upper gastrointestinal hemorrhage (UGH) has been reported to be 67–103 per 100,000 adults per year with mortality rates of 2%–8%.
Objectives of the work: Our goal is to study the impact of biological parameters in the prognosis of patients with upper digestive hemorrhage in a Tunisian population.
Methods: This is a descriptive single-center study over a period of 3 years from September 2019. We included all patients aged 18 or over, consulting the emergency room for non-traumatic UGH. We collected demographic, clinical and biological parameters for each patient included in our study. Data analysis was carried out using SPSS version 20 software. Different statistical tests were applied (independent t test, Chi square test, cross tables) depending on the variables.
Results: we included 143 patients. The average age of our population is 63.8±16.5 years. The majority of patients (38.8%) are aged between 60 and 74 years. A male predominance was observed. In our study, a urea level >10 and a creatinine level >150 were correlated with a poor prognosis: a urea level >10 had a mortality risk of 2.068 with a 95% CI [1.026-4.168] and increases the chance of having complications with an OR 2.049 and a 95% CI [0.988-4.249]. It was found that a lactate level greater than 2 mmol/l was predictive of intra-hospital mortality. In our study, a urea/creatinine ratio less than 75 was correlated with a poor prognosis.
Conclusion: After comparative analysis between patients “with good progress” and those who presented complications (death, rebleeding, readmission, etc.) we were able to conclude that the level of lactate, urea and creatinine can be risk factors. in patients consulting the emergency room for UGH.
Oumayma HWICHI, Hajer YAAKOUBI, Rahma JABALLAH, Rym YOUSSEF, Jalloul ESSID, Tasnim BOUKRIAAT, Imen TRABELSI (Sousse, Tunisia), Houda BEN SALAH, Asma ZORGATI, Lotfi BOUKADIDA, Riadh BOUKEF
00:00 - 00:00
#41193 - Variations in capillary and serum lactates levels based on different etiologies of septic patients in the Emergency Department.
Variations in capillary and serum lactates levels based on different etiologies of septic patients in the Emergency Department.
Background: Sepsis is a time-dependent and life-threating condition. The cytokine cascade, responsible for the clinical manifestations, compromises both macro- and micro-circulation leading to anaerobic metabolism and an increase of lactate levels. In a previous study we demonstrated that capillary lactates (CLs) predict short-term mortality (i.e. 48-hour and 7-day) better than serum lactates (SLs). In this new evaluation, we assessed whether variations in CLs and SLs levels vary according to sepsis etiology in patients admitted to the Emergency Department (ED). Furthermore, we evaluated whether neutrophil/lymphocyte ratio (N/L), diastolic shock index (DSI), National Early Warning Score-2 (NEWS-2) and mean arterial pressure (MAP) could statistically differ depending on etiology.
Methods: This was an observational, prospective, single-centre study conducted between October 2021 and May 2022 at the Emergency Department (ED) of Ferrara, where the following inclusion criteria were applied: i) clinical suspect of infectious disease; ii) qSOFA ≥2; iii) age ≥18 years; iv) a signed informed consent from recruited patients. Etiologies were divided in 4 groups: i) negative cultures (NC); ii) Gram positive (GP); iii) Gram negative (GN); and iv) fungal infections (FI). CLs were assessed immediately at patients’ admission in the ED using the LactateProTM2®.
Results: A total of 203 patients met the inclusion criteria. Among them 104 (51.2%) had NC, 37 (18.2%) were affected by GP, 54 (26.6%) by GN and 8 (3.9%) by FI. CLs (NC: median 5, IQR 3-8; GP: 9, 5-13; GN: 6, 4-11; FI: 4, 3-9, p=0.006) and SLs (NC: median 1, IQR 1-1; GP: 2, 1-3; GN: 2, 1-3; FI: 2, 1-4, p<0.001) were significantly different according to microbiological etiology. N/L ratio (NC: median 8, IQR 5-12; GP: 11, 6-20; GN: 12, 7-25; FI: 10, 4-31, p=0.018) was higher in GN infections, while DSI (NC: median 1.36, IQR 1.14-1.66; GP: 1.55, 1.23-2.00; GN: 1.63, 1.29-2.00; FI: 1.9, 1.28-3.25, p=0.012) resulted increased in FI. Finally, NEWS-2 (NC: median 8, IQR 5-10; GP: 9, 8-12; GN: 8, 5-10; FI: 9, 5-10, p=0.036) was higher in patients affected with GP, while MAP levels (NC: median 80, IQR 73-92; GP: 73, 70-83; GN: 73, 67-80; FI: 73, 53-73, p=0.003) were lower in FI. Mortality was not significantly influenced by the different microbiological etiologies.
Conclusions: Our data indicate that CLs and SLs statistically differ according to sepsis etiology and, in particular, CLs were higher in patients with GP infections. These results bear important implications, particularly in relation to the various pathogenetic mechanisms affecting the anaerobic metabolism. The ability of clinico-laboratory tools to early predict sepsis etiology could provide a significant contribution to improve empirical antimicrobial treatment.
None
Matteo GUARINO (Ferrara, Italy), Michele Domenico SPAMPINATO, Benedetta PERNA, Alice Eleonora CESARO, Giacomo MARONCELLI, Anna COSTANZINI, Chiara DONATI, Francesco LUPPI, Paolo BALDIN, Pesci CHIARA, Roberto DE GIORGIO
00:00 - 00:00
#42242 - Varicella pneumonia in an immunocompetent adult: a case report and literature review.
Varicella pneumonia in an immunocompetent adult: a case report and literature review.
Introduction: varicella is a highly contagious cosmopolitan viral infection due Varicella Zoster Virus (VZV) characterized by febrile and pruriginous papulo-vesicular eruption. It is a frequent and benign infection in the healthy child. In adults, its evolution could be fatal, especially due to complications such as varicella pneumonia. Varicella pneumonia incidence is estimated to be in between 5 and 50%. We report a case of respiratory distress in an immunocompetent adult due to varicella pneumonia.
Case report: we report the case of a 58 years old female patient, with no particular medical history, admitted to the ER with respiratory distress. On admission, vital signs were remarkable for a respiratory rate of 30 breaths/ min, pulse oximetry of 85%, cyanosis of the lips and extremities. The patient was conscious and hemodynamically stable. Her temperature was of 39.4 °C. Physical examination showed coarse crackles in both lungs, rapidly progressive papulo-vesicular lesions with scratching lesions. Chest X-ray was positive for reticulo-nodular infiltrate. Chest CT confirmed multiple confluent micronodular lesions, associated with ground-glass hyperdensities and bilateral parenchymal condensations at both bases. Echocardiography showed no disturbance of cardiac kinetics, and filling pressures were normal. Laboratory workup revealed elevated CRP 269 mg/L, hepatic cytolysis, anemia with a hemoglobin level of 9.3 g/dl, leukocytosis 11500 elements/mm3 and thrombocytopenia 111000 elements/mm3. Blood gases showed hypoxemia with a PaO2 59 mmHg, respiratory acidosis with pH = 7.29 and PaCO2 52 mmHg. HIV serology was negative and VZV serology was IgM positive. Sputum tests for Koch's bacillus were negative. In view of these arguments, the diagnosis of hypoxemic varicella pneumonitis was accepted. Treatment was based on high-flow oxygen therapy, acyclovir and a combination of amoxicillin and clavulanic acid, with daily sterile baths.
The evolution was favorable, with apyrexia achieved after 48 hours of treatment, improvement in dyspnea, correction of hypoxemia and regression of skin lesions. The patient was transferred to the Pneumology Department.
Discussion: varicella pneumonia is the most common serious complication of varicella in adults, with an estimated incidence of 16-33% and a mortality rate of up to 20%.
Several factors have been associated with the development of pulmonary involvement in varicella. Smoking, the extent of skin involvement (>100 elements), a history of close contact with an infected subject, pregnancy and immunosuppression are factors associated with a high incidence of pneumonia. Respiratory symptoms of varicella pneumonia usually begin one to seven days after the onset of the exanthem. They include a dry cough, sometimes accompanied by hemoptysis, chest pain, dyspnea, fever and even acute respiratory distress. The diagnosis of varicella pneumonitis may be based on the association of pulmonary involvement, with concordant clinical and radiological features, and a rash suggestive of varicella in the absence of any other possible cause. Thoracic imaging usually shows diffuse, possibly confluent nodules involving both lung fields; hilar adenopathy and liquid pleural effusion are not usually present. Our case report is particularly interesting due the severity of such a clinical manifestation of varicella and its rarity in the immunocompetent adult.
Ahmed YASEEN (Lilienthal, Germany), Mohamed Anas FAHDI, Badria AGGOUG, Asmae DAFIR, Mohamed MOUSSAOUI, Mohamed MOUHAOUI
00:00 - 00:00
#41660 - VBG Potassium or Lab Potassium.
VBG Potassium or Lab Potassium.
INTRODUCTION
Hyperkalaemia is a life-threatening condition, primarily due its effect
on the heart.
It is defined as a serum-potassium level higher than 5.5mmol/L. It is
seen in 1.1% to 10% of all hospitalized patients, with approximately 1%
having significant Hyperkalaemia of greater than 6.0 mmol/L and is
associated with a high mortality rate (14.3% to 40%).
In most patients, the pathophysiology of Hyperkalaemia is
multifactorial, with reduced renal function, medications, acidosis and
Hyperglycaemia being the most common contributing factors.
CATEGORIZATION of HYPERKALAEMIA:
Mild Hyperkalaemia: 5.5 – 5.9
Moderate Hyperkalaemia: 6.0 – 6.4
Severe Hyperkalaemia: 6.5 or higher
OBJECTIVE:
Patients arriving with Hyperkalaemia, instead of having to
wait for 45 to 60 minutes for the blood test results to arrive
before any treatment can be started, if done a VBG which
provides the results much quicker and thus resulting in
starting a treatment plan earlier.
AUDIT BASIS:
In patients with Hyperkalaemia and with or without ECG changes,
currently treatment is being delayed until the lab Potassium results
arrive. This delay could be anywhere between 45 minutes to an hour.
It is to address this delay in start of treatment, we have conducted
this audit. We gathered over 70 patients with Hyperkalaemia and
with or without ECG changes and analysed their Laboratory vs VBG
Potassium results.
AIM:
Check for Disparity in Potassium levels on VBG and U&E
Ensure to start immediate treatment based on VBG Potassium levels
Ensure to stop treatment upon receipt of U&E Potassium levels
Check for ECG changes
Any advise provided to patient to prevent further rise of Potassium
levels
INCLUSION/ EXCLUSION CRITERIA:
Patients with Potassium levels more than 5.5 with or
without symptoms/ with or without ECG changes
Statistical Results:
Paired T-test value for Laboratory K+ and VBG K+ is = 0.000204907 ,
where P value is < 0.05 which is statistically significant.
Un-Paired T-test –
assuming equal variance = 0.106949568
assuming un-equal variance = 0.108470604
CONCLUSION:
1. Null criteria met, implying no difference between VBG and Lab Potassium values (P<0.05)
2. Start treatment based on VBG while awaiting lab results, minimising delay risks.
QUALITY IMPROVEMENTS:
1. VBG results may facilitate discharge of patients referred for Hyperkalaemia.
2. For those on treatment, frequent VBG checks (every 3 hours) enable swift adjustments, aiding treatment assessment.
3. Potential nurse led discharge in ED based on VBG values of Electrolytes which can help in meeting Four Hour Target in these patients.
Chandra Rekha KOLLIBOYANA, Salman JAMSHED (Kettering UK, )
00:00 - 00:00
#41307 - Ventricular tachycardia (VT) in a young male diagnosed by wearable gadget.
Ventricular tachycardia (VT) in a young male diagnosed by wearable gadget.
Background
Wearable devices or smart devices in healthcare refer to devices that patients attach to their skin or body to collect health and fitness data, which they may provide to doctors, health providers, insurers and other relevant parties. The wearable technology market was valued at over $115.8 billion in 2021, as per a recent study, and by 2028, it is projected to reach a valuation of $380.5 billion. Apple, Samsung, Google, Amazon, and Informa are among the world’s leading companies for wearable technology.
We report a case of ventricular tachycardia (VT) in a young male diagnosed by Apple Watch
Case Summary
A 29-year-old male working as a chef with a history of asthma and bowel perforation due to a road traffic accident in 2010 presented with a history of chest discomfort associated with palpitations, mild dizziness, diaphoresis and mild shortness of breath for a 1-month history. While he was working in the kitchen, he experienced 4 episodes of palpitations and each lasted for a few minutes. His Apple Watch recorded an abnormal (ECG) with a heart rate of 150- 200 per minute. The patient was rushed to the emergency department with the above complaint. On arrival, his vital signs were normal with a pulse rate of 88/ min. 12 lead ECG was performed at triage and noted normal sinus rhythm (Figure 1). His iPhone ECG rhythm was recorded from his Apple watch (Figure 2) and the patient managed to record it in his phone. During the consultation in the emergency department, the medical officer diagnosed his life-threatening condition(Ventricular Tachycardia). His blood results were full blood count, renal function, troponin T and thyroid were normal. The patient was seen by a cardiovascular specialist and admitted for further monitoring. He was discharged on metoprolol with a plan to obtain a formal outpatient multiday ECG, Transthoracic Echocardiogram(TTE) and a later date for ablation.
Figure 1
Figure 2
Figure 3 I watch detected sinus tachycardia
Discussion
The advancement of wearable technology and the growing demand of consumers have influenced the medical industry. Technological innovations reach deeply into our daily lives and an emerging trend supports the use of commercial smart wearable devices to manage health. Examples include fitness trackers, smart watches, blood pressure monitors, jewellery smart apparel and biosensors. Because of these benefits, wearable medical devices have witnessed booming
demand. These devices have been intentionally designed to collect and monitor data from daily activities over a quantified period.
Conclusion
This case highlights the potential role of using data from wearable devices in emergency departments to detect life-threatening emergencies.
Keywords
Wearable devices, Apple Watch, smartwatch, Life-Threatening Emergency, Ventricular Tachycardia
*** Please take note that the figure can not be inserted in this document.
Thajudeen MOHAMMED ZUHARY, Sohil SOHIL POTHIAWALA (Singapore, Singapore)
00:00 - 00:00
#42267 - Vertebro-medullary wound (about an observation).
Vertebro-medullary wound (about an observation).
Introduction : Vertebro-medullary wounds are a rare entity among vertebro-medullary traumas. They are mainly due to stab wounds following assaults. Lesions may be related directly to the sharp object injury in the short term, or to local mechanical or infectious complications in the medium to long term. We report the medical observation of a patient with a vertebro-medullary stab wound.
Case report: A 27-year-old chronic alcoholic-smoker admitted to a life-threatening emergency room with a wound in the lumbar juxtamedian region following a stabbing incident. On initial assessment, the patient was conscious but reported lower-limb paresthesia with no initial motor deficit. He was hemodynamically and respiratorily stable, with a capillary blood glucose level of 0.93 g/L and a temperature of 37.4°C. Examination of the lumbar region revealed the handle of a knife penetrating the paravertebral region, obliquely upwards and medially. The patient was conditioned with a good-calibre venous line, immobilization of the head-neck-body axis with limited patient movement and effective analgesia. An abdomino-pelvic CT scan with reconstruction of the lumbar spine was performed, showing the blade of the vulnating agent passing superiorly and medially, with an intramedullary passage at D12-L1 and a stable fracture of D12, suggesting complete spinal cord transection. The patient's clinical course showed the onset of complete and rapidly progressive paraplegia. The patient was transferred to the operating theatre for surgical cure.
Discussion : Vertebro-medullary wounds are a rare reason for admission to the emergency department. Their prognosis and quality of management have been optimized by the development of imaging, given its broad indication for this type of trauma. Most sharp-edged injuries are of metallic origin, particularly stab wounds in the context of aggression. Given the metallic nature of these agents, MRI is not always an option. The neurological deficits caused are polymorphous and vary according to the degree of damage to the spinal cord. Complications are variable, mainly infectious and mechanical. Treatment is primarily surgical. Our case stands out for the rarity of the knife used and the rapid onset of motor deficit.
Youssef MANDOUR, Mohamed Anass FEHDI (Casablanca, Morocco), Asmae DAFIR, Badria AGGOUG, Mohamed MOUSSAOUI, Mohammed MOUHAOUI
00:00 - 00:00
#41262 - Visualization of foreign bodies in the gastrointestinal tract with point of care ultrasonography (POCUS).
Visualization of foreign bodies in the gastrointestinal tract with point of care ultrasonography (POCUS).
Introduction: Recently, point of care ultrasonography (POCUS) has been shown to be very effective in imaging foreign bodies (FBs) and their complications in the gastrointestinal tract (GIT). However, the utility of POCUS in the diagnosis of FBs in the GIT in adult patients is not well defined. In this presentation, two cases in which FBs in the GIT were visualized with POCUS were explained.
Case 1: A 32-year-old male patient admitted to the emergency department (ED) with the complaint of swallowing a razor blade for suicidal purposes. The patient's vital signs and physical examination were normal. The patient's abdomen was evaluated with POCUS. FB was observed as a hyperechoic image with reverberation artifact in the right lower quadrant. Hyperechoic image and reverberation artifact were detected to move along with intestinal peristalsis. This finding was interpreted as FB does not cause intestinal obstruction. Intestinal wall thickness was normal. There was no free fluid in the abdomen. Then the abdomen was imaged with XR. Radiopaque FB was visualized on XR at the level of the ileocecal valve. The patient was transferred to general surgery inpatient clinic. The patient, who was followed up conservatively, excreted FB by defecation the next day.
Case 2: A 55-year-old male patient admitted to the ED with complaints of abdominal and anorectal pain. In the patient's history, it was learned that her partner inserted FB into her rectum to achieve sexual satisfaction. The patient said that the FB was a pool noodle about 2O cm long. The patient's vital signs and physical examination were normal, the abdomen was normal, but a hard object was felt in the left lower quadrant during palpation. FB could not be palpated on digital rectal examination. The patient's abdomen was evaluated with POCUS. In POCUS, an FB with hyperechoic surroundings and acoustic shadowing behind it, starting from the left upper quadrant towards the lower quadrant, was imaged. When the patient turned to the right and left, it was observed that the FB did not move and there was no intestinal peristalsis. Subsequently, a standing XR showed a hypodense structure in the left lower quadrant (Figure 1). The appearance of a FB located in the sigmoid colon was detected in abdominopelvic CT images. FB has advanced approximately 20 cm proximally from the anal canal, completely fills the lumen and causes minimal diameter increase. It has dimensions of 200x60x73 mm, smooth contours, cylindrical structure and homogeneous air density (Figure 2). The patient was transferred to general surgery inpatient clinic. FB was removed with surgery.
Conlcusion: The type, number, size, shape, swallowing time, location of FBs in the GI tract and, more importantly, complications arising from FBs are important in the treatment decision. For this purpose, X-ray (XR) and computed tomography (CT) are used in imaging. However, identification of radiolucent foreign bodies by XR is limited. Inconsistencies have been reported in the detection of radiolucent FBs with CT. POCUS is an alternative method to XR and CT in imaging FBs.
Nalan KOZACI, Ismail Erkan AYDIN, Ebru TORUN, Ahmet Edibali TANRIKULU (ANTALYA, Turkey)
00:00 - 00:00
#41375 - Vit K Antagonists’ overdose in elderly: emergency department.
Vit K Antagonists’ overdose in elderly: emergency department.
INTRODUCTION: Vit K Antagonists (VKA) therapy carry a high risk of iatrogenicity especially in the elderly. Acenocoumarol is widely prescribed in preventive and curative thromboembolic diseases. Few studies had reported the epidemiological characteristics and prognosis of this entity.
OBJECTIVE: The study aims to analyze the epidemiologic characteristics and the management of both bleeding and asymptomatic overdose in elderly patients undergoing VKA therapy.
METHODS: We performed a retrospective study of all patients over 65 years old admitted in the emergency department during 15 months, from January 1st 2023 to march 31st 2024. Patients’ data and blood samples were collected. Patients with International Normalized Ratio (INR) greater than 5 were included.
RESULTS: Twenty-five patients were included. Media age was 77 years-old with feminine predominance (56%). All patients were treated with Acenocumarol for Atrial fibrillation with a median weekly dose was 2 mg. Fourteen were nonbleeding patients. INR ‘s average value was 9.43 {5-24.5]
Hemorrhagic symptoms were mainly represented by ecchymosis (n=4) and gingival bleeding (n=3).
Major bleeding episodes were represented by deep muscle hematoma (n=3), cerebral hematoma (n=2), abdominal hematoma (n=1) and digestive bleeding (n=1)
VKA assumption was suspended transiently in 18 patients. Vitamin K was given to all patients.
Five patients were transferred to specialized departments.
CONCLUSION: Appropriate dosing of VKA therapy is difficult to establish, due to significant inter-individual variability in the dose required to obtain stable anticoagulation particularly in elderly. Further studies are needed to establish the risk factors and to limit bleeding complications.
Rahma DHOKAR (Sousse, Tunisia)
00:00 - 00:00
#42344 - Wellen’s syndrome in a young smoker patient with occlusion of the proximal stenosis of the LAD coronary artery.
Wellen’s syndrome in a young smoker patient with occlusion of the proximal stenosis of the LAD coronary artery.
Introduction:
Wellens’ syndrom is an electrocardiogram finding suggestive of anterior wall ischemia and reflects stenosis of the proximal left anterior descending artery.This situation is an immediate precursor of myocardial infarction and could rapidly evolve to massive fatal myocardial infarction. It has the particularity to be highlighted when patient is pain-free and could be rapidly fatal if revascularization is not underwent.
Case report :
We report the case of a 56 year old patient, regular smoker with history of well-treated hypertension which was evaluated at the prehospital field by the emergency team for ongoing chest pain since a 12 hours period. On arrival of the emergency medical team, patient was less painful compared to last pain exacerbation. Physical examination showed an aware conscious patient, apyretic, with symmetric tension monitored about 180 mmHg of systolic blood pressure. No hypoperfusion signs were present nor pulmonary crackles were found on auscultation. Immediate 12 leads Electrocardiogramm showed a regular sinusal rhythm with acute biphasic T-waves on antero-septal wall. Despite non algic patient, an acute coronary syndrome was retained, anti-ischaemic with anti platelets agents and anticoagulation were initiated and optimal analgesia was attempted. Patient was immediately transferred to a catheterization room for urgent management and coronary revascularization. Coronary exploration objectived anterior interventricular obstruction with features of coronary dissection.
Discussion and conclusions:
Wellen’s syndrome was first described in 1980 and is a clinical presentation of an acute coronary syndrome characterized by the presence of abnormal EKG patterns and either biphasic or deeply inverted T-waves in anterior leads with obviously a free-pain patient consulting several hours after coronary pain -exacerbation. This EKG-pattern is correlated with proximal stenosis of the LAD coronary artery. The high-risk of this situation is its evolution into dissection of the coronary artery. This situation highlights the useful interaction between teams to propose an optimal management
Rym HAMED (Tunisie), Imen MEKKI, Anouar YAHMADI, Houda NASRI, Alaa ZAMMITI, Adel WALHA, Akim SADDAR
00:00 - 00:00
#41872 - What hides behind pleuritic pain?
What hides behind pleuritic pain?
Case description: a 26 year-old presented to the Emergency Room describing retro-sternal pain and to
the right hemithorax. The patient was in good general health, not a smoker, with an active lifestyle. He
had history of spontaneous popliteal Deep Venous Thrombosis (DVT) and he was in secondary
prophylaxis with rivaroxaban 10mg once daily. At the time of the diagnosis genetic screenings were
conducted to exclude thrombophilic states.
At first evaluation all vital signs were normal, with normofrequent heart rate, regular blood pressure
and SpO2 of 98%. He had low-grade fever and reported a mild cough in the previous days.
At physical examination there were no abnormalities to heart sounds, normal respiratory sounds. He
reported tenderness at the palpation of the right hemithorax base. EKG showed no abnormalities and
the result of laboratory tests showed elevation of C-reactive protein and white blood cell count. Point
of care ultrasonography showed no pleural effusion and a regular A pattern of the lung. There was no
pericardial effusion, normal atrial and ventricular volume for both heart sections. There were no sign
or symptoms of DVT relapse. Chest X-ray was unremarkable. At this stage our main clinical suspicion
was of a respiratory tract infective state, although it was not confirmed by radiological signs.
During observation the patient admitted to an irregular assumption of the anticoagulant prophylaxis.
D-dimer was then added to the laboratory testing and resulted elevated at 1788 ng/ml. Contrast
enhanced Computer Tomography showed pulmonary embolism of the lateral arteriosus segment of
the inferior right lobe with a corresponding area of parenchymal consolidation, of likely ischemic
nature. Anticoagulant therapy was promptly started with 6000UI of low-molecular-weight heparin
(LMWH) and he was admitted to the department of Urgent Medicine for observation and
anticoagulant therapy. During the brief hospitalization an echography of the heart was repeated with
no further findings, while Compression Ultrasonography of the lower extremities revealed DVT of the
right popliteal vein and right posterior tibial vein. The patient was discharged with an oral therapy with
rivaroxaban 15mg twice daily for 21 days, then 20mg once daily.
Pulmonary infarction (PI) is a relatively common complication of PE, with a reported incidence of 30%,
and a higher probability of affecting young individuals without cardiovascular risk factors. The most
obvious signs and symptoms of PI include dyspnea, chest pain, fever and hemoptysis, although the
presentation might be considerably more subtle and unspecific. Other signs and symptoms might
include dizziness, weakness, syncope, tachycardia, tachypnoea and chest wall tenderness. Imaging in
PI is often ambiguous or unreliable, but when positive it might present with a wedge-shaped
consolidation called “Hampton’s hump”.
Radiographic signs of lower lobes consolidations, particularly of the right lung, with absence of clinical
and laboratory signs of respiratory infection (no fever, no cough and no leucocytosis) should always
lead to consideration of PI as a potential diagnosis. This is particularly true for young, otherwise
healthy individuals, where the diagnosis of pneumonia is less likely.
Federica GRANDI (Modena, Italy), Giuseppe IARIA, Ennio LICHERI, Daniela GRISANTI, Geminiano BANDIERA, Luca RONCUCCI, Vazzana NATALE, Lucio BRUGIONI
00:00 - 00:00
#41475 - What is going on when the tongue goes wrong?: A rare case of internal carotid artery dissection.
What is going on when the tongue goes wrong?: A rare case of internal carotid artery dissection.
Introduction
Carotid artery dissections are a common cause of stroke among young patients. An undetected and untreated internal carotid artery dissection (ICAD) due to uncommon and non-specific clinical manifestations may have detrimental consequences. The aim of this case study is to raise awareness about ICAD, a potentially life-threatening and frequently underdiagnosed illness.
Case Description:
A 48-year-old male patient, with no known medical history, presented to the emergency department with a ten-day history of tongue deviation to the left side after vomiting.
On physical examination there were no carotid or vertebral artery bruits. Tongue deviated to the left when protruded; fasciculations were absent. The rest of the neurological and physical examination was normal.
An immediate head computed tomography (CT) was conducted which revealed no active parenchymal lesions followed by an angio-CT of the neck and intracranial vessels, which revealed left internal carotid artery dissection (ICAD) from its origin with partial occlusion of the vessel due to intramural hematoma, involving the intracranial trac. The rest of the vessels were normal.
Neurology consulting was asked for further evaluation and treatment.
Conclusion
Tongue palsy after ICAD due to isolated cranial hypoglossal nerve palsy is uncommon. Although dissections frequently relate to severe neck trauma, they can also result from less serious incidents like coughing or vomiting. ICAD should be suspected in cases of new unilateral cranial nerve palsy or Horner syndrome. Therefore, we would like to emphasize the significance of careful evaluation and assessment of every clinical finding and implementation of a thorough diagnostic pathway in order to improve patient care. Although rare, nerve palsy should be examined carefully and recognized as a potential symptom of ICAD.
Sofia-Chrysovalanto ZAGALIOTI, Sofia GKARMIRI, Ekaterini APOSTOLOPOULOU, Maria ZOUKA, Domna DELIGIANNI, Vasileios GROSOMANIDIS, Varvara (Barbara) FYNTANIDOU (Thessaloniki, Greece)
00:00 - 00:00
#41386 - What is known about exposure among individuals authorised to administer and handle ketamine across different occupational settings: a scoping review.
What is known about exposure among individuals authorised to administer and handle ketamine across different occupational settings: a scoping review.
Abstract
Objective: To systematically map and synthesise the available evidence on occupation exposure (OE) to ketamine among individuals authorised to administer or handle the drug across various clinical and occupational settings.
Introduction: Ketamine is frequently handled and administered in emergency situations by paramedics. However, the prevalence and extent of their OE to ketamine remains an understudied area of concern. While advanced drug testing technologies can detect ketamine and its metabolites to extremely low levels over extended periods, interpreting positive results in the context of OE is challenging due to the lack of internationally recognised cut-off values distinguishing legitimate exposure from illicit use, leading to potential misconduct allegations among healthcare professionals.
Methods: Predetermined search terms related to the research question were used to search the databases MEDLINE (via OVID), CINAHL Plus, Scopus, Emcare, and Embase for articles published in English language. Grey literature was found using advanced Google search techniques limited to Australian and New Zealand sources, and grey literature databases. Results were uploaded to the Covidence platform and screened for inclusion by independent reviewers adhering to the predefined inclusion and exclusion criteria, with a third reviewer acting as an arbitrator when necessary. The selection of final articles was based on the JBI recommended approach for source selection and data extraction.
Results: From 5395 studies screened, 16 articles were included and revealed key characteristics on what is known about ketamine exposure and which occupational settings were at a higher risk. Dermal exposure from preparation, handling and contacting contaminated surfaces was the primary route of OE with hair analysis being the main method used to detect ketamine and its metabolite, norketamine. The review identified occupational settings with a high risk of ketamine exposure that could be transferrable to paramedic practice. It also highlighted the need for established cut-off levels to differentiate between occupational exposure and illicit use.
Conclusions: This scoping review highlighted the OE risks that paramedics and other healthcare professionals may face when administering or handling ketamine. Further research is needed to better understand the exposure risks and develop guidelines to protect healthcare professionals from misconduct allegations.
https://doi.org/10.17605/OSF.IO/DA5FU
David SHANAHAN (Melbourne, Australia, Australia), Thornton CATHERINE, Evans RODNEY, Bronwyn BEOVICH
00:00 - 00:00
#41869 - Wheat-dependent exercise-induced anaphylaxis presenting with hypothermia and elevated plasma D-dimer levels as initial symptoms: a case report.
Wheat-dependent exercise-induced anaphylaxis presenting with hypothermia and elevated plasma D-dimer levels as initial symptoms: a case report.
Background:
Wheat-dependent exercise-induced anaphylaxis (WDEIA) presents a diagnostic challenge, particularly during the first episode of this acute, life-threatening IgE-mediated allergic reaction. We present a case of WDEIA characterized by vasodilatory shock, severe hypothermia, and elevated plasma D-dimer levels indicative of fibrinolysis.
Case report:
A 32-year-old man was brought to the emergency department after collapsing during a 3km race. The patient had eaten lasagna two hours earlier. He was conscious but in shock with a blood pressure of 65/53mmHg. The core body temperature was 33.5°C. There was no cutaneous rash, and no clinical signs of a septic source. Soon after admission, the patient vomited. ECG showed no arrhythmia. Due to the low core body temperature, there was no accompanying tachycardia response. Thoracic ultrasound examination showed a hyperdynamic left ventricle, and allowed to rule out tension pneumothorax, cor pulmonale, or cardiac tamponade. Arterial blood gas analysis revealed compensated lactic acidosis (pH 7.48, PCO2 21.9mmHg, HCO3- 16.5mmol/l, lactate 4.25mmol/l). There was no hypoxemia (PO2 95mmHg on room air). Laboratory tests showed normal C-reactive protein (CRP) level, acute kidney injury (blood urea nitrogen 39mg/dl, normal < 48mg/dl; serum creatinine 2.16mg/dl, normal < 1.17mg/dl), and very high plasma D-dimer levels (>35.2µg/mL, normal < 0.5µg/ml). Due to the distributive shock pattern observed in a young patient who had consumed wheat before physical exertion, a WDEIA has been considered. Acute phase measurements of serum tryptase and specific IgE to omega-5-gliadin were performed, confirming the diagnosis: serum tryptase level 45.4µg/l (normal < 12µg/l), IgE titer to omega-5-gliadin 0.72KU/l (normal <0.10KU/l). The patient was managed with active warming, intravenous fluids, epinephrine, antihistamines and systemic corticoids, and his condition improved slowly. Transient fever (38.4°C) arose seven hours after admission, attributed to the inflammatory phase of anaphylaxis. At 24 hours, the CRP level slightly increased (28.6mg/l, normal <5mg/l), the patient presented mild diarrhea, serum tryptase normalized (7.67µg/l), and plasma D-dimer levels gradually decreased to 15.4µg/ml before reaching complete normalization. A pulmonary embolism was ruled out by a ventilation perfusion scan. Blood and urine cultures remained sterile. The patient was discharged with two epinephrine auto-injectors and advice to avoid wheat consumption for 4h prior to and 4h following sports activity. A food allergies workup was planned.
Conclusion:
In the context of vasodilatory shock without cutaneous rash, the presence of hypothermia and elevated plasma D-dimer levels can complicate the diagnosis of WDEIA, prompting consideration of sepsis as the primary alternative diagnosis. Studies indicate that hypothermia may act as a protective response during severe anaphylaxis, mediated by transient receptor potential vanilloid 1 (TRPV1+) sensory neurons activated by chymase released from adjacent mast cells. D-dimers are specific indicators of fibrinolysis and can be released in significant quantities during anaphylaxis through tryptase-mediated activation of pro-urokinase and tissue plasminogen activator. This case report highlights the necessity of considering WDEIA in cases of collapse accompanied by hypothermia and fibrinolysis biomarkers during physical activity, even in the absence of skin rash, to facilitate timely diagnosis and improve patient outcome.
Samuel LUYASU (Luxembourg, Luxembourg), Farah HANNACHI, Marc SIMON
00:00 - 00:00
#40903 - When blood’s not thicker than water – An Interesting case with Pancytopenia.
When blood’s not thicker than water – An Interesting case with Pancytopenia.
Background:
Pancytopenia is a disorder of the blood characterised by a reduction in numbers of red blood cells, white blood cells and platelets. 1 The disorder may be caused by either marrow infiltration or replacement due to malignancies or secondly bone marrow aplasia which could be nutritional disorders or from infections, immune destruction and medications or thirdly from blood cell destruction or sequestration.
Here we present an interesting case report.
Case report:
A 40 year old female presenting to the emergency department (ED) with a couple of weeks history of gradual lethargy and exertional shortness of breath. She had no other symptoms and no weight loss.
Past medical history: Asthma and previous thyroidectomy for autoimmune thyroid disease. She took Levothyroxine but with poor compliance. No recreational drug use or herbal remedies.
In the ED she was noted to be hypotensive. Blood pressure of (BP) 94/57, severe pallor and had an ejection systolic murmur.
Initial laboratory blood tests: Hb 33 g/L, WCC 1.8 , Platelets 40. Normal reticulocyte count and serum chemistry tests, including electrolytes, renal and liver function tests, lactate dehydrogenase, calcium, and uric acid. Other results: TSH 45.13 (0.3-5), T4 4.3 (7-16). Direct antiglobulin test (DAT) was negative. Normal prothrombin time (PT) and partial thromboplastin time (PTT). Normal compliment and anticardiolipin assays. Normal Hepatitis and CMV viral screen.
Immediate management
The patient was managed as having severe anaemia (pancytopenia) of unknown cause. In ED the patient was transfused with 2 units of red blood cells with antibiotic cover. She was admitted under the medical team for further investigations. She had a further 2 units of blood transfusion on the ward with a target of Hb 80 on discharge. Haematology and endocrinology review was made on ward. It was noted that the blood film showed no blasts. One blood test eventually returned positive after 5 days: Epstein Barr Virus (EBV) DNA was detected with 176 EBV DNA copies/ml
Discussion and conclusion:
EBV infects B-lymphocytes and epithelial cells. Infection is usually subclinical and persists as a latent infection. Severe aplastic anaemia is a rare complication of EBV with really few reported cases in literature. This case is a good reminder to consider EBV and other viral pathogens as possible causes for pancytopenia in a young healthy adult.
Elsa DESMOND, Michael ACIDRI (Southend on Sea, United Kingdom), Dalip KUMAR, Dylan DALIP
00:00 - 00:00
#41477 - When focused and goal directed therapy does not work….
When focused and goal directed therapy does not work….
Introduction: Intravenous line placement for administration of clear fluids, blood, blood products and potentially vasoactive drugs is a key component in trauma management. Central venous access offers numerous advantages, however central venous catheterization is a procedure which requires adequate training and usage of appropriate equipment. Moreover, it is associated with several complications either insertion related or post-procedural.
Material and Methods: A 25yrs old male polytrauma patient was brought by ambulance to the Emergency Department after a motor vehicle accident. Patient was haemodynamically unstable and therefore assessment and resuscitation were performed simultaneously. During initial management, two peripheral venous lines were placed and a massive transfusion protocol was initiated immediately. However, patient remained haemodynamically unstable and needed vasoactive support. Decision was made to transfer patient to the operating room for emergency trauma laparotomy. In the OR, a goal directed transfusion of blood and blood products was applied, a right radial artery catheter and a right subclavian vein catheter were placed for monitoring and management purposes respectively. During laparotomy a transesophageal echocardiogram was performed, which did not reveal any cardiac dysfunction. Patient remained haemodynamically unstable despite successful surgical control of the bleeding in the abdomen and continuation of goal directed transfusion of blood and blood products. Thereafter, a right thoracotomy was decided in order to fix a right-sided diaphragmatic rupture since suturing of the diaphragm was impossible from inside the abdominal cavity due to the right liver lobe. After opening of the thoracic cavity, the tip of the central venous catheter (CVC) was identified in the pleural cavity. CVC was immediately removed and a new right internal jugular CVC was placed. After surgery patient was transferred intubated to the Intensive Care Unit, where he was successfully extubated on the next morning. Patients’ post-operative course was uneventful.
Discussion:
In our case, indications such as positive aspiration into the syringe during needle advancement, no resistance to the insertion of the guidewire through the introducer needle, smooth advancement of the catheter over the guidewire and positive aspiration of venous blood into the catheter were totally misleading. Based on those misleading factors we wrongly assumed that CVC was correctly positioned intravascular. Poor response to goal directed and focused management was attributed to clinical severity.
Assumption of correct CVC placement based only on clinical factors could be misleading and therefore appropriate verification of CVC position should always be performed. CVC malposition should be suspected especially in cases of unanticipated response to treatment.
Varvara (Barbara) FYNTANIDOU (Thessaloniki, Greece), Marianthi PERTSIKAPA, Ekaterini APOSTOLOPOULOU, Maria AGGOU, Sofia GKARMIRI, Sofia-Chrysovalanto ZAGALIOTI, Adamantia NANO, Vasileios GROSOMANIDIS
00:00 - 00:00
#42371 - When in “deep waters”! Psychogenic polydipsia case report.
When in “deep waters”! Psychogenic polydipsia case report.
Background:
What to do when you are in “Deep Waters”? or when faced with situations from which you can find no "way out" or when we can't communicate or explain what's happening to us but most of all when our life is in danger and we can't cry out for help.
Material and methods:
We report a case of a 50-year-old female patient presented to the Emergency Department (ED) in respiratory arrest preceded by an inaugural generalized seizure with traumatic lingual mark and sphincter relaxation. Post resuscitation, BP=90/50 mmHg, AV=80 bpm, sinus rhythm, had bilateral reactive myotic pupils, photomotor and corneal reflex present, no neck roll, apparently symmetrical mobilize to the bed plane (on cessation of analgosedation), bilateral positive Babinski. Due to extreme agitation, continuous analgesia with midazolam and fentanyl was maintained. After Foley catheterization, 3-hour diuresis was 6000 ml.
Biological: metabolic acidosis, pH 7.05, severe hyponatremia (115 mEq/L), potassium 4.7 mEq/L, osmolarity 253 mOsm, lactate 2 mmol/L. Acute hyponatremia correction treatment was initiated by reducing infusion solutions, administration of hypertonic sodium molar solution on continuous infusion in 30 minutes (30 ml saline and 20 ml natrium molar solution 58.5 mg/ml), loop diuretic 40 mg iv, cerebral depletive 150 ml and administration of desmopressin (Minirin Melt 60 mcg, sublingual, 2 tablets).
The patient was known to have polynodular goiter on thyrozole treatment.
Stage diagnosis: respiratory arrest, severe mixed acidosis, severe hyponatremia, in observation syndrome of inadequate antidiuretic hormone secretion, diabetes insipidus, water intoxication vs psychogenic polydipsia.
Emergency CT scan result- absence of acute intracerebral pathology; presence of a large amount of gastric fluid that depletes including the esophagus. After the insertion of nasogastric tube, we evacuated approximately 4000 mL gastric contents.
Toxicology tests were negative. The patient was admitted to the intensive care unit where, after sodium correction and appropriate management, her clinico-biological evolution was favourable. Diagnosis of diabetes insipidus was excluded (normal glycemic values, TP=4.9, NH3=33.8, anti-thyroglobulin antibodies=13, PRO-vasopressin=15 pmoL/L) and the endocrinological biomarkers were in normal parameters (TSH, T3,FT3, FT4). Syndrome of inadequate antidiuretic hormone secretion (SIADH) was ruled out by the endocrinology team, according to the patient's urine analysis. Further investigations excluded all medical conditions that are known to be etiologically related to hyponatremia.
After 5 days, the patient was conscious, hemodinamically stable and she kindly told the story about her severe depressive disorder diagnosed one year ago in the US, treated with selective serotonin reuptake inhibitors (Paroxetine) and about her diet with a water intake of 6-8 litres daily for 6 months.
Final diagnosis: Phychogenic Polydipsia aggravated by antidepressant treatment with Paroxetine.
Conclusion:
The most valuable treasure is life so give meaning to it and don't live shallow! Compulsive water consumption has no specific cause, but complications can be fatal (polydipsia, polyuria, seizures, coma, respiratory arrest). The diagnosis of this pathology in the ED is sometimes difficult to make, especially in comatose patients, or in cardiorespiratory arrest, or extreme psychomotor agitation with impossible anamnesis, without the possibility of obtaining medical history data.
Camer SALIM, Cristina Ramona TASE (Constanta, Romania), Andreea URECHE, Alexandru Vlad PETCU
00:00 - 00:00
#41377 - When raising blood sugar saves lives.
When raising blood sugar saves lives.
We were called to Summa 112 for an 80-year-old man with a low level of consciousness. On arrival, the patient was pale, sweaty and had a decreased level of consciousness (GCS 8 M4V2O2). His carer reported that the patient had been depressed lately. The patient's personal history included ischaemic heart disease, hypertension, LBP and depression, for which he was being treated with antiplatelet, diuretic and beta-blocker therapy. When she went to wake him up she found him in this state with a suicide note, so she decided to call us.
When we monitored him we found a blood pressure of 92/52mmhG, HR 40 bpm sat: 95%. We decided to perform an ECG which showed first-degree atrioventricular block and morphology of left bundle branch block (LBBB).
It was decided to cannulate the peripheral line and, given the suspicion of benzodiazepine and beta-blocker intoxication (due to the patient's clinical condition, blood pressure and ECG), it was decided to administer flumazenil and glucagon respectively. The patient improved and was transferred to the nearest useful hospital.
This case makes us reflect on the importance of antidotes, especially the out-of-hospital use of glucagon in the context of beta-blocker poisoning.
In recent years, the indications for ß-blockers have diversified, as in addition to their cardiological indications, they are used in migraines, essential tremor, anxiety, prevention of digestive haemorrhages, etc. These intoxications are rare, but can be particularly severe, with a mortality rate of 4-5%. They occur more frequently in people under 50 years of age, with propranolol as the main drug and with arrhythmias of the bradycardia and asystole type. Patients show symptoms in about 70% of cases (of which 20% are severe).
The most common symptoms of beta-blocker intoxication are hypotension, bradycardia and intrasinus, atrioventricular and intraventricular conduction disturbances.
In the case of a patient intoxicated by beta-blockers, therapeutic efforts are aimed at:
- Decrease drug absorption: gastric lavage may be indicated if early (< 2 h) or in delayed formulas up to 12 hours, using activated charcoal as long as it defends the airway.
- Maintain haemodynamic stability to ensure visceral perfusion and a diuresis greater than 0.5 ml/kg/h.
If the QT interval is long, high-dose isoprenaline (2-4 µg/kg/min) is recommended as the first drug of choice and, if ineffective, pacemaker placement. In cardiogenic shock, in addition to isoprenaline, we can use adrenaline and control of electrolytes and lactic acidosis, if necessary by administering bicarbonate.
This is important because in acute ß-blocker poisoning the response to vasoactive amines may be poor and cardiovascular depression may be refractory to atropine, isoproterenol and pacing. The antidote to be used is glucagon, which activates the membrane by allowing calcium entry through a different receptor. It is indicated for hypotension and symptomatic bradycardia. It is not effective in abolishing prolonged AV conduction, nor in case of neurological manifestations.
Miriam UZURIAGA MARTIN (Madrid, Spain), Vanesa Natalia ISAAC, Cristina BARREIRO MARTINEZ, Blanca GUERRERO MOÑÚS, Noemi SOTO TOSTADO, Marta HUEDO JIMÉNEZ, Maria REDONDO LOZANO, Pilar VARELA GARCÍA
00:00 - 00:00
#41883 - When the Dog bites the Hand that feeds it? An Advanced Nurse Practitioner in Minor Injuries perspective.
When the Dog bites the Hand that feeds it? An Advanced Nurse Practitioner in Minor Injuries perspective.
The relationship between man and dog is one of the most endearing and closest relationship with the animal world. Dogs are ubiquitous and their proximity to humans is the closest as compared to other animals. They have been regarded as man’s best friend for as long as they have been domesticated. Man has learnt over years of breeding to select traits beneficial for this relationship, sometimes though not just for the family environment but for sport. In these situations the natural aggressive seeking traits are selected to ensure they win or catch the best prey. For the family environment the gentle calm and sophisticated relationship which is ever so protective and comforting is most often breed. There are various breeds each having their own specific traits.
The Man-Dog relationship is overwhelmingly positive and provides many emotional and physical benefits. There are rare instances where man’s best friend is the offender. These situations though rare can be alarming and traumatic for both man and dog. The close proximity offers the potential for aggressive encounters resulting in injury and transmission of disease. Children are at higher risk of dog bites. They are at greater risk of bites to the head and/or neck, which can cause more severe injury and sometimes death. Households with 2 or more dogs are more likely to incur a bite compared with those without pets. Travelers are at greater risk of dog bites, depending on the geographical location and activities associated with travel.
Most countries have legislation to control ownership and possession of dogs. Depending on the dog-human interaction, dog bite incidents can lead to an array of repercussions, including but not limited to wound infections, rabies, disfigurement, death, and post-traumatic stress disorder (PTSD). When children are involved and the incident is fatal these make headlines.
Infections, bleeding, pain, skin tearing, and potential muscle or bone injury especially after deep or severe wounds can occur after a dog attack. Treatment depends on the health of the person bitten, location of the bite, and risk of bacterial infection, tetanus rabies transmission from the animal. Open wounds should be evaluated and the wounds thoroughly cleaned. Patients are given antibiotics if the bite wound is severe and infected. Bites on the hand are especially high risk of infection. An x-ray of the area may be performed to exclude any foreign bodies, bone injury or if they present later indicate serious infection with gas forming bacteria. Local debridement may be required depending on the severity and depth of the wound. A tetanus vaccination may also be given to prevent infection.
This case was reviewed in the minor injuries area of the emergency department by the advanced nurse practitioner of a man who was bitten by his dog not once but twice. He was still being treated for the first dog bites when he represented with multiple bites. This report discusses his assessment, management plan and also the complex difficult decision he had to make with regards to his dog.
Ciara MOONEY (Ballinasloe, Ireland), Kiren GOVENDER
00:00 - 00:00
#41009 - When the stars align: A case of survived cardiac rupture.
When the stars align: A case of survived cardiac rupture.
INTRODUCTION
Cardiac rupture is an often lethal complication of acute myocardial infarction. In the current era of urgent reperfusion therapy, the overall incidence has decreased to less than 2% from 6% as compared to the era of thrombolytic therapy. The mortality rates for left ventricular free wall rupture (LV FWR) is high at 75% to 90%. When LVFWR presents acutely with tamponade and cardiogenic shock, timely treatment with pericardiocentesis and extracorporeal membrane oxygenation (ECMO) support should be considered.
CASE REPORT
A 36-year-old man with a history of hypertension, hyperlipemia and alcoholic pancreatitis was brought into the emergency department (ED) after he found unconscious, gasping and cyanotic on hospital grounds while returning home from visiting others. He was tachycardic, HR 160, and hypotensive BP 60/45 and was immediately attended to by nearby healthcare workers and subsequently the ED code blue team. He was ventilated via bag valve mask with return of consciousness prior to arrival to the ED
In the ED, he was tachycardic with an unrecordable blood pressure and had a faint femoral pulse. He was in significant respiratory distress and complained of shortness of breath with no chest pain. Electrocardiogram showed an inferior myocardial infarction with bedside point of care ultrasound (POCUS) showing sonographic features of pericardial tamponade with right ventricular (RV) collapse and a distended inferior vena cava. The cardiac contractility was poor with a left ventricle (LV) aneurysmal dilatation seen with concerns of free wall rupture. The cardiologist and cardiothoracic surgeons were contacted immediately for consideration of early VA ECMO and emergent pericardiocentesis. The patient was started on inotropes and intubated for respiratory distress. 100ml of frank blood was aspirated via the emergency pericardial drain.
The patient subsequently arrested and was resuscitated whilst undergoing ECMO cannulation. Manual aspiration of pericardial drain yielded another 100ml of frank blood with transient return of spontaneous circulation after 8 mins. Shortly after, the patient had another transient collapse lasting 4 mins and was connected to the ECMO circuit at the 33 min mark. The ECMO circuit recorded low flows and 2 units of emergency packed cells with intravenous fluids were administered. Coronary angiogram showed occluded mRCA and distal LCx, with active extravasation from the LV aneurysm. Intraoperatively, bleeding was seen from thin-walled LV aneurysm measuring 4x3cm and over the diaphragmatic surface of right ventricle opposite the pericardial drain entry point. The patient underwent repair of rupture LV aneurysm and RV puncture with a single vessel CABG.
ECMO was explanted successfully on POD 3. However, his ICU stay was complicated by acute renal failure requiring temporary dialysis, acute intracerebral haemorrhage, acute ischemic strokes and ventilator associated pneumonia. The patient eventually recovered well and was transferred to the general ward for a course of rehabilitation before being discharged home well.
CONCLUSION
Timely diagnosis with point of care ultrasound can help in the emergent diagnosis prompting emergent therapy with pericardiocentesis and emergent surgery. And finally, VA ECMO can be used in ED to treat cardiogenic shock due to LVFWR when death is eminent.
Huiling HUANG (Singapore, Singapore), Evelyn WONG
00:00 - 00:00
#41485 - When the usual culprits fall away: Splenic infarction as the first clue to Median Arcuate Ligament Syndrome in an Elderly Woman.
When the usual culprits fall away: Splenic infarction as the first clue to Median Arcuate Ligament Syndrome in an Elderly Woman.
Background:Median Arcuate Ligament Syndrome (MALS) is a rare vascular disorder that can lead to significant abdominal manifestations, often misdiagnosed due to its nonspecific symptomatology. We present a case of an elderly female with acute thoracic and abdominal pain ultimately diagnosed as splenic infarction resulting from MALS.
Case Presentation:A 74-year-old female with a history of dyslipidemia, depression, iron deficiency anemia, chronic kidney disease, and Darier’s disease presented to the emergency department with acute onset of pain in the left thoracic area radiating to the abdomen, associated with nausea but no vomiting, fever, trauma, or dysuria. She reported nonspecific abdominal pain for several months, previously attributed to gastritis. Social history included social alcohol use; she lived independently and alone.
Clinical Findings: On examination, the patient appeared in pain and distress but was hemodynamically stable. Cardiovascular examination showed normal S1 and S2 heart sounds, and respiratory examination revealed bilateral normal vesicular breath sounds. Abdominal examination was unremarkable with no tenderness, but left paraspinal tenderness was noted in the thoracic and lumbar areas. Neurological and rectal examinations were normal.
Investigations: Hemoglobin was 81 g/L, MCV 55 fL, and CRP 1 mg/L. Bedside ultrasound showed no abdominal aortic aneurysm, free fluid, or hydronephrosis. Other laboratory tests including liver function, amylase, and urine dip were normal. Given the unexplained nature of her pain, a CT abdomen and pelvis (CTAP) was performed, revealing a splenic infarction likely secondary to celiac artery compression.
Diagnosis: Subsequent CT abdominal angiography confirmed the presence of Median Arcuate Ligament Syndrome compressing the celiac artery, explaining the etiology of the splenic infarction.
Management and Outcome:The patient was consulted with vascular surgery and admitted under surgical care. A multidisciplinary team decided on conservative management considering the patient's overall condition and comorbidities.
**Conclusion:** This case highlights the importance of considering MALS in differential diagnoses of unexplained abdominal and thoracic pain, especially in elderly patients with complex medical histories. It underscores the necessity for high clinical suspicion and the use of appropriate imaging modalities to diagnose this rare but significant condition effectively.
Siva Kumar AYTHA (Kolkata, India)
00:00 - 00:00
#41680 - When you do not know it.
When you do not know it.
Prehospital emergency medical service was called to treat a 36-year-old woman who had suffered a fall from 4 meters while doing a risky sport.
The patient had no personal history of interest. She was hemodynamically stable, with oxygen saturation of 98%, a blood pressure of 132/78 mmHg and a heart rate of 70 bpm. Cardiopulmonary auscultation was normal. She complained of pain in the pelvic area with a VAS score of 8. Physical examination showed neither functional impotence nor shortening of the lower limbs. Abdominal examination revealed lower abdominal tenderness without guarding or rigidity. On further examination vaginal bleeding was observed.
The patient was treated with analgesic and fluid therapy and was evacuated to the hospital on the vacuum mattress.
At the hospital she was diagnoses with pelvic fracture and spontaneous abortion due to an uterine contusion. The patient didn´t know that she was pregnant.
With this case as support, we will review the differential diagnoses of this situation.
The main one is pelvic fracture with injury to adjacent organs. Fractures of the pelvic ring account for around 2–8% of all skeletal fractures and can reach up to 25% in polytrauma patients. In young individuals most often occur as a consequence of high-energy trauma such as traffic accidents and falls from great heights. Pelvic fractures from high-energy mechanisms are often associated with injuries to the adjacent vascular and visceral structures (such as genitourinary and gastrointestinal systems). Approximately, 3-4% of females with significantly displaced pelvic fractures incur a Vaginal laceration or tearing, which is associated with a significantly increased Morbidity and mortality due to polymicrobial sepsis. In our case, a vaginal laceration was suspected at first as the origin of the vaginal bleeding.
But we cannot forget that the patient was a woman of childbearing age, and a traumatic abortion must be considered as a differential diagnosis. Different Studies have found that pregnant women who sustain pelvic fractures are at high risk for placental abruption and fetal demise. Pelvic fractures in pregnant patients are associated with a 9% maternal and a 35% fetal mortality rate, regardless of the type of fracture or the trimester of pregnancy.
During the approach and treatment of a pregnant trauma patient the priority should be timely treatment and resuscitation of the mother, because this leads to better outcomes for the fetus. Standard protocol of advanced trauma life support should be adhered to by addressing airway, breathing, circulation, disability, and exposure. However, the physiological characteristics of the gestational state should be considered, such as physiological anemia of pregnancy, increased cardiac output of up to 30% and hypocapnia.
This case is a good reminder that sometimes the patient's information may be incomplete (in this case due to the patient not knowing that she was pregnant) and to remember that women of childbearing age are those who in a high percentage do risky sports with a higher risk of suffering a high-energy trauma.
Maria REDONDO LOZANO, Varela García PILAR, Miriam UZURIAGA MARTIN (Madrid, Spain), Vanesa Natalia ISAAC, Cristina BARREIRO MARTÍNEZ, Blanca GUERRERO MOÑUS, Noemi SOTO TOSTADO, Marta HUEDO JIMENEZ
00:00 - 00:00
#41956 - Whispers of Vulnerability: Management Strategies and Epidemio-Clinical Insights on Proximal Humerus Fractures in the Elderly.
Whispers of Vulnerability: Management Strategies and Epidemio-Clinical Insights on Proximal Humerus Fractures in the Elderly.
Introduction:
Proximal humeral fractures (PHFs) are prevalent injuries, accounting for around 6% of all fractures in adults. This prevalence has escalated in recent decades, propelled by an aging demographic, an upswing in osteoporosis cases, and incidents of low energy falls from standing height. The management of PHFs continues to be a contentious issue due to their increasing incidence. It is crucial to conduct meticulous clinical assessments of patients, focusing on coexisting medical conditions and potential neurovascular injuries.
Aim of the study:
Analyzing the Epidemiological and Clinical Profile of Proximal Humerus Fractures in Elderly Patients at the Orthopedic Department of Fattouma Bourguiba University Hospital in Monastir.
Patients and methods:
This is a descriptive cross-sectional study conducted among patients aged 65 years and older who were hospitalized for a proximal humerus fracture at the Orthopedic Department of Fattouma Bourguiba University Hospital in Monastir from June 2014 to June 2021. Data collection was performed retrospectively using patients records and a structured form that included socio-demographic, clinical, and paraclinical information.
Results:
Our study comprised thirty-two elderly individuals with proximal humerus fractures, with a majority being female (56%) and an average age of 73 ± 5 years. Notably, 56% had a medical history involving diabetes or cardiovascular diseases. Falls accounted for the majority of trauma incidents (88%). Pain was universally reported, functional impairment was observed in 68% of cases, and localized edema was present in 94%. Standard radiographs revealed displaced fractures in 88% of patients. Treatment modalities included intramedullary nailing in 20 cases and osteosynthesis with a plate and screws in 12 cases. Per the NEER classification, type II fractures constituted the majority (68%), while in accordance with the AO classification (Swiss Association for Osteosynthesis), type B1 (intact torsion wedge) was the prevailing category.
Conclusion:
Among the elderly, proximal humerus fractures stand as the third most prevalent fracture. Primarily affecting women, especially those with a history of diabetes or cardiovascular conditions. low-energy trauma such as Fall is the most common injury mechanism in these fractures. Notably, proximal humerus fractures in the elderly are frequently displaced, highlighting the underlying bone fragility. Intriguingly, the use of surgical interventions for these fractures has been on a consistent rise for decades in various countries.
no trial registration or external funding
Jacem SAADANA, Khouloud KHEMILI (Tunisia, Tunisia), Habib HADJ TAIEB, Firas CHAOUECH, Insaf BEN MESSAOUD, Bilel FAIZI, Amine SIOUD, Kais KHARROUBI, Ahmed MDAOUKHI, Moez JELLALI, Iheb NTICHA, Aymen FEKIH, Abderrazek ABID
00:00 - 00:00
#42357 - Whole-Body CT Scan in Polytrauma: Indications Based on Vittel Criteria and CT Findings.
Whole-Body CT Scan in Polytrauma: Indications Based on Vittel Criteria and CT Findings.
Introduction :
Severe trauma is a leading cause of mortality and morbidity worldwide,
accounting for a significant number of emergency department visits and
hospital admissions. The rapid and accurate assessment of trauma
patients is crucial for timely intervention and improved outcomes. Whole-
body CT (WBCT) has emerged as an indispensable tool in the evaluation
of severe trauma patients, providing a comprehensive assessment of
injuries across multiple body regions.
AIM :
The aim of this study was to provide a comprehensive overview of
WBCT indications based on the Vittel criteria and the interpretation of CT
findings in severe trauma patients.
Methods:
It was a retrospective analytic study made in emergency department of a
teaching hospital during 2022 including all patients consulting for severe
trauma with at least one Vittel criteria. A whole-body CT was done for all
these patients.
Results :
We included 230 patients with a mean age of 41±17 years.
All of these patients had at least one Vittel criteria. A whole-body CT was
realized in 77.8% of cases according to the kinetic indications of the
Vittel criteria, 27,8% according to observed anatomical lesions, 19,1%
according to clinical examination and 10% according to the patient's
terrain.
Seventy patients had severe lesions on WBCT. Of these, 33 patients
have a clinical indication (p: 0.000); 48 patients have a kinetic indication
(p: 0.025) and 26 patients have an indication according to the anatomical
lesions observed (p: 0.037). Six patients benefited from a CT scan based
on the patient's terrain (p: 0.63).
Conclusion :
Using the Vittel criteria to determine the indication for WBCT in
a severe trauma patient may uncover serious lesions not
suspected by clinical examination, but at the cost of an increase
in the number of normal scans.
Khaireddine JEMAI (Tunis, Tunisia), Safia OTHMANI, Marouane SANAI, Mouna JEMAI, Dhekra HOSNI, Roua HAJJI, Yessmine KARRAY, Asma JENDOUBI
00:00 - 00:00
#40981 - Whole-body ischemia and reperfusion-induced neuronal loss, and BSCB disruption and leakage in the lumbar spinal gray matter of a rat model of asphyxial cardiac arrest.
Whole-body ischemia and reperfusion-induced neuronal loss, and BSCB disruption and leakage in the lumbar spinal gray matter of a rat model of asphyxial cardiac arrest.
Background and aims: Cardiac arrest (CA) and cardiopulmonary resuscitation (CPR) causes whole-body ischemia and reperfusion injury (IRI), including severe spinal cord injury. The levels of the lumbar spinal cord take charge of motor function of the lower limbs, which are important organs to move in life. Until now, CA/CPR-induced spinal cord injury has been investigated in the anterior motor nucleus at the lumbar spinal cord levels, but few studies on neuronal damage, and blood-spinal cord barrier (BSCB) disruption and leakage have been reported in all subregions (dorsal horn, intermediate zone and ventral horn) of the lumbar gray matter after CA/CPR.
Methods: This experiment investigated survival rate, physiological variables, neuronal damage/death, and BSCB disruption and leakage according to all subregions after CA (for 5 min)/CPR in rats. Sham group was given sham asphyxial CA/CPR operation, and CA/CPR group received asphyxial CA/CPR operation until the return of spontaneous circulation (ROSC) was obtained.
Results: The survival rate in the CA/CPR group was 76.8%, 43.9%, and 6.9% at 12, 24, and 48 h, respectively, after CA/CPR. In body weight, mean arterial pressure, and heart rate after CA/CPR, no statistical significances were shown between all groups. Neuronal loss was examined using Fluoro-Jade B (a marker of neuronal death) histofluorescence: the neuronal loss was detected in all subregions at 12 h and thereafter gradually enhanced. BSCB disruption was investigated using immunohistochemistry for caveolin-1 (a specific marker of caveolae) and glial fibrillary acidic protein (GFAP; a marker for astrocyte): strong caveolin-1 immunoreactivity was shown in endothelial cells at 48 h after CA/CPR and GFAP-immunoreactive astrocyte endfeet disappeared apparently at 48 h after CA/CPR. BSCB leakage was observed using immunohistochemistry for immunoglobulin G (IgG): weak and strong Ig immunoreactivity was detected in the parenchyma of all subregions at 24 h and 48 h, respectively, after CA/CPR.
Conclusions: In brief, neuronal loss, and BBB disruption and leakage occurred similarly in all subregions of the lumbar spinal gray matter within 48 h after CA/CPR. This finding indicated that IRI after CA/CPR occurred earlier when compared with IRI in the brain (i.e., neuronal loss at 4-5 days after 5-min transient cerebral ischemia).
Seong Mi HEO, Jun Hwi CHO (Chuncheon, Republic of Korea), Joong Bum MOON, Taek Geun OHK, Myoung Chul SHIN, Da Som HAN, Jae Seong NOH
00:00 - 00:00
#41543 - Winter pressures all year for urgent care services: a retrospective analysis of routinely collected healthcare data in England.
Winter pressures all year for urgent care services: a retrospective analysis of routinely collected healthcare data in England.
Background:
It is generally understood that demand for urgent care services in the United Kingdom undergoes a large increase during winter. However, little empirical evidence exists to support this understanding, and in recent years, very high demand for urgent care has been increasingly experienced during non-winter months. We aimed to understand whether, and to what extent, demand for urgent and emergency healthcare is subject to seasonal variation in England.
We utilised 12 months’ of routinely collected data from Emergency Departments (EDs) and acute Admitted Patient Care (APC) episodes across England to understand seasonal demand for urgent care. We examined outcomes and performance measures related to overall demand and avoidable emergency care use.
Methods:
Routinely collected healthcare data documenting adult ED attendances and acute hospital admissions was obtained from 26 hospitals and 21 associated EDs from 1/11/2021-31/10/2022. We examined patient case-mix, and key outcomes including: ED waiting times; the number of treatments, investigations or procedures received; length of stay; and whether the attendance or admission was considered ‘avoidable’.
Using a novel ‘federated’ analysis approach exploiting local relationships with data providers, regional researchers analysed local data and provided summary statistics and analysis results to the lead site. Aggregation of summary results established a picture of seasonal demand across the country, and an understanding of local variation in seasonal trends.
Results:
1,505,825 ED attendances and 747,685 acute inpatient episodes were analysed. There were no clear systematic effects of winter across sites for any outcome. Neither total numbers of attendances nor admissions, nor key performance measures varied consistently between winter and non-winter months. Seasonal respiratory illnesses were adjusted for in inferential analyses, but these were not sufficiently numerous to obscure any potential effect of winter.
Discussion & conclusions:
Routine emergency care data documenting ED attendances and acute hospital admissions does not demonstrate any impact of the winter season on demand for urgent care or service delivery. The analysis was unable to identify any consistent interactions between winter and clinical or demographic characteristics. This indicates that the high pressures previously associated with winter are now experienced year-round.
A clear route to public benefit would include the implementation of year-round - rather than seasonal - measures to reduce demand and improve patient flow through urgent care systems, and a targeted qualitative analysis of measures employed at well-performing sites to understand how year-round pressures are managed. This would support less well-performing sites in improving demand management to be in line with these standards.
The study was funded by Health Data Research UK. It was classified as a service evaluation with patient level data accessed with approval of local Research Ethics Committees and Caldicott Guardians.
Jennifer LEWIS (Sheffield, ), Richard JACQUES, Rebecca SIMPSON, Madina HASAN, Susan CROFT, Simone CROFT, Ross MCMURRAY, Suzanne MASON
00:00 - 00:00
#41460 - Wolff-Parkinson-White - A shocking story.
Wolff-Parkinson-White - A shocking story.
Background
Wolff-Parkinson-White (WPW) can be asymptomatic; symptomatic cases commonly present with palpitations, chest tightness, altered consciousness, recurrent supraventricular tachycardia (SVT), syncope, and can lead to sudden cardiac death.
Electrocardiography (ECG) features suggestive of WPW with atrial fibrillation (AF) include irregular rhythm, rapid ventricular response (RVR), a delta wave and wide QRS complexes. Unstable patients require electrical cardioversion to restore sinus rhythm.
Clinical case report
A 64-year-old female with a background of diabetes, hyperlipidaemia, hypertension, asthma, transient ischaemic attack and a history of WPW post-ablation of accessory pathway in 2008, presented with non-vertiginous dizziness. ECG revealed an irregular irregular rhythm with widened QRS complexes and delta wave, suggestive of AF with WPW.
Cardiology was referred and suggested for procainamide, followed by flecainide 50mg BD and bisoprolol 2.5mg OM. After IV procainamide, she became hypotensive (systolic blood pressure 60mmHg). Decision was made to proceed with synchronised electrical cardioversion of 50J. It subsequently turned into sinus rhythm with improvement of BP to 90s. She was referred to intensive care unit and subsequently admitted to High Dependency.
During her stay, she was started on apixaban 5mg BD, flecainide 50mg BD and bisoprolol 2.5mg OM. She was reviewed in outpatient heart clinic, and agreed to proceed with ablation.
Discussion
WPW syndrome refers to the presence of an accessory pathway resulting in pre-excitation and manifestation as tachydysrhythmias. It is characterized by typical ECG pattern changes showing short PR interval, widened QRS complexes and delta wave.
The development of AF in WPW is unclear, and thought to be contributed by effects of the accessory pathway on the architecture of the atrium and the intrinsic vulnerability of atrial muscle, among others.
Rapid atrioventricular conduction results from the accessory pathways resulting in AF, which can potentially degenerate into ventricular fibrillation (VF).
Factors associated with increased risk of malignant arrhythmias include syncope, younger age, symptomatic tachycardia, and multiple accessory pathways. Case studies have also showed history of thyroid disease to be a significant precipitant.
In stable patients, current guidelines recommend pharmacological treatment with procainamide or flecainide. Procainamide decreases conduction over the accessory pathway, thus terminating AF. Other atrioventricular-nodal blocking agents are contraindicated as they exacerbate the syndrome by blocking the heart’s normal electrical pathway, facilitating antegrade conduction via the accessory pathway, increasing the risk of degeneration into VF. In unstable patients, electrical cardioversion is the first-line recommendation to restore sinus rhythm.
A complication from cardioversion is systemic embolism. The thromboembolic risks in the setting of acute cardioversion arise from pre-existing atrial thrombus, a change in the mechanical function of the atrial myocardium post-restoration of sinus rhythm, atrial stunning post-cardioversion and transient prothrombotic state. In patients with AF for more than 48 hours, current guidelines recommend anticoagulation for 3 weeks pre-cardioversion, continued for 4 weeks post-cardioversion. In life-threatening haemodynamic instability from new onset AF, anticoagulation should not delay emergency cardioversion.
Definitive treatment of choice for recurrent symptomatic AF is catheter ablation. In asymptomatic WPW syndrome, therapeutic decision is based on the risk versus benefits of invasive ablation versus long-term pharmacotherapy.
Emmaline LAI (Singapore, Singapore)
00:00 - 00:00
#42375 - Wound of the left subclavian artery caused by a metal bar: a case report.
Wound of the left subclavian artery caused by a metal bar: a case report.
Introduction:
The management of cervical wounds which can be the cause of several vascular injuries given
the complexity of the anatomy of this region should be with extreme caution. We report the case
of a younger mason with a cervical wound from a metal bar with an injury to the left subclavian
artery (ASC) which is uncommon and constitute less than 2% of all vascular wounds.
Clinical observation:
We report the case of a 40-year-old mason who suffered cervical trauma from a metal bar. The
accident took place while handling a metal bar with a diameter estimated at 18mm, the point of
impact was the left base of the neck. He had no history or long-term treatment. The civil
protection team was on the scene 30 minutes after the accident and was transported to the
emergency department of the university hospital center in the area.
On arrival at the emergency department, we found a polypneic patient who was desaturating in
room air with an abolition of the vesicular murmur on the left and presence of left cervical
subcutaneous emphysema, systolic blood pressure at 75mmHg, and tachycardia at 132bpm
with signs of peripheral hypoperfusion. The patient complained of pain at the root of the left
upper limb and paresis of the same limb with absence of the left radial pulse. After restoring a
good hemodynamic state, a deterioration of the neurological state appeared requiring the use of
orotracheal intubation.
A cervicothoracic CT scan performed, demonstrating an absence of opacification of the left
subclavian artery just upstream of the emergence of the left vertebral artery with extravasation
of the contrast product opposite, in relation to a wound of the left subclavian artery associating
hemo-pneumomediastinum, and left hemothorax.
Following the CT scan, the patient's hemodynamic state worsened, hence the use of
norepinephrine. We then proceeded to place a left chest drain which immediately brought back
300cc of blood. Urgent surgical intervention was retained from cardiovascular surgeon. The
patient's approach was open via a left supra- and sub-clavicular approach and the operation
consisted of a left sub-clavi-sub-clavicular bypass using a PTFE6 prosthesis since it was an
almost complete section of the left subclavian artery just after the birth of the left vertebral artery
with an entire jagged segment. The patient was discharged after six days of hospitalization.
Conclusions:
ASC wounds are rare, but serious. The clinical manifestations are increased by massive
hemorrhage and associated neurological signs. In our case, it was the state of hemorrhagic
shock and damage to the brachial plexus which were responsible for the symptoms. In
developing countries, which do not have endovascular means, open surgery remains the only
solution.
Marouane SANAI, Safia OTHMANI, Khaireddine JEMAI (Tunis, Tunisia), Mouna JEMAI, Sarra JOUINI
00:00 - 00:00
#42389 - Wound of the left subclavian artery caused by a metal bar: a case report.
Wound of the left subclavian artery caused by a metal bar: a case report.
Introduction:
The management of cervical wounds which can be the cause of several vascular injuries given
the complexity of the anatomy of this region should be with extreme caution. We report the case
of a younger mason with a cervical wound from a metal bar with an injury to the left subclavian
artery (ASC) which is uncommon and constitute less than 2% of all vascular wounds.
Clinical observation:
We report the case of a 40-year-old mason who suffered cervical trauma from a metal bar. The
accident took place while handling a metal bar with a diameter estimated at 18mm, the point of
impact was the left base of the neck. He had no history or long-term treatment. The civil
protection team was on the scene 30 minutes after the accident and was transported to the
emergency department of the university hospital center in the area.
On arrival at the emergency department, we found a polypneic patient who was desaturating in
room air with an abolition of the vesicular murmur on the left and presence of left cervical
subcutaneous emphysema, systolic blood pressure at 75mmHg, and tachycardia at 132bpm
with signs of peripheral hypoperfusion. The patient complained of pain at the root of the left
upper limb and paresis of the same limb with absence of the left radial pulse. After restoring a
good hemodynamic state, a deterioration of the neurological state appeared requiring the use of
orotracheal intubation.
A cervicothoracic CT scan performed, demonstrating an absence of opacification of the left
subclavian artery just upstream of the emergence of the left vertebral artery with extravasation
of the contrast product opposite, in relation to a wound of the left subclavian artery associating
hemo-pneumomediastinum, and left hemothorax.
Following the CT scan, the patient's hemodynamic state worsened, hence the use of
norepinephrine. We then proceeded to place a left chest drain which immediately brought back
300cc of blood. Urgent surgical intervention was retained from cardiovascular surgeon. The
patient's approach was open via a left supra- and sub-clavicular approach and the operation
consisted of a left sub-clavi-sub-clavicular bypass using a PTFE6 prosthesis since it was an
almost complete section of the left subclavian artery just after the birth of the left vertebral artery
with an entire jagged segment. The patient was discharged after six days of hospitalization.
Conclusions:
ASC wounds are rare, but serious. The clinical manifestations are increased by massive
hemorrhage and associated neurological signs. In our case, it was the state of hemorrhagic
shock and damage to the brachial plexus which were responsible for the symptoms. In
developing countries, which do not have endovascular means, open surgery remains the only
solution.
Marouane SANAI, Safia OTHMANI, Khaireddine JEMAI (Tunis, Tunisia), Mouna JEMAI, Sarra JOUINI
00:00 - 00:00
#41399 - Younger age is associated with increased 7-day mortality after paediatric emergency calls: A national observational cohort study.
Younger age is associated with increased 7-day mortality after paediatric emergency calls: A national observational cohort study.
Background:
Mortality from paediatric emergencies is low in the Scandinavian countries. However, research on risk factors for an adverse outcome is needed, as survival after paediatric out-of-hospital cardiac arrest remains poor. The study objective was to investigate the association between age and 7-day mortality after paediatric emergency calls.
Methods:
In this national population-based cohort study, all emergency calls to 1-1-2 regarding children aged 15 years or younger were collected from 2016-2021 inclusive. Interhospital transfers were excluded. Data from The Danish Quality Database for Emergency Medical Services and the Civil Registration System were linked. Age was grouped into newborns (0-2 months), infants (3-11 months), toddlers (1-2 years), ‘preschool and school children’ (3-7 years) and adolescents (8-15 years). A patient was considered ‘dead on arrival of the emergency medical services’, if death date was equal to date of emergency call and the patient had not received any resuscitative efforts. Crude and sex-adjusted Cox regressions were performed with age as exposure and all-cause 7-day mortality as outcome, both for all patients and after excluding patients who had been ‘dead on arrival’.
Results:
76,956 patients from all of Denmark were included with a median (IQR) age of 5 (1-12) years and 53.8% male patients. Newborns and infants had an increased risk of death compared to the oldest age group (crude HRs: newborns 4.9 [3.4;7.1], infants 2.5 [1.7;3.6]). There were insignificant differences in mortality among toddlers or ‘preschool and school children’ compared to the oldest age group, respectively (crude HRs: toddlers 0.8 [0.5;1.1], ‘preschool and school children’ 1.1 [0.8;1.6]).
Almost a third (30.2%%) of the non-survivors were considered to be ‘dead on arrival’ of the emergency medical services. When excluding these 77 patients, age less than 1 year was still associated with an increased 7-day mortality (crude HRs: newborns 5.4 [3.5;8.3], infants 2.4 [1.5;3.6]). Sex-adjusted HRs were similar.
Conclusions:
Newborns and infants had an increased 7-day mortality following paediatric emergency calls compared to older children, also when excluding the patients who were considered to have been dead on arrival of the emergency medical services. The study findings imply that death following paediatric emergency calls for younger children are not only attributed to sudden unexpected infant death, and further research is needed to explore other risk factors.
Funding:
VMLN has received a research grant from the Danish Air Ambulance.
Ethical approval and informed consent:
In Denmark, obtaining informed consent from each individual patient not required for entirely registry-based research studies. Permission to collect outcome data from patient medical records according to the General Data Protection Regulation was granted by The North Denmark Region on behalf of the Danish National Health Authorities (id nos. F2022-151 and 2022-011290).
Trial registration:
None. There was no collection or analysis of any biological material, and no interventions were introduced.
Vibe Maria Laden NIELSEN (Aalborg, Denmark), Morten Breinholt SØVSØ, Lars BENDER, Alasdair CORFIELD, Hans Morten LOSSIUS, Erika Frischknecht CHRISTENSEN
00:00 - 00:00
#41494 - ‘Foundations in simulation.’ A qualitative study based on the introduction of a foundation year 1 doctor simulation training program in the Southern Health and Social Care Trust.
‘Foundations in simulation.’ A qualitative study based on the introduction of a foundation year 1 doctor simulation training program in the Southern Health and Social Care Trust.
Background:
We identified that there was no dedicated simulation training program for the foundation year 1 (FY1) doctors within our trust. This was a core requirement for their FY1 sign-off. We posited that the introduction of such a program would be beneficial and ensuring that the clinician’s would meet their core competencies for FY1 and be more confident in their clinical practice in future. Overall improving clinical care and patient safety.
Methods:
This qualitative teaching study began with the design of a simulation course with the aim of putting all FY1 doctors (42) in the SHSCT, through a dedicated simulation training program in order to help them achieve their core competencies. The program took place over two dates between February and March 2024, with each day split into AM and PM sessions. The program was carried out in the trusts’ new state of the art simulation suite.
Our program focused on one individual patient’s journey throughout admission, with three separate stations with pre-defined learning objectives focused on: A-E assessment; succinct clinical handover; basic airway management; breaking bad news; DNAR discussions. Each station was followed by a focused debrief under the guidance of senior colleagues. The 'patient' was based on serious adverse incidents that had previously been documented and therefore empowered embedded learning and reflection.
Pre- and post-intervention data was collected via the use of qualitative surveys.
Results:
Despite the fact that 82% of our cohort of FY1s had not been involved in simulation-based education in the SHSCT outside of their induction, 88% felt that there was a role for simulation during foundation training.
One of the key things that participants hoped to gain from the course was experience managing the acutely unwell patient in a safe, less pressurised environment. Several FY1s also highlighted their desire to gain further experience via simulation training specifically, as they found this to be more beneficial to their learning when compared with more traditional methods.
Pre-intervention: 67% felt confident in their ability to manage the acutely unwell medical patient; 52% felt confident in their ability to provide a succinct clinical handover; only 29% felt confident in their ability to break bad news.
Post-intervention, 100% of participants felt confident in their ability to manage the cases presented to them during the course if they were to arise during their clinical practice. 100% said that they would recommend the course to their fellow FY1s and 100% felt confident that they had achieved their core competencies in Foundation simulation.
When asked about what they enjoyed most, a common theme was receiving constructive feedback from senior colleagues in a safe, judgement free atmosphere where the emphasis was strongly placed on group learning.
Discussion and Conclusion:
Based on the results outlined above, we recommend that dedicated simulation training should not only be incorporated into foundation training within our trust, but also regionally.
Registration not required as study did not involve patients. This study not receive any specific funding. As per trust, no specific ethical approval required and no conflict of interests.
Ryan BROLLY, Julie Anna RANKIN (Craigavon, United Kingdom), Aleena JOY, Paul DIAMOND
00:00 - 00:00
#40957 - “Don't let them get under your skin!"e;: toxic shock syndrome, a case report.
“Don't let them get under your skin!"e;: toxic shock syndrome, a case report.
Compulsory Question: Is this “just” a septic shock?
Answer: Every critically ill patient should receive individualized management. In this case, early clinical diagnosis would facilitate early initiation of inotropes and most appropriate antibiotics, suitable fluid resuscitation and consideration of IVIG.
Brief Clinical History:
33-year-old lady was brought in by ambulance with lethargy and skin peeling. She visited the beach a week ago and developed itchiness over bilateral legs, which progressed into skin peeling the next day. On presentation, the patient was septic looking and dehydrated. She had poor perfusion with tachycardia and hypotension. There was desquamation of the bilateral lower limbs circumferentially, from thigh to ankle, involving the external genitalia, affecting 36% of total body surface area. (Photo to follow in actual presentation) Point of care tests showed leucocytosis, thrombocytopenia, and severe metabolic acidosis with hyperlactaemia. Further investigations revealed acute kidney injury and transaminitis. She was resuscitated aggressively and started on inotropes.
Misleading Elements:
History taking can be challenging in critically ill patients. Establishing a diagnosis with the likely pathogen can be difficult. Eventually, the diagnosis was made clinically, which can be trying to those new to Toxic Shock Syndrome(TSS).
Helpful details:
It is important to understand the chronology of the disease as a whole to be able to diagnose TSS. Flu-like symptoms may occur 2-3 days after menstruation or post-operation, followed by rapid progression into high grade fever, fluid resistant hypotension and rash. At 1 to 2 weeks after onset of illness, a variety of skin manifestations are seen. The initial nonspecific rash may progress into desquamation of skin with mucosal involvement as in this case. The presentation of Streptococcus TSS is similar however presence of fever and rash are not mandatory. It is important for clinician to understand that the disease chronology and the diagnostic criteria of TSS doesn’t require a positive culture in order to correctly diagnose and treat the patient. It requires a high level of suspicion, early clinical recognition of the disease, proper assessment of fluid tolerance and response, leading to proper fluid resuscitation and early inotropes initiation, then correct initiation of antibiotics with treatment adjuncts like IVIG.
Differential Diagnosis:Toxic Epidermal Necrolysis Syndrome,Burn
Actual Diagnosis:Toxic Shock Syndrome
Educational and/or clinical relevance:
It has been a great debate to discuss if achieving definitive diagnosis is the sole responsibility of an emergency physician.Most of the time,critical emergency medicine focuses on supportive therapy,but this is an exceptional case where capability of diagnosing this uncommon disease clinically may lead to improved outcome. From the clinical presentation,one can educate on how to recognize,diagnose and treat this highly fatal disease, how to clinically determine which TSS patient would benefit from IVIG. Another important highlight of this case is fluid resuscitation, it is an art to resuscitate a severely dehydrated patient who has fluid resistant hypotension and also at risk of fluid overload at the same time.Essentially, this case can be a determinant of a good clinical resuscitation leader. Missing any of these essential knowledge and skills would result in patient mortality.
See Mun MAK (Oxford, United Kingdom), Han Sheng CHIA, Jessica NATHAN
00:00 - 00:00
#42066 - “If you want to survive, you need to persevere”- lessons learned from observations during and interviews with older patients after a stay in the emergency department.
“If you want to survive, you need to persevere”- lessons learned from observations during and interviews with older patients after a stay in the emergency department.
Introduction
Older patients requiring emergency department (ED) care have a high risk for prolonged treatment times, a high number of medical procedures and long waiting times. Long ED stays are potentially associated with the development of delirium and an increase in mortality. How older patients experience ED stays has not widely been studied in the German health care system. Qualitative methods such as observations and interviews allow access to patient’s experiences and reflections. This analysis focused on the time courses of ED stays of more than four hours, the frequency and contents of patient-provider communication, and the reflection on waiting times by ED patients
Methods
Observations (passive accompaniment) were conducted with 72 patients of at least 60 years in six inner city EDs in Berlin, Germany in 2021. In a semi-structured protocol, all events – medical and nursing care, procedures, diagnostic measures and communication – and respective time points were documented in chronological order. In this analysis, all protocols with at least four hours of ED stay after the first contact to an ED physician (n=32) were included and analyzed for communication patterns (time and content). The analysis followed an inductive scheme.
Semi-structured qualitative interviews were conducted with 29 patients of at least 65 years of age after an ED stay. Patient recruitment took place in the ED, interviews were conducted at participant’s homes or public spaces. Relevant themes regarding the current research question on patients’ perceptions of waiting times were identified with qualitative content analysis.
Patient samples from observations and interviews were independent from each other. The study was approved by the ethics committee of Charité – Universitätsmedizin Berlin (EA1/130/20).
Results
The analyses of observations revealed various temporal interaction patterns. Common elements were irregular information on the course of treatment, which was often implicit and procedural. The predominant communication style was directive and active involvement in treatment decisions was rare. Processes that took place outside the patients' perception and caused waiting times were rarely discussed.
In interviews, positive retrospective assessments of the ED stay and awareness for the time pressure on ED staff predominated. Some patients addressed the stress caused by uncertainty and waiting times as well as incidents of unmet needs such as hunger and thirst. Some patients further voiced a desire to be actively addressed and to receive unsolicited information on the progress of their treatment, preferably by a fixed contact person.
Conclusion
Older patients experience long waiting times in the ED and tend to receive insufficient and scattered information on processes and the course of treatment. This might lead to stress and a passive role in the provider-patient-relationship. To enhance patient-centeredness and allow for shared decision making, active and regular information provision is mandatory. This conclusion is in line with older ED patients’ wishes and demands.
The study was funded by the German Federal Ministry of Education and Research.
The trial was registered in the Deutsches Register klinischer Studien (German Clinical Trials Register, ID: DRKS00014273)
The study was approved by the ethics committee of Charité – Universitätsmedizin Berlin (EA1/130/20).
Dorothee RIEDLINGER (Berlin, Germany), Anna SCHNEIDER, Martin MÖCKEL, Andreas WAGENKNECHT, Liane SCHENK, Johannes DEUTSCHBEIN
00:00 - 00:00
#41196 - “NLP-DeVal: Development and validation of a natural language processing tool to enable clinical research in emergency and acute care medicine: retrospective cohort study”.
“NLP-DeVal: Development and validation of a natural language processing tool to enable clinical research in emergency and acute care medicine: retrospective cohort study”.
BACKGROUND AND RATIONALE
The ability to automatically extract reliable data on the demographic and medical characteristics of patients arriving at the emergency department (ED) would dramatically improve the possibility of doing research in this medical field. However, this is a difficult task because a large part of the information is contained in unstructured free-text notes. Today, large language models that can accurately interpret natural language are available. These models are trained on huge amounts of general data, but their performance in the medical domain may not be optimal.
OBJECTIVES OF THE STUDY
In the EU-funded eCREAM project context, this study aims to develop and validate a large multilanguage model (eCREAM_LM) that can interpret EHR contents and extract relevant information for research purposes.
STUDY DESCRIPTION
This observational, retrospective study involves 35 centres from Greece, Italy, Poland, Slovakia, Slovenia, Switzerland, and UK. The creation of the eCREAM_LM language model entails training and fine-tuning different language models through exposure to both a massive amount (billions) of medical texts derived from the literature and a large quantity of non-annotated (millions) and annotated (thousands) clinical notes derived from ED EHRs.
The validation of eCREAM_LM will be done by assessing its concordance with a panel of experts in extracting crucial information from 3,000 clinical notes per each language considered.
PRELIMINARY RESULTS
The LLM applied in this preliminary study was Llama2-70B, which was 56% accurate when tested on annotated data from 8 simulated patients in a feasibility evaluation. After a first round of fine-tuning, an agreement between the annotator and the LLM on a small validation set (217 sentences) from E3C publicly available dataset resulted in: Precision 65.74, Recall 46.7, and F1 54.61.
CONCLUSION
The performance of an existing LLM that is not specifically trained to interpret free text notes contained in EHRs is already at a good level. These results suggest that an adequate level can be achieved after specific training and fine-tuning.
Disclaimer: the opinions expressed are solely those of the authors and do not express the views or opinions of their employer.
FUNDING
The study is supported by the European Commission (Grant Agreement no. 101057726), UKRI (UK Research and Innovation), and SERI (Swiss State Secretariat for Education, Research and Innovation).
Clinicaltrials.gov: NCT06240572
Vicky RUBINI (BERGAMO, Italy), Rita BANZI, Giulia GHILARDI, Chiara PANDOLFINI, Jacek GORKA, Alberto LAVELLI, Bernardo MAGNINI, Federica MORETTI, George NOTAS, Peter MITRO, Gregor PROSEN, Pankaj SHARMA, Mihaela MATEI, Guido BERTOLINI
00:00 - 00:00
#41413 - “PREGNANCY AND PULMONARY THROMBOEMBOLISM: A CHALLENGING CLINICAL CASE”.
“PREGNANCY AND PULMONARY THROMBOEMBOLISM: A CHALLENGING CLINICAL CASE”.
“PREGNANCY AND PULMONARY THROMBOEMBOLISM: A CHALLENGING CLINICAL CASE”
Clinical summary
In Mexico there is an incidence of pulmonary embolism of 4.7 cases per 10,000 obstetric consultations with a reported mortality of 6.6%. During pregnancy there is physiological hypercoagulability demonstrated by high levels of prothrombotic factors and venous stasis associated with a decrease in mobility, which increases the risk of venous thromboembolism in these patients.
The diagnosis of pulmonary thromboembolism (PTE) in pregnant women represents an important challenge for the doctor, because the patient may present with symptoms such as dyspnea and tachycardia in a physiological pregnancy, which results in a non-specific clinical picture; On the other hand, therapeutic conduct imposes both maternal and fetal risks to quickly select pulmonary reperfusion therapy or hemodynamic replacement.
The objective of this analysis is the dissemination of the information obtained in this case as it is a successful case, pointing out that the patient's prognosis will depend on the timely diagnosis and treatment.
Evolution of the case
31-year-old female, with a history of pregnancy of 25.1 SDG by LMP, prenatal control appointments: 3, G:3 C:2 A: 0, without family planning method. He presented generalized weakness and oppressive chest pain that radiated to the left arm and dyspnea on small efforts with intensity 5/10, BP: 90/60mmhg HR 99bpm RR 23rpm temperature 36.0c saturation 89%, auscultation did not include pleuropulmonary syndrome with rhythmic precordium, globose abdomen with uterine fundus of 21cm, with spontaneous fetal movements.
Admission electrocardiogram with presence of negative t waves in DII, DIII and AVF and precordial leads.D-dimer 8.9 ug/ml, pro- BNP: 614 pg/ml.
Given the high clinical suspicion of PE, management was started with supplemental oxygen at low flow 3lt/min, low molecular weight heparin at 1.5mg/kg/dose, PESI 31 points and simplified PESI 2 points were calculated. Angiotomography was performed where bilateral pulmonary thromboembolism was identified.
He was admitted to the Coronary Intensive Care Unit where right and left pulmonary angiography was performed with visualization of thrombi in both branches. Massive pulmonary thromboembolism was determined in both pulmonary and subsegmental branches, so an ultrasonographic probe of the EKOS system was placed for 12 hours. hours, 12 mg of plasminogen activator (TNK) + 500 IU unfractionated heparin was administered by continuous perfusion for 12 hours in each femoral access (Figure 3), the EKOS system probe was removed and a new angiography was performed where dichotomization of the arteries was observed. lungs without evidence of filling defects.
He was discharged home 1 week after admission due to clinical improvement, he was re-admitted to tocosurgery after 2 months and a eutocic delivery was performed, a healthy live product was obtained.
Relevance of the case
Pulmonary thromboembolism is associated with significant maternal morbidity and mortality. Therefore, the presentation of this case reminds us of the importance of integrating the clinical picture and timely diagnosis in the face of high suspicion, performing appropriate diagnostic tests, the importance of starting anticoagulant therapy or even immediate thrombolytic therapy in case of instability data, demonstrating the effectiveness of said management.
Alejandra BLAS HERNANDEZ (Veracruz, Mexico), Enrique Alejandro COLORADO PEÑA, Eduardo MARQUEZ ROSALES
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