Background: The management in acute setting of patients with minor head trauma (MHT) still remains a matter of debate. The current guidelines and decision rules do not consider all the commonly known risk factors for post-traumatic sequences in a homogeneous and comprehensive manner. So they do not provide physician with concordant indications for CT scan, mainly in low-risk patients

Aim: The aim of our study was firstly to evaluate in a multivariate model each risk factor as predictor for the appointed outcome (CT positive or need for neurosurgery). Then these factors was used to create two predictive tools, a risk score and a nomogram, able to provide every single patient with MHT with an individual risk level for positive outcome.

Patients and methods: We prospectively evaluated all the patients observed for MHT from June 2016 to December 2017 and submitted to Ct scan in the Emergency Department of the University Hospital of Verona (Italy). The study population was divided in a creation (June 2016 to June 2017) and a validation dataset (July 2017 to December 2017). All risk factor proved to be significantly associated with outcome in univariate and multivariate analysis, at significance level p<0.05, were included in the final model to create a risk score. This score was further validated in an indipendent dataset by means of discrimination and calibration. The nomogram was developed from creation dataset using a multivariate logistic model and then validated as well as risk score.

Results: We enrolled 3479 consecutive patients (1983 males, 1496 females; mean age 64 years), forming the creation (2353 pts) and the validation dataset (1126 pts). An intracranial bleeding (outcome CT+) was detected in 316 patients (8.5%), but only 28 of them (0.7%) needed for neurosurgical intervention or intensivve care (outcome NS+). The eleven risk factors confirmed to be significantly related to outcome in the statistical analysis were included in the fianl model and a defined score, ranging from 1 to 4, was assigned to each factor. The total score ranged from 0 (no risk) to 26. In the ROC curve of risk score AUC was 0.809 (p<0.05), thus reaching a very high accuracy level. We reported a positive CT in all patients with score > 15 and in 82% with score > 12 (specifity 0.99, PPV 0.82). Instead, the 99.2% of patients with score < 2 and all those completely risk free (6.3%) had a negative CT (sensibility 1.0, PPV 1.0). Also the concordance index of nomogram appeared to be very high (AUC 0.802). Out of the 17 patients with probability > 0.8%, most of them (76.5%) were reported with an intracranial lesion (specifity 0.99, PPV 0.76). A probability of 0.1% was associated with a specifity of 83.2%, while in case of probability < 0.2% (87.9% of pts) specifity rate increased to 92.4%.

Conclusions: Our combined model allows to arrange every patient with MHT in an individual level of risk to develop intracranial lesions and represent an easy tool to support emergency physicians in better managing these patients.

Systemic capillary leak syndrome, also known as Clarkson Syndrome, is a rare condition with a severe presentation and a potential fatal outcome. The disease is characterized by transient episodes of increased vascular permeability and leakage of plasma proteins to the interstitial space. The most important characteristics are: severe edema, tissue hypo-perfusion, hypoalbuminemia and hemoconcentration. We present a case of a 49-year-old woman who was admitted to the Emergency Department with anasarca and hypovolemic shock. She had been diagnosed with Clarkson Syndrome two years before but had no medical follow-up. The anamnesis found a history of diarrhea in the days preceding the first crisis as well as in the days preceding the current episode. The patient received massive fluid perfusion and intravenous noradrenalin but she had a cardiac arrest. She was resuscitated and admitted to the Intensive Care Unit. She further developed severe complications of the hypovolemic state: hepatic, intestinal and cerebral ischemia. She died of multi-organ failure after 15 days. The pathophysiology of the disease is poorly understood and the acute treatments are empirical. We describe a case of Clarkson syndrome as a rare cause of hypovolemic chock presenting to the Emergency Department with particular focus on the need of rapid solute resuscitation and adrenaline.

Background: The use of multirow detector computer tomography pulmonary angiography (CTPA) has increased the number of diagnosed subsegmental pulmonary embolism (SSPE). It is unknown if SSPE require the same treatment with anticoagulation therapy (AC) due to venous thromboembolic (VTE) recurrences, as acute pulmonary embolisms (PE). AC therapy carries the risk of major bleeding. Thus, it is important to know if patients with an SSPE requires AC therapy. The purpose of this systematic review is to investigate if it is safe to withhold AC therapy in hemodynamically stable patients diagnosed with an unprovoked SSPE.  

Methods: We conducted a systematic literature review, based on the PRISMA guidelines using the Pub.Med, Ovid Medline and Embase databases. Combined search using text strings: Subsegmental, SSPE, Pulmonary embolism, pulmonary thromboembolism, subsegmental PE, subsegmental thromboembolic disease, CT angiography, anticoagulant* was done. We further added several Medical Subject Headings to the search string. The search was conducted between January 1981 – April 2020. In addition, we conducted a snowball search by screening the title of the paper through all the references in the individual paper and then including the paper that seem to fulfill our inclusion criteria’s until no new references regarding our topic were to be found. 

We included: 1) Studies investigating the outcome of patients diagnosed with SSPE who did/didn’t receive therapy. 2) Only original studies included. 3) Studies that clearly defined SSPE. 4) Patients included in the study were ≥ 18 years of age. 5) The patients were hemodynamically stable. 6) No DVT. We excluded 1) Case reports or abstracts. 2) Studies investigate PEs based on an underlying factor (e.g. cancer, former history of PE or DVT, pregnancy, anticonception, thrombophilia). 3) Papers written in another language than: English, Danish, Swedish, Norwegian, German and French. All systematic reviews regarding SSPE and AC-therapy were excluded post snowball search due to duplication of patients already included in original studies in our review. The Selection of papers was performed by reviewing titles, abstracts and full texts. 

Results: 415 papers were identified. 82 removed due to duplication. 333 title and abstracts were screened. 37 papers were read in full (28 where systematic reviews). Snowball search identified one additional paper. 28 systematic reviews excluded leaving 10 papers for the final group discussion. Post group discussion and further analysis consisted of 6 papers. The 6 studies identified a total of 366 patients with SSPE.  123 patients did not receive any AC therapy. Among the 123 patients who did not receive AC therapy there were 0 VTE recurrence, 0 major bleeding, 0 VTE related mortality within 3 months follow-up.

Discussion & Conclusion: In our study the literature is limited, sample size small, 5 out of 6 studies are retrospectives.  All studies with total of 123 pts. who didn’t receive AC-therapy show 0 VTE recurrence, 0 major bleeding, 0 VTE related deaths within 3 months. Our review of the available literature till as of April 2020, shows that it is safe to withhold AC therapy in patients with single SSPE and no DVT.

During the COVID-19 outbreak, a key-role of Emergency Department (ED) physicians is to safely discharge patients who won’t require hospital admission in the next few days. For that purpose, a normal clinical exam including normal oxygen saturation in room air is required but does not rule out an early potential respiratory decompensation. Chest X-Ray has a sensitivity of only 69% in detecting COVID-19 lung involvement. Lung Ultrasound (LUS) has demonstrated better diagnosis performance than chest X-Ray. Preliminary findings of LUS in COVID-19 showed promising results for improving diagnosis [7].

The aim of our study was to develop a composite score, clinical and LUS (EchoVID), predicting rapid respiratory decompensation in patient presenting to the ED with suspected COVID-19.

Patients and methods

The WINFOCUS-France group designed an electronic anonymized database used in 10 ED in France and Belgium since March 30, the VIRUS registry (Verification of Initial Respiratory signs with UltraSound). EchoVID is the first observational cohort study extracted from this database. For each patient presenting to the ED with suspect COVID-19, clinical and LUS characteristics were registered at ED presentation and clinical follow-up at Day 2 and Day 14. This study was approved by the Nantes University Ethic Committee and registered on clinicaltrial.gov (NCT04370249).

LUS was provided by trained operators. 6 zones were identified for data gathering: upper and lower half of anterior, lateral and posterior regions in each hemithorax. We used a scoring according to previously published LUS classification: ‘0’, no or less than 3 B-lines, ‘1’, 3 B-lines or more, ‘2’, multiple coalescent B-lines or ‘3’ lung consolidation. The global score was then calculated by summarizing results obtained for each region.

Rapid respiratory decompensation was defined at day 2 and day 14 by onset or increase in oxygen requirement, need for mechanical ventilation or death.

Statistical analysis was realized with R v3.6 and included multivariate logistic regressions with variables with p<0.2 in bivariate analysis.

Results

On April 23, 191 patients were included in the VIRUS registry. The sex ratio (F/M) was 1. A decompensation at D2 occurred in 26 (14% [CI95% 9-19%]) patients. In bivariate analysis, age range, body mass index, respiratory rate, oxygen saturation, qSOFA score and LUS score were significantly different between patients with or without decompensation. The area under the curve (AUC) of LUS score in ROC for a decompensation was 0.69. The logistic regression identified the following factors associated with decompensation at D2: current cancer, diarrhea, respiratory rate, oxygen saturation, qSOFA and LUS scores. The AUC in ROC was 0.91.

Discussion and conclusion

The major result was that the composite EchoVID score had better diagnosis performance than LUS score alone to predict D2 decompensation. However, these preliminary results on 191 patients need further statistical analysis to be performed on D2 and D14 decompensation occurrences. This by pursuing data gathering on VIRUS registry and EchoVID analysis in the next few months. Finally, we intend to develop and validate a algorithm in order to optimize the pathway of care, and especially to discharging safely low-risk patients.

INTRODUCTION:  

A new approach to ambulatory care was introduced in Beaumont Hospital on May 3rd  2019. The  patients who  historically would have been admitted to a ward bed for investigation and treatment had their care” fast tracked” in the Emergency Department. Patients in this ambulatory pathway are under the care of the relevant on call service but nursed by the Emergency Department nursing staff in the Emergency Department. A Clinical Nurse Manager was appointed to help expedite the investigations and coordinate the care of patients undergoing ambulatory care. For these patients radiology investigations (MRI, CT, US, Xray) and laboratory investigations were prioritised to facilitate quick decisionmaking. This study was performed to assess the impact of this intervention on Emergency Department performance indicators and patient care. METHODS: 

Data was gathered from the Emergency Department information system on all attendances to the Emergency Department from 1/5/2019 to 31/8/2019. Data was analysed using an excel spreadsheet. Descriptive statistics are used to present the data. Data on the patient experience times of those on the Ambulatory pathway was compared with those not requiring admission and those admitted to the wards under the on call services.

RESULTS:  

The number of presentations to the ED over the four month study period was 19,789 of whom 857 patients were placed on the ambulatory pathway. During the study period the average PET for patients discharged by the Emergency Medicine team without onward referral  (11,436) was  6 hours 32 minutes. The average time in the Emergency Department for patients referred to the on call services (6482) was 14 hours and 4minutes. The average time in the Emergency Department for the 857 patients  on the ambulatory pathway was 21 hours 53 minutes with 326 (38%) spending more than 24 hours in the ED. 46% (398) of those on the ambulatory pathway went on to ward admission. Of the ambulatory patients where no bed request was generated their average length of stay in the ED was 19 hours 13 minutes with 71 (25%) being there in excess of 24 hours.

CONCLUSIONS: 
Patients on the ambulatory pathway spend an average of 21hours 53 minutes in the Emergency Department of whom 46% require admission to a ward bed. Of great concern is the fact that 38% of ambulatory patients are in the ED for in excess of 24 hours. Ambulatory care does have a time and place but it should be performed in an appropriate setting and appropriately resourced. Care that utilises clinical space in an already crowded ED and uses nursing resource in a busy Emergency Department should be provided in an ambulatory care area and not in the ED.

Background: Ageing population increase prevalence of atrial fibrillation (AF). It leads to significant health care resource use, essentially because of hospitalizations cost. Based on European and French recommendations, we built ACSAF (Ambulatory Care Score for Atrial Fibrillation) for ambulatory management without cardiological advice in an emergency department (ED). It includes 8 items: age > 75 years old, heart failure, myocardial infarction, chronic kidney disease, valvular atrial fibrillation, AF < 48 hours, bleeding risk with anticoagulation, heart rate, trigger factor. The main objective of the study is to develop a score for new-onset atrial fibrillation (NOAF) management in an ED without cardiological advice in comparison with cardiological advice (gold standard). The secondary objectives are to evaluate cardiological follow-up and rehospitalization.

Methods: This prospective, observational, comparative and monocentric study was realized from November 2018 to October 2019. All patients aged 18 years old and older with NOAF were included. Patients with systolic blood pressure < 80 mmHg or heart rate > 180 bpm were secondarily excluded. Clinical and paraclinical data for calculation of ACSAF were recorded. Calculation of ACSAF was made in blind of orientation decision during the ED visit. Follow-up within 3 months consists of a phone interview for data collection of cardiology visit, delay and rehospitalization. The primary outcome is the mean of ACSAF between ambulatory care group and hospitalization group with the ROC curve to search the best threshold. The secondary outcomes are the cardiology visit rate, mean of delay and rehospitalization rate between ambulatory care group and hospitalization group.

Results: 81 NOAF was included, aged 69 ±16 years old, including 42 men (51,9 %). ACSAF is higher in hospitalization group 2,16 ± 1,05 against 1,03 ± 0,97 in ambulatory care group (p < 0,05). The optimal ACSAF threshold is 2 with a sensibility of 71,4% IC95% [57,1-83,7] and a specificity of 81,2% [68,8-93,8]. The area under the ROC curve of ACSAF was 0,70 IC95% [0,70-0,89]. The comparison between ambulatory care and hospitalization group is significantly different for variables in relation with items of ACSAF. 69 patients could be called within 3 months (30 in ambulatory care group and 39 in hospitalization group), 27 patients (90%) had a cardiological visit in ambulatory group against 23 (59 %) in hospitalization group (p< 0,05) without an increase visit delay (66 days ±62,6 in ambulatory group vs 56,4 days ±45,7 in hospitalization group; p=0,55). 3 patients (10,3 %) was readmitted in ambulatory care group against 17 patients (43,6%) in hospitalization group (p<0,05).

Discussion & Conclusion: ACSAF allows to determine orientation for NOAF during the ED visit without cardiological advice. Follow-up is better in ambulatory group than hospitalization group, and less rehospitalization within 3 months.

Premise and goals: Severe trauma is the first cause of death worldwide for patients of age 40 or less. About 30% of severe trauma patients presents with trauma induced coagulopathy at arrival to the E.D. About 40% of trauma deaths are related to bleeding, a quarter of which seems preventable.  The goal of this study is to determine if patients with coagulopathy present with more severe anatomical injuries.

Methods: We conducted a monocenter prospective observational study involving all patients affected by severe trauma in the Emergency Department of the Fondazione Policlinico IRCCS S. Matteo in Pavia in 12 consecutive months: from the 1st of January 2018 to the 31st Decembe 2018. All patients registered as affected by severe trauma in our Emergency Depatment have been enrolled. Inclusion criteria are to satisfy at least one of the pathognomic classification criteria for severe trauma as defined by the American College of Surgeons, Advanced Trauma Life Support (ATLS@) and approved by regional deliberation...

These criteria are: Physiopathological Criteria (compromised health parameters or necessity for advanced life support); Anatomical Criteria (e.g. puncturing wound to the head, neck, thorax or abdomen); Mechanism of Injury Criteria (e.g. ejection from vehicle, death of an occupant in the same vehicle...).
We considered patients affected by coagulopathy if positive for at least two altered biochemical values traditionally used to study coagulopathy. Patient undergoing an anticoagulant therapy have been excluded.

Results:  We evaluated 503 patients in total.
204 were affected by trauma induced coagulopathy (80% of which males) with an average age of 44 years and peak incidence between 55 and 65 years old; Of the patients affected by coagulopathy, 91% satisfied MOI criteria, 22% anatomical criteria and 15% physiopathological criteria.
299 were not affected by coagulopathy (68% of which males) with an average age of 43 years and peak incidence between 25 and 35 years old; of these patients, 91% satisfied MOI criteria, 10% anatomical criteria, 8% physiopathological criteria.

Trauma causes among patients affected by coagulopathy are: 68% traffic accident, 8% domestic accident, 3% self inflicted injury, 3% work related injury, 0.5% violence, 5% other.

Trauma causes among patients not affected by coagulopathy are: 77% traffic accident, 8% domestic accident, 2% self inflicted injury, 6% work related injury, 0.3% violence, and 3% other.

Conclusions: Among the vast sample from us considered, there is no significative causative difference between trauma patients who develop trauma induced coagulopathy and those who do not. 

Title

Are children presenting to the paediatric emergency department with acute wheeze being appropriately followed up in primary care?

Background

Viral wheeze and acute exacerbations of asthma are one of the commonest ED presentations amongst the paediatric population. Whilst the vast majority of these children are treated successfully and discharged home, a further problem arises from their aftercare. 

Many children with asthma have poor control of their condition, often as a consequence of poor compliance to preventative therapy. We estimate that that 75% of hospital admissions for asthma and as many as 90% of the deaths from asthma are preventable.

Most patients can achieve effective control of their asthma in partnership with primary care. Current British Thoracic Society (BTS) guidelines state that “prior to discharge, follow up should be arranged with the patient’s general practitioner or asthma nurse within two working days”, with the aim to prevent further emergency admissions by exploring factors that contribute to poor self-care.

Aims

This study was based in St. Georges University Hospital in South London – a tertiary hospital with a dedicated paediatric emergency department and respiratory team, who were involved in the care of 316 children presenting with acute wheeze in 2019. The aim of this project was to elicit what proportion of patients presenting with acute wheeze were followed up within 2 working days in primary care, and what was contributing towards their non attendance.

Methods

We performed a retrospective quantitative study, obtaining a consecutive sample of children and young people aged between 1 and 18 years with a final diagnosis of Asthma or Viral Wheeze. These patients should have received repeated doses of bronchodilators and/or steroids to warrant a review within 2 days. 

From this patient cohort, their respective general practice was contacted to elicit whether the patient attended within 2 working days and the rationale for their attendance.

Results

There were 51 paediatric patients presenting with acute wheeze between the 30^th August and 19^th September 2019, of which 45 warranted a review in primary care within 2 working days. Only 20 (44.4%) received appropriate follow up by their GP or Asthma nurse. For the remaining 25 patients, 11 had difficulty getting access to an appointment on time, 2 had a telephone consultation instead, and 11 were unexplained. We also found deficits in documentation where 19 patients failed to have discharge summaries prompting GPs for the need of a review.

Discussion and Conclusions

This study highlighted that most children presenting to ED with acute wheeze were unable to attend a follow up appointment in primary care within 2 working days. We are in the process of engaging with key stakeholders to highlight and address what barriers are contributing towards these difficulties, as part of a quality improvement project in the trust. The hope is that we can emphasise the importance and awareness of the review to patients and primary care through education, clear channels of communication and facilitating access to GP appointments.

Background

CT head/Neuroimaging formulates one of the key investigations to guide the diagnosis, management and prognosis of head injuries. Head injury is the commonest cause of death and disability in people aged 1-40 years in the United Kingdom. This study evaluated whether we were appropriately using NICE Guidelines to assess head injury patients by performing CT head.

Methods

A single centre retrospective study was carried out looking at patients attending the Emergency Department in August 2019 with suspected head injury.

102 patients were identified using iCare and data collection was completed using FirstNet and PACs.

Results

Total of 102 patients fit the criteria out of which 40 patients had CT head. 20 out of 40 patients fit the criteria for CT head as per NICE guidelines. Mean time to be triaged in ED was approximately 25 minutes. Mean time to be seen after triage was approximately 2 hours. CT head performed within 1 hour of request was 36% and CT head performed within 1 hour of triage was 7%. CT head reported within 1 hour was 75%.

Discussion and Conclusion

This retrospective study showed that doctors and nurses are not compliant with the NICE guidelines as 50% of CT head were done when it was not warranted. CT head was not being performed within the 1^st hour of head injury presentation: delay of approximately 2-hour 20minutes between triage and assessment by a medical practitioner. 75% of data suggest CT head was being reported within 1 hour, which is compliant with NICE guidelines. Moreover, it was impossible to say whether some of the risk factors such as seizures, loss of consciousness or amnesia was not assessed or merely not documented. This data suggested that an intervention is required to improve the documentation process and compliance of doctors and nurses in order to improve the delays between triage, assessment and performing CT head. Furthermore, by reducing the unwarranted CT heads performed the emergency department can save money and patients can be spared from unnecessary exposure to radiation. Hence, we are implementing two quality improvements projects in order to address the above issues and then re-audit.

Background. The link between increased air pollutant levels and worsening of chronic respiratory diseases is widely known. Particularly, asthma exacerbation is among the most established associations between air quality and disease, responsible of a number of outpatient visits and hospital admissions every year. Nevertheless, most of the studies in this context focus on big cities with great pollution while the influence of lower pollutant levels is scarcely investigated.

Aim. Assessing the influence of air pollution levels on the number of Emergency Department (ED) visits due to asthma exacerbation in Valladolid, a small city in Spain.

Material and methods. ED visits due to asthma worsening were collected from January 2010 to December 2018 in the Río Hortega University Hospital of Valladolid (Spain). Air pollutants (NO, NO₂, CO, O₃, PM₁₀, PM_2,5) were obtained from the monitoring stations of the Valladolid City Council. Temperature and rainfall were included in the study as potential confounding factors. The association between each pollutant and the number of ED visits was analyzed using linear regression with Poisson distribution. In order to assess the potential delayed influence of pollution, both daily values and the peak value within four time-lags prior exacerbation (0, 1, 3, and 7 days) were used to characterize air quality.

Results. A total of 2527 visits from 1588 patients were collected. By means of univariate analyses, temperature and month raised as confounding factors. Accordingly, using them as covariates, statistically significant association with ED visits was found for particulate matter with a diameter less than 2.5 micrometers (PM_2.5: OR 1.006, 95%CI 1.000-1.011; p <0.05), nitrogen oxide (NO: OR 1.002, 95%CI 1.000-1.004; p <0.05), nitrogen dioxide (NO₂: 1.005, 95%CI 1.001-1.010; p <0.05), and ozone (O₃: OR 0.997, 95%CI 0.994-1.000; p <0.05). The pollutants reached its highest influence on different time lags. A time lag of 3 days maximizes the link between increased ED visits and NO₂(average value 3 days ago), NO and O₃ (peak value 3 days ago) while for PM_2,5 the association was maximum considering the peak value 1 week ago. 

Conclusion. Our findings suggested a connection between NO, NO₂, O₃, and PM_2,5 levels within the last week and the number of ED visits due to asthma exacerbations. This association is also significant even in a small city with moderate pollutant levels.

Background

Withholding or withdrawing life-sustaining treatment decisions have to be made right from the emergency department. Terminal patients or patients with acute disease and vital prognosis engaged are concerned. This situation remains complex.  A working group wrote and has implemented an enquiry to be completed for all patients who the physician decided a withholding or withdrawing life-sustaining cares. In a first part, autonomy, comorbidities and acute situation, patient’s desire, family contact and wishes are collected and who make the decision. In the second part we can find a list of different cares (cardiac monitor, urinary probe, antibiotics, transfusion, cardiac resuscitation…) the monitoring and the possible prescription of pain killer and sedation.

The aim of study is the assessment of this document.

Methods

It’s an observational, monocentric and retrospective study from 01/01/2018 to 31/12/2019.

A file is completed for all patients who have withholding care decision. The data collection was made by a senior doctor and a copy of the enquiry was made.

Results

84 files were recovered. 52% were women. Middle and mean age were respectively 85 and 89 year old [48-104]. 45% had respiratory distress, 27% neurological failure, 14% septic shock, 6% heart failure, 3% hemorrhagic shock. Glasgow Coma scale when the decision was made was less than 13 in 72.6% of patients. 19 patients (22.6%) had an active cancer and 5 had even palliative care decision. 89% had a limited autonomy and 39% had cognitive disorders. In 67.8% of patients, ICU physician was called. Withholding or withdrawing life-sustaining treatment decision was in all cases a collegial medical decision. In 14% of cases, patients were concerted, family in 84.5% and paramedical team in 63%. For all patients, no intensive care unit (ICU) admission and no invasive care were decided, for 27 patients (32%), sedative and morphine prescription was immediately introduced.  For 12 patients, all the therapeutics was stopped. 61 patients (72.6%) have died during hospitalization, 21 the first day.  2 patients refused admission and were discharge after the consultation. 16 patients (19%) went back home. Their middle length of stay was 9 days.

Discussion and conclusions

Withholding or withdrawing life-sustaining treatment decision is a part of the emergency physician’s job. It’s a balance between medical ethics and patient’s desire. Pain, lack of therapy, airway management, length and quality of life should be considered. In this study there is two types of patients : a part of them had a vital prognosis immediately engaged, the second part are patients with serious pathology and the decision is maximal medical care but no cardiac resuscitation and non ICU admission if deterioration.

The implementation of this enquiry in our department was agreed by all the team and the fact to complete the file is not equivalent of death. The collegial decision and the family implication improve the communication and the care’s organization.

Background: Acutely admitted patients who are dependent on homecare may be especially challenged with regard to readmissions and mortality. The aim of this study was to assess the association between number of hours of received homecare and readmission and mortality after an acute admission in an Emergency Department (ED).

Methods: This study was planned as a register-based cohort study. Data were extracted from Danish registers through Statistics Denmark to construct a database on readmission rates and associated variables. We included all patients above 65 years living in Denmark with an acute admission to any hospital in Denmark, from 1^st of December 2016 to 30^st of November 2017. We include all acute admissions, registered as in-patients, with a length of stay ≤ 48 hours to represent the majority of patients discharged directly from an ED. Patients living in caring-home and patients without Danish citizenship were excluded. The primary outcome was readmission, defined as an acute, unplanned contact, registered as in-patient or out-patients, within 30 days from the index admission. Secondary outcomes were mortality after 30 days and 180 days. Descriptive statistics were used to describe age, sex, marital status, income and whether they received community nursing care and physiotherapy. Logistic regression analyses were used to clarify the association between use of homecare (hours a week) and readmissions and mortality. Comorbidity, diagnosis, use of medication for mental illness, and length of stay were included as confounders.

Results: In total 177,109 patients had an acute admission during the one year period. Of these, 83,653 met the inclusion criteria. Mean (SD) age was 77(8) years, 51 % were female, 54 % were married and mean (SD) length of stay was 19(13) hours. Among these patients, 20 % received homecare, 13% received community nursing, and 4 % received physiotherapy. The analyses are expected to be completed in October.

Conclusion: Knowledge about the risk profile of patients who are dependent on homecare can be used to organize and coordinate patients’ different contacts at the hospital. Furthermore, knowledge about their risk of readmission and mortality may, in combination with the patient’s wishes, be used to develop care and treatment interventions to be implemented in collaboration between the ED and primary sector.

Inconsistency among referral letters from General Practice (GP) to Emergency Departments (ED) was addressed by the Irish College of General Practitioners (ICGP) and the national General Practice Information Technology (GPIT) group in 2010, resulting in formulation of a National Referral Template compatible with four major GPIT-accredited practice management systems used throughout Ireland, or which can be utilised in paper format. The goal of standardising referrals was to ease this process for GPs through use of a streamlined template, whilst ensuring doctors receiving patient care are provided with accurate, and relevant clinical and adminstrative data, in a legigible and organised fashion, to allow optimal patient assessment and interpretation of findings. The template was recommended by the Health Information and Quality Authority (HIQA) in their 2011 report. We undertook an audit aimed at examining quality of GP referral letters to Cavan General Hospital (CGH) ED, including Paediatric Assessment Unit, over a 1-month period, and determinig need to highlight existence of this recommended referral form to GPs in the catchment area, so as to improve patient flow and care in ED.

The National Referral Template published on ICGP/HIQA websites was used as the comparator. Sections, and in some instances subsections, of the template were allocated a score of 1, to total maximum score of 12 for fully-completed referral letters. Every patient record registered in CGH ED from 01/07/18-31/07/18 inclusive was individually analysed for mode of presentation, and all GP referrals were further studied for scoring and to compare accuracy of information with that recorded in ED notes. In cases of handwritten letters, whereby information was deemed illegible by three doctors, a score of 0 was allocated to the section/subsection. Data was collected in Excel spreadsheet. After data accumulation and interpretation, a generic letter detailing audit results was compiled and sent to GPs in the catchment, along with a copy of the National Referral Template and instructions on where to find these resources online, along with GPIT/HIQA reports supporting its use. After a 6-week period, re-audit was performed on 150 randomly-selected patients presenting to ED.

2,612 patients presented to ED during first audit cycle; 1,698 patients self-presented [1,326 walk-in, 372 ambulance], and 914 patients were referred by GP [873 walk-in, 41 ambulance]. Average score for GP letters to ED was 7.24 on this first cycle. Certain areas of information were identified as consistent omissions, including past history/medications/allergies/social history. Quality of letters were also found to vary between patient populations; letters for paediatric patients were overall higher-scoring, compared with adult/geriatric patients.

A total of 150 patients were analysed for re-audit; 78 patients self-presented [70 walk-in, 8 ambulance], and 72 patients were referred by GP [68 walk-in, 4 ambulance]. Average score for second cycle was 7.47, showing no statistically significant difference after the intervention.

Despite extensive nationwide endeavours by GPIT/HIQA to standardise referrals to ED, and our direct efforts to surrounding GPs, much work remains to increase GP acknowledgement of the National Referral Template, and to create awareness about importance of informative, accurate letters to ED.

Brief clinical history: A 32-year-old gravida 2 para 1 woman at 36 weeks of gestation presented at the Emergency Department with vaginal hemorrhage due to severe placenta abruption and fetal distress. She was immediately transferred to the operating theater where she underwent emergency caesarian section under general anesthesia. The infant had an Apgar score of 5/10 one minute after birth. We performed pharyngeal suction due to presence of blood and since the infant remained in distress, we proceed to intubation. In order to be safely transferred to the nearest hospital with a NICU, which is approximately 60 minutes away, we decided that it was necessary to secure vascular access. After multiple unsuccessful attempts of peripheral vein cannulation, we discussed the possibility of umbilical vein catheterization.

Misleading elements: Obtaining vascular access is a crucial and demanding task during neonatal resuscitation. Since it is an extremely rare event outside a Neonatal Intensive Care Unit (NICU), many hospitals, including ours, do not have the appropriate equipment needed.

Helpful details: The umbilical vein can be found through the exposed umbilical stump, where it has to be distinguished from the two umbilical arteries by its position at the head end, the thinner wall and the larger lumen. It can be cannulated by a 5Fr (=1,667mm external diameter) catheter in the case of a full-term infant (over 1500gr) or a 3.5Fr (=1,167mm external diameter) catheter in pre-term infants (less than 1500gr).

Differential and actual diagnosis: Since the hospital wasn’t equipped with specialized UVC kits, we attempted to insert an epidural catheter, instead. An epidural catheter is a sterile atraumatic flexible multi-orifice 19-gauge catheter (≈1,1mm external diameter) used for continuous infusion to the epidural space. The attempt was successful and the infant was transferred to the nearest NICU where the catheter’s positions was confirmed with an X-ray.

What is the educational and/or clinical relevance of the case? Informed consent by patient’s parents was obtained in order to report the case. Infants requiring vascular access is an extremely rare event outside the NICU. It is recommended by the European Resuscitation Council neonatal guidelines that umbilical vein catheterization is a viable technic to secure central venous access for infants up to 14 days old. Although the preferred technique for obtaining vascular access remains peripheral vein catheterization, this is not always a choice. The past few years, intraosseous route has gain acceptance during emergency cases for adult and pediatric resuscitation. The use of this technic is also restricted by the availability of the appropriate devise and practitioners’ knowledge. Resuscitation of a neonate in low-resources setting requires competency in the use of the available equipment and adaptability of the provider.

Fascia Iliaca nerve block with local anaesthetic is recommended to achieve safe and timely analgesia for patients with fracture proximal neck of femur. In our hospital, performing a fascia iliaca nerve block is part of our care pathway for patients when a fracture proximal third of femur is confirmed on x-ray. The national guideline for this block was developed in our department and all doctors receive training in how to perform it. With reconfiguration of trauma services in Ireland, our department is now receiving trauma bypass patients and we have had an average increase in presentations by three per week.

Use of local anaesthetic minimises the requirement for opiate analgesics which can cause significant adverse events in this patient population. Delays in delivering a nerve block can mean patients are given opiate analgesia in the interim period until a nerve block can be given. 

Aims

We aimed to 

1. Audit current practice in our department in delivering pain relief including fascia iliaca nerve block to patients presenting with proximal third of femur fracture.

2. Identification of factors delaying nerve block delivery.

3. Introduce a designated fascia iliaca nerve block trolley to our department that contained a hand-held ultrasound and all the equipment necessary to administer the nerve block.

4. Re audit our practice.

Methods 

We performed a retrospective audit of all patients presenting with proximal third of femur fracture between October and December 2019 inclusive (following introduction of trauma bypass). We then introduced a designated fascia iliaca nerve block trolley and re audited our practice. The trolley contains a hand-held ultrasound machine and the specific equipment detailed in our fascia iliaca block guideline (attached).

Results

Pre-block trolley results

Nerve block performed in 86% of patients with proximal third of femur fracture.

Time to block was on average 50 minutes.

Concurrent use of opiate analgesia in 60%.

Average pain score at 2 and 4 hours 6/10.

The top two factors identified in causing delay to nerve block delivery were

1. Availability of the ultrasound machine

2. Gathering equipment

Post block trolley results

Nerve block performed in 96% of patients with proximal third of femur fracture.

Time to block was on average 15 minutes.

Concurrent use of opiate analgesia in 5%.

Average pain score at 20 minutes and 4 hours 2/10.

Conclusion

Introduction of a designated fascia iliaca nerve block trolley in our department reduced time to delivery of the block by an average of 35 minutes and a reduction in concurrent opiate use, which causes significant adverse events in this patient population. 

Additionally, using the block trolley was associated with a reduction in patient pain scores measured at 20 minutes and 4 hours.

Introducing a designated fascia iliaca block nerve trolley is useful for providing faster better patient care for patients with proximal third of femur fractures. Furthermore, we speculate if we could use our mobile block trolley to effectively deliver the nerve block on ambulance trolleys as the patient arrives to the ED i.e. prior to x-ray in overt cases.

Background: Coronavirus disease (COVID-19) has been spreading around the world like a dramatic pandemic, the wide spectrum of clinical variability ranging from asymptomatic patients to critical ones. Since the frequent respiratory involvement could develop into a rapid and often unexpected manner into acute respiratory distress syndrome (ARDS), to promptly identify which patients need for timely hospitalization and intensive care is a crucial issue. Several studies have already assess the relationship between laboratory abnormalities and outcome in COVID hospitalized patients, but none of these has been carried out in acute setting.

Aim: The aim of this prospective observational study was to investigate whether simple and easy to collect clinical and laboratory findings could affect the choice between admission and discharge in COVID patients.

Patients and methods: We carried our study in the Emergency Department (ED) of the University Hospital of Verona (Italy) between 16^th and 31^th March 2020, considering all consecutive patients with SARS-CoV-2 detection by polymerase chain reaction in nasopharyngeal swab. Patients were then enrolled if fullfill one or more of these symptoms: fever equal or more than 38°, cough, shortness of breath, tachypnoea. In all patients medical history and risk factors and underlying conditions likely affecting the course of disease were reported and blood gas analysis, laboratory examinations and chest x-rays were performed. At the end of ED evaluation physician decided for patient discharge or admission. All discharge patients were followed until disease resolved without sequel.

Statistical analysis: Sensitivity, specifity, positive predictive value (PPV) and negative predictive value (NPV) were derived from the receiver operating characteristic (ROC) curves and analysed. The optimal cut-off values of biomarkers were established by ROC curves and cut-off values for each parameter affecting hospitalization were calculated from the areas under ROC curves (AUC). The groups were compared with Mann-Whitney test and proportion of patients with Chi-square test. Difference set at p<0.05 was considered significant.

Results: Out of 190 positive for SARS-CoV-2, 109 symptomatic patients (69 males, 40 females; mean age 67 years, range 27-93) formed the study population. After ED evaluation, 86 patients (78.9%) were admitted, while 23 (21.1%) were discharged and then healed without sequel. The variables more significantly related with hospitalization were: age, partial oxygen pressure (pO2), percutaneous oxygen saturation (SO2), C-reactive protein (CRP), white blood cells count (WBC) and imaging positive for pulmonary infilatrates (p<0.001). The rispective cut-off values were: age over 60 years (95% CI 0.78-0.95, PPV 95.9%), pO2 less than 72 mmHg (95% CI 0.90-0.99, PPV 98.7%), SO2 less than 97% (95% CI 0.83-0.95, PPV 96%), CRP superior to 19 mg/l (95% CI 0.89-0.99, PPV 96.4%), WBC superior to 5.8 x 10⁹/l (95% CI 0.65-0.88, PPV 92.4%) and positive chest x-rays (95% CI 0.60-0.90, PPV 91.9%). We reported the higher hospitalization rate for pO2 (167 times) and CRP (108 times) respectively.

Conclusion: The values of pO2 and CRP appeared to be a simple a reliable prognostic factors and could support ED physicians in the short-time decision to admit the COVID patients.

Background

The “silent epidemic” of traumatic brain injury (TBI) is the biggest cause of death for those under 40 years old in the UK. Mild TBI (mTBI) is defined by a GCS score of 13-15 and is a common presentation to the Emergency Departments (ED). In certain situations, patients with mTBI will require a head CT scan as recommended by NICE guidelines to rule out an intracranial haemorrhage.

CT scans are readily available in most EDs but they still impose a significant amount of ionising radiation and can be sometimes challenging to perform in patients with underlying learning difficulties, dementia, alcohol intoxication or concurrent anticoagulant therapy.

S100 calcium binding protein B (S100B) is a glial-specific and expressed primarily by astrocytes, and is released following a head injury. It is one of the most studied biomarkers in TBI with several published studies.

Methods

This systematic review evaluated the potential use of S100B as a point-of-care (POC) test in mTBI in reducing the need for CT imaging.

PubMed, Scopus and Cochrane Library were used to look for English language cohort studies and control trials published up to February 2020 on S100B release on mTBI injury in humans. Duplications were removed and articles were assessed out of a total of 303 results.

26 studies were consequently selected for analysis. The studies were categorised according to their aim: determining reliability of S100B (n=21) and comparison of S100B against other markers (n=5).  

Results

A cohort of 7,434 patients were enrolled into 26 studies. The majority (n=18) produced results that were in support of S100B being a clinically reliable point of care (POC) test for mTBI – owing to its high negative predictive value and sensitivity. From 15/18 papers, S100B had an average sensitivity of 95.4% (range 83.3%-100%) and a specificity of 32.2% (range 2%-100%). However, 5 studies also compared S100B against other well-known neuro-biomarkers and found that they were more clinically appropriate biomarkers such as glial fibrillary acidic protein (GFAP) (n=4) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) (n=1). 3 papers concluded that S100B was not a suitable clinical biomarker for reducing CT scans as they found that it: is only good in combination with other biomarkers (n=1) and has limited accuracy when blood samples are collected greater than 3 hours post-mTBI (n=2).

Conclusion

Research into S100B and its potential use in clinical decision making has produced some ground-breaking results. The promising results of this systematic review suggest that S100B should have a place in the UK guidelines for mTBI management in the near future. Nonetheless, it is felt that more studies must take place to confirm its reliability. A cohort study using well-defined S100B reference ranges, larger sample sizes, and serum sampling within 3 hours post-injury could be used to establish how much S100B can reduce the use of head CT scanning.

Study Objective: Recent studies demonstrate that the emergency department (ED) can play a critical role in Hepatitis C screening and linking care for those who test positive. Along with other public health initiatives, ED HCV screening programs help reduce community HCV burden. Historically, HIV/HCV co-infected patients have had poorer rates of linkage to care, treatment initiation and treatment completion for HCV than HCV mono-infected patients have. We sought to compare the rates of linkage to care between HCV mono-infected and HIV co-infected patients who were screened for HCV and HIV as part of a non-targeted ED HCV/HIV screening program.

Methods: Retrospective review of prospectively collected program evaluation data collected between June 6, 2018 and June 5 2019.  Eligible patients had to be 18 years of age and older, triaged to the adult or pediatric ED and able to provide consent for HCV and HIV testing.  Socio-demographic variables, HIV and HCV status and linkage to care outcomes were abstracted from the program-screening database. Successful linkage to care was defined as attending at least one outpatient appointment with an HCV care provider.  Descriptive statistics (measures of central tendency and dispersion) were computed to characterize the data. Comparisons of groups (HCV mono-infected vs. HIV/HCV co-infected) were compared using Chi-square.

Results: Of the 427 patients found to have active HCV infection (VL+) during the screening period, 41 (9.6%) had unknown HIV status and were excluded from analysis. Of the 386 patients with known HIV status, 56 (13%) were found be HCV/HIV co-infected. HIV/HCV co-infected patients had a mean age was 51.  The majority of HIV/HCV co-infected patients were male (70%), African American (25%) and had public insurance (64.2%). Successful linkage to care was achieved in 37.5% of HIV/HCV co-infected patients. HCV mono-infected patients had a mean age was 51. The majority of HCV mono-infected patients identified as male (78%) and white (24.4%). Most had public insurance (58.7%).  Successful linkage to care was achieved in 31.8% of HCV mono-infected patients.  A total of 49 patients, (4 with HIV/HCV co-infection and 45 with HCV mono-infection) were lost to follow up. There were no statistically significant differences in demographics, insurance status, or rates of linkage to care between HCV mono-infected and HIV/HCV co-infected patients.  

Conclusion: Non-targeted HCV screening in the ED identified a large number of patients with active HCV infection, of which a significant portion were co-infected with HIV. There were no significant differences in age, gender, race, ethnicity or insurance status between HCV mono-infected and HIV/HCV co-infected groups. Contrary to prior studies, there were also no differences in linkage to care rates between these two groups.  Further investigation is required to determine if there are significant differences in HCV treatment initiation and sustained viral response (SVR) between HCV mono-infected and HIV/HCV co-infected individuals.

Background:

The Emergency departments are one of the areas where the Covid-19 pandemic is being treated. In the analysed emergency department, a specific zone for the care and treatment of suspected Covid-19 infected patients has been created.  That zone works with personal protection equipment that can affect the professional performance but also are essential to avoid contagion.

Aims:

To Know the characteristics of the healthcare workers who works in the Covid zone of an Emergency department based on their job position.

Material and Methods:

A study of volunteer health care staff who worked in  a Covid-19 zone in an Emergency Department during the month of April 2020 was carried out. The following variables were analyzed: Age, age group: 18-40 years, >40 years.  gender, job title: doctor, nurse, assistant, years of experience: <6, 6-15, >15 years;  temporality: permanent or temporary;  previous pathologies: hypertension, mellitus diabetes (MD), headache, previous respiratory disease, hypothyroidism, physical state: survey: sedentary, active, athlete; training perception, fear of working in the COVID zone: low, medium, high.  Descriptive analysis of the sample according to job position, comparison of qualitative variables, by  Chi-square and ANOVA for quantitative variables.  Software: SPSS 24.0;  p <0.05.

Results: 

N: 107; Median age: 39.6 (10.0) years; GE: 22-40: 54 (50.5%), >40: 53 (49.5%); Female: 82 (76.6%); Fixed: 34 (31.8%); Medical: 27 (25.2%), Nursing: 51: 47.7%, Assistant: 29: 27.1%. Previous pathologies: Hypertension: 2.8%, MD: 0.9%, Hypothyroidism: 8.4%, previous respiratory disease (asthma, copd, allergy): 9.3%, headache: 3.7%. Sedentary: 44.9%, active: 36.4%, sports: 18.7%; Training: low: 15.0%; medium: 33.6%, high: 51.4%. Analysis by position: Mean age: physician: 41.1 (7.3) years, nursing: 35.9 (9.5), ATSD: 44.9 (10.8) (p<0.001): GE: >40: physician: 51.9%, nursing: 37.3%, assistant: 69.0% (p<0.05); Sex: female: physician: 77. 8%, Nursing: 70.6%, assistant: 86.2% (p>0.05); Marital status: married: physician: 51.9%, Nursing: 33.3%, assistant: 37.9% (p>0.05); Employment status: Fixed: physician: 40.7%, Nursing: 25.5%, assistant: 34.5% (p>0.05). Physical condition (sedentary, active, sportsman): physician (37.0%, 37.0%, 25.9%), nursing (47.1%, 35.3%, 17.6%), assistant: (44.9%, 36.4%, 18.7%) (p>0.05): Training received (low, medium, high): doctor: (7.4%, 37.0%, 55.6%), nursing (17.6%, 33.3%, 49.0%), assistant (17.2%, 31.0%, 51.7%) (p>0.05), Level of fear of entering (low, medium, high): doctor (59.3%, 18.5%, 22.2%), nursing: (33.3%, 25.5%, 41.2%), assistant (37.9%, 20.7%, 41.4%) (p>0.05). 

Discussion: 

Healthcare workers entering the covid area are generally young, without previous pathologies and preferably of the female gender. The nursing group is significantly younger than the rest. It is observed that the medical personnel are the ones who show more training and less fear of work, which may indicate that training makes the level of fear of this type of work decrease, although no statistically significant differences have been observed with the other groups of professionals analysed.

BACKGOUND:

Head traumas are a frequent reason for attendance at an ED, Up to 75 % of  traumas  are classified as minor, more likely associated with elderly people. Between 1 and 4 % of patients, presenting minor head trauma will develop life threatening brain injury. The biggest challenge is to ensure correct management and diagnosis. Head CT scan is the first line diagnosis tool. The purpose of the study is to analyse head trauma patients characteristics in a first level Hospital following the implementation of a new protocol.

METHODS:

A Descriptive observational study was performed including patients assessed in Urduliz Hospital ED after setting up a head trauma protocol during the period of 2 months, between the 25th of January and 15th of March. To adequate the CT performing criteria, a Head injury form was used. All patients included had a final discharge diagnosis of head injury. The epidemiological variability, the number of head CT scans, radiological findings, second CT scan performance and the final discharge destiny were studied. Statistical data analysis was made with SPSS Statistics Version 22.0.

RESULTS:

The sample included 147 subjects examined and diagnosed with head Injury. 51.7 % were women and 48.3 % men. The average age was 67 with a range between 14 to 98 years. 50% of the patients were older 75 years, 14.3 % had dementia history, associated with an increased risk of falling. Drug and alcohol abuse was present in 7.5 % of the cases. Regarding the use of bleeding risk drugs 24.5 % of the patients were on antiplatelet, 11.6 % were on anticoagulants and only 8.2 % were taking direct acting anticoagulants. 96.6 % of patients on bleeding risk drugs were older than 65 years.

The new protocol was followed in 98.6 % of the cases, but the form to adequate indication to undergo a CT scan was not fulfilled in 95.2 % of the cases.

123 patients underwent a head CT scan, 83.7 % (103) were reported with no abnormal findings, nine with intracranial haematoma and one was reported as subarachnoid haematoma.

Following the new protocol 25 patients with normal first CT underwent a second CT scan, in 80 %, the second examination was normal, 4 cases were reported with intracranial haematoma and one case as subarachnoid haematoma.

The average hospital admission was of 25 hours. 90.5 % of the patients were discharged home with a written discharge advice; only six patients were referred to a neurosurgical department.

DISCUSSION AND CONSLUSIONES:

The implementation of a new protocol has shown a decrease in the risk of discharging patients with potentially serious brain injuries.

In addition in patients on anticoagulant drugs, the second head CT scan has been reported with abnormal findings in up to 20 % of cases.

On the other hand, the protocol has increase the hospital admission time and the number of CT scan performed.

Since the beginning of COVID19 pandemia, scientific societies reviewed the useful role of Chest Ultrasound (US) in patients with interstitial pneumonia from COVID19 1. In the Emergency Department (ED) of Civico Hospital in Lugano (TI, CH) US has been employing as a first bed-side step of chest imaging in suspected COVID19 patients. Our aim was to evaluate chest US images and CT results in patients with high suspicion of COVID19 and to assess the clinical outcome of patient discharge from ED after US evaluation. We analysed also the time of staying in the ED, as a secondary outcome. We performed a retrospective observational analysis of first consecutive 43 patients, considered suspected for COVID19, evaluated in a military tent of the ED of Civico Hospital during 25 days of COVID19 Pandemia. Forty-three consecutive non severe ill patients, 19 males and 24 females, 20 to 89 years old, evaluated in the ED for suspected COVID19 between01.04.2020 to 25.04.2020, underwent a chest US, performed by a skilled emergency physician. Patients data and vital signs and were registered by a nurse at a first triage tent. Chest US images were available in a hard-copy form and results were reported assigning a score calculated on numbers of areas interested and type of abnormality. Tomography results were registered and evaluated using CORAD-S system of examination. Average age of patients was 49,6 years; all 43 patients underwent a chest US examination: 28 (65%) patients had a completely normal US with 0, while 15 (34%) patients presented abnormalities at US. Among the 19 patients (44%) who underwent a chest CT  11 (25,5% of total) resulted CORADS 1 and, among them 8 (72%) presented positive US. We found no patients with a CORADS 2 score; 3 patients were CORADS 3 (6,9%) and, among them, we found 2 patients (66%) with US abnormalities. No patients received a CORADS 4 score. Five Patients received CORADS 5 (11,6%) score and among them all (100%) presented US abnormalities. No patients were found to have a CORAD 6 score. The average time in ED was 3 hours: 02h10m for US vs 04h04m for US+CT. Six patients presented a P/F < 40 KPa at arrival: all had US (100%) 2 patients (33,3%) were discharged without readmission and 4 (66,6%) patients were admitted to a non-intensive ward. Conclusions: as in recent studies, in our experience we found that US is comparable to CT especially for the high grade of abnormalities, reduces the time of staying in ED, thus reducing exposure of patients and workers to viral infection. Use of US appears safe since we had a very low rate of re-admission for patients who were discharged according to US results and without respiratory impairment. Limits are the retrospective structure of the study and the small number of patients. Anyway, this first analysis is a starting small study useful for further investigation of a possible role of simple algorithms to discharge or admit of patients with COVID19 evaluated in EDs. Ethic: not needed. Informed consent obtained.

Background: The variation in the size distribution of monocytes, referred to as Monocyte Distribution Width (MDW), is a new biomarker that aids in the early detection of sepsis and is available on a routine blood cell count with differential (CBC-DIFF). MDW’s performance in the Emergency Department (ED) has already been reported in two North American studies. The objective of this study was to evaluate MDW in a European population and compare MDW to PCT, CRP. We also sought to determine if MDW, when combined with clinical parameters such as SIRS or qSOFA improves the early detection of sepsis in the ED. 

Methods: An IRB-approved observational cohort study, funded by Beckman Coulter, was carried out in France and Spain between August 2018-June 2019 to assess MDW’s ability to detect the development of sepsis in consecutive adult patients presenting to the ED who have a CBC-DIFF ordered. Whole blood venous samples collected in K3EDTA were tested on the Beckman Coulter UniCel DxH900 hematology analyzer. Each patient had blood drawn concurrently for MDW, PCT and CRP. Demographic data, SIRS, qSOFA, SOFA, imaging, microbiological testing and treatments were collected and patients followed up through 72-hours after ED admission or discharge. The study endpoint was the diagnosis of sepsis-2 or sepsis-3 determined by 2 independent emergency physicians, blinded to MDW results. Discordant cases were arbitrated by a third physician.

Results: 1517 patients were enrolled (837 men and 680 women, average age 61 ±18 years) sepsis was diagnosed in 260 (17%), 197 SIRS, 241 infections and 819 controls according to sepsis-2 criteria. The areas under the ROC curve (AUC) and [ 95% confidence interval ] for the diagnosis of sepsis-2 were 0.81 [0.78-0.84], 0.78 [0.75-0.81], 0.85 [0.83-0.87] and 0.86 [0.84-0.89] for MDW, PCT, CRP, and MDW combined with white blood cell count (WBC), respectively. For sepsis-3 the biomarker performance was 0.82 [0.79-0.85], 0.84 [0.81-0.87], and 0.85 [0.82-0.87] for MDW, PCT, CRP, respectively. The statistical cut-off for MDW was 21.5 for K3EDTA. Inclusion of MDW with SIRS or qSOFA during the initial evaluation in the ED enhanced the odds of sepsis detection by 7- fold for sepsis-2 and 8- fold for sepsis-3.

Discussion: This large European study confirms the clinical performance of MDW coupled with leukocytes as an early biomarker of sepsis in the emergency room. MDW’s performance is comparable to that of PCT and CRP but superior to both biomarkers when combined with WBC. MDW +WBC are readily available on a routine CBC-DIFF, unlike PCT and CRP that are ordered only if the physician has a high index of clinical suspicion of sepsis. MDW +WBC has the advantage of being one of the first parameters tested at the time of ED admission, and when elevated may alert for potential sepsis even in situations of low clinical probability.

Conclusion: This study confirms the potential clinical utility of MDW as an early indicator of sepsis in the emergency room.  Combined with components of SIRS and qSOFA, MDW significantly improves the post-test probability of detecting sepsis among ED patients.

Backgrounds

The purpose of this study was to investigate the efficiency of nasal airway inserted in the oral airway (ON airway) in securing the airway patency during mask ventilation.

Methods

 Fifty eight patients undergoing general anesthesia were randomly assigned to either oral airway group (group O) or ON airway group (group N). In both group, 2 mg/kg of propofol was infused intravenously and mask ventilation was performed in the sniffing position without head extension or jaw thrust. The patients were ventilated with a volume-controlled ventilator with O2 flow of 10 l/min, tidal volume of 10 ml/kg (IBW), and respiratory rate of 10 /min. Before the start of mask ventilation, airway was placed in the oral cavity. Oral airway was used in group O and ON airway was used in group N. Peak inspiratory pressure (PIP), tidal volume and EtCO₂ were compared between the two groups. The location of airway tip was graded by fiberoptic bronchoscope as; 0: airway obstructed by tongue, 1: epiglottis visible, 2: airway touches epiglottis tip, 3: airway passes beyond epiglottis tip.

Results

 Compared with group O, group N significantly decreased the PIP (25.0 [18.0 – 29.0] vs. 18.0 [16.0 – 19.0], P < 0.001, Group O and N, respectively) and increased tidal volume and EtCO₂ during mask. In the bronchoscopic findings, airway obstruction was more frequent in group N. (P< 0.001).

Conclusions

Compared with oral airway, nasal airway inserted in the oral airway facilitates the mask ventilation by promoting the patency of airway.

Introduction: The concept of end of life (EoL) care, which is care offered to patients during the end of their lives, includes a combination of medical, psychological, social, emotional and spiritual care, both for the patient and those close to him. Compared to previous decades, it is more common nowadays for patients with acute diseases capable of producing death, or patients with the progression of a terminal illness, to visit an Emergency Department (ED) for care close to their EoL. EuSEM has recognized the importance of this issue by developing specific guidelines for EoL care in the ED. It is important to understand the current weaknesses of Greek EDs in EoL care in order to organize appropriate and more humane healthcare services. Purpose: The purpose of this study was to evaluate the compliance of Greek EDs with EUSEM EoL care guidelines. Methods: A questionnaire with 43 questions, based on the EUSEM guidelines on EoL care, was sent to either the head physician or the head nurse of all Greek hospitals with independent EDs. Pediatric, psychiatric, and other special hospitals were excluded. Results: 50 out of the 84 eligible hospitals responded to the survey (60% of all Greek hospitals, >70% population coverage). Only 18% of EDs reported having formal communication instructions for the staff regarding EoL issues and 22% reported having some form training in announcing a patient’s death. Although 80% of EDs reported that their physicians were able to identify EoL patients and in 72% discussions for advanced care-planning is performed, in less than 20% these discussions are formally recorded and in less than 30% “Do Not Attempt Resuscitation” (DNAR) decisions are documented. Around 60% of the EDs reported discharging patients with a care plan to die at their home and written discharge instructions. In more than 80% of the EDs a senior physician is responsible for EoL issues, EoL decisions (if nobody else can take them for the patient) and the announcement of a death. However, only in a minority of Greek EDs family is included in EoL decisions or discussions. 78% of EDs reported ignorance for the legal status of DNAR orders in Greece and only 14% had access to legal advice. In most cases (92%) DNAR is decided by a senior specialist, but in 34% CPR is continued if the family insists, and in 22%  CPR is performed even against expressed patient wishes. 38% provide palliative care but only 12% have an organized checklist. Most Greek EDs do not have special rooms for the family during EoL situations but 66% have facilities for their cultural and spiritual needs. Finally, in 62% of EDs, staff members are encouraged to talk about EoL events. Conclusion : Greek EDs should further improve EoL care. Our study shows that there are several improvements that could be made in communication training, discussion/decision recording,
DNAR management, dedicated use of space and support of ED staff on legal and stress-related EoL issues.

Premise and goals: Severe trauma is the first cause of death worldwide for patients of age 40 or less. About 30% of severe trauma patients presents with trauma induced coagulopathy at arrival to the E.D. About 40% of trauma deaths are related to bleeding, a quarter of which seems preventable.  Goal of this study is to determine if patients presenting with trauma induced coagulopathy (TIC) were also more frequently affected by greater hemodynamic instability.

Methods: We conducted a monocenter prospective observational study involving all patients affected by severe trauma in the Emergency Department of the Fondazione Policlinico IRCCS S. Matteo in Pavia in 12 consecutive months: from the 1st of January 2018 to the 31st December 2018. All patients registered as affected by severe trauma in our Emergency Department have been enrolled. Inclusion criteria are to satisfy at least one of the pathognomonic classification criteria for severe trauma as defined by the American College of Surgeons, Advanced Trauma Life Support (ATLS@) and approved by regional deliberation...

These criteria are distinguished in anatomical and mechanism of injury criteria.
We considered patients affected by coagulopathy if positive for at least two altered biochemical values traditionally used to study coagulopathy. Patient undergoing an anticoagulant therapy have been excluded.

Results:  We evaluated 503 patients in total.
204 were affected by trauma induced coagulopathy (80% of which males) with an average age of 44 years and peak incidence between 55 and 65 years old.
299 were not affected by coagulopathy (68% of which males) with an average age of 43 years and peak incidence between 25 and 35 years old.
In our population, the incidence of hemodynamic instability as defined by the American College of Surgeons is greater in the population with coagulopathy than without (15% vs 8%).
Patients affected by TIC have greater need for blood transfusion compared to patients without TIC. This is valid both for blood transfusions at arrival to the ED (8.5% vs 3.3%; p=0.028) and for blood transfusions required during hospital stay (11.32% vs 4%; p=0.016).

Conclusions: Among patients presenting with severe trauma within the same population (400.000 people ca.) in an Italian Trauma Center of II level, those who at arrival in ED have already developed trauma induced coagulopathy have a greater necessity for blood transfusions in comparison with the patients without TIC.

Background

Cardiac arrest (CA) is a serious threat to human life. After returning of spontaneous circulation (ROSC), the ischemia-reperfusion injury (IRI) damages the blood-brain barrier (BBB), increases its permeability and loses brain protection function, which is an important cause of subsequent brain injury. Exploring factors affecting the BBB injury after ROSC has important research value. The thoracic cage is the direct position of external chest compression, the thoracic cage size variation may affect the blood pressure during CPR according to the “thorax pump” theory. Therefore, we established a CA-CPR-ROSC rat model to explore the variation between the thoracic cage size and the severity of BBB injury. We hypothesized that the variation of thoracic cage size may cause difference of MAP level during CA-CPR-ROSC and the inflammation level after ROSC, and thus cause differences in BBB damage.

Methods

Forty male Sprague-Dawley rats were performed chest computed tomography scans to compare the thoracic cage size variation. At the 4th intercostal level, the following thoracic cage size parameters were measured in chest CT images using Mimics 17.0 software: internal transverse diameter, internal anteroposterior diameter and cross-sectional area. After CT scanning, twenty small thoracic cage male SD rats were randomly divided into small thoracic cage sham group and small thoracic cage CPR group. Similarly, 20 large thoracic cage male SD rats were randomly divided into the large thoracic cage sham group and large thoracic cage CPR group. We established CA-CPR-ROSC rat model and used fluorescence to compare the degree of EB exudation in the cerebral cortex, immunofluorescence and Western blot to compare the changes of tight junction protein occludin and claudin-5 expression; Furthermore, we compared the mean blood pressure (MAP) difference during CA-CPR-ROSC, IL-1β and TNF-α expression, microglia activation and M1 type polarization.

Results

Compared with the small thoracic cage CPR group, the EB exudation in the large thoracic cage CPR group was significantly higher (p<0.05). Compared with the small thoracic cage CPR group, the occludin and claudin-5 expression in large thoracic cage CPR group were significantly reduced (p<0.05). Repeated variance analysis found that compared with the small thoracic cage CPR group, the MAP in the large thoracic cage CPR group was significantly reduced during CA-CPR-ROSC (p<0.05). Compared with small thoracic cage CPR group, the IL-1β and TNF-α expression in the large thoracic cage CPR group were higher. The microglia activation and M1 type polarization in the large thoracic cage CPR group were higher than small thoracic cage CPR group.

Conclusion

Rats with large thoracic cage size had more severe BBB damage after ROSC. The reasons might be related to lower MAP level during CPR, more inflammatory factors and release higher levels of microglial activation, M1-type polarization, in the cerebral cortex of rats with large thoracic cage size.

Background

Cervical spine injuries (CSIs) are amongst the most devastating injuries following trauma. Several patient groups are at high risk of having missed CSIs. These include elderly patients where CSIs can occur with lower energy trauma and patients with a decreased conscious level (whether that be due to confusion, dementia or intoxication) where clinical assessment of CSIs is more difficult.

National and local hospital guidelines state that adults with indications for a CT head should also have a CT C-spine (CT CSP) if they fulfil one of the following criteria:

1)     age >65

2)     confused or GCS < 15    

The objective of this audit was to assess whether patients are being appropriately sent for CT CSP according to this guideline.

Methods

A list of all adults (age >18) sent for CT Head in the Norfolk and Norwich Emergency Department from December 2018 - February 2019 (3 months) was obtained. Radiology requests were viewed for all patients and all head injury patients identified. 

For these head injury radiology requests were examined to see if the patient was >65 years of age, confused (as defined by a note of confusion / intoxication in the description) or GCS <15. CT CSP requests were noted. The audit standard was 100%.

Interventions included discussion at clinical governance, teaching for Emergency Department clinicians and discussion with radiology that for ambulatory patients C-spine protection was not needed for transfer to radiology unless there was a strong suspicion of CSI.

Re-auditing took place between June 2019 – Aug 2019.

Results

During Dec 2018 – Feb 2019 47% of patients meeting the above criteria were sent for CT CSP (272/514 patients). This improved to 59% in the re-audit period June 2019 – Aug 2019 (58/99 patients).

Discussion & Conclusions

Our interventions improved the overall proportion of at-risk head injury patients that received appropriate c-spine imaging. However overall concordance with the guidelines was still fairly low on re-audit. 

One recurring scenario where elderly patients were routinely not sent for CT CSP involved patients taking anticoagulants. In such patients, who are alert and orientated with no clinical suspicion of C-spine injury but meet the NICE criteria for CT Head based on use of blood thinning medication, it is an interesting question to ask whether incorporating CT CSP is appropriate.

The incidence of acute C-spine pathology in this subgroup of head injury patients was 3% overall which lower than the reported incidence of CSI in trauma (4 to 8%). This suggests that the department is detecting fewer C-spine injuries, further emphasising the importance of high clinical suspicion and low threshold for CT scanning in high risk groups. 

Overall, we show that appropriate C-spine imaging is important and may be under-utilised. Education, discussion at departmental meetings and appropriate agreements between EDs and radiology can improve decisions to image the C-Spine in head injury patients.

Introduction: Stroke, which can be hemorrhagic or non-hemorrhagic and either benign and self-limited or life-threatening, needs appropriate diagnosis and treatment in the emergency department (ED).  The aim of this study was to compare the delivery time of primary care for patients with signs and symptoms of stroke before and after applying stroke-specific triage system (SSTS) in ED. 

Methods: Medical records were reviewed of twenty-one patients (group I) with a chief complaint related to stroke who referred to ED between April and August 2019 (before installing SSTS) and twenty-three patients (group II) with the same chief complaints who referred between September and December 2019 (after installing SSTS). The time between patients’ arrival and beginning of diagnostic and therapeutic interventions including cardiac monitoring, first physician visit time, intravenous line insertion, and Brain CT scan and ECG performance was compared between the two groups. 

Results: Based on the findings, the mean age and sex ratio of studied patients in the two groups were not significantly different (p=0.33). Door to Brain CT scan performance, Door to ECG performance, Door to intravenous line insertion, and Door to cardiac monitoring were significantly shorter in post stroke-specific triage installing period than previously (p<0.01). Door to first visit by a physician was not statistically different in the two study periods (p=0.421). 

Conclusion: It is likely that patients with signs and symptoms of stroke who referred to ED benefit from installing SSTS in terms of performing some physician and nursing care including Brain CT Scan and ECG performance, starting cardiac monitoring, and IV insertion.

Does a proforma perfect paediatric elbow radiograph reports? Original research report.

L Dann^{1, 2}, C Blackburn^1,4, M J Barrett^{1,3, 4} , T Beattie²

1.      Children’s Health Ireland at Crumlin, Dublin

2.      University of Edinburgh

3.      National Children’s Research Centre, Dublin

4.      School of Medicine, University College Dublin

Background:

Interpretation of elbow x-rays is an important and frequently encountered area of injury assessment and may result in lifelong morbidity if fractures are missed. Studies have demonstrated that there are more errors when interpreting paediatric images and when the interpretation is performed “out of hours”. Studies have also demonstrated that inaccuracies in x-ray interpretation by trainee doctors may result in mismanaged fractures. We introduced a structured proforma to improve trainee reporting of elbow radiographs and aimed to evaluate its effect on the quality of reporting amongst trainee doctors.

Outcome Measure:

To evaluate the effect of a structured proforma on quality of reporting of elbow x-rays amongst trainee doctors.

Methods:

Trainee doctors in a paediatric emergency department of a tertiary paediatric hospital were recruited for this evaluative study. Over a single educational session trainees reported 10 elbow x-rays. These were reported initially on blank paper and then using the structured elbow proforma (same images, different order).

Reports were scored from 0-10 with 10 being the highest achievable score. Marks were awarded for mentioning important aspects of the image, e.g. presence/absence of fat pads. Descriptive statistics were used where relevant and appropriate. Paired t-tests were used to compare pre and post proforma results. A p-value of <0.05 was selected as statistically significant.

Results:

Thirteen trainees took part in the study. The median report scores before and after the proforma were 1 (IQR 0, 2) and 10 (IQR 10, 10). Overall there was a median increase in reporting score of 8 (IQR 8, 8). [T value 44, and two-tailed p <0.001].

Discussion:

Many hospitals use proformas for various tasks but there is limited published evidence of their use in x-ray interpretation.  The authors propose this study is the first to analyse the impact of a proforma on reporting of paediatric elbow radiographs. Results demonstrate that the use of a structured proforma greatly improves the quality of reporting. Results were consistent among all grades and types of trainees. Strengths of this study are its originality, variety of trainees recruited and the consistent results demonstrated. Limitations are the small participant numbers and the single site nature of the study undertaken.

Conclusion:

This study demonstrates that the introduction of a structured proforma for reporting paediatric elbow radiographs can significantly improve the quality of radiograph reporting among all levels of trainees. A larger multi-centre study is required to validate the results of this study and assess if it has an impact on fracture identification.

Background

Penicillin allergy (PenA) is the most common reported drug allergy in the emergency department (ED). Given that most antibiotic allergy labels acquired in childhood are carried into adulthood, the over labelling is an absolute drawback resulting in undesirable health care risks, antibiotic resistance, and increased costs. There is growing data to support key historical features to accurately stratify patients into low and risk groups which is crucial in application of direct oral challenge. The aim of this study was to evaluate the knowledge of reported PenA and impact of PenA labels amongst prescribers in the children’s ED. It was hypothesized that while over 70% will correctly identify the high-risk symptoms of PenA, much less than 50% may be aware that oral drug challenge is the gold standard for PenA diagnosis.

Methods

This was a cross-sectional anonymised survey of prescribers working in the children’s ED of Leicester Royal Infirmary, UK. The paper-based survey was distributed to prescribers over a 2-week period in December 2019. The survey comprised several sections: characteristics of respondents, clinical vignette, knowledge of high- and low-risk symptoms of PenA, questions on allergy focused history, and knowledge of impact of PenA labels. Primary outcome measure was knowledge of low- and high-risk symptoms of reported PenA.

Results

Sixty-two questionnaires were returned from clinical grades ranging from consultants to foundation year doctors, as well as advanced nurse practitioners. Over 90% of respondents correctly identified signs and symptoms suggestive of anaphylaxis as high-risk symptoms. Knowledge of onset of rash over an hour of penicillin ingestion as a low-risk symptom was significantly associated with penicillin antibiotic prescription (21/37 versus 16/37; p-value 0.01). While less than 50% of respondents would clarify the time interval between ingestion and symptoms, a lower proportion (38%) would verify if allergy was confirmed by testing. Eighty seven percent agreed that PenA was over diagnosed but 66% agreed that it can lead to antibiotic resistance. Only 33% agreed that confirmation of PenA was by oral challenge.

Conclusion

There is low rate of allergy focused history in addition to deficient understanding of low-risk symptoms of PenA amongst prescribers in the ED. Allergy education in conjunction with an algorithm to safely de-label children with such symptoms in the ED will contribute immensely to antimicrobial stewardship. The survey demonstrated willingness of prescribers to adopt such decision tool.

Introduction

Emergency Airway Management (EAM) has now become an integral part of core and advanced specialty training in Emergency Medicine (EM) in Ireland. Although EAM is frequently performed in Emergency Departments (EDs) today, there is a paucity of literature on airway management in Irish settings. The aim of this study was to assess the resources and infrastructure in Irish EDs in relation to EAM. This study was facilitated by the Irish Trainee Emergency Research Network (ITERN) as part of an overall airway project entitled the National Emergency Resuscitation and Airway Audit (NERAA).

Methods

ITERN recruited sites in Ireland to participate in NERAA. A survey was then distributed to each site and data including site demographics, airway equipment, airway trolley and airway training data was extrapolated. The survey data was handled by Google forms™.

Results

A total of 15 ED sites were enrolled. 86.7% of these sites (n=13) were designated as training site for the National Emergency Medicine Training Program. Eighty six percent of sites (n=13) had a rapid sequence induction (RSI) checklist in the ED. Seventy three percent(n=11) had a video laryngoscope available in ED and all sites had one available in their respective hospitals. The brand of ventilator in each ED varied with 40.0% of sites (n=6) using an Oxylog, 20.0% (n=3) using a LTV, 13.3% (n=2) Draeger, 13.3% (n=2) Hamilton, 6.7% (n=1) Phillips and 6.7% (n=1) Maquet. Regarding simulation training in ED, 33.3% (n=5) sites have ran RSI or airway simulations in the past 6 months. 80.0% (n=12) of sites had a difficult airway trolley in ED with 91.7% (n=11) having a checklist for contents and 50% (n=6) of these trolleys having a difficult airway algorithm to refer to.

Conclusion

This site-survey is the first multi-site analysis of airway management in Irish EDs. This study also highlights the feasibility of a research network to perform multi-site data collection and in this case, provide a summary of current airway practices in Irish EDs. This study shows that there is variation between EDs regarding brand of ventilator used and that the majority of EDs have an RSI checklist and a video laryngoscope in the ED. Particular points of focus relating to EM training are that only one third of sites have ran an RSI or airway simulation in the past 6 months. The findings of this study could provide a vector for the development of national standard for EAM in Ireland.

BACKGROUND

Major incidents (MI) occur with little or no warning. During an MI emergency department (ED) registered nurses (RN) are among the first to receive, assess and treat patients. Emergency department RNs’ emergency operating plan (EOP) competencies are crucial in effectively mitigating somatic and psychological afflictions that patients may present to the ED. While previous research has indicated the ED nurses’ disaster competencies are low, little is known about the current state of emergency department registered nurses’ EOP competencies in Sweden.

AIM

To assess emergency department registered nurses’ EOP competencies.

METHOD

Study design: A cross sectional online survey was conducted during a six-week period between January and February 2019. Purposive criterion sampling method was utilized in recruiting participants.

Participants:  All registered nurses’ (n ≈ 370) employed at six participating emergency departments in the region of Stockholm, Sweden were included.

A total of 100 questionnaires were completed (response rate = 28%). Competencies were rated utilizing a five-point Likert scale based on Benner’s competence model of clinical competence.

The primary outcome variables are five competencies concerning ED EOPs. 1. Content of the EOP 2. Areas of responsibilities. 3. Differences between decision making processes in the Incident Command System for a major incident vs. non-emergency situations. 4. Hospital levels of preparedness and its significance. 5. Decontamination procedures according to the EOP. Predictor variables included ED experience, education levels and frequency of training.

Data was analyzed using descriptive statistics generating means, standard deviations, frequency counts, and percentages. Kendall’s tau b assessed correlation. A p value of <0.05 was considered significant.

RESULTS

The majority of nurses (77%) had at least 3-5 years of nursing experience. The overall mean of five combined competencies was 2.95 or just below “competent” on Benner's model. The primary outcome variables mean ranged from 2.77- 3.27. (1. “contents of the EOP” (mean 2.77 SD 1.25.), 2: “Areas of responsibilities” (mean 2.8 SD 1,23), 3. “decision making processes in the Incident Command System” (mean 2.88 SD 1.21), 4. “Hospital levels of preparedness and its significance.” (mean 3.27 SD 1.18) and 5. “Decontamination procedures according to the EOP” (mean 3.03 SD 1.29).  The strongest positive correlation (r=0,502 p= 0.01) was between clinical experience and self-assessed levels of competency (range mean 1.2 to 3.80 ,< 1 year and > 20 years respectively).

CONCLUSION

Nurses’ overall competency concerning disaster preparedness is slightly lower than “competent” according to Benner’s competence estimation model. The majority of nurses disaster experience. Accruing actual MI experience may be elusive due to the rarity of MI.  The results of this study however indicate that nurses’ disaster competencies may be inadequate. However, despite relatively low levels of competency, these results indicate that ED RNs may increase their disaster medicine competencies through clinical experience, training and education.  Due to the relatively small sample size, the results may be generalized in similar settings with caution.

Introduction

Cancer patients are likely to use emergency care resources for medical complications that may occur during or after cancer therapy. We aimed to estimate the prevalence of cancer patients that present to the Emergency Departments (EDs) in France, report their chief complaint, describe their characteristics and identify predictors of 30-day mortality.

Methods Cross-sectional, prospective study during three consecutive days in 138 EDs. All consecutive patients with cancer were included. Estimation of cancer patients’ prevalence, identification of main reasons to attend ED, and predictors of 30-day mortality for patients admitted to the hospital after ED presentation. The study was approved by the Institutional Review Board of the French Speaking society for respiratory medicine – Société de Pneumologie de Langue Française (number CEPRO 2017-038).

Results A total of 1,380 cancer patients were included. Prevalence was 2.8%. The most frequent reasons patients sought ED care were fatigue (16.6%), dyspnea (16.3%), gastro-intestinal symptoms (15.1%), trauma (13.0%), fever (12.5%) and neurological disorders (12.5%). Patients were admitted to the hospital in 64.9% of the cases, of whom 13.4% died at day 30. Variables independently associated with higher in-hospital mortality at day 30 were male gender [OR, 1.67; 95% CI, 1.07-2.60], poor performance status [OR, 3.40; 95% CI, 2.15-5.38], solid [OR, 3.15; 95% CI, 1.30-7.61] or uncontrolled malignancy [OR, 2.25; 95% CI, 1.35-3.73], ED attendance for a neurological disorder [OR, 2.13; 95% CI, 1.23-3.69], high shock-index [OR, 1.76; 95% CI, 1.02-3.05] or oxygen therapy [OR, 2.55; 95% CI, 1.61-4.05].

Conclusion

This large prospective nationwide study about cancer patients seeking emergency care, representing 3% of total ED attendance, shows high need for hospitalization and case fatality. Malignancy and general health status both play a major role in patient outcomes, and should be taken into account by emergency physicians in adapting the level of care.

Background: The rate of annual healthcare visits involving prescription benzodiazepines increased from 3.8% to 7.4% between 2003 and 2015 in the United States. Benzodiazepines-related overdose mortality has risen sharply, from 0.6 per 100,000 adults in 1999 to 4.4 per 100,000 adults in 2016. Approximately 30% of overdoses involving opioids also involve benzodiazepines. The objective of the study was to describe the epidemiology of benzodiazepines exposures using a national poison center (PC) database.

Methods: The National Poison Data System (NPDS) was queried for human exposures to benzodiazepines from 2013 to 2019 using the specified generic code identifiers. We descriptively assessed the relevant demographic and clinical characteristics. Reports from acute care hospitals and emergency departments (ACHs) were analyzed as a sub-group. Trends in benzodiazepines frequencies and rates (per 100,000 human exposures) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2013) were reported with the corresponding 95% confidence intervals (95% CI).

Results: There were 490,572 human exposures to benzodiazepines reported to the PCs from 2013 to 2019, with the annual calls decreasing from 75,108 to 58,377 during the study. Polysubstance exposures accounted for 73.5% of benzodiazepines exposures. Of the total benzodiazepines calls, the proportion of calls from ACHs increased from 63.7% to 69.3% during the study period. Multiple substance exposures accounted for 70.6% of the calls involving benzodiazepines from ACHs. Approximately 23.1% of the patients reporting benzodiazepine exposures were admitted to the critical care unit (CCU), while 12.3% of the patients were treated and released. Residence was the most common site of exposure (93.6%) and 75.8% cases were en-route to the hospital when the PC was notified. Among the patients, 61.4% were females, with the majority of benzodiazepine exposures occurring between the ages of 20-29 years (18.6%). Suspected suicide (60.6%) was the most commonly reported reason for exposure. The proportion of such cases was higher in reports from ACHs (74.1%). Compared to the overall sample, suspected suicide intent was significantly lower among single substance benzodiazepine exposures (60.6% vs 47.6%). Major effects were seen in 6% of cases and the case fatality rate was 0.5%. Notably, there was an approximately 54% decrease in the number of annual deaths reported to the PCs. The most frequently co-occurring substances associated with the cases were alcoholic beverages (15.9%) and antipsychotics (8.8%). Tachycardia (15.2%) and respiratory depression (5.5%) were commonly observed clinical effects. During the study period, the frequency of benzodiazepine exposures decreased by 22.3% (95% CI: -21.5%, -23.2%; p<0.001), and the rate of benzodiazepine exposures decreased by 20.8% (95% CI: -16.7%, -24.7%; p=0.03).

Conclusions:  Benzodiazepine exposures decreased during the study period. However, a larger percentage of the calls were from healthcare facilities suggesting higher healthcare utilization related to benzodiazepines. Although the deaths declined, this fails to capture patients who died before reaching medical care, and the true death rate should be compared with other sources, such as medical examiner data.  Benzodiazepines have also been increasingly associated with suicidal ideation, which was the most common reason for exposure in our sample.

Background: Drug overdoses are a leading cause of unintentional injury-associated death in the United States (U.S.) with 68,577 fatalities in 2018. Between 2016 and 2017, oxycodone comprised of approximately 18.8% of all prescribed opioids in the United States. There were 182,748 visits to emergency departments (ED) related to oxycodone products in 2010. This study aims to examine the national trends in oxycodone exposures reported to the U.S. poison centers (PCs).

Methods: The National Poison Data System (NPDS) was queried for human oxycodone exposures from 2008 to 2018. Severe outcomes (SO) were cases that resulted in major medical outcomes or death. We descriptively assessed the relevant demographic and clinical characteristics. Trends in oxycodone frequencies and rates (per 100,000 human exposures) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2008) were reported with the corresponding 95% confidence intervals (95% CI). We developed a predictive logistic regression model to identify important predictors of severe outcomes with oxycodone exposures.

Results: There were 183,058 oxycodone exposures reported to the PCs from 2008 to 2018, with the calls decreasing from 16,644 to 12,982 during the study period. Among the overall oxycodone calls, the proportion of calls from acute care hospitals and EDs increased from 40% to 58.8% from 2008 to 2018. Multiple substance exposures accounted for 54.5% of the overall oxycodone calls. Cases between ages 30 – 49 years were more common among the SO group (41.3%) as compared to the non-SO group (39.3%). Suspected suicides (55.8% vs 34.4%) and intentional abuse (19.1% vs 11.1%) were more frequent in the SO group. Additional co-occurring opioids were reported in 14% of the SO cases and 7% of non-SO cases. Benzodiazepines were the most frequently reported non-opioid co-occurring substance in both groups. The frequency of oxycodone exposures decreased by 22.5% (95% CI: -24.2%, -20.8%; p<0.001), and the rate of oxycodone exposures decreased by 14.1% (95% CI: -22.6%, -5.3%; p=0.009). In multivariable-adjusted analyses, the risk of SO with oxycodone exposures was significantly associated with older age with cases between 50-59 years (Adjusted Odds Ratios [AOR]: 2.15, 95% CI: 2.00 – 2.31) demonstrating significantly increased odds of such outcomes. Males were 10% more likely to have a SO as a result of an opioid exposure (AOR: 1.10, 95% CI: 1.06 – 1.15). Suspected suicide (AOR: 2.22, 95% CI: 2.10 – 2.36) and abuse (AOR: 3.21, 95% CI: 2.98 – 3.35) were strong predictors of SO (Reference: Unintentional Reasons). Exposures to more than three substances (AOR: 3.16, 95% CI: 2.95 – 3.39) and involvement of parenteral route of administration (AOR: 2.53, 95% CI: 2.09 – 3.06) significantly increased the risk of a serious outcome in oxycodone exposures.

Conclusions: PC data demonstrated a decreasing trend of oxycodone exposures, which may in part be attributed to the reformulation of this medication with abuse‐deterrent properties in 2010. However, the increase in the calls from the acute-care hospitals and EDs indicates a higher risk of such exposures which may be mediated by several clinical and demographic factors. 

Background: Ultrasound guided fascia iliaca compartment block has increasingly been utilised in the emergency and anaesthetic departments in the initial symptom control of patients presenting with neck of femur fractures. High-fidelity simulation models that are reproducible and sustainable for effective teaching and training have been lacking. The aim of this study was to establish a model, and to assess its educational and training impact on local and regional courses.

Methods: Three fresh chicken breasts were stacked on top of each other, with the middle breast placed inside a plastic sandwich bag representing the fascia lata and iliaca on either side. Two modelling balloons were filled with water, and a stripped electric wire was prepared, to represent femoral vessels and nerve respectively. These were placed accordingly between the chickens and bag. The whole model was sutured using size one suture and a cling film were applied around it all before placing the completed assembly on a tray. Ultrasound linear probe was used to ensure the correct sonographic representation of the structures. This represented a high-fidelity simulation model which was used at the Leeds Teaching Hospital Trusts Emergency Medicine Junior Clinical Fellows teachings, and the Yorkshire and Humber deanery Acute Common Care Stem (ACCS) Trainees mandatory regional introductory ultrasound courses. All trainees had the opportunity to perform the procedures in real time with injecting water as a representation for local anaesthetic agent with direct supervision. At the end the candidates were asked to anonymously complete an electronic feedback form with four questions. These were confidence level pre- and post-simulation, the tactile feedback of the model, and the sonographic representation of the structures. The scale was 1-5, with 1 indicating lowest and 5 highest. The median and interquartile range of for each response was calculated as the primary outcome.

Result: All the 65 participants completed the questionnaire. The median improvement levels were 2 (IQR 2), 4 (IQR 1), 4 (IQR 1),4 (IQR 1) for confidence level pre- and post-simulation, the tactile feedback of the model, and the sonographic representation of the structures, respectively.

Discussion and Conclusion: We have shown that it is feasible to establish a reproducible and sustainable high-fidelity simulation model for effective teaching and training of ultrasound guided Fascia Iliaca Compartment Block. This could improve the confidence level of trainees in performing the procedure in clinical practice with less supervision level.

Background: In patients with unwitnessed out-of-hospital cardiac arrest (OHCA), the actual no-flow duration (the time with no organ perfusion) is unclear. However, when these patients have a shockable rhythm as an initial recorded rhythm, the no-flow duration may be relatively short as compared with other initial rhythms, and some patients can obtain a good functional outcome after OHCA.

Purpose: The purpose of the present study was to estimate the no-flow duration and to determine the relationship between no-flow duration and neurologically intact survival in patients with an initial shockable rhythm after OHCA.

Methods: We reviewed 82,464 patients with OHCA (aged ≥18 years, non-traumatic, witnessed, and without any bystander interventions) who were included in the All-Japan Utstein-style registry from 2013 to 2017. The study end point was 1-month neurologically intact survival (Cerebral Performance Category scale 1 or 2). No-flow duration was defined as the time from emergency call to emergency medical services (EMS) arrival at the patient site.

Results: The rate of 1-month neurologically intact survival in the patients with an initial shockable rhythm (n = 10,384, 12.6% of overall patients) was 16.5% (1718/10,384). No-flow duration was significantly and inversely associated with 1-month neurologically intact survival (adjusted odds ratios for 1-minute increments: 0.85, 95% confidence interval: 0.84–0.86). The proportion of patients with a shockable rhythm to the overall patients (y, %) had a high correlational relationship with no-flow duration (x, min), depicted by y = 21.0 - 0.95 × x, R² = 0.935. In this analytical model, the number of patients with shockable rhythm reached null at 22 minutes of no-flow duration. The no-flow durations, beyond which the chance for initial shockable rhythm diminished to <10%, <5%, and <1%, were 12, 13, and 17 minutes, respectively. The rate of neurologically intact survival in the patients with shockable rhythm (y, %) and no-flow duration (x, min) were also found to have a strong correlation, depicted by y = 0.16 × x² - 5.12 × x + 45.0, R² = 0.907. The no-flow durations, beyond which the chance for 1-month neurologically intact survival diminished to <10%, <5%, and <1%, were 10, 11, and 15 minutes, respectively.

Conclusions: In OHCA patients without any bystander interventions before EMS personnel arrival, when a shockable rhythm is recorded by EMS personnel as an initial rhythm, the no-flow duration after cardiac arrest is highly likely to be

Background

 Risk prediction for hepatotoxicity in acute paracetamol (AAP) overdose has been dependent on the classic nomogram, but the emergency medical centers in some developing countries do not have laboratory resources to provide drug level in time. The Medicines and Healthcare Products Regulatory Agency (MHRA) and the Commission on Human Medicines in the United Kingdom revised the guideline in 2012, which recommends that the treatment threshold for the patients who ingested more than 75 mg/kg in 24 hours, should be lowered to ‘100-treatment line’ without risk stratification of hepatotoxicity. The primary aim of the study is to evaluate the optimal AAP dose that could be used as cutoff value for N-acetyl cyteine(NAC) treatment in the environment that AAP serum level cannot be provided in time.

Methods

 Data were collected retrospectively from two emergency departments(ED) that more than 60,000 patients visit annually, between 2010 and 2017. Inclusion criteria were acute single AAP intoxication with dose ≥75 mg/kg, visited ED in 15 hours after overdose and over 14-year old. The trend of change in the frequency of toxic level with increasing dose was determined by chi square test for trend. The sensitivity, specificity of 100, 125, 150 and 175 mg/kg for the level above 100-line were calculated.

Results

 A total of 196 patients were enrolled in the primary analysis. 187 patients (95.4 %) were intentional self-harm attempt and the majority of the patients, 166 (84.7 %) were overdosed with extended-releasing tablets, compound preparation with caffeine, decongestants, antihistamines or cough suppressants, or medications of other different classes.  56 of 196 subjects (28.6 %) showed AAP toxic serum level on the first test. 6 subgroups were created by 25 mg/kg of reported dose per weight. There was positive trend that the higher intoxicated dose per weight, the higher the frequency of toxic concentration in the first AAP serum level test (chi square test for trend, chi square=7.63, p-value = 0.0057). The sensitivities for predicting serum APAP toxic levels over the 100-treatment line at, ingestion doses of 100, 125, 150, and 175 mg/kg were 85.7%, 76.8%, 69.6%, and 60.7%, respectively, while the corresponding negative predictive values were 77.1%, 80.3%, 80.5%, and 79.4%, respectively.

Discussion & Conclusions

 Following the revised UK guideline that lowered the treatment line to 100 mcg/ml on 4-hour and 15 mcg/ml on 15-hour without risk stratification of hepatotoxicity, for the patients over 14-year old, visited ED in 15 hours after acute single AAP overdose, the dose over 100 mg/kg can be safely suggested as a toxic exposure for NAC antidote therapy.

Background:
The early diagnosis of stroke remains a challenge in emergency medicine. In Germany, the FAST (F=Face; A=Arms; S=Speech and T=Time) algorithm – a structured assessment of several focal neurological deficits – is currently used to determine its probability. However, a systematic validation and evaluation of the algorithm’s performance is lacking. We thus aimed to evaluate the predictive value of the FAST algorithm in a retrospective analysis.

Methods:
The presented retrospective mono-center validation- study included all patients who were admitted to the emergency department of a single neurology and university hospital in the county Marburg-Biedenkopf with the suspected diagnosis stroke within less than 6 hours'' over a eighteen-month period (from July 2018 to December 2019) for analysis. Results of preclinical examination, performed by mainly non-physician staff, were retrieved from emergency service protocols.

Immediately after arrival at the emergency room of the university hospital Marburg, neurological examinations have been investigated by medical doctors of the department for neurology, following well established standards of neurological examination of the National Institutes of Health Stroke Scale (NIHSS). In case of suspicion of a stroke after clinical examination, diagnose was validated by MRI (magnetic resonance imaging). Sensitivity, specificity, and positive likelihood ratio were calculated as recommended by Wilson and Brown.

Results:
1278 patients were included in our analysis and have been examined in emergency room.
The pre-clinical investigation of the FAST algorithm predicted a stroke with a sensitivity of 64% (95% CI 60-69%, n = 1126) and a specificity of 51% (95% CI 48-55%, n = 1126). The positive likelihood ratio was 1.347.  Within the clinical setting, sensitivity increased to 77% (95% CI 73-80%, n = 1278) with a specificity of 60% (95% CI 56-63%, n = 1278) and a likelihood ratio of 1.945.

Discussion & Conclusion:
While modest specificity might be tolerable in the present setting, the FAST-algorithm provided low sensitivity for correct detection of a stroke within the analysed cohort. Although, applying the same algorithm, results of pre-clinical examination considerably diverged from results of the clinical examination, following NIHSS. Since cerebral ischemic stroke is a time-sensitive diagnosis, the development of highly sensitive tests is crucially necessary to enable rapid interventions of treatment. Therefore, an advanced algorithm is desperately needed for further improvement of stroke-diagnostics in emergency medicine.

Background
Screening tools assessing geriatric vulnerability in older Emergency Department (ED) patients are seldom put to use in routine care. This study explores experiences with and attitudes towards routine screening for geriatric vulnerability among older ED patients.
Methods
Individual face-to-face semi-structured interviews were conducted at home in older patients (≥70 years) within one month after they completed the ‘Acutely Presenting Older Patient’ (APOP) screener at the ED of Leiden University Medical Center. Purposive convenience sampling was used to select a heterogeneous sample of participants regarding age, disease severity and APOP-screening result. Interviews were audio recorded and transcribed verbatim. Transcriptions were analyzed inductively using thematic analysis with Atlas.ti software.

(Preliminary) results
After 13 interviews (6 men, 7 women, median age 81 years), data saturation was reached. Most participants considered the vulnerability screening to be part of routine care and could not remember the particular screening questions, except for the cognition test. Their overall attitude towards the concept of screening was positive. Participants believed that vulnerability screening could help to identify the patient as a whole and adapt care to the patient’s needs, which they considered important for all patients, regardless of age. Participants who did not consider themselves to be vulnerable, did not personally experience an added value of the screening but they did believed in the added value for others.

Conclusion

From an ED-patients’ perspective, screening for geriatric vulnerability was experienced as a part of routine ED care and was considered to be of added value for optimal ED care.

Background / problem / goal

The proportion of the elderly population in Taiwan is rapidly increasing. It is estimated that by 2026, the elderly population will exceed 20%, becoming a "super-aged society." The emergency medical resources used by the elderly over 65 years are much higher than those of other age groups. The purpose of this study is to explore the factors related to "unplanned return visits" of elderly emergency patients at a medical center in the south to improve emergency congestion.

Method

Retrospective data analysis was adopted, according to the data of emergency patient registration. (1) Return visits to the emergency department within 24 hours; (2) Return visits to the emergency department of the elderly over 65 years; perform descriptive statistical analysis, and the study period is 2019.05.01 ~ 2019.10 .31

Results

During the study period, 872 people returned to the emergency department within 24 hours, accounting for 1.9% of the total number of emergency departments, and there were 248 elderly people over 65, accounting for 28.4% of all age groups.

The chief complaint reasons for the second visit were different,

 28.6%, the condition worsening or complications occurring, 1.6%, the symptoms not improving, 23%, the recurrence of symptoms, 44.8%, patient requested by physician to return, 1.2%, 2 reasons were not entered, 0.8%.

In terms of in-patient department , the hospitalization rate for returning to the emergency department within 24 hours was 47.6%, among which 95.8% was the most in internal medicine, and 4.2% in the other (surgical, trauma, and ophthalmology).

Out-of-hospital order for returning to the emergency department, AAD (Against Advice Discharge), 11.7%, MBD (May Be Discharged), 40.7%, and hospitalization, 47.6%. After discharge from the hospital, the study subjects used only 1.6% of home-based care, and  6.5% of care institutions, 4.4% of elderly care centers, and 2% of nursing homes.

Conclusion

"Unexpected return to the emergency department in the short term" will cause the hospital emergency department quality to decline,

Among them, the majority of people over 65 years old (28.4%).

Analysis of the reasons is that: due to physical deterioration and cognitive decline in the elderly, the elderly have many companion diseases, which leads to patients often seeing emergency doctors. In terms of mental state, Because the elderly are old, living alone and lacking social support, they often have depression. which is also one of the reasons for returning to the clinic..

Nursing staff can communicate with patients and their families during the emergency department to understand their physical, psychological and social support status. When the patient is discharged from the emergency department for the first time, giving good health care instructions may reduce unnecessary return visits.

Regarding the lack of integration of long-term care institutions, if the local community can implement a cross-field cooperative service model by the nurses, combined with physicians, physiotherapists, and social workers, nurses will perform care, disease education, and nursing home visits, call care, resource links and referrals will bring more benefits and implement localized care services.

Background

Chest blunt trauma is an important contributor to morbidity and mortality, which affect 15% of total blunt trauma patients. This is particularly injurious among the elderly, who display a predilection for the development of pneumonia and other pulmonary complications.
On 2016, Western Trauma Association recommend all chest trauma patient aged older than 65 years old with more than 2 ribs fractures need to be admitted to intensive care unit for strictly monitor. But this recommendation is only based on their experience and institutional protocol lack of proper documented
evidence support.
The aim of this study is to identify the factors and mechanism associated with pulmonary complication after chest contusion with rib fracture among
elderly. The results would help emergency physician to identify high risk patient at emergency department.

Material and method

This was a retrospective study conducted from January 2016 to October 2018 at a level I trauma center in Taiwan. MacKay Memorial hospital is a medical center. All patients aged ≥65 years with blunt chest trauma with rib fracture between 1 January 2016 and 31 October 2018 were identified. We excluded patients with any of the following : (1) admission for medical disease, (2) any body region except chest with AIS score >3 (3) no rib fracture reviewed by radiologist (3) out hospital cardiac arrest.

Results

We identified rib fracture(s) in 315 cases among 2,765 elderly presented to emergency department with thoracic trauma. There were 159 males (50.5%) and 156 females (49.5%) ranging in age between 65 and 98 years (mean . years). Two-third of patients injuried outdoor(215/315, 68.3%). The leading cause of the trauma was falls (N=174, 55.2%) and following as riding motorbike(N=103, 20.3%) and pedestrian hit by vehicle(N=18, 5.7%). One-third of elderly with rib fracture (N=107, 34.0%) had at least one of pulmonary complication including hemothorax(N=78, 24.8%), pneumothorax(N=37, 11.8%), pneumonia(N=24, 7.7%), Respiratory failure(N=16, 5.1%) and flail chest (N=4, 1.3%).
Pulmonary complications increase as the numbers of rib fractures increased. There were moderate correlation between the numbers of rib fractures and pulmonary complication rates (r = 0.550, p <0.001). Besides, there were no significant correlation between admission days and the numbers of rib fracture (r = 0.007, p =0.929). 
We also identified patients with more than two ribs fracture or more than two comorbidities had significant increase pulmonary complications : ≥3 ribs fracture(aOR :13.935, 95% CI: 6.916-28.079,) and more than two comorbidities (aOR : 3.317, 95% CI: 1.579-6.964)

Objectives : We investigate the reliability of a survey question on forgone health care services for financial reasons, based on analysis of actual healthcare use over the three-year period preceding response to the question. We compare the actual use of different health services (general practitioner, emergency department, hospital admission) by patients who report having forgone health care to those who do not.

Methods : Based on a prospective cohort study (CONSTANCES), we link survey data from enrolled participants to the Universal Health Insurance (UHI) claims database and compare use of health services of those who report having forgone health care to controls. We present multivariable logistic regression models and assess the odds of using different health services.

Results : Compared to controls, forgoing care participants had lower odds of consulting GPs (OR=0.83 ; 95% CI=0.73, 0.93), especially specialists outside hospitals (gynecologists : 0.74 (0.69, 0.78) ; dermatologists : 0.81 (0.78-0.85); pneumologists 0.82 (0.71-0.94); dentists 0.71 (0.68, 0.75) ;  higher odds of ED visits (OR=1.25 ; 95% CI=1.19, 1.31) ;  and no difference in hospital admissions (OR=1.02 ; 95% CI=0.97, 1.09). Participants with lower occupational status and income had higher odds of forgoing health care.

Conclusion : The perception of those who report having forgone health care for financial reasons is consistent with their lower actual use of community-based ambulatory care (CBAC). With lower odds of consulting physicians in CBAC and higher odds of visiting ED, our study supports the notion that EDs might partially replace GPs and specialists for populations that forgo seeking health care in CBAC. While UHI may be necessary to improve healthcare access, it does not address the social factors associated with the population forgoing health care for financial reasons. 

Background:
Although skin adhesives have been used for decades to treat pediatric skin lacerations, uncertainty remains about long-term results and complications. Objective of this study was therefore to evaluate early and long-term complications, aesthetic results, costs, duration of treatment, and quality of life (QoL) for tissue adhesive versus suture to repair facial lacerations in children.

Methods:

Design: Prospective, controlled, single-blind study
Setting: Emergency Department of the University Children’s Hospital Zurich, a tertiary hospital with a census of more than 42’000 annual emergency visits
Participants: Children aged 0-16 years presenting with a laceration on the face between 07/2017 and 08/2018
Main Outcomes and Measures: Outcomes were assessed by five independent, blinded adult or pediatric plastic surgeons by means of photographs at 6-12 months using a modification of the validated Patient and Observer Scar Assessment Scale (POSAS) and the Vancouver Scar Scale (VSS). Additionally, POSAS was performed at day 5-10 (early follow-up) and month 6-12 (late follow-up) by the patients or caregiver(s) and the physician. Complications and QoL were assessed by standardized measures.

Results:
367 patients were enrolled, of which 230 were included in the main analysis. 96 wounds were closed using tissue adhesives (group 1); 134 were sutured (group 2). Assessment by the independent observers revealed an improved mean modified overall POSAS score in group 1 in comparison to group 2 (of 2.1 ± 0.7 vs 2.5 ± 0.7; p< 0.001) and mean VSS score (1.2 ± 0.9 vs 1.6 ± 0.9; p< 0.001). At the early follow-up, dehiscence rate was 12.5% in group 1 and 3.7% in group 2 (p< 0.001). At the late follow-up, 1 dehiscence remained per group. Mild impairment of QoL was found at the early follow-up in both groups, with no impairment remaining at long-term follow-up. Mean duration of treatment was significantly lower in group 1 than in group 2 (6.3 ± 4.0 min vs. 11.6 ± 7.2 min; p< 0.001). Treatment costs were 33.5% lower in group 1.

Discussion and Conclusions:
Both modalities of wound closure yield favorable aesthetic results and lead to low rates of complications. Adhesives are more cost-effective and application is less time-consuming and, therefore, tissue adhesives offer considerable advantages when used appropriately.

Background

Health outcome goals are the results which individuals seek from healthcare. These may not be limited to health state and could incorporate holistic themes including function, mood, social roles, and quality of life. Healthcare preferences here are the processes and procedures which individuals would accept in order to achieve their health outcome goals.

Our recent systematic review thematically classified older people’s health outcome goals as efficient and comprehensive care, sensitivity towards vulnerability, and person-centred and informed care. We stressed the importance of understanding individual perceptions.

People living with frailty are known to have poorer outcomes from even short hospital stays. They benefit from person-centred, goal-directed care over protocol-driven pathway approaches. A better understanding of their healthcare goals would enable best care to be initiated in emergency departments.

Methods

This qualitative study design is based on grounded theory. 35 older people (aged over 65) with frailty (clinical frailty score over 4) are being recruited using opportunistic sampling during their emergency department attendance at Leicester Royal Infirmary (a large teaching hospital with diverse multicultural catchment). People with cognitive and communication barriers such as dementia are included, with familiar caregivers assisting as consultees.

Semi-structured interviews are being audio-recorded in participants’ homes within one month of their acute care episode. Discussions focus on identifying the events and outcomes that participants wanted to take place during emergency care. Verbatim transcripts are being analysed contemporaneously using a blended approach based on constant comparison. Ideas expressed in the data are assigned codes, which are expanded and merged to yield theme categories.

Initial results

Data collection was paused due to the outbreak of COVID-19. Initial results showed a predominance of person-centred and holistic care themes among health outcome goals. ‘Management of symptoms’ was participants’ most common goal for emergency care. People often had pain and wanted to feel comfortable. Participants were often living with severe frailty and wanted their mobility to be assessed, with goals of recovering their functional baseline. Within the ‘information and understanding’ theme, while participants had confidence in healthcare professionals and were generally willing to “do as we are told to feel better”, they expected to undergo at least basic tests in order to receive a working diagnosis for their problem. People not only wanted to understand their illness, but also for explanations to be communicated to their relatives.

Participants reported healthcare preferences to include emergency department accessibility, cleanliness, and efficiency. People felt vulnerable and forgotten, both when in busy waiting rooms and on trolleys in closed cubicles. They wanted staff to be aware of their need for assisted feeding and toileting.

Discussion

Initial results showed older people with frailty to have some unique health outcome goals for emergency care. These should be assessed on an individual basis, and may show people to seek control of pain and maintenance of mobility in preference over cure of disease.

Background: Oral factor Xa inhibitors (oFXaIs) are used as anticoagulation therapy to reduce stroke risk of patients with atrial fibrillation (AF). However, as anticoagulants, these medications are associated with increased bleeding risk.

Purpose: To examine the healthcare burden of AF patients treated with oFXaIs who were hospitalized in the U.S. with a major bleed (MB) with a breakdown by MB type.

Methods: Patients (≥18 years) treated with oFXaIs (rivaroxaban, apixaban, or edoxaban) who had an inpatient hospitalization with MB (January 1, 2015-April 30, 2018) were extracted from the MarketScan claims databases. The index date was defined as the first MB inpatient hospitalization. Patients were grouped into 3 study cohorts based on the type of MB: gastrointestinal (GI), intracranial hemorrhage (ICH), and other MB type. Healthcare resource utilization and costs were evaluated for index MB hospitalizations and during the 6-month period prior to the index event and a variable follow-up period of 1-12 months for the study cohorts. Multivariable regression analyses were conducted to examine the impact of having ICH or other MB type vs. GI MB on index event hospital length of stay and cost, as well as all-cause healthcare costs in the follow-up. The covariates in the regression analyses included age, gender, U.S. geographic region, payer type, Charlson Comorbidity Index score, CHA₂DS₂-VASc score, HAS-BLED score, select comorbidities, oFXaI type, and AF type. All costs were inflated to 2019 USD and annualized.

Results: Among the study population of AF patients treated with oFXaIs who had an MB hospitalization (N=7,577), 55.9% had GI MB (N=4,236; mean age: 76.8 years; 48% female), 9.9% had ICH (N=753; mean age: 77.9 years; 42% female), and 34.2% had other types of MB (N=2,588; mean age: 74.4 years; 39% female). For index GI MB, ICH, and other MB hospitalizations, unadjusted mean lengths of stay were 5.0, 6.8, and 5.5 days, respectively; mean costs were $26,901, $54,163, and $36,645, respectively. From the adjusted analyses, for index hospitalizations, patients with ICH vs. those with GI MB spent on average 1.6 more days in the hospital (p<0.001) and had an average of $15,630 higher hospitalization cost (p<0.001); patients with other types of MB vs. those with GI MB spent on average 0.6 more days in the hospital (p=0.001) and had an average of $5,859 higher hospitalization costs (p<0.001). During the follow-up period after the index hospitalization, all-cause inpatient, outpatient medical, and total healthcare (inpatient, outpatient medical, and outpatient pharmacy) costs per patient were $9,376 (p=0.019), $4,734 (p=0.008), and $14,037 (p<0.001), respectively higher for ICH patients vs. GI MB patients; they were $1,738 (p=0.350), $3,089 (p=0.003), and $5,208 (p=0.011), respectively higher for other MB patients vs. GI MB patients.

Conclusions: Among 7,577 AF patients treated with oFXaIs and hospitalized for MB in the U.S., GI MB was most prevalent. All 3 MB categories were associated with high hospitalization costs; however, in comparison to GI MB, ICH and other types of MB had higher average costs for index events and all-cause total healthcare costs during the time period following MB hospitalization.

BACKGROUND:

One of the most important therapeutic complication for the patients with diabetes mellitus (DM) is hypoglycaemia.

While administering the treatment, it is important to follow guidelines´ recommendations and protocols, since the overcorrection in the glucose level, can provoke metabolic alterations and a descompensatory process in the diabetes regulation.

OBJECTIVE:

To determine the rate of patients presenting hyperglycaemia subsequent to hypoglycaemia at the emergency department and to analyse the same rate according the type of diabetes and the previous treatment.

MATERIAL AND METHODS:

Observational descriptive and analytical exploratory study performed at the Emergency Department in La Ribera University Hospital. it has been studied patients with a diagnosis of hypoglycaemia at discharge during the months of March and July 2019.

The variables used were: sex, age, cause of hypoglycaemia, hypoglycaemia treatment and presence of subsequent hyperglycaemia (blood glucose at some time during admission after starting treatment greater than or equal to 180mg/dl).

RESULTS:

A total number of 93 pacients were studied. The 81,7% has Type II DM. The 21,7% has as basal treatment with non-insulinic hypoglycaemic drugs and insulin previous to the admission to the emergency department. Low-dietary intake of glucose was the main reason of hypoglycaemia (64,52%) followed by administering mistakes (9,68%) and bad control of the disease (8,60%). A 94,6% of the patients was treated with glucose saline (5-10%), a 90,3% of the patients was treated orally and  86% was prescribed with Glucosmon.

Subsequent hyperglycaemia was notice in 43% of the cases and it was slightly superior in patients with Type I DM (56,3% vs 41,3%) p= 0,373, oberserving no significant differences (p=0,652) while styding the presence of hyperglycaemia regarding the patient’s previous treatment: 45% of  hyperglycaemia was observed in the group of patients with a basal treatment with non-insulinic hypoglycaemic drugs, 48,6% in patients receiving insulin and 37,8% in patients treated with a combination treatment with the above mention drugs.

CONCLUSION:

The study found a high percentages of hyperglycaemia in the group of patients who visited the emergency department due to hypoglycaemia, which results give us an evidence of non-follow up correctly of the clinical recommendations and guidelines.

Background: Door-to-balloon time in patients with ST-elevation myocardial infarction is reported to be an independent predictor of the prognostic implication and was suggested to be included in current guidelines. However, the effect of door-to-deployment time (DTDT) of venoarterial extracorporeal membrane oxygenation (VA-ECMO) on patients with out-of-hospital cardiac arrest (OHCA) is unclear.

Purpose: This single-center, retrospective, observational study aimed to evaluate the effect of DTDT of VA-ECMO for mortality or neurological outcome of extracorporeal cardiopulmonary resuscitation (ECPR) in patients with cardiogenic OHCA.

Method & Result: This single-center, retrospective, observational study was conducted from January 2008 to April 2019. The primary endpoint was 1-month overall survival measured after ECMO initiation. Moreover, the secondary endpoint was 1-month survival with favorable neurological functions defined as having a cerebral performance category score of 1 or 2. A total of 3082 patients with OHCA were brought to our institution and 84 received ECPR. Of these, 51 consecutive adult patients with cardiogenic OHCA without sustained return of spontaneous circulation during transport were included in this analysis. Approximately 18 patients (18/51, 35.3%) survived after 1 month and were discharged. Among the survivors, 15 (15/18, 83.3%) were discharged with a favorable neurological outcome. The baseline characteristics between the survivors and non-survivors were not significantly different, except for the initial shockable rhythm [18/18 (100%) versus 28/33 (84.9%), P = 0.03]. There were no statistically significant differences between the median time from collapse to hospital arrival [31.0 min (IQR 25.0–31.0) versus 29.0 min (IQR 25.0–39.5), P = 0.53] and from call to hospital arrival [28.0 min (IQR 22.0–32.5) versus 27.0 min (IQR 23.3–34.5), P = 0.56]. The median DTDT of VA-ECMO was significantly shorter in survivors [13.0 min (IQR 11.5–18.3) versus 21.0 minutes (IQR 15.5–32.0), P = 0.01]. The Kaplan–Meier survival analysis showed that 1-month overall survival rate and survival rate with a favorable neurological outcome were significantly higher in the group with a DTDT ≦ 20 min (31 patients) than that with a DTDT > 20 minutes (20 patients), [11 patients (50.0%) versus 4 patients (19.0%), P < 0.01 and 11 patients (46.0%) versus 4 patients (14.0%), P = 0.01, respectively]. Using the Cox proportional hazards analysis, DTDT ≦ 20 minutes and bystander-witnessed significantly affected the overall survival rate at 1 month [adjusted hazard ratio (HR), 0.44; 95% confidence interval (CI), 0.20–0.95; and P = 0.03 and adjusted HR, 0.31; 95% CI, 0.13–0.74; and P < 0.01, respectively]. Regarding survival rate with a favorable neurological outcome, the result was relatively similar [adjusted HR, 0.46; 95% CI, 0.22–0.96; and P = 0.04 and adjusted HR, 0.37; 95% CI, 0.16–0.85; and P = 0.02, respectively].

Discussion & Conclusions:  Bystander-witnessed, bystander CPR and initial shockable rhythm are considered as favorable predictors of adult ECPR. However, there is still limited information about DTDT of VA ECMO in the previous studies. This study revealed that the DTDT of VA-ECMO is significantly associated with the 1-month mortality and neurological prognosis of patients with cardiogenic OHCA. However, further studies will be required to confirm these findings.

INTRODUCTION

Over the years, emergency services have experienced a sharp increase in requests for consultations, contributing to the progressive saturation of these structures. At the same time, for several years now, there has been easier access to GAFAs (Google, Amazon, Facebook, Apple) allowing patients to have 24-hour access to medical information. To our knowledge, no French study has evaluated the impact and prevalence of consulting a website before admission to the emergency room.

The objective of our work is to assess the impact of a prior search for medical information on a website in patients presenting to an emergency department, as well as the relevance of consultation in the emergency department.

METHOD:

This is a pilot, observational, monocentric, prospective study carried out within the adult emergency department of a teaching hospital over the period from 11/03/2019 to 24/03/2019. Patients presenting to the emergency department on their own were included. An anonymized questionnaire was given to patients at the reception. (NCT03881839)

RESULTS:

Among the 462 patients included in our study, 14% of patients consulted the internet versus 86%, with 50.8% and 58.8% respectively of diagnoses qualifying the passage to the emergency room as "justified / relevant". Patients accessing the internet are more commonly between the ages of 18 and 24, have a higher level of education and have a mobile phone. These patients said they sought medical information several times a day, sometimes for symptoms that started less than 5 days ago. After multivariate analysis, the justified / relevant nature of the passage is less frequent in patients who consult the internet every day (OR = 0.48, CI 95%: 0.28-0.84, p = 0.01) and in those who consult medical information websites (OR = 0.51, 95% CI: 0.24-1.06, p = 0.072). On the other hand, the justified / relevant nature of the passage appears more frequent in patients who have symptoms progressing for less than 24 hours (OR = 1.85, 95% CI: 1.25-2.72, p = 0.002) and for those who have consulted the internet (OR = 2.11, 95% CI: 1.25-3.56, p = 0.005).

CONCLUSION:

Our study showed that certain criteria influence emergency room visits: age, level of study and date of onset of symptoms <5 days. It also highlighted more unjustified passages in patients visiting medical information sites or consulting the internet daily.

Introduction : Influenza occurs seasonally and affects between 3 and 6 million people each year, resulting in a sharp increase in emergency consultations. With the arrival of the rapid point-of-care testing (POCT), the questions of the use of this technology arose. The main objective of this study was to show that the use of POCT in emergency department could reduce the length of stay of these patients.

Method : We conducted a prospective, monocentric, randomized and controlled study in a French Universitary hospital between january and march 2019. Patient presenting with a suspected flu were randomly assigned to the laboratory group (standard of care performed in the laboratory with Simplexa Flu A/B & RSV Direct Diasorin) or to the point-of-care testing (POCT with Xpert Flu/RSV Cepheid). The two devices have equivalent sensitivity and specificity (97,9%/99,4%). The primary outcome was the length of stay in the emergency department. This study received an ethical approval by the ethic committee of Sud-Ouest et Outre-Mer II.

Results : 203 patients were included with 111 (54.7%) in the POCT group and 92 (45.3%) in the laboratory group. An overall decrease in emergency department length of stay was highlighted by 1.7 hours (p=0.02, 95%CI: 1.13-2.42) and more specifically by 3.5 hours (p=0.02, 95%CI: 1.48-4.17) in the influenza patient subgroup. Without, however showing any evidence of significant increase in costs (p=0.17).

Conclusion: This study shows the value of using point-of-care testing by rapid influenza diagnostic test in emergency unit in the management of patients suspected of influenza during the epidemic periods. With sensitivity and specificity equivalent to the techniques used by the laboratory, its proper use allows a reduction in emergency time without significant increases in costs.

Background

To strengthen health services in the Beira district, Mozambique, after the Idai Cyclone, an ambulance emergency referral system was implemented by the Italian NGO CUAMM - Doctors with Africa. With an average of 800 patients transported each month from the peripheral primary care centers (CS) to Beira Central Hospital (HCB), the system worked at the full capacity. Initially, the selection of transported patients was based on the clinical experience. To improve the appropriateness of the referrals, CRIMEDIM - Research Center in Emergency and Disaster Medicine (Università del Piemonte Orientale, Novara, Italy) implemented the South African Triage Scale (SATS) in three of the 15 CS covered by this system. A two-days course focused on SATS was delivered to the local personnel and an operation manual was developed and made available.

This study aims to assess whether the implementation of SATS had a positive impact on the appropriate selection of critical patients who needed urgent transport and to assess the accuracy of the triage performed by the local personnel.

Methods

This quasi-experimental study is composed of two periods: a pre-implementation phase, from 08/10/2019 to 07/12/2019, where patients were assessed, selected, loaded in the ambulance and transferred without using the SATS; and a post-implementation phase, from 08/12/2019 to 08/02/2020, where patients were assessed, selected, loaded in the ambulance and transferred following principles and rules stated out in the SATS and in the referral protocol. The data of the transported patients was gathered from the referral charts. The measured outcomes were expected code (triage code retrospectively calculated by researchers using the information from the referral charts), triage accuracy (percentage of assigned codes matching with expected ones) and under and over-triage rates (assigned codes lower or higher than expected ones respectively). Pearson's Chi-square Test was used to investigate if distribution of color codes sent to hospitals and time in which they have been sent were independent. A hypothesis test was used to look at the proportions between the single categories, to analyze in which of them the null hypothesis could be rejected.

Results

A total of 979 referral charts were collected. 209 records were excluded and 770 records were analyzed, 552 from the pre-implementation phase and 218 from the post-implementation phase. The number of transported red codes increased (+10,54%)  and the number of green codes decreased (-12,71%), both with a statically significant difference. Accuracy was 30% for green codes, 29,3% for yellow, 20,2% for orange, 39,4% for red. The overall rate of accuracy, over and under-triage were 29,22%, 47,49% and 23,28% respectively.

Discussion & Conclusions

This study demonstrated that the introduction of SATS, in this low resource context, modified the pattern of transported patients. It showed an increase of red codes transported and a reduction of green codes. Although the accuracy of the triage performed by local professionals can be considered low, the implementation of this triage protocol significantly reduced the number of non-urgent transports. We recommend the inclusion of a triage protocol in the design of emergency referral systems for developing countries.

Introduction: Carbon monoxide (CO) is increasingly recognized as a serious and relatively common cause of intoxication. It is also estimated to affect about 50,000 patients per year in the United States, with an annual mortality rate between 1000 and 2000. Its clinical manifestations can be subtle and non-specific, thus broadening the differential diagnosis. In current literature, only a few works examine the incidence of CO poisoning, and none addressed the incidence of problems in diagnosing this ominous intoxication in the emergency department (ED).

With this study we investigated the incidence of delayed and missed CO poisoning diagnosis in the ED, to evaluate the burden of such an event.

Methods: This retrospective study was carried out by reviewing carboxyhemoglobin values measured with point-of-care analyzers among the EDs of North-east Italy. The analysis included patients that accessed the EDs between June 2014 and July 2019 and had COHb values > 10%, without limitations of age or gender. Normally, non-smokers are diagnosed with CO intoxication if COHb values are above 4%, while smokers must have values above 10%. We chose the cutoff of 10% because smoking habits are usually not disclosed in ED charts, thus underestimating the phenomenon but increasing the specificity of our results. Patients' charts were consulted to quantify delayed and missed diagnoses. As the primary outcome, a diagnosis was defined as "missed" if no mention of CO intoxication was found in the chart or in the diagnosis of discharge or hospitalization. Lacking a benchmarking value, a diagnosis was defined as "delayed" if the blood analysis was performed after 30 minutes from the beginning of the medical examination (secondary outcome).

Results: Out of 126,000 analyses, 127 patients were included in the study (Male: 55.1%; age: median 47 years old, IQR = 32 – 55 years old). Median COHb value was of 14.3% (IQR = 10.9 – 20.3; min: 10.1%; max: 39.8%). Only 54 patients received a diagnosis of CO poisoning (42.5%) and only 52 were treated with oxygen. Of the 73 missed diagnoses, 42 were then discharged. Moreover, a diagnostic delay was found in 13 out of 127 patients (10.2%).

Discussion and Conclusions: There is a significant number of delayed CO poisoning diagnoses and an even higher number of missed diagnoses. This study did not investigate the clinical consequences of such mistakes. However, it is well known that a delayed or, even worse, a missed diagnosis of CO intoxication can have serious impacts on the outcome of patients, in terms of possible end-organ damage such as delayed neurologic sequelae. More worrying, discharging a patient back to an unnoticed, contaminated environment could have fatal consequences. This study depicts an unprecedentedly reported problem that should prompt quality improvement processes to increase the awareness about this ominous intoxication and the level of care delivered by emergency medicine physicians and healthcare systems. In the future, a wider study including other EDs will clarify if this phenomenon is diffused or restricted to only a cluster of EDs.

Background: Primary postpartum haemorrhage remains the primary cause of maternal mortality in low-resource countries such as Ethiopia. National datasets about the incidence of primary postpartum haemorrhage are often limited. This study was designed determine the incidence mortality, and factors associated with primary postpartum haemorrhage following in-hospital births.

Methods: This was a cross-sectional study design, an audit of 1060 maternity care logbooks of discharged women at Felege Hiwot Referral Hospital and University of Gondar Comprehensive Specialized Hospital. The data were abstracted December to May 2018/2019 using systematic random sampling. Exclusion criteria were logbooks of women aged less than 18 years old or women with maternity care logbooks which had been transferred to another department. The tool used was the Facility Based Maternal Death Abstraction Form. The diagnosis of the woman’s primary postpartum haemorrhage was informed by one of two methods. The first was by the estimated blood loss recorded by the staff. The second was the medical staff diagnosis and recording of the woman as having primary postpartum haemorrhage. Data were entered, cleaned then analysed using SPSS version 25. Bivariate logistic regression was fitted. Adjusted odds ratio with 95% confidence interval was used to determine the statistical significance.

Results: The incidence of primary postpartum haemorrhage was nearly 9.0%. Of these, there was 7% maternal mortality. Predominant to women in Ethiopia health facility referrals of women in labour (AOR: 2.13; 95% CI: 1.19, 3.80), birth attended by final year medical students (AOR: 3.59; 95% CI: 1.89, 6.84), women who were discharged six hours following birth (AOR: 3.50; 95% CI: 1.24, 9.91) were associated with primary postpartum haemorrhage (p<0.05).

Discussion & Conclusions: This study found that the reported incidence of primary postpartum haemorrhage was relatively low, however, the associated deaths of women found was comparatively high. Most factors contributing to incidence of primary postpartum haemorrhage were similar to those found in previous studies. However, three factors prevail for women in Ethiopia, women discharged 6 hours post-partum, transfers from primary health centres, birth attendance by final year medical students.

Funding: This study was unfunded

Ethical approval and informed consent: Prior to commencing data collection ethics approval was sought and approved by Human Research Ethics Committee, Monash University (Project ID: 14113) on 24/08/2018 and Institutional Review Board for Human Research of the University of Gondar on December 20/2018. As the women were already discharged, and not all contactable in rural areas, they could not consent to this research retrospectively providing permission to the reviewing of their maternity care logbooks. The ethics committees granted a waiver of consent.

Background: S-100 B protein was identified a biomarker for traumatic brain injury, but studies suggest that extracranial injuries may also lead to increased S-100 B serum levels. In this study, we aim to quantify the impact of injury patterns on S-100 B levels in patients with suspected multiple trauma.

Methods: Patients with suspected multiple trauma treated at a Level 1 Trauma centre in Switzerland were included in this retrospective patient chart review. Extent of injuries and severity was assessed and S-100 B levels on admission measured. Potential predictors of increased S-100 B levels (>0.2 µg/L) were identified through uni- and multivariable analyses.

Results: 1,338 patients with suspected multiple trauma were included. Multivariable logistic regression showed a significant association with increased S-100 B levels in long bone fracture (OR 2.3, 95% CI: 1.3-4.1, p=0.004), non-long bone fracture (OR 3.0, 95% CI: 2.2-4.3, p<0.001), thoracic injury (OR 2.6, 95% CI: 1.6-4.2, p<0.001), and deep tissue injury/wounds (OR 1.9, 95% CI: 1.4-2.6, p<0.001). Head trauma with intracerebral bleeding was only weakly associated (OR 2.0, 95% CI 1.2 - 3.5, p=0.01) and head trauma without intracranial bleeding was not associated with an increased S-100 B protein level (p=0.71). Trauma severity was also related to increased S-100 B levels (OR per ISS: 1.1, 95% CI 1.0-1.1, p<0.001). S-100 B levels <0.57 µg/L had a high diagnostic value to rule out in-hospital mortality (negative predictive value: 1.0, 95% CI: 0.98-1.00).

Conclusion: Fractures and thoracic injuries appeared as main factors associated with increased S-100 B levels. Head injury may only play a minor role in S-100 B protein elevation in multiple trauma patients. A normal S-100 B has a good negative predictive value for in-hospital mortality. S100-B levels were associated with trauma severity and might thus be of use as a prognostic marker in trauma patients.

Background

Benchmarking is an important tool in quality improvement, but is hardly done in Dutch emergency departments (EDs). As “proof of principle” study, we assessed independent determinants, including ED location, of ED length of stay (LOS)>4 hours as one important aspect of quality of care. This was done per triage category because we assumed that benchmarking of EDs should be done per disease severity category. 

Methods

An observational multi-centre study including all visits of three EDs in the Netherlands Emergency department Evaluation Database (NEED), the Dutch Quality registration for EDs. Patients were stratified by triage category; ‘non-urgent’ (blue&green), ‘urgent’ (yellow), ‘very urgent’ (orange) and ‘immediate’ (red). In every triage category, independent determinants (including ED location A, B, or C as potential determinant, with A being the reference) of ED-LOS>4hrs (primary outcome) were assessed using multi-variable logistic regression analysis.

Results

We included 172.104 ED visits. Independent determinants of ED-LOS>4hrs differed per triage category, with ED location being an independent determinant in all triage categories except ‘red’. The three most important independent determinants of ED-LOS >4hrs in triage category ‘blue&green’ were >2 consultations in the ED (Adjusted Odds Ratio (AOR(95%-CI)) 3.92(3.39-4.54), the presenting complaint ‘intoxicated’ (3,63(2.39-5.54) and  blood sampling 3.56(3.23-3.93). For ‘yellow’ these were >2 consultations (4.61(4.25-5.01), ‘intoxicated’ 3.50(2.88-4.24), and visiting hours 0-6PM (2.97(2.79-3.28, reference was 0-6AM). In ‘orange’ these were ‘intoxicated’ 3.46(2.79-4.30), >2 consultations 3.45(3.16-3.75), and ‘ED location B’ (2.21(1.99-2.46). In ‘red’ these were >2 consultations 2.62(2.10-3.27), headache 2.91(1.37-6.17) and fluid administration >500ml in the ED (1.75(1.34-2.29). 

Discussion

Our “proof of principle” study suggests that benchmarking of EDs with respect to ED-LOS should be done per disease severity category given the different independent determinants  found in triage categories and the different impact of ED location per triage category. Our study shows in which way the NEED can be used for benchmarking EDs with respect to ED-LOS. 

Background and Objectives: The majority of countries around the globe are disaster-prone and volunteers have proved a pervasive and comprehensive presence in various disasters. Nonetheless, a shortage of knowledge and awareness has always been detected among volunteers. The present study aimed at determining the instructional programs required by volunteers based on the studies carried out worldwide.

Methods: A systematic search was carried out in PubMed, Cochran Library, Scopus, EMBASE, Science Direct, Web of Science, and ProQuest databases between January 1970 and end of June 2019. The articles were selected based on the keywords chosen by the author. In the end, the instructional titles required for volunteers in disasters were extracted from the articles.

Results: After studying the titles, abstracts, and complete texts of the articles, eleven articles were chosen for final analysis following which 45 instructional titles were extracted. The most frequent scales in terms of repetition were ethics, kinds of exercises, personal protection instruments, general hygiene, awareness of certain disasters, accident command system, disaster triage, and emergency planning.

Conclusion: Considering the daily increasing growth in the number of volunteers in natural and manmade disasters, governments should offer programs that can best serve the improvement of their performance. Universities and schools play determinant roles in this regard. It is hoped that the present study findings can be effective in codifying an efficient instructional program for elevating the performance of the volunteers taking part in response to disasters.

Background and Objectives: Coagulation factor V (FV), that has both procoagulant and anticoagulant functions, plays a role in the blood coagulation cascade. FV deficiency is a rare coagulation disorder with an estimated incidence of 1 in 1,000,000. Affected patients become symptomatic in early childhood with spontaneous or post-traumatic bleeding complications. In these patients, it can be observed variable spectrum of bleeding manifestations ranging from mucosa and soft tissue bleeding (such as epistaxis and hemarthroses) to life-threatening hemorrhages. In this report, it was presented an infant with intracranial hemorrhage due to severe factor V deficiency.

Case report: A 8-month-old male admitted to the emergency department (ED) with pallor, fever, decreased feeding and lethargy for 2 days. He had also a seizure that lasted about within 5 minutes, 6 hours before the presentation. There was no history of previous illness or head trauma. There was no family history of bleeding diathesis. The mother had a normal pregnancy with full antenatal care. 1 mg of Vitamin K was given intramuscularly after the delivery. Upon arrival to the ED, he was irritable and had severe pallor. His body temperature, pulse, blood pressure and oxygen saturation were 38.2 oC, 170/min, 86/48 mm Hg and 99%, respectively. His pupils reacted normally to light and ocular movements were normal. No evidence of raised intracranial tension such as hypertension, bradycardia, hypoventilation or a full fontanelle. Laboratory assessment revealed the hemoglobin of 6.4 mg/dL, platelet count of 357000/mm3,  international normalized ratio (INR) 4.2, Prothrombin time (PT) 42, activated partial thromboplastin time (APTT) 98. Brain CT showed 5.5 x6 centimeter intracranial hemorrhage in left frontal area with right shift. While all the other factor levels were in the normal range, his Factor V levels were less than 1%confirming a diagnosis of severe FV deficiency. After rapid fresh frozen plasma and erythrocyte suspension were given, the patient was operated. After intensive care follow-up, he completely recovered.

Conclusion: Although FV deficiency is rare in childhood, that should be kept in mind in patients with unexplained bleeding and be treated quickly.

FOREWORD: Stroke is one of the main causes worldwide of mortality and residual disability (about 35% of stroke patients remain with severe impairment), representing the leading cause of disability in elderly people. Over the past 25 years, since 1990 to 2010, prevalence of stroke has gradually raised in a directly proportional way to increasing age. Although it is a time-dependent disease, its early detection can sometimes be insidious, leading to delays in assistance and therapy.

PURPOSE: According to different symptomatological spectrum at presentation, the purpose of this study is to analyze times needed for recognition (in terms of attribution of priority codes to medical examination and waiting time) and management of patients over 75 years affected by stroke evaluated in our Emergency Department. Methods: We conducted a prospective and monocentric observational study of all patients with acute stroke referred to the Department of Emergency and Acceptance of the IRCCS Polyclinic Foundation S. Matteo in Pavia  from May 1, 2017 to May 1, 2018.

RESULTS: We enrolled a total of 430 patients with more than 75 years who received diagnosis of stroke at our Emergency Department from May 1^st 2017 to May 1^st 2018. The average age was 83.8y and women were in slight majority (female 60%). At presentation, symptomatological spectrum was so divided: 56.7% (242 patients, pt) motor symptoms, 15.7% (67 pt) sensory symptoms, 46.8% (200 pt) speech disorder and 36.5% (156 pt) atypical symptoms (including dizziness, confusion and syncope). The four groups appeared to be superimposable by age, gender distribution, number of risk factors and hospitalization outcome. While the first three groups with typical symptoms accurately presented an high priority code for medical examination (about 90% had yellow code or higher), only 74% of patients belonging to the forth group (atypical symptoms) had a high priority code for medical examination. This resulted in different waiting times: average of 38 minutes (min) and median of 20 min for the first three categories, average of 55 min and median of 27 min for patients with atypical symptoms. This time delay in the fourth group was primarily dependent on recognition at door, while subsequent times (request for imaging, neurological consultation and process time) were normalized with respect to other three symptomatological categories after the medical examination. CONCLUSIONS: As our results demonstrated, patients presenting atypical symptoms of stroke were more difficult to recognize at door as neurological acuities, leading to increased waiting times. However, at medical examination these patients were rapidly recognized, thanks to multidisciplinary collaboration between Emergency Doctors, Neurologists and Interventional Radiologists, and there was no further delay in management and treatment times. Therefore, it’s important to pay attention in order to identify risk factors that could allow earlier recognition at triage especially in patients presenting atypical symptoms.

Background

At present, blood component therapy is considered the gold-standard treatment for haemorrhaging major trauma patients. In the military setting, soldiers are commonly transfused with whole-blood and studies involving this patient group have demonstrated the benefits of this method. Military procedures are often found to be effective within civilian major trauma patients and then implemented accordingly as shown recently with the CRASH-2 study.

Methods

Our study is a systematic review aimed to identify if the use of whole-blood should replace component therapy as common civilian major haemorrhage protocol.

A review of published literature was performed to identify studies or control trials which explored the use of whole-blood in military or civilian major trauma patients. Articles from the past 10 years (2010-2020), involving humans in the English Language were searched within PubMed and MEDLINE. Excluded were paediatric patients and singular case studies.

Results

306 articles were identified with 16 papers included for analysis. The papers were then placed into 4 different topic groups based on their focus: clinical outcomes and transfusion volumes (n=6): safety, feasibility and implementation (n=4); effects on coagulation (n=2); storage and processing (n=4).

11 papers produced results in favour of whole-blood use amongst trauma patients; improved survival (n=2; CI=0.02-0.53; 1.314-7.618), decreased transfusion volume after sensitivity analysis (n=1; p=0.02), shortened time to normalised lactate (n=1; p=0.05), reduced traumatic coagulopathy (n=1; CI=0.00-0.18), delayed benefit of whole blood use on coagulation (n=1), successful implementation of protocols (n=2), whole blood use is both feasible and safe (n=2), refrigeration of whole-blood attenuated decrease in aggregation and increase in prothrombin time (n=1; p ≤ 0.001).

5 papers produced results which opposed the use of whole-blood amongst trauma patients; no significant difference in clinical outcomes or transfusion volumes (n=2; p=0.24, p=0.33; p=0.52, p=0.72), minimal difference in coagulation effects between whole-blood and component therapy (n=1), filtration has a negative impact upon platelet aggregation (n=2), leukoreduction has a negative impact upon platelet aggregation (n=1).

Overall, the majority of papers showed potential benefits to the use of whole-blood in haemorrhaging major trauma patients.

Conclusions

There are potential benefits to implement a whole-blood centred protocol. However, further discussion must take place within the medical profession. This should include larger scale randomised control trials exploring the direct impact of lactate clearance in major trauma patients upon clinical outcomes and a cost comparison to ascertain the most economically viable protocol.

Background:   Renal colic is often very painful, but rarely dangerous.  For most patients, making the diagnosis of renal colic “rules out” other potentially dangerous diseases such as aortic aneurysm and appendicitis.  Non-contrast computed tomography (NCCT) has been touted as the best radiology test for renal colic, but has high cost and radiation exposure.  The abdominal x-ray (KUB) together with renal ultrasound have been proposed as an alternative to NCCT.  We sought to determine whether the KUB alone could reduce NCCT testing.

Methods: Study Design: Retrospective cohort.   Population: 1000 consecutive patients from 7-1-17 to 12-31-17 who received a NCCT at a suburban community teaching hospital with annual ED visits of 90,000.  Here, when a NCCT is ordered for suspected renal colic, a KUB is obtained automatically as per the hospital radiology “renal stone protocol.”  (NCCTs may also be done for other reasons.)  We randomly sorted 1000 records of NCCTs and arbitrarily chose the first 188; 74 had no KUB, leaving 114 for further analysis.  The KUBs and NCCTs were initially interpreted together by attending radiologists. One of the radiologists re-read the 114 KUBs without knowledge of the NCCT results and reported each KUB as being positive, negative or indeterminate for ureteral stones found on NCCT (the latter usually because of problems distinguishing stones from phleboliths).  We calculated sensitivities, specificities and likelihood ratios (LRs) and their 95% confidence intervals (CIs) for the diagnosis of urolithiasis for the KUB, using the NCCT as the criterion standard.

Results:  The median age was 52 years (interquartile range: 41, 61); 54% were female.  Fifty-one (45%) had a positive NCCT and 34 (30%) had a positive KUB.  Using the NCCT as the criterion standard, the number of true positives, true negatives, false negatives and false positives for the KUB were 34, 63, 17 and 0, respectively. The sensitivity and specificity of the KUB for urolithiasis were 67% (95% CI 52, 79%) and 100% (95% CI 93, 100%), respectively. The LRs associated with a negative and positive KUB were 0.33 (95% CI:  0.23, 0.49) and infinity (95% CI: 14, infinity), respectively.

Conclusion: The specificity and the positive LR for the KUB are high, so when the KUB is “positive” the diagnosis is almost certainly renal colic.  Since 30% of the patients had a positive KUB, using the KUB as the initial test could reduce NCCTs by 30%.

Background: Mild Traumatic Brain Injury (mTBI) is a common problem: each year in Canada, its incidence is estimated at 500-600 cases per 100 000. Between 10 and 56% of mTBI patients develop persistent post-concussion symptoms (PPCS) that can last for more than 90 days. It is therefore important for clinicians to identify patients who are at risk of developing PPCS. We hypothesized that blood biomarkers drawn upon patient arrival to the Emergency Department (ED) could help predict PPCS. The main objective of this project was to measure the association between four biomarkers and the incidence of PPCS 90 days post mTBI.

Methods: Study design and setting: This multicentre prospective cohort study took place in seven large Canadian Emergency Departments (ED) (five level I trauma centres, one level II trauma center and one academic non-trauma centre) between 30/04/2014 and 30/09/2018. Inclusion criteria: patients aged ≥14 who had a documented mTBI that occurred within 24 hours of ED visit, with a Glasgow Coma Scale score of 13-15. Exclusion criteria: Patients who were admitted following their ED visit or unable to consent. Procedures: Consecutive potential participants were identified by the treating emergency physicians. Informed consent was obtained, sociodemographic and clinical data as well as blood samples were collected in the ED. A research assistant then conducted phone follow-ups at 7, 30 and 90 days post-injury, in which they assessed symptom evolution using the validated Rivermead Post-concussion Symptoms Questionnaire (RPQ). The following biomarkers were analyzed using enzyme-linked immunosorbent assay (ELISA): S100B protein, Neuron Specific Enolase (NSE), cleaved-Tau (c-Tau) and Glial fibrillary acidic protein (GFAP). Primary outcome: The presence of persistent symptoms at 90 days after mTBI, as assessed using the RPQ. Statistical methods: A ROC curve was constructed for each biomarker.

Results: 1276 patients were included in the study. The median age for this cohort was 39 (Q1-Q3: 23-57) years old, 61% were male and 15% suffered PPCS. The median values (IQR) for patients with PPCS compared to those without were: 43 pg/mL (26-67) versus 42 pg/mL (24-70) for S100B protein, 50 pg/mL (50-223) versus 50 pg/mL (50-199) for NSE, 2929 pg/mL (1733-4744) versus 3180 pg/mL (1835-4761) for c-Tau and 1644 pg/mL (650-3215) versus 1894 pg/mL (700-3498) for GFAP. For each of these biomarkers, Areas Under the Curve (AUC) were 0.495, 0.495, 0.51 and 0.54, respectively.

Conclusion: Among mTBI patients, S100B protein, NSE, c-Tau or GFAP during the first 24 hours after trauma do not seem to be able to predict PPCS. Future research testing of other biomarkers is needed in order to determine their usefulness in predicting PPCS when combined with relevant clinical data.

Background: Acute cardiovascular disease (ACVD) represents the leading cause of mortality in our environment, and especially coronary heart disease. For every 30 minutes of delay in the management of acute myocardial infarction, the one-year mortality rate increases by 7.5%, so time is a determining factor to minimize morbidity and mortality.

The objective of this study is to compare the diagnostic accuracy of two prehospital biomarkers: lactate (pLA) and glucose (pGL) to predict early mortality (less than two-days) in patients with AVCD treated by emergency medical services.

Methods: Multicentric prospective observational longitudinal study, between June 22, 2018 and October 30, 2019. The study was developed on Castilla y León region (Spain). All adult patients with ACVD treated consecutively by the emergency medical services and transferred to the emergency department of their referral hospital were included in the study. Patients who did not require evacuation or discharged in situ, cases with terminal pathologies, pregnant women and cardiorespiratory arrest were excluded.

Demographic data (age and gender) and analytical determinations were obtained by the emergency registered nurse during the first emergency medical services contact with the patient. The FreeStyle Optium Neo device (Abbott Laboratories, Illinois, USA) was used to determine blood glucose values, with a measuring range of 20-500 mgr / dl. The Accutrend Plus device (Roche Diagnostics, Mannheim, Germany), with a measurement range of 0.8-21.7 mmol/L, was used to obtain the lactic acid values. All measuring devices were calibrated every 50 determinations, always by the same researcher, using the Accutrend® BM-Control-Lactate control solution (Roche Diagnostics, Mannheim, Germany).

At 2-days of the index event, by reviewing the patient's electronic history, hospital admission and 2-day mortality data were obtained. The main outcome variable was early hospital mortality (within the first 48 hours) from any cause.

The area under the curve (AUC) of the receiver operating characteristic (ROC) of the pLA and pGL was calculated in terms of 2-day mortality. Youden's test  was calculated for the cut-off point with better sensitivity and specificity combined for each biomarker.

Results: a total of 1296 patients with ACVD were included in our study. The median age was 67 years (IQR: 51-81 years), with 504 females (38.8%). The 2-day mortality was 3.85% (50 cases).

The AUROC of pLA was 0.934 (95% CI: 0.88-0.98; p> 0.001) and for pGL was 0.636 (95% CI: 0.55-0.72; p = 0.002). The cut-off point for the pLA was 4.1 mmol / L with a sensitivity of 0.96 (95% CI: 0.90-1) and a specificity of 0.83 (95% CI: 0.81-0.85)

and for the pGL of 171 mg / dl with a sensitivity of 0.46 (95% CI: 0.32-0.59) and a specificity of 0.79 (95% CI: 0.77-0.82).

Conclusions: Routine use of biomarkers can help stratify the risk of deterioration in patients with ACVD early. The performance of the pLA is excellent, far superior to that offered by the pGL. In view of the data, the determination of the pLA should be a routine procedure in all advanced life support units, providing very useful information about your close prognosis.

Left without being seen: a quality indicator in the emergency department

Rafael Kneuts, Inge Roggen, Ives Hubloue

Abstract

Background: Patients leaving the emergency department (ED) without being seen (LWBS) by a physician are a worldwide known phenomenon. These patients represent 0.36 to 15% of the total number of patients visiting the ED, depending on the region and the settings of the ED. We wanted to identify the prevalence and possible causes of this phenomenon in a large tertiary ED, with 75000 yearly visits.

Methods: A prospective study was conducted with patients of one large tertiary ED. Between 01/06/2018 and 30/11/2018, patients who had left the ED prematurely were contacted by phone, one week after their ED visit. A standardised questionnaire was used to conduct a phone survey. Additional information was acquired from the patient’s medical record. Statistical analysis was performed using MedCalc® version 18.11.3 (MedCalc Software bvba, Mariakerke, Belgium). All data are presented as mean ± standard deviation (SD) or as median (range), when not normally distributed. D'Agostino-Pearson K-squared test was used for assessing normality of data. Spearman’s rho test was used to calculate rank correlation coefficients.

Results: 598 out of 30127 patients (1.98%) left the ED prematurely, of which 509 (85.1%) were contacted by phone and 259 (43.4%) agreed to participate. LWBS patients were significantly younger, and the degree of emergency was significantly lower compared to the general population.

The top 3 of the main reasons why people left the ED prematurely were the waiting time (74.9%), 13.1% suddenly felt better and 13.1% needed to be elsewhere. Of the LWBS patients, 40.1% are admitted between 6 pm and midnight, while only 31.7% of total ED visits take place in that timeframe.

Conclusion: In our ED, patients who LWBS are young adults with less severe diseases as reported in literature. The waiting times are the main reason why patients leave the ED prematurely. Strategies to reduce waiting times or to inform these patients about waiting times could be implemented to reduce LWBS.

Opioid analgesics have been the analgesics of choice for the last decades in most emergency conditions, but these potent analgesics are not without negative side effects, particularly in uncontrolled scenarios, such as hypotension and hypoventilation. Currently approved as anesthetic agent, ketamine is finding new use as an off-label analgesic showing promise for severe pain control in the ED. Many studies of subanesthetic administration termed as low-dose ketamine (LDK) suggest that it provides analgesia with eventually minor adverse effects when administered in single bolus or as an adjunct to opioids. We suppose that Ketamine infusion is an alternative option which can provide the same analgesic efficacy with less adverse effects.

The aim of the trial study is to study the analgesic efficacy and side effects of intravenous infusion of two doses of ketamine versus IV bolus in the emergency settings. We performed randomized, prospective, double-blinded trial at the emergency department of Farhat Hached university Hospital in Sousse, Tunisia. A sample of patients aged 18 to 65 years with moderate to severe acute pain, were enrolled. Subjects were consented and randomized to three groups; 0.3mg/kg of ketamine through an IV push; 0.3mg/kg of ketamine over 5 minutes and 0.6mg/kg over 10 minutes. Our primary outcome was the maximum change in Numeric Rating Scale (NRS) scores and secondary outcomes were patients’ satisfaction, the use of rescue analgesia (morphine) and the side effects of LDK.

59 patients were enrolled with similar demographic characteristics. The group receiving 0.3mg/kg of ketamine through an IV push appeared significantly more efficient from T45 until the end of the study. The 0.3mg/kg IV push Group patients showed a higher PRS than the other groups from 30 minutes after the beginning of the protocol until the end of the study. The use of rescue analgesia was significantly lower in the group receiving 0.3mg/kg of ketamine through an IV push compared with the other two groups. No major side effects were observed during the study. Psychomimetic events were more frequently observed in the group receiving 0.6mg/kg of ketamine over 10 minutes.

Ketamine has been effective in the management of moderate to severe acute pain, but the 0.3mg/kg IV push group has been associated with a larger decrease in NRS, a longer maintenance of analgesic effect and a less common reliance on rescue analgesia. We recommend to conduct further studies with larger samples to evaluate the efficacy and safety of the use of 0.3mg/kg of ketamine through an IV push associated or not with the same drug infusion in order to deal with moderate to severe acute pain.

Background: Chest imaging is a key tool for the management of COVID-19 patients in the emergency department (ED). A correlation between chest CT features and COVID-19 severity has been demonstrated, suggesting a potential use as a triage tool. However, systematic chest CT in COVID-19 patients may overwhelm available resources during an outbreak, and is costly and associated with a high risk of nosocomial infections. Point-of-care lung ultrasound (LUS), already widely used in EDs, can be performed at the bedside of patients requiring protective isolation. However, data on its use for early risk stratification of COVID-19 ED patients is lacking. This study describes and compares early LUS characteristics across of range of clinical outcomes.

Methods: Prospective observational study of consecutive PCR-confirmed COVID-19 patients in the ED of Lausanne University Hospital. LUS images were recorded within 24hours of ED presentation using a standardized protocol, according to the “10-zone method”, with five zones per hemithorax (anterior-superior, anterior-inferior, lateral, posterior-superior, posterior-inferior). For every zone, the following patterns were reported and graded with a 0 to 3 points score: (1) normal appearance (A lines, < 3 B lines) = 0 points, (2) pathological B lines (≥3 B lines) = 1 point, (3) confluent B lines = 2 points, (4) thickening of the pleura with pleural line irregularities (subpleural consolidation < 1 cm) or (5) consolidation (≥ 1 cm) = 3 points. Each patient’s normalised score (nLUS score) was the sum of the graded points at every zone (possible range from 0 to 30 points) divided by the number of examined zones. Two experts, blinded to patients' outcome, retrospectively reviewed all images. LUS images were described and compared between patient groups based on their outcome on day 7 after inclusion, defined as: 1) self-resolving outpatients, 2) hospitalised, and 3) intubated/death. nLUS score was used to discriminate between groups.

Results: Between March 6 and April 3 2020, 80 patients were included (18 outpatients, 41 hospitalized and 21 intubated/dead); 73 patients (91%) had abnormal LUS (72% outpatients, 95% hospitalised and 100% intubated/death; p=0.004). The proportion of involved zones was lower in outpatients compared with other groups (median 30% [IQR 0-40%], 44% [33-70%] and 70% [50-88%], p<0.001). Predominant abnormal patterns were bilateral and multifocal thickening of the pleura with pleural line irregularities (70%), confluent B lines (60%), and pathological B lines (50%), affecting more often the posteroinferior zones. Median nLUS score was 0.45 (IQR 0.2, 0.8), 1.1 (IQR 0.62, 1.7) and 1.5 (IQR 1, 2) (P<0.001), with an area under the ROC curve of 0.81 (95% CI 0.70-0.92) between outpatients and the two others categories.

Conclusion: Our study shows that, in COVID-19 patients presenting at EDs, LUS using standardized procedures for acquisition and reporting, correlated to disease severity. A simple ordinal scoring system has the potential to discriminate patients requiring hospitalisation and thus better allocate scarce resources. LUS is a reliable, cheap and easy-to-use triage tool to decide on hospital admission. Although promising, the use of LUS for early risk stratification requires further studies with a larger sample size

Background: On January 30, 2020, the World Health Organization designated an outbreak of a Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2). In most symptomatic patients, Coronavirus Disease 2019 (COVID-19) comprehend interstitial pneumonia that can be rapidly and early detected by bedside point-of-care ultrasound (POCUS).

Objective: Aim of the study was to check the performance of bedside lung ultrasound in the ED diagnosis of COVID-19 during the SARS-CoV-2 outbreak period.

Methods: We enrolled consecutive patients with ILI admitted to the Santa Maria Nuova ED in Florence from march 12th to April 12th 2020. ILI was defined as the presence of at least one symptom among fever, cough or dyspnea.  These patients were identified at a pre-triage area outside the hospital and managed separately from other patients according to infection control local protocols. All patients were tested for SARS-CoV-2 with nasal-pharyngeal swabs. According to the WHO guidance, COVID-19 diagnosis was defined as a positive result of real-time reverse transcriptase–polymerase chain reaction assay for SARS-Cov-2.For each patient we collected physical end anamnestic features, laboratory and diagnostic test results and outcome. For each patient we performed a point-of-care (POCUS) lung ultrasound. Based on the lung POCUS findings, we identified 5 ecographic patterns: A pattern (A-lines prevalence, normal B lines), cardiogenic B pattern (uniform, cranio-caudal progressing B pattern, possibly with pleural effusion), typical flogistic B or C pattern (single basal consolidation or focal B pattern), atypical flogistic pattern (apical or bilateral single consolidation and/or less than 3 focal B lines), C pattern (multiple consolidations), ARDS pattern (multifocal B pattern and multiple consolidations). C and ARDS pattern and according to sonographer opinion some atypical flogistic pattern (integrated point-of-care cardiac and inferior vena cava evaluation) were considered as possible COVID-19. We recorded the final diagnosis according to SARS-CoV-2 infection at hospital dismission or at 14-days follow-up.

Results: We enrolled 269 patients with COVID-like symptomps, mean age 66±20 years, 50,6% male gender. SARS-CoV-2 was found in 136 (50,6%) patients. Fifty (18,6%) more patients that never showed positive to naso-pharingeal swab are still under investigation. COVID-19 patients were male in 53,3%, mean age was 70±16 years. Among COVID-19 patients 67 (31,6%) needed oxygen supply, 24 (11,3%) required non-invasive ventilation and 12 (5,9%) needed Intensive Care Unit (ICU) admission. In-hospital mortality was 7,4% in COVID patients vs 4,7% in NO-COVID. Seven (3,4%) patients died at 14-days follow-up after hospital dismission. Most COVID-19 patients (63%, n=78) showed a C or ARDS pattern and 21 (10.3%) atypical flogistic pattern, while 14 (6,9%) showed a normal A pattern. POCUS showed 87% sensibility and 80% positive predictive value. Among 7 COVID-19 patients with negative nasal-pharingeal swab in ED, POCUS showed a COVID-suggestive pattern in 6 (86%).

Conclusions: In our experience POCUS is an useful tool for early COVID-19 diagnosis in ED. Lung ultrasound can help identifying potential false-negative SARS-CoV-2 testing and avoiding inappropriate patients managing, especially to prevent in-hospital infection spread

Background

Early insight in which emergency department (ED) patients need hospitalization could contribute to reduction of ED lengths of stay and thereby ED overcrowding with all its negative consequences. 

Aim

We aimed to develop prognostic models for prediction of hospitalization of ED patients with machine learning and conventional regression techniques.

Methods

Observational multi-centre cohort study using the Netherlands Emergency department Evaluation Database (NEED) in which all consecutive ED-patients of three hospitals were included. We assessed whether machine learning techniques were better than conventional multivariable logistic regression analysis by comparison of the discriminative performance (Area Under the Curve (AUC)) of the prediction models. Three machine learning models were developed: random forest (RF), deep neural net (DNN) and gradient boosted decision tree (GBDT). Demographics, time of day, presenting complaints, disease severity (triage category, arrival mode, referral status, vital signs, blood tests), administration of ECG and other scans, treating specialty and ED location were used as covariates in the modelling. 

Results 

We included 139,557 ED patients of whom 56,630 (41%) were hospitalized.We split the data in a train and test set (2/3 train, 1/3 test). The AUC of the conventional multivariable logistic regression model was 0.833 (95%-CI: 0.828-0.837), slightly higher than that of the RF 0.828 (0.823-0.833). The remaining machine learning models had the highest AUC: GBDT 0.843 (0.838-0.847) and DNN 0.861 (0.858-0.864) respectively.

Conclusion 

In our sample of ED patients, the DNN performed best compared with the conventional logistic regression and tree-based machine learning methods. However, differences between models were relatively small. Future studies should point out whether larger sample sizes will improve the discriminative performance of the machine learning techniques and which model could best be implemented in clinical practice.

Introduction

In young girls horse-riding is one of the most common sports injuries. It is considered as one of the most dangerous sports with the severity of injuries comparable to motoring incidents. Since 2010 there have been 3,700 horse related incidents and 43 deaths in the UK on roads alone. A thorough and focussed history is likely to identify and help eliminate factors which contribute to an injury occurring and its severity, like wearing protective gear. A Haddon matrix, four by three grid, provides a structured approach to gather relevant information. The three rows represent different phases of an injury (pre-event, event, and post-event), and the four columns represent different influencing factors (host, agent/vehicle, physical environment, social environment).

Method

We populated a Haddon matrix for horse related injuries in children with possible avoidable/protective factors that are essential to explore when history-taking. 29 cases of horse-related injury with an ISS (injury severity score) of greater than 4 attending a regional trauma centre were extracted from the national TARN (trauma audit & research network) database, covering the last 15 years. Electronic patient records date back 5 years so 10/29 cases were included. The Haddon matrix was applied to these 10 cases and assessed for the quality of information documented.

Results

These 10 children were aged between 3 and 15 years, 80% were female, 60% were transferred from another hospital and one later had a further horse-related admission. Only 4/10 cases documented whether protective equipment was worn. Of these four cases 3/4 children were said to be wearing helmets and 2/4 wearing body protection. Most of the injuries were sustained by a child falling off whilst horse-riding. However, 3/10 cases involved children being kicked by a horse, none of these 3 cases mention any protective equipment whilst around the animal or the level of supervision they were receiving despite their age being less than 6 years. Only 1/10 cases filled 50% of the matrix or more (6+/12 boxes). 5/10 children expressed interest in continuing to work with horses after their injury.

Conclusion and recommendation

Identification of injuries related to equestrian activities was limited to the most severe cases as only these are captured by TARN. Even in those cases, the history documented in the patients’ records often omitted important information which may help to identify injury modifying factors. Therefore, questions relating to the environment, supervision, training and use of protective gear of children while around horses needs to be investigated better when children come into hospitals with horse-related injuries. These findings could inform changes to improve the safety of these and other children around horses in future. We propose use of the Haddon matrix as a structured tool for data collection and identification of injury modifying factors, similar to current guidance and advice in relation to children presenting with safeguarding concerns. Children presenting even with minor trauma related to equestrian activity are likely to benefit from this intervention. Further research as to the impact of intervention when attending the emergency department is required.

Background:

Coronary Artery Disease (CAD) is one of the major causes of death. Evidence suggests that some preventive measures by patients in emergency phase can reduce the rate and risk of mortality. Thus, understanding the signs and risk factors of CAD from the patients’ perspective and their ways of dealing with this disease is of vital importance.

Objectives: This qualitative study aimed to explore the Iranian patients’ experiences about CAD and how they manage it in their first encounter.

Patients and Methods: This study was a grounded theory study conducted on 18 patients with CAD. The data were collected through semi-structured interviews. Initially, purposeful sampling was performed followed by maximum variety. Sampling continued until data saturation. Then, all the interviews were recorded and transcribed verbatim. After all, the data were analyzed by constant comparative analysis using MAXQUDA2010 software.

Results:

The themes manifested in this phase of disease included 1- "Invasion of Disease"  with subthemes of "warning signs" and "risk factors", 2- "Patients’ Primary Challenges" with subthemes of "doubting primary diagnosis and treatment", and feeling of being different from others", 3- "Psychological Issues" with subthemes of "mental preoccupation", "fear of death and surgical intervention", "stress due to recurrence",  and "anxiety and depression", 4- "Management Strategies" with subthemes of "seeking for information", "follow-up' , and "control measures".

Conclusions: Based on the results, physicians and nurses should focus on empowerment of patients by facilitating this process as well as by educating them with regards to dealing with CAD. Further, it is also essential for the mass media to educate the public on how to treat patients with CAD.

Introduction:

Recent events with public usage of chemical warfare agents have highlighted the importance of chemical disaster preparedness, to which resource estimation is paramount. Mathematical modeling systems for casualty estimation already exist for military purposes, as reported in the AMedP-7.5 and AMedP-8C publications. This methodology can be applied to the general population for victim estimation in a civilian chemical mass casualty incident. Sarin gas was used as an exemplary agent due to the large amount of available evidence for clinical course and treatment, based on human and animal exposures. 

Methods:

The AMedP-7.5 mathematical model and AMedP-8 victim profile for casualty distribution calculation were adapted for the general population using the methodology described originally by Crosier & Sommerville. Using the parameters obtained, severity estimations were assigned using the NATO Triage system which is divided in 3 main categories: T3 (= green) representing the least severe category, T2 (orange) representing moderatly injured victims and T1 (= red) representing severely injured victims. Triage was assumed to take place in between 30 and 90 minutes after exposure, using signs and symptoms expected during this period. Untreated victims with lethal injuries are presumed to have died in this period.

Victims triaged as T1 are severely injured and require airway management and antidote treatment, while T2 victims are able to support their own breathing. T3 victims mainly have ocular symptoms and slightly to no respiratory compromise. Three exposure levels were selected for further analysis, representing mild, moderate and severe exposures, adapted from AMedP-7.5. These exposure levels assume a normal sized, healthy adult of 70kg.

Results:

Calculated exposure values were 0.81, 16.9 and 22.3 mg.min.m^-3 for mild, moderate and severe exposures respectively. Mild exposures will result in 18.1% unaffected individuals and 81.9% T3 victims, having no T2 or T1 victims. Moderate exposures will result in 0.3% T3 victims, 84.2% T2 victims, 8.5% T1 victims and 7.0% deaths on site. Severe exposures will result in no T3 victims, 59.1 T2 victims, 16.4% T1 victims and 24.4% deaths on site.

Discussion:

Hospital capacity estimation is usually based on an assumed relationship between T1, T2 and T3 victims, based on earlier experiences in traumatic mass casualty incidents. A commonly cited distribution in Belgium is 1-2-4, meaning 4 T3s and 2 T2s for every T1 victim. This mathematical modeling exercise casts doubts on the applicability of these rules-of-thumb and suggest the need for flexibility.

While in this exercise Sarin was used as the principal chemical agent, other agents can be modeled by adapting the parameters. This approach uses a one-size-fits-all approach and assumes equal effects of the same exposure throughout the population. Caution should be used when extrapolating these results to selected populations such as children or elderly, as they are assumed to be more severely affected.

Conclusion:

Victim severity distribution during chemical incidents can vary from a large percentage of mildly intoxicated victims, to a high number of victims requiring intensive treatment, depending on their intoxication level. Hospitals should prepare for both extremes in their hospital disaster plan.

Mental health patients represent an increasing proportion of presentations to our large city based emergency department (ED). This audit follows a sequence of audits that have been produced in our department assessing quality of physical care in mental health patients. Since our most recent audit, we have relocated to a newly re-structured ED. We aim to review the quality of care following this change.

We have focused on the adherence to the current pathway for medical clearance of mental health patientsprior to referral to the mental health team. This is currently a two- stage pathway. In the first stage, all patients are assessed regarding suitability for direct referral to the mental health team. If unsuitable, patients undergo a second stage of assessment in which they undergo full medical assessment by an ED clinician.

Based on previous audits, our aim isthat 100% of patients presenting with mental health problems to ED should be assessed using the Mental Health Integrated Care Pathway (MHICP) proforma, have full clinical observations (respiratory rate, oxygen saturations, pulse rate, blood pressure, temperature, GCS and pupil size), a urine dip, blood sugar level and a documented Mental State Examination (MSE). For those deemed unsuitable for the direct pathway, a further medical assessment is necessary and 100% of these patients should be seen by an ED clinician, have a documented full clinical history and a full physical examination. 

The Symphony audit tool was used to identify patients who presented to the ED at St Thomas’ Hospital with mental health complaints in between September-November 2019. A total of 1748 patients were identified. Patients were randomized and then data was collected from the first 20 appropriate consecutive patients from each week. A total of 123 patients were excluded due to incorrect coding.

Preliminary results reflect inadequacies in assessments prior to medical clearance. Only 40% of patients had the MHICP proforma completed. This is a reduction from 48% in 2017. No patients had a full set of observations. Only 6% of patients had their pupil check documented whereas compliance with performing the other observations was 80-90%. We will continue to review this data to assess overall quality of care in both the direct and indirect pathways used prior to medical clearance.

In order to address these already evident short fallings we will intervene with a 3-pronged approach. Firstly, we aim to organize targeted teaching sessions for senior staff such as nurses in charge. Secondly, we will influence decision makers such as high level trainee doctors. Finally, we will amend the MHICP proforma to prompt the documentation of assessments currently lacking, for example pupil check. We will then re-audit to assess the impact of our interventions.

Introduction:

In this century, we have reached a progress in life expectancy, but it comes with an increase of elderly patients with several diseases, including head trauma. Despite the high prevalence of elderly, a few trials were interested in assessing the relevance of acts and congestion of emergencies departments (ED).

Goal: To study the epidemiological features of minor head injury and the pertinence of head computed tomography (CT) in elderly admitted in the ED.

Methods:

A retrospective observational study was conducted over four years. Inclusion of patients (age ≥ 65) admitted to ED for minor head trauma undergoing Computed tomography. The diagnosis of minor head injury was based on Glasgow Coma Scale (CGS).  The demographics, co-morbidities, clinical and biological data and in-hospital procedures were collected.

Results:
of 467 minor head trauma patients, 67 are aged over 65 years. Mean age 76± 8 years with sex-ratio of 1.48. Twenty-eight patients (42%) had a positive head CT: three (11 %) patients had an urgent neurosurgical indication and 25 patients (89 %) were send home.

The comparative study of positive head CT group versus negative head CT group N (%) (p value) has found :  male gender 18 (64) vs  21(54)  (NS), antiplatelet therapy 7(25) vs  3 (8) (0.04) , anticoagulant therapy 4 (14) vs 5(13)  (NS), initial loss of consciousness  22(79) vs  6(15)  (0.04), sub clavicular trauma 9(32) vs  14 (36)  (NS).

Conclusion:

It seems that the antiplatelet therapy and initial loss of consciousness are frequently associated with positive head CT in elderly patients.

Background: Need for recovery (NFR) describes an individuals’ need to physically and psychologically recuperate following a period of work and can be measured using the validated 11-item NFR scale. Increased NFR has been reported to be associated with the development of occupational health complaints with effects likely to be cumulative over time. Currently experiencing a workforce challenge, strategies to determine and reduce NFR amongst Emergency Physicians may conceivably reduce rates of burnout, improve wellbeing and aid retention. The objective of this study was to determine the NFR among Emergency Physicians in the United Kingdom and Ireland and to identify characteristics associated with higher NFR scores.

Methods: This study adopted a cross-sectional electronic survey design targeting a representative sample for six weeks from the 3^rd June 2019. All Emergency Physicians employed within 112 participating Emergency Department (ED) in the UK and Ireland were eligible. The survey was developed following a single centre feasibility study, a patient and public involvement consultation and adhered to the Checklist for Reporting Results of Internet E-surveys. The final participant survey included the NFR scale plus 44 additional items exploring demographic, occupational and self-perceived wellbeing characteristics. The number of positive responses to NFR items were summated into the NFR score, from 0, indicating lowest attainable NFR, to a maximum of 100. An additional single site survey gathered data on department-specific and workforce characteristics. 

The primary outcome was the NFR score. Descriptive statistics are presented along with findings of a multiple regression analysis to determine associations between NFR and relevant characteristics.

Results: The median NFR score for all 4247 eligible consented participants with a valid NFR score was 70.0 (95% CI: 65.5 to 74.5), with an IQR of 45.5 – 90.0. A linear regression model found significant associations between NFR score and the participant characteristics: clinical grade; gender; patient type and long-term health conditions or disabilities. After adjusting for these characteristics, the NFR score increased by 3.7 (95% CI: 0.3 to 7.1) and 6.43 (95% CI: 2.0 to 10.8) for those with difficulty obtaining requested study and annual leave, respectively. Increased percentage of out of hours (OOH) work increased NFR score linearly: 26-50% OOH = 5.7 (95% CI: 3.1 to 8.4); 51-75% OOH = 10.3 (95% CI: 7.6 to 13.0); 76-100% OOH = 14.5 (95% CI: 11.0 to 17.9).

Discussion and Conclusion: Higher NFR scores were observed among Emergency Physicians than reported in any other profession or population to date. Four non-modifiable demographic factors were noted to decrease NFR; clinical seniority at consultant level, male gender, absence of long-term health condition or disability and working in a paediatric only ED. Three modifiable occupational characteristics were identified associated with increasing NFR score; poor access to study and annual leave and proportion of out of hours work. These factors correlate with previous work and support the hypothesis that broader perceptions of job autonomy and control may be explicitly linked to wellbeing in healthcare. Future strategies to reduce fatigue and improve physician wellbeing and staff retention should target these modifiable characteristics.

Background

TBI is the leading cause of death and disability in children and adults ages 1 to 44. Each year about 2.5 million individuals suffer from this injury , of which 50,000 results in death. More than 80,000 of these will suffer permanent disability and undoutedly will lead to an increase in the financial burden on health systems. 

Every year Scottish hospitals on their own will see on average 150-300/100,000 per year of patients who sustained traumatic brain injuries . Out of those, third of patients will require Rapid Sequence Induction(RSI), and 65/100,000 will unfortunately die in the first year.

All these patients will be admitted through ED and given the severity and long-term consequences of brain injuries, ensuring consistent and high level of neuroprotection, is of vast importance.

Methods/Design

At the start, we performed a retrospective assessment of intubated TBIs presented to ED QEUH January 2018 -December 2018, using STAG data. Results were synthesized with a survey of clinical team who has experience in managing of intubated TBIs.

Then, an aide memoir incorporating a data capture sheet was created by the researcher after presenting the aforementioned clinical evidence, and was used after the staff group had been given refresher training in TBI management and had the document explained to them. The sheet had main 6 metrics and space to record additional information.

Prospective phase of QIP was based on Pan DO Study Act (PDSA)cycles with 6 weeks reviews, synchronized with post implementation survey of medical and nursing staff on the shopping floor.

A total of 20 patients were intubated and ventilated in ED secondary to isolated TBI from January 2018 till end of December 2018, with only 3 metrics been achieved on average.  The improvement in the performance of the team during the prospective phase of the study demonstrated that capture sheets increased compliance criteria up to 5 metrics reading.

Results/Summary

The existing method of treating TBI’s was underperforming consistently with no intervention to assist in correcting or improving the process.

We identified a need and successfully developed Neuroprotection Bundle for intubated TBIs. This enabled the user to follow a structured approach to care delivery without missing any stages of care.

Background: Recent reviews have discussed pathophysiological changes in the central nervous system after exposure to high altitude, but none have systematically discussed the clinical significance of an increased optic nerve sheath diameter (ONSD), and it remains unclear whether ONSD changes are correlated with altitude or whether acute mountain sickness (AMS) directly affects the ONSD. Therefore, we performed a systematic review and meta-regression analyses to assess ONSD changes in high altitude in subjects with and without AMS.

Methods: Cochrane Library, EMBASE, Google Scholar, and PubMed were searched for articles published until October 18^th, 2019. The definitions applied were high altitude: > 2500 m; AMS: Lake Louise Score (LLS) ≧ 3 with headache or AMS-C score ≧ 0.7. Outcome measures were comparison of the means of ONSD between sea level and high altitude, and between subjects with or without AMS. Meta-regressions of ONSD change were conducted for correlation with altitude and time spent at that altitude. Restricted cubic spline regression was used to evaluate non-linear trends. PROSPERO registration number is CRD42018110917.

Results: Seven studies with 228 participants comparing ONSD from sea level to high altitude, and five studies with 463 participants comparing subjects with or without AMS, were included. ONSD was found to increase by 0.15 mm per 1000 m after adjustment for time (95% Confidence Interval: 0.11 to 0.18; p < 0.01). Restricted cubic spline regression revealed an almost linear association between ONSD change and time within 2 days. ONSD was larger in subjects with AMS (mean difference = 0.47; 95% CI: 0.14 to 0.81; p = 0.01).

Discussion & Conclusions: Our analyses show ONSD changes are correlated with altitude. The currently available data suggest that although ONSD change may tend towards increase in subjects with AMS, but there are not enough data to show the statistically significant effect. Small study numbers indicated substantial bias and warrant more studies.

Background:Pain is the most common symptom in the emergency setting however acute pain management in children is often sub-optimal in the pre-hospital and emergency environment. There is a paucity in the research on parental administration of analgesia to children prior to arrival at the emergency department with the majority of the literature focusing on pain management by emergency medical services. Acute paediatic pain management has not commanded the same level of research compared to the adult population and recent studies have highlighted the need for high-level evidence and further research. The aim of this study was to describe the prevalence of pre-hospital analgesic administration by parents/guardians of children.

Methods:A prospective cross-sectional study was conducted between May 2019 and September 2019 in the EDs of Cork University Hosptial (CUH) and Mercy University Hospital (MUH). Systemic sampling was used to recruit a defined proportion of consecutively approached parents of children who met the inclusion criteria. The inclusion criteria was children between the ages of 6 months - 16 years, who were self-referred to the ED with an acutely painful condition. They were approached following ED triage and asked to complete an anonymous questionnaire using an electronic table provided by the research team. Data was collected on patient demographics (age/gender), cause of pain (i.e. injury/illness), pain score on ED arrival, analgesia adeministration prior to ED arrival, type and dose of analgesia administered, reasons why analgesia was not administered. Data was then exported to Microsoft Excel and analysed using SPSS software.

Results:Overall 400 parents/guardians completed this questionnaire. 189/400 (47%) of children received analgesia from their parents/guardians prior to arrival at the ED. Factors which were independently associated with increased parental administration of pain relief were having a pain score ≥5 (53.4% vs 29%, p<0.001), children with siblings (49.7% vs 35.3%,  p=0.03) and presenting No correlation was seen between administration of pain relief and age (p=0.804), gender (p=0.114), cause of pain (p=0.079) or site of pain (p=0.098). Analgesics administered included Calpol® (44%), Nurofen® (30 %), Paracetamol (14%), Ibuprofen (8 %). Overall, 211/400 (53%) children received no analgesia before attending ED. Reasons for parents not administering pain relief included: 30% (62/211) of parents did not think the child needed it, 19% (39/211) did not give pain relief because the accident did not happen at home, 16% (34/211) did not want to mask the presence of the pain, 9% (20/211) believed the hospital should give the medications, and  9% (18/211) were afraid it would be wrong/harmful.

Conclusions:This study has demonstrated that over 50% of children presenting to the ED, with acutely painful conditions, did not receive adequate or timely pain relief pre-ED arrival, causing avoidable suffering. Children were more likely to receive pain relief from parents/guardians if they: have siblings, had a pain score >5, present to ED <48 hours after the onset of pain. Parental misconceptions surrounding pain management are a major barrier to them administering pain relief. Further education is required to dispel these myths surrounding analgesia and improve the care to this population.

Background

Current cardiopulmonary resuscitation (CPR) guidelines lack statements of appropriate mechanical ventilation if automated mechanical chest compression devices (AMCCDs) are used. Aim of this pilot study was to compare three common ventilation modes during CPR with AMCCD.

Methods

This randomised prospective pilot study was conducted at the Technical University Munich between 01.11.2017 and 12.12.2019. Patients suffering from an ongoing out-of-hospital cardiac arrest treated with an AMCCD and an endotracheal tube in place were included in the resuscitation room as long as the attending expected to continue with the resuscitation for another 15 minutes. Randomization assigned to the three groups “biphasic positive airway pressure with assisted spontaneous breathing” (BIPAP-ASB), “continuous positive airway pressure” (CPAP) and “volume-controlled ventilation” (VCV) using an Oxylog3000® (Drägerwerk AG & Co. KGaA, Lübeck, Germany). For safety reasons the treating team was allowed to change ventilation whenever clinically necessary. The primary outcome was the mean tidal volume (VT) during the study period. Secondary outcomes were mean minute volume (MV) and mean end-tidal CO₂ (etCO₂). Statistical analysis was done using R version 3.6.2. with Kruskal-Wallis-test and Mann-Whitney-U-test for post-hoc analysis.

Results

We screened 53 patients of whom 30 patients were randomized, analyzing ten patients in each group. Patients were mainly male (80%), with a mean age of 65±16 years. Since two patients never received the assigned ventilation mode intention-to-treat (ITT) and per-protocol (PP) analysis were performed. In the ITT analysis there was a significant difference in VT with median 242 [IQR 137-435] ml, 68 [64-106] ml and 200 [158-278] ml in the BIPAP-ASB, CPAP and VCV group, respectively (p = 0.010 ITT and p=0.001 PP). Post-hoc analysis showed a significant difference of CPAP compared to BIPAP-ASB  and VCV (all p<0.05 in ITT and PP). There was no significant difference in the secondary outcome parameters MV 7.0 [5.2-9.6] l/min, 6.3 [5.3-6.8] l/min, 7.3 [3.6-7.9] l/min and etCO₂ 25.6 [20.12-33.5] mmHg, 17.6 [10.2-26.1] mmHg, 31.8 [23.4-38.3] mmHg in above order in ITT. The results in PP showed differences in etCO₂ (p=0.047) and PEEP (p=0.017).

Discussion & Conclusion

This pilot study showed a significant lower tidal volume with CPAP compared to BIPAP-ASB or VCV during CPR with AMCCD.

We showed previously in a case series that CPAP seem to result in adequate ventilation in CPR with AMCCD. Bertrand et al. suggested using a constant flow insufflation of oxygen during AMCCD resuscitation is reasonable. This study confirms that an adequate respiratory minute volume can be achieved even with CPAP, however, with very small tidal volumes. Such low tidal volume could possibly result in dead space ventilation with the risk of inadequate oxygenation. Evidence of sufficient peripheral oxygenation by CPAP exists only from an animal study by Hevesi et. al. of 18 pigs.

In conclusion, all ventilation modes achieved an adequate MV, however, BIPAP-ASB and VCV seem to be superior in CPR with AMCCD to achieve an adequate VT. Therefore we would recommend using those ventilation modes primarily at the moment.

Introduction: Pneumonia is one of the most common serious infections in pediatric population worldwide. Scoring systems have been adopted to quantify the severity of the disease but they were based on clinical findings that could vary according to subjective assessment of clinician. Diaphragm ultrasound (DUS) has been used to evaluate diaphragmatic fatigue after cardiac surgery or to predict extubation success from mechanic ventilator in adult and pediatric intensive care units recently. However, there is no study providing information on the evaluation of DUS in children with diagnosis of pneumonia. We hypothesized that DUS parameters could be useful to objectively score the severity of the disease and predict outcomes in previously healthy children with pneumonia in the emergency department.

Methods: Previously healthy children diagnosed with pneumonia using the methodology previously described by lung ultrasound, aged between 1 month and 18 years were prospectively evaluated in the pediatric emergency department. The Pediatric Respiratory Severity Score (PRESS) was used to indicate the severity of the disease and when the patient looked calm, DUS was performed with a linear transducer. Subjects were imaged in supine position. If the infiltration was unilateral, the pathological side was evaluated, if bilateral lung sides were affected, then the mean of right and left side measurements were calculated. Diaphragm thickness at the end of inspiration (TEI) and expiration (TEE), diaphragm excursion (EXC), inspiratory slope (IS), expiratory slope (ES) and total duration time of the respiratory cycle (TRC) were calculated. The thickening fraction (TF) was calculated as follows: (TEI-TEE)/TEE and recorded as a percentage.

Results: There were 96 patients enrolled in the study. Inspiratory slope and ES measurements had  a significant positive correlation between respiratory rate and length of stay in hospital and a negative correlation between oxygen saturation (SpO2) levels evaluated at the time of admission. Also, TF values were negatively correlated with respiratory rate and length of stay in the emergency department. Patients with higher clinical scores had increased IS, ES and decreased TF values. Receiver operating characteristic curve (ROC) analysis was performed and the value of the area under the curve (AUC) for IS in PRESS grade 4 and 5 was 0.805 (95% confidence interval (CI): 0.670-0.910). At a cut-off level of 0.277 cm/s, the sensitivity and specificity of IS values for PRESS grade 4 and 5 were 87.5% and 51.9%. For ES, the value of the AUC in PRESS grade 4 and 5 was 0.761 (95% CI: 0.650-0.890). At a cut-off level of 0.248 cm/s, the sensitivity and specificity were 87.5% and 58.2%, Patients who required respiratory support had higher IS and ES measurements.

Discussion&Conclusion: Point of care diaphragm ultrasound can be a new promising and useful tool to assess diaphragmatic dysfunction and help the pediatric emergency physician to rapidly make decision about patients diagnosed with pneumonia. Diaphragm parameters, especially TF, IS and ES may provide objective and reliable information to predict the severity of the illness, need for respiratory support and outcomes.

Background: Mild traumatic brain injury (mTBI) is a serious public health issue and as much as one third of mTBI patients could be affected by persistent post-concussion symptoms (PPCS) three months after their injury. Even though a significant proportion of all mTBIs are sports-related (SR), little is known on the recovery process of SR mTBI patients and the potential differences between SR mTBI and patients who suffered non-sports-related mTBI. The objective of this study was to describe the evolution of PPCS among patients who sustained a SR mTBI compared to those who sustained non sport-related mTBI.

Methods: Study design and setting: This multicentre prospective cohort study took place in seven large Canadian Emergency Departments (ED) (five level I trauma centres, one level II trauma center and one academic non-trauma centre) between 04/07/2010 and 30/09/2018. Inclusion criteria: patients aged ≥ 14 who had a documented mTBI that occurred within 24 hours of ED visit, with a Glasgow Coma Scale score of 13-15. Exclusion criteria: Patients who were admitted following their ED visit or unable to consent. Procedures: Consecutive potential participants were identified by the treating emergency physicians. Informed consent was obtained, and clinical and sociodemographic information were collected during the initial ED visit. A research assistant then conducted phone follow-ups at 7, 30 and 90 days post-injury, in which they assessed symptom evolution using the validated Rivermead Post-concussion Symptoms Questionnaire (RPQ). Primary outcome: presence of ≥3 symptoms of ≥2 points at 90-days. Secondary outcomes: prevalence of 1) individual RPQ symptom (≥2 points) 2) total RPQ score ≥21 and 3) return to normal activities. Statistical methods: Adjusted risk ratios (RR) were calculated to estimate the influence of co-injuries.

Results: A total of 1676 mTBI patients were included, 358 (21.4%) of which sustained a SR mTBI. Median age was 39 years old (Q1-Q3: 23-57) and 60% of our cohort were males. At 90 days post-injury, patients who suffered a SR mTBI seemed to be significantly less affected by fatigue (RR: 0.70 (95% CI: 0.50-0.97)) and irritability (RR: 0.60 (95% CI: 0.38-0.94)). However, no difference was observed between the two groups regarding each other symptom evaluated in the RPQ. Moreover, the proportion of patients with three symptoms or more, a score ≥21 on the RPQ and those who did return to their normal activities were also comparable.

Conclusion: Although persistent post-concussion symptoms are slightly different depending on the mechanism of trauma, our results show that patients who sustained SR-mTBI could be at lower risk of experiencing some types of symptoms 90 days post-injury, in particular, fatigue and irritability.

Background:

Trauma leading to destabilisation of the pelvic ring is associated with high mortality rates due to massive haemorrhage. Correct prehospital management and treatment of patients with a pelvic ring fracture starts with the use of a non-invasive pelvic binder device (NIPBD), in order to prevent exsanguination. Pelvic fractures are often not recognized during prehospital assessment. The aim of this study is to evaluate the diagnostic accuracy of Emergency Medical Services (EMS) clinical judgement for the on-scene identification of pelvic ring fractures and NIPBD application rate.

Methods:

We performed a retrospective cohort study including all patients transported by EMS to our level one trauma centre with a pelvic fracture (2015-2018). All patients with a pelvic ring injury were included and radiologically categorized using the Young & Burgess classification system. Lateral compression type II/III, anterior-posterior and vertical shear were considered as unstable pelvic injuries. Injury Severity Scores (ISS) were calculated. EMS charts and in-hospital patient records were evaluated to determine the prehospital clinical suspicion of a pelvic injury and application of an NIPBD.

Results

In total, 233 patients with a pelvic fracture were identified of which 145 sustained a pelvic ring injury (62%). Lateral compression type 1 was the most common ring injury (58%). Unstable ring injuries were classified in 61 patients (42%). An ISS ≥ 16 was calculated in 79 patients with a ring injury (54%). In 36%, the EMS professional suspected a pelvic ring fracture (95% CI: 0.28-0.44). Moreover, in 51% of the patients with an unstable pelvic injury EMS applied an NIPBD (95% CI: 0.38-0.64). 

Conclusion

The prehospital diagnostic accuracy for a pelvic ring fracture and overall NIPBD application rate is low. EMS suspected less than 40% of all cases and did not apply an NIPBD in half of the unstable pelvic injuries. Recognizing a pelvic ring injury in the prehospital setting continues to be challenging and could potentially risk optimal patient care. We advise further education in the routine use of an NIPBD in any patient with either a suspect clinical setting or any relevant mechanism of injury.  

Background

Current studies underline the importance of a successful first intubation attempt (FPS), if intubation is performed during clinical cardiopulmonary resuscitation (CPR). The intubation process usually goes along with pausing the chest compressions. It is known that those interruptions reduce the chances of the return of spontaneous circulation (ROSC). In the context of hospital treatment of out-of-hospital cardiac arrests (OHCA), it was observed that patients achieved ROSC less frequently after initially failed intubation.

The purpose of this study was to research factors, which influence FPS and ROSC, and to analyse the association between both during prehospital treatment of OHCA. We hypothesised that, if FPS was achieved, probability of ROSC increased and time to ROSC decreased.

Methods

This was a retrospective multicentre registry study of 5 german physician-staffed ambulance stations in the period of 01.07.2017 to 31.12.2018. We examined data of 213 adult patients with non-traumatic OHCA on whom prehospital airway management was practiced by physicians. For information on airway management and FPS we used the Intubation Registry. Additionally, we used data from the German Resuscitation Registry about CPR and ROSC. The registries data were gathered by online questionnaires. The primary outcomes were FPS and ROSC, the secondary was time to ROSC. For the statistical evaluation we applied Mann-Whitney tests, Chi-square tests, Fisher´s exact tests and multivariate binary logistic regressions. 

Results

The study population (n=180) showed following demography: average age of 69.74 years (SD 12.9), median body weight of 82.5 kg (IQR 75.95) and 71.7% male patients.

The FPS was 83.3%. Increased body weight was significantly associated with lower FPS (p=0.044). The connections between level of education (p=1.000) or specialisation (p=0.335) of intubators and FPS were not significant. Most patients (83.9%) were intubated using endotracheal tube. We found no significant connection between selected equipment (p=0.196) or intubation method (p=0.901) and FPS. The tube position was most often verified using auscultation (80%) and capnography (72.2%). FPS decreased with an increasing degree of airway assessment according to Cormack and Lehane (p<0.001). The multivariate regression showed, that complications correlated negatively with FPS (OR 0.056, CI 0.014-0.214).

Overall, 82 patients (45.6%) achieved prehospital ROSC with an average time of 22.16 min. The multivariate regression showed, that the chance of ROSC increased, if initial heart rhythm was ventricular fibrillation (OR 2.661, CI 0.762-9.294) and initial breathing was gasping (OR 2.436, CI 0.289-20.543).

We found positive correlation (p=0.027) between FPS and ROSC. The probability of ROSC increased significantly with FPS (OR 5.281, CI: 1.810-15.521) and decreased with increased number of intubation attempts (49.3% first attempt, 0% fourth attempt). With achieved FPS, time to ROSC was reduced by an average of 10 min, but not significantly (p=0.059).

Discussion & Conclusion

For complete evaluations of registry data, it is important to increase the compliance with complete filling of the questionnaires. Prospectively this first intersection of the Intubation Registry and German Resuscitation Registry should be repeated with larger power. Nevertheless, our study still showed, that prehospital FPS is important for reaching ROSC and reducing time to ROSC while treating OHCA.

Background: Right ventricular (RV)/left ventricular (LV) diameter ratio on computed tomography pulmonary angiography (CTPA) have been proposed as potential predictors of outcome in pulmonary embolism (PE). The aim of this study was to evaluate the prognostic value of RV/LV diameter ratio for predicting the in-hospital or 30-day PE-related mortality in patients with PE.

Methods: We searched CENTRAL, PubMed, EMBASE, VIP, CNKI and Wan Fang Database for studies that reported on the association between RV/LV diameter ratio and in-hospital or 30-day mortality in patients with PE. A random-effect model was used for meta-analysis of single proportions and calculation of pooled odds ratios (ORs). We calculated the sensitivity and specificity, positive likelihood ratio (PLR) and negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) and diagnostic score in the model of diagnostic test accuracy meta-analysis. Spearman’s correlation and meta-regression analysis was performed to quantify and explain inter-study heterogeneity.

Results: Twelve studies reported on in-hospital or 30-day deaths resulting from PE in 3795 patients. The rates of PE-related mortality were 8.97% (95% CI, 3.89% to 19.34%) and 2.89% (95% CI, 1.03% to 5.66%) in patients with vs. without RV/LV diameter ratio increased on CTPA, respectively. RV/LV diameter ratio was associated with an increased in-hospital or 30-day PE-related death (OR 2.59, 95% CI 1.45 to 4.61). The pooled sensitivity, specificity, PLR, NLR, DOR and diagnostic score and the area under summary receiver operating characteristic of increased RV/LV diameter ratio measured on computed tomography (CT) images were 0.72 (95% CI, 0.54 to 0.84), 0.55 (95% CI, 0.44 to 0.67), 1.61 (95% CI, 1.26 to 2.05), 0.51 (95% CI, 0.32 to 0.86), 1.15 (95% CI, 0.48 to 1.82), 3.15 (95% CI, 1.61 to 6.15) and 0·67 (95% CI 0·63 to 0·71) respectively. Spearman’s correlation and meta-regression revealed that publication year, and study location of America contributed to inter-study heterogeneity.

Conclusions: The prognostic value of RV/LV diameter ratio measured on CT images does not support a role for the parameter as a single tool for predicting the early PE-related death. It is recommended that it should be integrated into other scoring systems to improve the prognostic value in patients with PE.

INTRODUCTION: The use of lung point-of-care ultrasound (L-POCUS) for the diagnosis of pneumonia is worldwide extended. However, data about L-POCUS implementation in paediatric emergency departments (PED) are lacking.

OBJECTIVE: Evaluate the impact of including L-POCUS in an algorithm to diagnose pneumonia in a PED.

METHODOLOGY: Prospective registry of L-POCUS done in a PED, from February to November 2019. After all PED attendings received training in L-POCUS, we introduced an algorithm to diagnose pneumonia including L-POCUS. The algorithm included the possibility of doing a confirmatory chest x-ray (CXR) according to the attending criteria. We collected data of the outcome of those managed only with L-POCUS. The principal investigator reviewed periodically all L-POCUS, analysing the agreement with CXR, in those were both exams were done, and the agreement between the attending’s interpretation and the principal investigator’s interpretation of L-POCUS.

As control measures, we compared total number of CXR, return visit to PED rates, admission rates and length of stay in all patients in the PED with discharge codes of “pneumonia”/”upper respiratory tract infection”, during the study period and the same period the previous year.

RESULTS: We registered 466 L-POCUS: 183 pneumonia (39,3%), 197 normal (42,3%), 86 interstitial (18,5%). We avoided use of CXR in 103 cases (22,1%), 49 pneumonia (47,6%), 44 normal (42,7%), 10 interstitial (9,7%). Of those managed without CXR, 11 patients returned to the PED, with no diagnostic errors or complications detected. The monthly average of L-POCUS was 46,6/month (24,5 L-POCUS/attending [57-4]) and the monthly rate of patients managed without CXR increased, reaching 50% the last month of the study. Globally L-POCUS had a 69,3% sensitivity, 94,5% specificity, 92,5% positive predictive value, 76% negative predictive value. Kappa coefficient was 0,77.

Compared to the previous year, there was a 35,8% decrease in the CXR use in patients investigated for pneumonia, without significant changes in return visits to PED rates, admission rates and length of stay in the PED.

CONCLUSIONS: Implementation of L-POCUS has safely decreased the CXR use in patients investigated for pneumonia, without changes in any control measures.

Health and logistical needs in emergencies have been well recognised. The last seven years has witnessed an improving professionalization and standardisation of care for disaster affected communities – a change which has been brought about in part by the Emergency Medical Team initiative (2013) of the World Health Organization (WHO EMT). Since its origin in 2013, this initiative has provided a platform for the evolution and development of specialist emergency medical teams, strengthening specific health and logistical needs in emergencies. National capacity strengthening has been a focus, with particular resources targeted to building National EMT specialist teams. The initiative supports and encourages trained and appropriately skilled teams of national and international personnel to deliver a co-ordinated approach to targeted health needs whilst adhering to minimum standards of care. The evolving nature, and changing definition, of humanitarian emergencies has highlighted the need for a widened scope of practice for EMTs. In addition to EMT’s influential role in outbreaks, conflict and chronic complex disasters, smaller scale but high impact emergencies have also brought to attention a need for specialist EMTs able to target specific health needs.

Mass casualty incidents resulting in burn injuries present some unique challenges. Accounting for at least 200,000 deaths annually, burn injuries and the resultant morbidity, mortality, and disability-adjusted life-years lost, rank high as a global public health problem. The high prevalence in low and middle-income countries, non-fatal burns are among the leading causes of Disability Adjusted Life Years (DALY) lost. Burn management of those injured requires specialist skills, expert knowledge, and timely availability of specialist resources. Lack of immediate (on-scene) patient care and the consequences of poor early decision-making in patient management can impact significantly on patient outcome and capability of health facilities to deliver good burns care. Recent examples of mass casualty incidents with multiple burn injured patients have demonstrated the extensive demands placed on health care workers and local health facilities and the resultant high morbidity and mortality rates. With burn mass casualty incidents occurring globally, and the wide variance in existing burn care capacity in different parts of the world, the need to strengthen burn care capability is evident.

In accordance with the processes used to create minimum standards of care amongst the emerging EMT specialist cells, a number of global burn experts were invited to participate in a succession of Working Group consensus meetings over a two year period. The aims of this work were to 1) review the literature on mass burn casualty incidents and 2) define and achieve agreement on recommendations for burn care in mass casualty incidents.

The resulting 21 recommendations are meant to provide a framework to guide National and International specialist burn teams and health facilities to ensure delivery of safe, appropriate, and relevant care to burn victims.

Background and objective: simplified pulmonary embolism severity (sPESI) has limited prognostic value for patients with acute pulmonary embolism (APE), and one of parameters of sPESI was invasive. This study aimed to evaluate whether replacing SaO₂ with SpO₂/FiO₂ improves the prognostic value of sPESI.

Methods: we retrospectively collected the data of consecutive patients with APE in the Zigong fourth people’s hospital, from January 1, 2014 to January 1, 2019. The endpoint was 1-month all-cause mortality. We tried to modify sPESI by replacing SaO₂ with PaO₂/FiO₂ (new scoring system named psPESI), and modify sPESI by replacing SaO₂ with SpO₂/FiO₂ (new scoring system named ssPESI), and performed a receiver-operating characteristic curve, integrated discrimination improvement (IDI), net reclassification improvement (NRI), calibration and decision-curve analysis (DCA) analyses to investigate whether ssPESI and psPESI can improve sPESI for risk prediction in patients with APE. 

Results: a total of 280 patients (109 with low-risk, 155 with intermediate-risk and 16 with high-risk PE) were enrolled in the study. Of these patients, 165 (58.93%) were male and the all-cause mortality after admission within 1 month was 10.71% (30/280). ssPESI had similar discrimination ability with psPESI, and ssPESI had better discrimination ability and obtained more net benefits than sPESI. psPESI and ssPESI were well-calibrated in the internal validation cohort with the Hosmer-Lemeshow test being not statistically significant and obtained more net benefits within wide threshold probabilities than sPESI.

Conclusions: the prognostic value of sPESI for patients with APE was enhanced by replacement of SaO₂ with SpO₂/FiO₂.

Objective: To analyze the risk factors in a large cohort of patients who have been diagnosed with acute stroke in our emergency room.  In particular we have analyzed the risk factors such as diabetes mellitus, arterial hypertension, smoking, previous stroke, ischemic cardiopathy, atheroma of supra-aortic vessels and atrial fibrillation in various patients over 75 years of age evaluated in our emergency room for a consecutive year (May 2017-May2018).  We have therefore divided the population according to the presentation of the following symptoms: motor, sensory, language deficit and atypical (dizziness, confusion and syncope).

Results: 430 patients were enrolled in the study.  These patients presented the average age of 83.8 Y.O. with a predominance for the female sex (60% F). The general population evaluated demonstrated a high incidence of risk factors: over 91.3% presented at least one risk factor, 63.7% of the study population presented at least two risk factors, and 34.6% presented three or more.  The most common risk factor represented was arterial hypertension, which was present in 73% of the cases.  Following: Smoking in 5.1 %, previous stroke in 27.6%, ischemic cardiopathy in 23.8%, atheroma of supra-aortic vessels in 30%, atrial fibrillation in 25.5% and diabetes mellitus in 23.1%. 56.7% showed motor system symptoms, 15.7% sensory symptoms, 46.8% language deficit, 36.5% non-specific symptom.  The 4 symptom based groups are results are superimposable for age, distribution of sex and outcome o the hospitalization.  The symptom based group with motor disturbances, language deficit and non-specific have been substantially demonstrated to be superimposable for the number and distribution of risk factors.  In particular: arterial hypertension 71-74% with a peak in 83% of patients with sensory symptoms; cigarette smoking in 5-6%, previous stroke in 23-27%, ischemic cardiopathy in 22-29%, atheroma of supra-aortic vessels in 29-33%, atrial fibrillation in 23-27% and diabetes mellitus in 15-20% with a peak in 26% in patients with atypical symptomatology.

Conclusions: It can be deduced from the careful analysis of the risk factors together with the collection of signs and symptoms that an improvement in early recognition can be brought to the attention to patients with acute neurological problems and as a consequence the entire diagnosis and treatment process in elderly patients can be facilitated when recent medical history can be correctly be collect.

Background

The diagnosis of sepsis-induced myocardial dysfunction (SIMD) is based on the echocardiographic evaluation. The aims of the present study were: 1) to test the diagnostic accuracy of troponin for the presence of SIMD, with identification of LV systolic dysfunction by the Global Longitudinal Strain; 2) to evaluate the prognostic value of this biomarker for the day-7 and day-28 mortality rate.

Methods

Between October 2012 and June 2019, we enrolled prospectively 354 patients admitted to our High-Dependency Unit for sepsis (41% with shock). All patients underwent a complete echocardiographic examination within the first 24 hours. SIMD was defined as LV systolic dysfunction (using speckle-tracking-based global longitudinal peak systolic strain, GLS, > -14%) and/or RV systolic dysfunction (using Tricuspid Annular Plane Systolic Excursion, TAPSE <16mm).

Troponin levels were measured upon admission (T0) and after 24 hours (T24); they were analysed as continuous values and dichotomized (< or ≥0.1 ng/ml). The end-points were day-7 and day-28 mortality rate

Results

One hundred fifty-five patients had normal T0 and T24 troponin level (G1), 74 either T0 or T24 abnormal levels (G2) and 129 both abnormal levels (G3). The three groups did not show any significant difference in terms of demographic data or previous medical conditions. Compared to G1 patients, those in G3 had higher SOFA score (G1: 5.6±2.7; G2: 6.7±3.0; G3: 6.4±3.1, p<0.05 between G1 and G3). LV (GLS: G1 -13.7±3.6%; G2 -13.0±3.4; G3 -11.3±3.5% p<0.05 between G3 and G1 and G2) and RV systolic function (TAPSE: G1 1.9±0.5; G2 1.7±0.5; G3 1.7±0.5, p<0.05 between G1 and G3)were significantly worse in G3 patients, as well the day-7 and (10%, 16% and 21%, p<0.05 between G1 and G3) day-28 mortality rate (21%, 32% and 37%, p<0.05 between G1 and G3).

We found 247 patients with SIMD, 134 with isolated LV dysfunction, 29 with RV dysfunction and 84 with a biventricular dysfunction. The percentage of patients with SIMD was higher in G3 (n=103, 80%) patients, compared to G1 (n=89, 59%, p=0.004 vs G3) and G2 (n=48, 65%, p=0.058 vs G3). Based on the ROC curves analysis, troponin showed a fair diagnostic accuracy for the presence of SIMD (T0 troponin: AUC 0.66, 95%CI 0.59-0.73; T1 troponin AUC 0.67, 95%CI 0.61-0.73, all p < 0.001)

In a multivariate Cox survival analysis, including age, SOFA score, the presence of SIMD and troponin level ≥0.1, the biomarker did not display an independent prognostic value, while SIMD did (RR 3.28, 95%CI 1.75-6.15, p<0.001).

Conclusions

High troponin levels indicated with a fair diagnostic accuracy the presence of SIMD, but were not independently associated with an increased short- and medium-term mortality rate. A high level of troponin is highly suspicious for SIMD, nevertheless an echocardiographic evaluation is mandatory.

Background

Pulmonary embolism (PE) is recognized as a complication of Covid-19 pneumonia, with possible detrimental effects on outcomes. Excluding PE in the emergency department (ED) is challenging. This is particularly true in patients with Covid-19, due to their clinical instability (limiting computed tomography pulmonary angiography [CTPA] use), high D-dimer levels, and the similar presentation of the syndromes. Aim of this preliminary analysis is to describe Covid-19 patients with PE and to create a simple risk score to safely exclude PE in these patients.

Methods

Preliminary retrospective analysis of electronic charts of Covid-19 patients undergone CTPA for suspected PE at Papa Giovanni XXIII Hospital ED (Bergamo, Italy) during initial Covid-19 outbreak (February 22nd - April 4th). Comparison of epidemiological, clinical and laboratory data between patients with and without PE was made. Statistically different variables were chategorized accordingly to their distribution and reference ranges, and a regression analysis was created. Standard coefficient (β) for each variable was used to compute a score for PE. Receiver-operator characteristic (ROC) curve for the score was obtained, and different cut-offs were tested (chi-square). This preliminary analysis suffers from selection bias (CTPA was ordered by the doctor on duty) and from the small sample and event sizes. More cases are being analyzed and, if the results will be confirmed, external prospective validation will be needed. No funding were received. Given retrospective nature, informed consent was waived by local ethical committee.

Results

During the study period, 44 CTPA were obtained, 17 of which (38.6%) presented PE. Thirty patients were male (68.2%), and median age was 62 years (IQR: 52.5-71.7). All patients had D-dimer levels higher than age-corrected cut­-off (median: 2718.0 [1377.5 – 8034.0] ng/mL). Patients with PE had more frequently chest pain (p=0.043), higher D-dimer (p=0.020) and white blood cell (WBC) levels (p<0.001). D-dimer values were chategorized into 3 groups accordingly to normal values (<500 ng/mL) and to the 75° percentile (8760 ng/mL), while WBC values were divided accordingly to reference ranges in our lab (4200 - 9400 cell/mm3). Applying β obtained in the linear regression gave y= ChestPain*0.346 + DDimer*0.400 + WBC*0.338, and the score was defined as follows:

Chest pain

    no=0

    yes=3.5

WBC

   <4200 =0

    4201-9400 =3.4

    >9400 =6.8

Ddimer

    <500 =0

     500-8761 =4

     >8761 =8

 ROC curve for PE had an area-under-the-curve (AUC) = 0.900 (IC95%: 0.807 - 0.993, p<0.001), with an optimal cut-off for sensitivity and specificity of 10.9 (75% and 89.3%, respectively), with PE prevalence of 13.8% and 80%. Setting the cut-off at 10 gave a 100% negative likelihood ratio and a 100% sensitivity for PE.

Discussion and conclusion

Clinical presentation and laboratory parameters alone lack sensitivity and specificity for PE. However, chest pain is one of the most typical symptom of PE. Given the tight relationship between the coagulation cascade and the inflammatory response during Covid-19, it seems reasonable that both D-dimer and WBC are associated with PE. If validated in multicenter study, our simple score will safely rule-out PE in Covid-19 patients in the ED.

Background

Children with forearm fractures who present to the emergency department (ED) commonly need closed reduction which is a painful procedure. In recent years it has been performed safely and with no complications under sedation in the Pediatric ED.

In our institution, up until 2017, all pediatric trauma patients used to present to the general trauma ED where no sedation service for pediatric patients was available. Closed reductions were performed under general anesthesia in the operating rooms or with no sedation in the ED. From 2017, pediatric trauma patients presented to the Pediatric Emergency Department where all closed reductions were performed under sedation.

We aim to compare the length of stay (LOS) and hospitalization rates of pediatric patients who underwent a closed reduction for radial or ulnar fractures under sedation in the pediatric ED, versus pediatric patients with radial or ulnar fractures who presented to the general trauma ED and needed a closed reduction.

Methods

This was a retrospective observational study in a regional hospital serving northeastern Israel. The study population consisted of all patients younger than 18 years presenting to the emergency department with ulnar or radial fracture who needed a closed reduction. We compared the patients presenting to the general trauma ED between 1.1.15-30.6.16 and the patients presenting to the Pediatric ED between 1.1.18-30.6.19. Primary outcome measures were hospitalization rates and length of stay. Secondary outcome measure was the rate of analgesia provision.

Results

One hundred seventy-five patients with forearm fractures who needed a closed reduction were included in our study; 79 patients presented to the general trauma ED and 96 patients presented to the Pediatric ED. Median ED LOS was longer among patients undergoing procedural sedation in the pediatric ED compared to the general trauma ED (237 Vs 168 minutes respectively; p< 0.0001). Among patients who underwent closed reduction in the general trauma ED 52.9% were not treated with any analgesia.  23% underwent the procedure with hematoma block. In a sub-analysis, there was not statistically significant difference in LOS between patients who underwent closed reduction with hematoma block in the general ED, compared to those who underwent closed reduction under sedation in the Pediatric ED. Hospitalization rate was lower for patients undergoing closed reduction under sedation in the pediatric ED compared to the general ED (6.3% and 21.5% respectively; P=0.003).

Conclusion

Sedation and appropriate analgesia have long become the standard of care for fracture reduction in the ED. Despite the need for more resources to perform procedural sedation in the Pediatric ED (staff, time and medications), patients who underwent closed forearm fracture reduction under sedation in the Pediatric ED, had only 69 minutes increase in LOS when compared to the general ED, where closed reduction was performed without sedation. Furthermore, sedation for closed forearm fracture reduction in the Pediatric ED was associated with more than 3 times decrease in hospitalization rate.

Our results could guide local policy makers with resource allocation.

BACKGROUND

Studies carried out in simulated environments suggest that checklists improve the management of surgical crises and crises in the intensive care setting.  The objective of the current study was to evaluate whether checklists improve the management of medical crises simulated in actual emergency departments.

METHODS

Checklists were developed for the management of the following eight crises:  anaphylactic shock, life-threatening asthma exacerbation, hemorrhagic shock due to upper gastrointestinal bleeding, septic shock, calcium channel blocker poisoning, tricyclic antidepressant poisoning, status epilepticus and increased intracranial pressure.  Each checklist outlined interventions to be considered based on current authoritative sources and consensus from four specialists in Emergency Medicine.  Scenarios were developed for each crisis based on real cases.  Each scenario featured seven to ten emergency interventions.  Simulations were run in the resuscitation rooms of four emergency departments (ED) in Southern Sweden and performed by resuscitation teams during their normal clinical shifts.  Scenarios and the order of access to the checklists were randomly assigned.  Team-members were explicitly allowed to use local cognitive aids (e.g. local guidelines, pocketbooks, internet).  Checklists were displayed on a large screen visible to all team members throughout the simulation.  All simulations were recorded using video and independently reviewed by two investigators.  The main outcome measure was the percentage of performed emergency interventions analyzed using mixed-effects proportional odds regression.  Personnel who participated in simulations with checklist access filled out a questionnaire regarding the usability of the checklist.

RESULTS

A total of 31 physicians, 54 nurses, 37 nursing assistants and 16 medical secretaries composing 41 resuscitation teams participated in the study.  Each resuscitation team consisted of 4 or 5 personnel (1-2 physicians, 2-3 nurses or nursing assistants and 0-1 medical secretaries).  Each scenario was performed twice (once with and once without checklist access) in each ED.  In each of three EDs, 4 additional simulations were performed, resulting in a total of 76 simulations (38 with and 38 without checklist access) with a total of 631 emergency interventions.  Thirty-five teams completed two different scenarios, one with and one without checklist access.  Six teams could only perform one scenario due to actual emergencies.  Local cognitive aids were used during 68% of simulations without checklist access.  The median percentage of performed emergency interventions was 38.8% (95% CI 33% – 44%) without checklist access and 85.7% (95% CI 81% – 90%) with checklist access (p  = 5.3 x 10^–10).  The benefit of checklist access was similar in the four EDs and independent of physician experience, type of scenario and use of local cognitive aids.  On a Likert scale of 1 to 6, 94% of all participants agreed (gave a score of 5 or 6) with the statement “I would use the checklist if I got a similar case in reality."  Profession and type of scenario had no significant effect on the responses to the questionnaire.

CONCLUSION

Checklists markedly improved local ED resuscitation teams’ management of medical crises simulated in-situ, and most personnel expressed that they would use the checklists if they had similar cases in reality.

Background: Staff mental health and wellbeing is now at the forefront of the medical profession. This was highlighted in the recent GMC report ‘Caring for Doctors Caring for Patients,’ which showed that almost 25% of trainees reported high levels of burn-out, with physicians working in Emergency Medicine having a considerably higher rate of burn-out than other specialties. Improved staff wellbeing promotes a safer environment for both staff and patients. The main aim of our study was to establish how supported members of the multi-disciplinary team were whilst working in a busy urban emergency department.

Methods: An initial online survey was distributed to all members of staff via social media and email cascade. This was open for 7 days (from 21/08/2019 - 28/08/2019) and there were 87 responses. 10 questions were used to assess baseline staff morale. The following interventions were then implemented: team activities out-with work; food-themed days; buddy systems established, wellbeing education sessions, a team Christmas video created and several social media pages created. A second survey received 38 responses. This followed the same format and 7 day duration (from 07/01/2020 – 14/01/2020), but had modified questions. Every member of our emergency department team was invited to participate, regardless of role. Participation was optional.

Results: 74% of staff felt their individual wellbeing at work had improved, and 53% felt team morale had improved after the interventions.

92% of staff felt the Wellbeing Social Media accounts had had a positive impact on promotion and eduction of staff wellbeing

More staff reported suffering from burn-out symptoms (increase of 38% to 50%)

Less people felt able to approach an appropriate member of the team (from 83% to 63%)

53% of staff did not feel a valued member of the team, with the majority of these respondents being doctors.

Discussion: The education around the importance of individual and team wellbeing within an emergency department is paramount in promoting patient and staff safety. Our second survey was distributed shortly after our junior doctors had commenced their new rotation, and may account for the increased number of staff feeling undervalued and also the increase in staff reporting burn-out symptoms. During the current SARS-Cov-2 Pandemic, the sense of team has never been so great nor so vital. Our aim is to redistribute this survey once this pandemic is over, and determine whether the introduction of a dedicated Wellbeing Team successfully helped our department during this challenging time, whilst also ensuring the protection and support of every team member.

Background

Management of acute behavioural disturbance in patients presenting to the Emergency Department (ED) is notoriously challenging, time consuming and risky. When de-escalation and non-pharmacological strategies are ineffective, the next step is to administer medication to calm and protect patient safety. This medication can be administered orally if the patient is compliant or parenterally. There is international guidance on the choice of drug regimen from the National Institute for Health and Care Excellence. There is also a consensus statement from the World Federation of Societies for Biological Psychiatry.

Aims

We aimed to

1.     Audit the medication regimen used for management of acute behavioural

disturbance in our ED.

2.     Perform a literature review of the current international evidence on pharmacological regimens for management of acute behavioural disturbances in the ED.

3.     Introduce a policy for the safe and effective pharmacological management of acute behavioural disturbance in our ED.

Methods

We performed a retrospective audit of patients presenting to Tallaght University Hospital Emergency Department with acute behavioural disturbance between January and December 2019 inclusive.

We then performed a literature review of the evidence on the pharmacological approach to management of acute behavioural disturbances.

We cross referenced the evidence and formulated a policy for management of acute behavioural disturbance in our ED.

Results

We noted the difficulty in capturing all patients presenting with acute behavioural disturbance since this may be due to a wide variety of medical, surgical and psychiatric pathologies including but not limited to delirium, dementia, intoxication, injury and psychosis.

We identified 120 patients (n=120) that required pharmacological management of an acute behavioural disturbance.

Documentation of the pharmacological approach was poor with 5% having a clear plan including escalation plan documented in the notes.

The pharmacological approach was varied with the same underlying diagnosis being made but a different pharmacological plan in 50%.

There was adherence to the NICE guidelines in 10% cases.

There was no electrocardiograph performed and olanzapine prescribed in 30%.

Conclusion

Managing a patient with an acute behavioural disturbance in a busy and chaotic ED setting is challenging, time consuming and risky. We sought to determine if, in our institution, we were using the international evidence base to inform our decisions regarding pharmacological management of these patients. Our audit revealed poor documentation, lack of a consensus approach and some unsafe prescribing behaviours. We reviewed the evidence and amalgamated it to create a local policy and proforma for managing these patients safely and effectively in our ED. We are currently re auditing post introduction of a standardised rapid tranquillisation pathway.

Background. Clinical and laboratory markers of possible disease progression are needed to differentiate between patients who can be discharged promptly and those who will develop a more severe COVID-19 progression. We investigated whether baseline clinical signs, suPAR, and routine biomarkers in patients with COVID-19 can predict if a patients develops respiratory failure and need of ventilator support during a 14-days of follow-up.

Methods. A single centre prospective cohort-study carried out at Copenhagen University Hospital Hvidovre, Denmark including patients presenting with symptoms of COVID-19 in the period of 19th of March until 3rd of April and with follow-up until 17th of April 2020. SARS-CoV-2 testing was carried out using a RealStar® SARS-CoV-2 RT-PCR Kit RUO from Altona Diagnostics (Hamburg, Germany) on material obtained from respiratory tract specimens. The assay had a limit of detection of 50 copies of RNA. Routine biomarkers (Dif. Cell counts, hemoglobulin, creatinine, creatinine kinase, C-reactive protein (CRP), Aminotransferase, Lactate dehydrogenase, and bilirubin were measured on a Roche 8000 platform. Soluble urokinase plasminogen activator receptor (suPAR) was measured using a Point-of-care test which allows quantitative results within 25 minutes after blood drawing (suPARnostic QT, ViroGates, Denmark). Data are shown as N (%) or median (interquartile range, IQR). Area under the curve (AUC) and 95% Confidence intervals (CI) were calculated using C-statistics. The endpoint was respiratory failure defined as patients intubated and mechanically ventilated. The statistical program R version 3.60 (R Foundation for Statistical Computing, Vienna, Austria) was used for statistical analysis.

Results. 405 patients with COVID-19 symptoms were tested for SARS-CoV-2, and 117 tested positive and were included in the present study. Mean age was 71 years and 68 (58%) were female. Median duration of symptoms were 5 days (IQR: 2-7) before admission to the ED. At admission, Early Warning Score was 3 (1-5), suPAR 5.3 (4.0-7.7) ng/ml and CRP 44 (18-99) ug/ml.

A total of 87 patients (74%) were deemed eligible to receive intensive care treatment if needed whereas 30 were not due to frailty. During follow-up, 25 (29%) of the 87 patients developed respiratory failure. Strong baseline predictors of respiratory failure were suPAR with an AUC of 0.86 (CI95%:0.79-0.94), EWS 0.82 (0.72-0.91), lactate 0.81 (0.69-0.92) and CRP 0.78 (0.68-0.88). Other baseline parameters including age, cell counts, and other routine biomarkers had AUC of 0.63 or lower.

Discussion and conclusions

In patients presenting at the Emergency Department with symptoms of COVID-19 and tested positive for SARS-CoV-2, approximately one third developed respiratory failure and were intubated and ventilated during the 14 days follow-up. We identified baseline suPAR values as a strong predictor of respiratory failure during follow-up, suggesting that suPAR can aid in the decision of discharging (low suPAR) or admission (high suPAR) of patients with COVID-19.

Background Appropriate interpretation of blood tests is important for risk stratification in the Emergency Department (ED) but may change with increasing age of patients. Specific values for blood tests are used in many ED risk stratification tools and guidelines suggesting that above or below this value prognosis changes drastically. however, it is unknown whether relevant clinical thresholds for blood tests truly exist and if the association between blood tests and in-hospital mortality differs per age-category.

Aims To assess the association between biochemical signs of renal dysfunction, inflammation and oxygen transport and case-mix adjusted mortality, within different age categories.

Methods Observational multi-centre cohort study using the Netherlands Emergency department Evaluation Database (NEED). All consecutive ED patients ≥18 years of three hospitals were included. The associations between blood tests and in-hospital mortality were assessed in three age categories (18-65;66-80;>80 years) using multivariable logistic regression. Blood tests were divided in four to six categories, e.g. creatinine (0-50 (=reference),51-100,101,150,>150µmol/L). Significant deterioration of adjusted odds ratios between categories were reckoned as relevant thresholds.

Results We included 94.974 patients in whom blood tests were performed, 2550( 2.7%) died in-hospital. In ED-patients aged 18-65 and 66-88 years, prognosis deteriorated substantially at CRP >50mg/L, while deterioration started at CRP >100mg/L for patients >80years. Haemoglobin <7mmol/L was associated with increased mortality in patients aged 18-65 and 66-80 years, but not >80 years. Sodium >135mmol/L was protective in patients aged 18-65 and 66-80 years, compared to >80 years. Age hardly affected the approximately linear associations between creatinine, urea, leucocytes and mortality.

Conclusion Our study suggests that several blood tests need to be age-adjusted for risk stratification. The prognostic value of blood tests is substantial and deteriorates linearly in several blood tests. Our results have implications for interpretation of blood tests and their use in existing risk stratification tools and guidelines in the ED.

Background Appropriate interpretation of vital signs is important for risk stratification in the Emergency Department (ED) but may change with increasing age of patients. Specific thresholds for vital signs are used in many ED risk stratification tools and guidelines, suggesting that above or below this threshold prognosis changes drastically. However, it is unknown whether relevant clinical thresholds for vital signs truly exist and if the association between vital signs and in-hospital mortality differs per age-category.

Aims To assess the association between initial vital signs and case-mix adjusted in-hospital mortality in different age categories.

Methods Observational multi-centre cohort study using the Netherlands Emergency department Evaluation Database (NEED) in which all consecutive ED-patients ≥18 years of three hospitals were included. The association between vital signs and mortality was assessed in three age categories (18-65;66-80;>80 years) using multivariable logistic regression. Vital signs were each divided in three to five categories, e.g. systolic blood pressure categories (≤80,81–100,101–120,121-140,>140 (=reference) mmHg). Significant deterioration of adjusted odds ratios between categories were reckoned as relevant thresholds.

Results We included 101.415 patients of whom 2374 (2.4%) died in-hospital. Age-category hardly influenced the association between vital signs and relevant outcomes. Mortality increased approximately linearly with increasing heart rate categories, similar for decreasing peripheral oxygen saturation and systolic blood pressure categories. Relevant thresholds for mortality were found for mean arterial pressure (MAP) <80mmHg, respiratory rate >20/min, and for a temperature <35^oC, while the odds for mortality did not increase with temperatures between 35-42^oC.

Conclusion Age hardly influenced the association between vital signs and in-hospital mortality. Short term prognosis deteriorated approximately linearly with oxygen saturation, heart rate and systolic blood pressure. Only for respiratory rate, MAP, and temperature relevant clinical thresholds existed. Our results have implications for interpretation of vital signs and used thresholds in existing risk stratification tools and guidelines in the ED.

Background:  Carotid and vertebral artery dissections are rare events. The most frequent symptoms are head and neck pain and neurological deficits, but these are common emergency department (ED) chief complaints and other diseases causing these occur much more often. Furthermore, about one-third of patients have no headache, one-third have no neck pain and over 10% have no neurologic deficits. For these reasons, diagnosing dissections is challenging.  We wished to quantify the magnitude of this problem in a large ED database.  Our goal was to determine the number of total ED visits for every carotid and vertebral artery dissection diagnosed by ED physicians.

Methods: Design: Multicenter retrospective cohort. Setting: 27 suburban and urban New York and New Jersey EDs with annual visits between 20,000 and 119,000. Population: Patients seen by ED physicians in the four year period from 11-1-2015 through 10-31-2019. Protocol:  We identified carotid and vertebral artery dissections using ICD-10 codes.  Data Analysis:  We calculated the number of ED visits for every carotid and vertebral artery dissection, along with 95% confidence intervals (CIs).

Results: From a database of 6,223,499 ED visits, we identified 115 carotid artery dissections and 97 vertebral artery dissections.  The median ages (with interquartile ranges) and percent female of carotid and vertebral artery dissection patients were 54 years (41, 64), 47 years (38, 63), and 55% and 51%, respectively. Of the total ED visits there was one carotid artery dissection for every 54,117 (95% CI 45,089 to 64,953) visits and one vertebral artery dissection for every 64,160 (95% CI 52,599 to 78,261) visits.

Conclusion: The diagnosis of carotid and vertebral artery dissections by ED physicians is rare. An ED physician seeing 3,000-4000 patients a year would diagnose one carotid artery dissection every 13 to18 years and one vertebral artery dissection every 16 to 21 years.

Introduction

Diagnostic performance of many frailty screeners have been validated for the emergency department

(ED) but successful implementation in routine practice also depends on the additional value over

clinical judgment, and the experienced quality and usability by healthcare professionals. Our aim was

to assess  the diagnostic performance of frailty screeners and compare it with clinical judgment. Also, we

assessed the experienced quality and usability of four screening tools among healthcare

professionals.

Methods

This was a prospective multi-center study in which healthcare professionals of two Dutch EDs were

included. Included healthcare professionals assessed whether a hypothetical older patient presented

in a clinical scenario was frail by applying their clinical judgment and two randomly selected screening

tools (PRISMA-7, Identification-Seniors-At-Risk-score (ISAR), Clinical Frailty Scale (CFS) or APOPscreener

(Acutely Presenting Older Patient, APOP). Diagnostic performance was assessed by using

the opinion of an expert panel as gold standard. Time needed to complete the tool was measured and

a questionnaire was taken about experienced quality and usability of the tool.

Results

We included 125 emergency healthcare professionals who performed 250 screeners. Clinical

judgment had the highest sensitivity (93.5% (95%CI: 88.2-96.6%)) but the lowest specificity (51.0

(95%CI 41.5-60.4%)). APOP had the highest specificity (92.0 (95%CI 75.0-97.8%)) but lowest

sensitivity (47.2 (95%CI 32.0-63.0%)). The combination of clinical judgment and the APOP-screener

resulted in a sensitivity of 91.7 % (95%CI 78.2-97.1%) and specificity of 56.0% (95%CI 37.1-73.3%).

Time to complete screening was ~1 min, not different among screeners (p>0.05), as was the

experienced quality and ease of use (p>0.05).

Conclusions

Our study suggests that frailty can most accurately be assessed in the ED by combining clinical

judgment with a validated frailty screening tool. EDs should choose a screening tool based on

institutional preferences because of similar time to complete different screeners, experienced quality

and usability of the tools.

Background:

Patients requiring procedural sedation and analgesia (PSA) in the Emergency Department (ED) are often pre-oxygenated with high flow oxygen via a non-rebreathing mask (NRBM). Previous studies have shown that (prolonged) hyperoxia may have negative haemodynamic effects. Therefore, in this study we aimed to investigate the effect of pre-oxygenation for PSA on non-invasively measured cardiac output (CO), cardiac index (CI), stroke volume (SV) and systemic vascular resistance (SVR).

Methods:

In a prospective cohort study, CO, CI, SV and SVR were measured non-invasively in a convenience sample of patients who were pre-oxygenated  for PSA in the ED of a large teaching hospital in the Netherlands between May 2018 and June 2019 using the Clearsight® system. After baseline measurements were performed,  oxygen was administered at rates of 15L/min and at flush rate during a total of 10 minutes, after which measurements were repeated. The primary outcome was the absolute difference in CO after respectively 15L O2/min and flush rate preoxygenation for PSA compared to baseline measurements. Repeated measures ANOVA or Friedmann test was used for analysis. Secondary outcomes were differences in CI, SV, SVR, systolic blood pressure (SBP), heart rate and saturation, and differences in baseline characteristics between patients with and without a decrease of >10% of CO after preoxygenation, for which Student’s t-test, Mann-Whitney U test, Chi-square test or Fisher’s exact test were used. Mixed ANOVA was used to calculate oxygen dose-to-group interactions for these groups. 

Results:

60 patients were included. Mean CO was 6.5 L/min at baseline, after 5 minutes of 15L O₂/min 6.3 L/min and after 5 minutes of flush rate oxygen 6.2 L/min, which was significantly different (p=0.037). SVR and SBP also increased significantly during preoxygenation (781, 1244, 1337 dyn/sec/cm^-5 respectively, p = <0.001; 133, 138, 144 mmHg respectively, p = <0.001). A clinically relevant decrease in CO, pre-specified as >10%, was present in 16/60 (27%) patients. Baseline characteristics did not differ in these patients.

Discussion and Conclusions:

In this study we found a significant decrease in CO of 0.3 L/min after pre-oxygenation. Short duration high-flow oxygen administration resulted in a clinically relevant drop in CO in 27% of the patients undergoing pre-oxygenation for PSA in the ED. SBP and SVR increased significantly. These effects could be attributed to negative effects of hyperoxia, since this can lead to peripheral and coronary vasoconstriction. Baseline characteristics and haemodynamic measurements could not predict which patients would demonstrate a significant drop in CO. Limitations: the effects of hyperoxia might be most harmful in patients with known heart failure or who are critically ill or haemodynamically instable. There were no patients with known heart failure or critical illness in this cohort, although they suffered a painful condition. Despite administering high flow oxygen, we did not measure PaO2 to prove true hyperoxemia. Saturation increased to 100% in all patients, which previous studies have shown to correspond with hyperoxemia. Conclusion: Short duration high-flow oxygen administration resulted in a clinically relevant drop in CO in 27% of the patients undergoing pre-oxygenation for PSA in the ED.

Purpose.  In this field trial of rapid blood culture identification (BCID), we aimed to determine whether the Effect of Quick Cause Septic Diagnosis on Time to Clinical Response in Sepsis Suspected Patients according to modified SIRS criteria.

Methods.

We trained local hospital laboratory staff to operate the FilmArray equipment and act on the results.  modified sepsis criteria was created by discussion by medical specialists and applied to patients to access clinical usage.

Results.
Of 100 positive blood culture episodes, BCID FilmArray results were correct in all significant bacterial cultures, with a fully predictive identity in 95% and a partial identity in another 5%. We found that almost clinically significant mono- and polymicrobial culture results were fully predictive of culturebased identification to bacterial species level at a mean of 25 hours after specimen collection.
Conclusions. There was a reduction of 3days in the time taken to produce a definitive BCID compared to the previous year, translating into earlier communication of more specific blood culture results to the treating physician. Reduced time to definitive blood culture results has a direct benefit for isolated local korea communities at great distances from specialist hospital services.

Background

The COVID19 pandemic has transformed health services throughout the world. However, compared to adults, there is little evidence that children are severely affected. In many countries attendances to Children's Emergency Departments have significantly reduced prompting some concerns that parents and carers were delaying bringing their children to hospital even when they may require urgent medical care.

Aim and Methods

In order to determine the impact of COVID19 on our tertiary Children's Emergency Department we compared attendances, diagnosis at discharge, initial paediatric observation priority score (POPS - a bespoke ED Early Warning Score) and Healthcare Resouce Group (HRG) code for the months of March and April 2018, 2019 and 2020. HRG is a grouping consisting of patient events that have been judged to consume a similar level of resource; a lower score indicating increased resource utilisation. 

Results

Presentations in March and April fell to 5399 (2020) having been 10898 (2019) and 8254 (2018) however overall HRG weighting only slightly increased to 8.71 from 8.48 (2019) and 8.98 (2018) which is a clinically negligible change. Intial mean POPS of all attendances was not statistically different at 1.10 having been 1.07 (2019) and 1.19 (2018). Children diagnosed with an infectious disease fell by 30.5 attendances per 1000 presentations and soft tissue injuries fell by 10.0 attendances per 1000 presentation comparing 2020 and 2019. There were increases in codes relevant to specific paediatric diagnoses (croup, febrile convulsion etc.) by 11.4 attendances per 1000 presentations in the same time periods and fracture/dislocations by 9.1 attendances per 1000 presentations. Other diagnostic codes, including mental health, increased or decreased by less than 10 attendances per 1000 presentations compared to the previous years. 

Discussion

While anecdote and clincal experience may have concorded with the face validity that SARS-CoV-2 may have had a negative impact on acuity of children presenting to Children's Emergency Departments our local experience is that overall it appears to not be significantly different in March/April 2020 compared to 2019 and 2018. Despite a significant drop in attendances this was mainly made up of infectious diseases (such as gastronteritis) and soft tissue injuries. Further detailed analysis is needed to confirm these observations and this work is ongoing and will be available by time of presentation, including an analysis of specific conditions. 

Conclusion

While having a huge impact on childrens' presentations to Emergency Departments there is no evidence, at this stage, of significantly elevated acuity, or a large change in case-mix, as a result of the COVID19 pandemic compared to previous years. 

Introduction : 

The pre-hospital care of the ACS with ST elevation involves several links from the reception of the call to the patient’s orientation. The optimization of this sector is essentially based on the evaluation of our practices. The aim of our study is to evaluate the progress after 20 years of the acute coronary  syndrome with ST elevation supported by prehospital medical teams.

Materials and methods : 

It is a comparison of two retrospective studies ; the first carried out between 1994 and 2002, and the second in 2018 included all patients with  acute coronary syndrome with ST elevation supported by SAMU03 teams. We analyzed the epidemiological and clinical characteristics of the patients, the delay of management, the reperfusion strategy adopted in pre-hospital and the outcome of the patients. 

Results : 

There was a significant increase in incidence between the two study periods. The average age was similar between the two groups (p = 0.4). However, there has been an increase in the frequency of ACS in women (SR 7 to 3). Hypertension and diabetes were the most important risk factors. The calls came from peripheral public structures in more than 70% of the cases. Electrical abnormalities are the most frequent reason for call. The anterior territory was the most affected in the two studies. However, in 2018 there was an increase in the frequency of inferior ACS (45 % in 2018 compared to 18% between 1994 and 2002). Complications of ACS with ST elevation at the time of diagnosis became less frequent in 2018 compared to the first period with 33.3% and 75% respectively. In both cases, arrhythmias and arterioventricular blocks are the most common complications. The median pain-to- medical contact delay was 141 min ; it is <4 h in half of the cases in 2018. The median pain-fibrinolytic therapy delay was 168 min. No primary percutaneous coronary intervention (PCI)  was performed between 1994 and 2002. Only 5.7% of patients received fibrinolytic thearpy. The number of not re-infused patients decreased from 72.3% to 38% in twenty years. In 2018, 48 patients (30.18%) received fibrinolytic thearpy, including 3 patients who required rescue percutaneous coronary intervention (PCI). Primary percutaneous coronary intervention (PCI) was undergone in 46 patients (28.9 %). Percutaneous coronary intervention (PCI) was realised in private sector in 63% of cases. The percentage of patients admitted to the SAUV was multiplied by 10 between the two study periods (4% vs 40%) against a drop in the number of patients admitted directly to the ICU (22% vs 51.4%).  

Conclusion : 

The prehospital management of ACS with ST elevation has progressed in recent years. Improving care involves controlling risk factors, educating at-risk patients on the importance of symptoms and the time factor, and providing catheterization centers in public deprived governorates. The creation of a coronary care network with a partnership between the public and private sector is necessary.

Background: One of the fundamental tasks of emergency medical services (EMS) is to discriminate the severity of cases and prioritize the evacuation order and the most suitable destination hospital for each situation.

The objective of this study is to analyze the diagnostic precision of the modified rapid emergency medicine score (MREMS) performed at the pre-hospital level to predict the need for admission to the intensive care unit (ICU) or hospital mortality.

Methods: Prospective observational longitudinal study, between October 15, 2019 and February 29, 2020. The study was developed on Valladolid (Spain). All adult patients with acute disease treated consecutively by the emergency medical services and transferred to the emergency department of their referral hospital were included in the study. Patients who did not require evacuation or discharged in situ, cases with terminal pathologies, pregnant women and cardiorespiratory arrest were excluded.

Demographic data (age and gender) and vital signs set (systolic blood pressure, heart rate, respiratory rate, oxygen saturation and Glasgow coma scale) were obtained by the emergency registered nurse during the first EMS contact with the patient with LifePAK® 15 monitor (Physio-Control, Inc., Redmond, USA). 

At 30-days of the index event, by reviewing the patient's electronic history, hospital admission and 30-days mortality data and ICU admission were obtained. 

The main outcome variable was hospital mortality (within the first 30-days) from any cause. In addition, the ability of the score to predict ICU admission is explored.

The area under the curve (AUC) of the receiver operating characteristic (ROC) of the MREMS was calculated in terms of 30-day mortality and ICU admission. Youden's test was calculated for the cut-off point with better sensitivity and specificity combined.

Results: a total of 177 patients were included in our study. The median age was 62 years (IQR: 42-79 years), with 73 females (41.2%). The 30-day mortality was 13.5% (24 cases). The AUROC for an 8-points cut-off point was 0.786 (95% CI: 0.67-0.89; p> 0.001), with a sensitivity of 0.66 (95% CI: 0.47-0.85), specificity of 0.78 (95% CI: 0.71-0.84), positive likelihood ratio of 3.09 and negative likelihood ratio of 0.42.

The ICU admission was 16.9% (30 cases). The AUROC for an 9-points cut-off point was 0.696 (95% CI: 0.58-0.80; p=0.001), with a sensitivity of 0.46 (95% CI: 0.22-0.64), specificity of 0.84 (95% CI: 0.78-0.90), positive likelihood ratio of 2.98 and negative likelihood ratio of 0.64.

Conclusions: The MREMS presents a good discriminative capacity to detect patients with a high-risk of deterioration, either at the level of hospital mortality or ICU admission, with excellent specificity for this particular outcome. EMS should consider the use of early warning scores as a routine procedure within the systematic evaluations carried out in the prehospital scope.

Introduction

Community acquired pneumonia (CAP) is a leading cause of hospitalization and mortality worldwide. When managing CAP in the emergency department (ED) critical decisions must be made with consideration to timely initiation of antibiotic therapy. International guidelines recommend that the initial dose of antibiotic therapy is administered within 4 hours of arrival. However, this creates a clinical dilemma of striving to follow the 4-hour criteria while being considerate to the emerging antimicrobial resistance. Knowledge on clinically relevant outcomes can help assist the decision-making when in dilemma about initiating antibiotic therapy. This study aims to compare difference in length of stay (LOS), 30-day readmission and 30-day mortality among patients with CAP receiving early versus delayed antibiotic therapy defined as <4 hours and ≥ 4 hours upon arrival to the ED.

Method

This cohort study includes all contacts (≥18 years) attending the ED at Aarhus University Hospital in a full year period from 1^stof July 2016 to 30^thof June 2017. Patients were identified using the final discharge diagnosis (ICD10 codes: J15 and J18) (n=950). Patients with CAP who did not receive antibiotic therapy were excluded (n=565).  Data was retrieved from the electronic medical record system used by the Central Denmark Region and vital status from the Danish Civil Registration System. Exposure was time to first dose of antibiotic therapy from arrival to the ED and patients were stratified into two groups: early (<4 hours) and delayed (≥ 4 hours) initiation. Outcomes were total hospital LOS in days and incidence proportions of 30-day readmission and 30-day mortality. A linear regression model was applied to determine differences in LOS and for binary outcomes a logistic regression model was applied to determine odds ratios (OR). The logistic regression models were adjusted for age and triage colour.

Results

Out of 385 patients with CAP 130 received early and 255 delayed antibiotic therapy. The mean age at arrival was 73 years and 51.69% of patients were male. Early initiation had a mean LOS of 5.14 (95%CI 4.10;6.17) days and the delayed 4.69 (95%CI 4.21;5.17) days. 14.17% of patients in the early group and 16.21% in the delayed group were readmitted within 30 days. The 30-day mortality in the early group was 16.15% and 12.97% in the delayed group. The logistic regression model showed a crude OR=0.77 (95%CI 0.42;1.39) on 30-day mortality for the delayed group compared to the early group. After adjusting the OR was 1.33 (95%CI 0.62;2.82)). For a readmission within thirty days the crude OR was 1.17 (95%CI 0.64;2.13) and the adjusted OR was 1.39 (95%CI 0.72;2.71).

Conclusion

This study found no clinically relevant difference in LOS, 30-day readmission or 30-day mortality between the early and delayed initiation of antibiotic therapy groups. Although timely administration of antibiotic therapy is important and should be encouraged, initiation of early antibiotic therapy within 4 hours of arrival is not supported by the clinical evidence. This knowledge can help assist the decision-making of initiation of antibiotic therapy.

Premise and goals: Severe trauma is the first cause of death worldwide for patients of age 40 or less. About 30% of severe trauma patients presents with trauma induced coagulopathy at arrival to the E.D. About 40% of trauma deaths are related to bleeding, a quarter of which seems preventable.  The goal of this study is to determine if patients with coagulopathy present with more severe anatomical injuries.

Methods: We conducted a monocenter prospective observational study involving all patients affected by severe trauma in the Emergency Department of the Fondazione Policlinico IRCCS S. Matteo in Pavia in 12 consecutive months: from the 1st of January 2018 to the 31st Decembe 2018. All patients registered as affected by severe trauma in our Emergency Depatment have been enrolled. Inclusion criteria are to satisfy at least one of the pathognomic classification criteria for severe trauma as defined by the American College of Surgeons, Advanced Trauma Life Support (ATLS@) and approved by regional deliberation...

These criteria are: Physiopathological Criteria (compromised health parameters or necessity for advanced life support); Anatomical Criteria (e.g. puncturing wound to the head, neck, thorax or abdomen); Mechanism of Injury Criteria (e.g. ejection from vehicle, death of an occupant in the same vehicle...).
We considered patients affected by coagulopathy if positive for at least two altered biochemical values traditionally used to study coagulopathy. Patient undergoing an anticoagulant therapy have been excluded.

Results:  We evaluated 503 patients in total.
204 were affected by trauma induced coagulopathy (80% of which males) with an average age of 44 years and peak incidence between 55 and 65 years old.
299 were not affected by coagulopathy (68% of which males) with an average age of 43 years and peak incidence between 25 and 35 years old.
More severe anatomical injures have been identified in patients affected by coagulopathy: 21.26% of them presented an ISS>16, compared to the 15.7% of the patients not affected by coagulopathy (p=0.0000).
Additionally 22% of patients affected by coagulopathy satisfies the anatomical criteria for the classification of severe trauma, compared to the 10% of patients not affected by coagulopathy.
Besides, the number of involved anatomical districts  is higher in patients with trauma induced coagulopathy, which presented with 3 or more injured districts in 47% of the cases, against the 23% of patients without trauma induced coagulopathy (p=0.000).

Conclusions: Among patients presenting with severe trauma of the same population (400.000 people ca.) in an Italian Trauma Center of II level, those who at arrival in ED have already developed trauma induced coagulopathy present a higher number of injured anatomical districts and a greater anatomical severity compared to younger subjects despite trauma causes perhaps erroneously considered of lesser entity. 

Background: For out-of-hospital cardiac arrest (OHCA), current cardiopulmonary resuscitation (CPR) guidelines recommend chest compression-only bystander CPR (C- BCPR) for both untrained and trained bystanders unwilling to perform rescue breaths before emergency medical services personnel arrival. However, during 3 consecutive guideline periods, changes in type of BCPR and neurologically intact survival rate are unclear in paediatric OHCA cases.

Purpose: We aimed to determine the change in the rate and type of BCPR in correlation to the 1-month neurologically intact survival and causes of OHCA.

Methods: We reviewed 5461 children with bystander witnessed OHCA included in the All-Japan Utstein-style registry from 2005 to 2017. Patients were divided into 3 groups according to the type of BCPR: no BCPR (NO-BCPR), standard BCPR with rescue breaths (S-BCPR), and C-BCPR. Guideline periods 2005 to 2010 (pre-G2010), 2011 to 2015 (G2010), and 2016 to 2017 (G2015) were used for comparison over time. The study endpoint was 1-month neurologically intact survival (Cerebral Performance Category [CPC] scale 1 or 2; CPC 1–2).

Results: The rates of patients receiving any BCPR and 1-month CPC 1–2 by year significantly increased from 46.2% and 9.4% in 2005 to 61.3% and 15.7% in 2017 (all P for trend <0.0001), respectively. The rates of patients receiving C-BCPR in the pre-G2010 period significantly increased from 21.6% to 35.5% in the G2010 period, and to 40.4% in the G2015 period (P for trend <0.0001); the overall proportion of cases with 1-month CPC 1–2 increased from 9.1% to 10.8% and 14.7%, respectively (P for trend <0.0001). Particularly, in patients receiving C-BCPR, CPC 1–2 rate significantly increased from 9.5% in the pre-G2010 period to 19.0% in the G2015 period (P for trend <0.0001). For all time periods, 1-month CPC 1–2 rate in the S-BCPR (17.2%) cohort was significantly higher than those in the C-BCPR (12.5%) and NO-BCPR (6.4%) cohorts (adjusted odds ratio [aOR] of S-BCPR compared with C-BCPR, 1.59; 95% confidence interval [CI], 1.25–2.01; P < 0.0001; compared with NO-BCPR, aOR 2.31; 95% CI, 1.82–2.94; P < 0.0001). No significant difference between S-BCPR and C-BCPR was found in 1-month CPC 1–2 rate for patients with non-traumatic origin (17.7% vs. 16.3%; aOR, 1.23, 95% CI, 0.95–1.59, all P >0.05). However, in patients with traumatic origin, S-BCPR was superior to C-BCPR (15.1% vs. 3.4%; aOR, 4.53, 95% CI, 2.39–8.61, all P <0.0001). During the 3 guidelines periods, the CPC 1–2 rate in patients with non-traumatic origin significantly increased from 11.8% to 19.7% (P for trend < 0.0001), but not in patients with traumatic origin (from 4.9% to 4.1%, P for trend = 0.29).

Conclusions: During the 3 guidelines periods, the rate of C-BCPR and 1-month CPC 1–2 increased by approximately 2-fold each over time. C-BCPR was associated with increased odds of 1-month CPC 1–2 similar to S-BCPR for children with non-traumatic origin but not in those with traumatic origin.

Background:

Knowing the prognosis of patients early is important to initiate appropriate care measures for each patient. The use of artificial intelligence techniques such as neural networks can be an advance in this type of analysis.

Aim:

To assess the usefulness of a neural network to determine the probability of admission of patients upon arrival at the emergency services.

Material and methods:

Multicentric prospective observational longitudinal study, january 21 and february 22, March 20th, Abril 24th, May 27th, 2019 (8: 00-22: 00) in four Spanish ED and had a triage level II or III according to the Spanish triage system (STS). It was considered that a patient fulfilled criteria to be included in the study if he had been attended by ED study and did not meet any exclusion criteria: <18 years, I, IV and V level in STS, pregnant women, psychiatric pathology, terminal pathotology or not sign the informed consent. Dependent variable: 30-day mortality. Independent variables: Factors: gender, suspicion of infection, triage level , high blood pressure, some alteration in consciousness. Co-variables: age, Charlson index (CI), systolic blood pressure (SBP) (mmHg), Heart rate (HR) (bpm), breathing rate, (BR) (BPM), oxygen saturation (OS) (%), temperature. Creation of a neural network SPSS 24.0 program using the multilayer technique, use of a random partition and batch training. Creation of an Area under the diagnostic performance curve (AUROC) and relative percentage in the created model of each variable used. The AUROC of the NEWS scale is also performed. 

Results:

N: 937; Average age 67.55 (19.47) years: female: 51.1% Summary of RN case processing: Training: 683 (72.9%); tests: 254 (27.1%). Number of hidden layers: 1, number of units in the hidden layer: 5; Activation function: Hyperbolic tangent; Layer of Activation function of the output layer: Softmax. Error Function: Cross Entropy. Correct training percentage: 96.8%, reserve percentage: 96.5%. AUROC of neural network created: 0.890. Normalized importance of the entered variables: age: 100%, BR: 76.4%, Sat O2: 69.3%, SBP: 58.8% .2%, CI: 56.9%, some alteration in consciousness: 52.4%, HR: 40.9%, gender: 33.4%, suspected infection: 20.9%, triage level: 17.5%, temperature: 15.8%, hypertension: 7.9%. AUROC obtained by NEWS scale: 0.744 (0.648-0.839) (p <0.001).

Conclusions:

The use of RN for the creation of mortality prediction models among patients arriving at ureteral services may be of great help in the future. The model created presents a great predictive capacity with some variables accessible in any emergency department, based on the patient's history and the constants on arrival. Relatively, age, BR, Sat O2, SBP and IQ are the variables with the greatest weight in the model that has been created. It highlights that it improves the NEWS scale in its predictive capacity.

Background: Continuous aerosolized albuterol therapy (CAA) is superior to intermittent albuterol for severe acute asthma exacerbations (AAE). Current practices dictate that continuous albuterol be administered only in the Pediatric Emergency Department (PED) or Pediatric Intensive Care Unit (PICU), which utilizes significant resources at high cost. However, increasing data support the safety and feasibility of CAA in other clinical settings.

Objective: To determine if CAA for children with severe AAE in a Pediatric Observation Unit (POU) may improve PED throughput and reduce the need for PICU admission.

Methods: We performed a retrospective chart review of children less than   After that time, those advancing to intermittent therapy remained in the POU, and those requiring continued CAA or with clinical deterioration were transferred to the PICU. Children requiring >48 hours of care were transferred to an inpatient unit. The PED course, overall length of stay (LOS), and number of patients requiring escalation of care were recorded.

Results: During the study period, 27,062 children were seen in the PED, resulting in 1,114 (4.1%) admissions to the POU. Of these, 284 (25.9%) were for AAE and 49 (4.4%) with severe AAE requiring CAA. Mean age was 9.3yrs (SD 5.0). 25 (51%) were male. In the PED, patients received 4 (IQR 3, 5) albuterol and 3 (IQ 2, 3) atrovent treatments; 100% received systemic corticosteroids, and 60.9% received magnesium sulfate. Following 6 hours of CAA, 15 (30.6%) were transferred to the PICU, and 34 (69.4%) were transitioned to intermittent albuterol therapy. Of these 24 (70.5%) were successfully discharged from the POU and 10 (29.4%) were transferred to an inpatient unit.  The average LOS for patients in the observation unit was 35.9 hours (SD 9.8). No patients were readmitted within 72 hours of discharge.

Conclusion: A majority of children with severe AAE avoided PICU admission following short-course CAA and were safely discharged within the timeframe of an observation admission (<72hrs). A POU may provide a valuable alternative setting for CAA in patients meeting appropriate clinical criteria.

Introduction

Northumbria Specialist Emergency Care Hospital (NSECH) is an acute hospital in Northumberland, UK. The triage system used in the emergency department (ED) at NSECH is unique. It is based on the Manchester Triage System (MTS) but is modified by certain physiological parameters at the time of presentation.

Aim

Our aim was firstly to test the ability of the NSECH triage system (NTS) to predict the true urgency of a presentation and secondly to compare it to internationally recognized triage systems. The triage systems selected for comparison were MTS, Emergency Severity Index (ESI), South African Triage Scale (SATS), Canadian Triage and Acuity Scale (CTAS) and Australasian Triage Scale (ATS).

Method

Every adult presentation to ED in one 24-hour period was retrospectively reviewed by ED physicians using electronic case notes. NTS score was recorded and each patient was retrospectively re-triaged using MTS, ESI, SATS, CTAS and ATS and given a triage category by each respective system. Triage categories indicate decreasing level of priority with P1 being the highest. National Early Warning Score (NEWS) at presentation (more deranged physiological variables result in a higher NEWS), admission to hospital and admission to intensive care were used as surrogate markers of need for urgent assessment.

Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each triage system for categorising patients with NEWS≥5, NEWS<2, hospital admissions or intensive care (ITU) admissions correctly as either high priority (P1 or P2) or low priority (≤P3).

Results

There were 218 adult attendances to ED in 24 hours. NTS categorised 24% patients as high priority. Sensitivity of triaging patients who required ITU admission as high priority was 100% with NTS, MTS, CTAS and ATS. As opposed to 75% by SATS and 50% by ESI. The PPV for NTS was 7.2% for ITU admission (% triaged as high priority who required ITU admission) and 52.9% for hospital admission. PPV for other systems ranged between 2.6% - 6%, and 44.8% - 57.2% for ITU and hospital admission respectfully. NTS is 92.9% specific for triaging patients with NEWS

Conclusion

This study shows NTS triages truly urgent patients, such as those requiring hospital and ITU admission, as high priority comparably to other widely used triage systems. NTS appears to outperform other systems in triaging non urgent cases as low priority. This is an important consideration given exponential increase in pressures facing Emergency Departments globally. Limitations include the sample size and the study’s retrospective nature. The re-triage process is limited by the quality of clinical documentation and inter-user variability. Future research should consider a larger prospective analysis comparing real time triage between different systems.

Background: This prospective observational study investigated the effect of the early administration of norepinephrine on cardiac performance in patients with septic shock.

Methods: 14 patients with septic shock were enrolled since January 2019 to January 2020 in the Emergency Department of the Careggi University Hospital. Patients needing vasopressors to maintain a mean arterial pressure (MAP) ≥ 65 mmHg after volume replacement were enrolled in the study. Norepinephrine was initially infused at a dose of 0.1 μg/Kg/min and was increased by the same value every 5' until a MAP≥65 mmHg was obtained. A complete transthoracic echocardiographic examination was performed before starting the norepinephrine infusion (T0), every 10 minutes, when the patient reached the pressure target (T-fin) and after one hour (T-1h). 

Results: the study population included 14 patients, mean age 75±14 years, 43% male gender, upon admission SOFA score 5.1±1.9. From T0 to T-fin, we observed a significant improvement (p<0.050) of the systolic function in terms of left ventricular ejection fraction (LV EF) [mean (sd): from 50(18) to 56(16) %], LV global longitunal strain (GLS) [from -12.4(3.0) to -14.0(4.1) %] and TAPSE [from 15(5) to 17(6) mm]. We did not observe significant changes of the diastolic function. The improvement of these parameters was maintained at T-1h.. Based on LV GLS, 11 patients improved their LV systolic function during NA infusion, while in 3 itworsened. We observed that patients who did not improve during NA infusion and those who did had a similar prevalence of a known history of LV systolic dysfunction 33 vs 36%), an equivalent LV EF  (42±0.5% vs 52±20%), LV GLS (-13.2±1.7 vs -12.2±3.3) and TAPSE (19±3 vs 11±5 mm, p=NS for all). Day-7 mortality rate was 33% in patients with and 9% in patients without improvement of LV systolic function.

Conclusion: in most patients, the early administration of norephineprine for the treatment of septic shock determined an improvement in left and right ventricular systolic function, which was maintained after one our of treatment. The same improvement in the above parameters was present in patients with baseline systolic dysfunction too. The increase of the ventricular preload, alongside a positive inotropic direct effect of norepinephrine due to the beta-receptor stimulation, determined the improvement and prevailed on the increase of the afterload.