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00:00 - 00:00 #23701 - 'Sim'plifying Sepsis.
'Sim'plifying Sepsis.

Background

High fidelity simulation based medical education is effective for training technical and non-technical skills. Sepsis is recognised as a life threatening condition that if recognised and treated early is potentially treatable. Missed sepsis is a significant cause of mortality worldwide with several high profile cases.

Compliance with the sepsis pathway in our urban Emergency Department was less than 30% in January 2019. We hypothesized that introducing a mandatory sepsis training programme including e learning and a simulation based training programme for all doctors in our Department would improve compliance with the sepsis pathway.

 

 

Aims

We introduced a standardised sepsis simulation training programme for all junior doctors in our ED (18). The programme included an online elearning module and a one hour simulation session.

The elearning module included a short test component that had to be passed.

The sepsis simulation was a standardised one hour in situ session that had learning outcomes including the recognition and declaration of a suspected sepsis diagnosis, institution of the sepsis six and adherence to the sepsis pathway. The participants actions and responses were monitored by an independent observer.

There was a short test component where doctors had to perform the sepsis six within 20 minutes in order to receive a certificate of completion of training. For consistency, the training was conducted by an Emergency Medicine Physician and a nurse clinical facilitator from the Emergency Department.

 

Methods

A retrospective audit of compliance with our sepsis pathway before and after introduction of the training programme was performed.

The audit was conducted between June and August 2019 inclusive and June and August 2020 inclusive.

The electronic care record/symphony database was searched using sepsis as a key word.

 

Results

June- August 2019

Total number of presentations to triage with sirs criteria n=98

Suspected source of infection chest 60% urine 30% other 10%

Average time to first dose antibiotics > 1 hour 80% < 1 hour 20%

500 ml fluid bolus given in < 25%

Intravenous (IV )access in 100%

IV lactate taken within 1 hour 65%

IV blood cultures taken within 1 hour 30%

Urinary catheter inserted in 10%

Urinary output monitored in 10%

 

June-August 2020

Pending

 

Discussion

Sepsis is a potentially life threatening condition that if recognised and treated promptly can be successfully treated. We hypothesized that introducing a mandatory training programme (an elearning module plus a practical simulation based session) for recognition and management of sepsis would improve adherence with our sepsis pathway. Results pending.

Victoria Claire MEIGHAN (Dublin, Ireland), April WALSH, Sandra HARTIGAN
00:00 - 00:00 #22838 - 24-hour fluid administration in emergency department patients with suspected infection - a prospective, descriptive, multicenter study.
24-hour fluid administration in emergency department patients with suspected infection - a prospective, descriptive, multicenter study.

Background

Fluid administration to patients with sepsis and septic shock has traditionally been regarded a cornerstone of treatment. Knowledge about fluid administration for patients with suspected infection and sepsis without shock is lacking, even though sepsis is 60 times more common than septic shock. We aimed to describe current fluid administration practices in Emergency Department (ED) patients with suspected infection.

 

Methods

This study was a multicenter, prospective, observational study investigating early fluid administration practices in ED patients with suspected infection.  Consecutive patients were included from Jan 20th through March 2nd 2020 at Aarhus University Hospital and two regional hospitals (Randers and Herning). Suspected infection was defined as ordering of a blood culture and/or intravenous antibiotics within 6 hours of admission to the ED.

Oral and intravenous fluids were registered for 24 hours on a paper case report form. The primary outcome was the total amount of fluid within 24 hours.

 

Results

Preliminary data from the first 362 patients show that the median volume of administered fluid was 1300 ml. (1. and 3. quartile: 975;1950) within 6 hours and 3175 ml. (1. and 3. quartile: 2100;4325) within the first 24 hours, equivalent to 18 and 42 ml/kg bodyweight, respectively. Peroral fluids accounted for 400 ml. (1. and 3. quartile: 150;850) within 6 hours and 1450 ml (1. and 3. quartile: 800;2200) within 24 hours. The remaining data is being processed and will be presented at EUSEM 2020.

 

Conclusions

Preliminary data indicate that ED patients with suspected infection receive a large volume of fluid within the first 24 hours.  This study will add important knowledge about fluid resuscitation in patients with suspected infection and sepsis without shock. The results will provide data for the design of a randomized feasibility trial investigating two fluid strategies in patients with sepsis without shock.

Marie Kristine JESSEN PEDERSEN (DK-Aarhus, Denmark), Sofie KILDEGAARD, Poul PETERSEN, Anders PERNER, Jens Aage Kølsen PETERSEN, Lars Wiuff ANDERSEN, Hans KIRKEGAARD
00:00 - 00:00 #23153 - 3,4-Methylenedioxymethamphetamine (MDMA) Toxicity in the Emergency Department.
3,4-Methylenedioxymethamphetamine (MDMA) Toxicity in the Emergency Department.

Case Report 

 

A 20-year-old previously healthy male patient brought in by ambulance to the emergency department was found actively seizing inside a house in which his friends admitted taking MDMA with alcohol.

 

In the ED he was Able to maintain clear airway with no secretion, Increase work of breathing, Heart rate 150 beats/minute, blood pressure 90/45 mmHg, capillary refill time 3 seconds. GCS 11/15, severe agitation, hyperreflexia, and myoclonus were present. Temperature 40 °c recorded.

ECG showed signs of hyperkalemia (ECG attached). 

 

Diagnosis of serotonin syndrome established.

 

Ice packs covered the patient, IV normal saline and diazepam in order to reduce the temperature. Dextrose insulin infusion with Ca gluconate 10 ml 10% to control hyperkalemia.

 

Patient intubated and hemodialysis as K after treatment was 8.3 mmol/L, stayed in ICU for four days then RIP with INR of 4.8.

 

 

Learning points 

 

1. Peaked T wave, Wide QRS, Absence of P wave, and Sinewave pattern (wide QRS merge with the T wave) are signs of hyperkalemia in the ECG.

 

2. MDMA causes toxicity by the release of serotonin, noradrenaline and, to a lesser extent, dopamine.

 

3. Features of serotonin syndrome: 

 

                 S     Spontaneous clonus.  

                  H   Hypertonicity, Hypertension or Hypotension, Hyperthermia.

                  O    Ocular clonus.

            

                  T     Tremors, Tendon reflex increased. 

                 

                  S     Sweating, Struggling (agitation).

 

 

4. Rapid intervention recommended for the hyperthermia 

 

5. Death usually is due to hyperpyrexia induced multi-organ failure.

 

Conclusion 

 

We presented a case of MDMA toxicity complicated with serotonin syndrome, managed in the ED for hyperthermia, hyperkalaemia and agitation. Care continued in the ICU but unfortunately, did show fruitful recovery.

Dr Mohamed SULTAN (Limerick, Ireland)
00:00 - 00:00 #22855 - 30-day mortality of elderly medical patients after short-term acute admissions in Denmark – a nationwide cohort study.
30-day mortality of elderly medical patients after short-term acute admissions in Denmark – a nationwide cohort study.

Background. A growing number of older people with need of acute hospitalizations are expected in the future. Short hospital stays for elderly patients could reduce costs, crowding, and risk of adverse events related to hospitalization. However, mortality of elderly patients after early discharge from hospitals is sparsely described. Therefore, the aim of this study was to examine the 30-day mortality rate among elderly medical patients discharged ≤24 hours after admission, and to examine the impact of demographic factors, comorbidity and admission diagnoses on mortality. 

Methods. All medical patients ≥ 65 years admitted acutely to Danish hospitals between 1 January 2013 and 30 June 2014 surviving a hospital stay of ≤24 hours were included. Data on mortality within 30 days, comorbidity, demographic factors and reasons for admission (discharge diagnoses) were obtained from the Danish National Registry of Patients and the Civil Registration System. We used Cox regression to estimate adjusted hazard ratios (aHRs) with 95% confidence intervals (CI) for mortality. We examined potential predictors of 30-day mortality including age, gender, Charlson Comorbidity Index score (CCI), marital status, and discharge diagnosis.  

Results. A total of 93,271 patients (49.5% male) with a median age of 75 years (interquartile range: 69-82 years), were acutely admitted with a medical diagnosis and discharged within 24 hours. A total of 2,749 patients (3.0%; 95% CI 2.8-3.1%) died in the 30-day period following discharge. The age groups (65-75 years as reference) 76-85 years (aHR 1.60; 1.45-1.75) and 86+ years (aHR 3.40; 3.04-3.70), male sex (aHR 1.24; 1.14-1.34), a Charlson Comorbidity Index (0 as reference) of 1-2 (aHR 2.17; 1.94-2.42) and 3+ (aHR 4.11; 3.69-4.59), and unmarried status (aHR 1.17; 1.08-1.28) increased the risk of 30-day mortality. Discharge diagnoses associated with increased risk of 30-day mortality were heart failure (aHR 1.50; 1.16-1.94), respiratory failure (aHR 2.79; 2.13-3.67), dehydration (aHR 2.89; 2.52-3.32), constipation (aHR 1.32; 1.03-1.68), anemia (aHR 1.47; 1.28-1.67), pneumonia (aHR 2.24;1.93-2.59), urinary tract infection (aHR 1.33; 1.14-1.55), dyspnea (aHR 1.50; 1.25-1.79) and suspicion of malignancy (aHR 2.08; 1.65-2.61). The symptom-diagnoses chest pain (aHR 0.31; 0.22-0.43), headache (aHR 0.20; 0.07-0.64) and vertigo (aHR 0.33; 0.21-0.52) were associated with a reduced risk of 30-day mortality. 

Discussion and Conclusions. Three percent of the acutely admitted medical patients aged ≥65 years died within 30 days after early discharge. High age, male gender, the comorbidity burden, unmarried status and several primary discharge diagnoses were identified as predictors of 30-day mortality. The results of our study should be considered in future research and planning of the discharge process of elderly patients. 

Martin AASBRENN, Christian Fynbo CHRISTIANSEN, Buket ÖZTÜRK, Charlotte SUETTA, Finn Erland NIELSEN (Copenhagen, Denmark)
00:00 - 00:00 #22759 - A Bechet’s disease patient presented as Sinus of Valsalva aneurysm.
A Bechet’s disease patient presented as Sinus of Valsalva aneurysm.

Brief clinical history:

     A 28-year-old male presented at our emergency department (ED) due to productive cough, mild dyspnea and intermittent fever for 3 days. Physical examination revealed coarse breathing sound and his chest x ray (CXR) showed increased lung marking at both lower lung fields. Bronchopneumonia was diagnosed and oral form antibiotics was given. Because of feeling mild dyspnea, he stayed in our observation section. 

    During the observation, he presented worse dyspnea and cyanosis in about 20 hours later. The CXR revealed air-space fillings and infiltrates in both lung fields. We placed endotracheal tube. Severe aortic regurgitation (AR) was diagnosed on the echocardiography. The chest computed tomography (CT) revealed dilated aortic root (maximal diameter about 4cm). Sinus of Valsalva aneurysm with severe AR and pulmonary edema was diagnosed, and the patient had received emergency aortic valve and sinus of Valsalva aneurysm repair. 

    After repair surgery, his condition was improved smoothly. However, scrotal ulcer, hyperpigmentation over lower limbs and recurrent oral ulcer were noted. Antinuclear antibody, Anti-ds DNA, Anti-SmD3, Anti-RNP, Complement C3c and C4 were all negative. Bechet’s disease (BD) was diagnosed, and we provided Prednisolone and Colchicine. After discharged, he was doing well at two-year follow-up untile now. 

Misleading elements:

The patient had productive cough, mild dyspnea, and fever for 3 days. The CXR showed increased lung marking at both lower lung fields. Therefore, we thought the symptom of dyspnea was just caused by lung infection. 

Helpful details:

Severe AR was diagnosed on the echocardiography. The CT revealed dilated aortic root (maximal diameter about 4cm). These all helped us to diagnose SOVA. 

Differential and actual diagnosis:

Sinus of Valsalva aneurysm (actual diagnosis), acute respiratory distress syndrome, myocarditis or endocarditis with heart failure and pulmonary edema.

Educational and/or clinical relevance: 

    Sinus of Valsalva aneurysm (SOVA) is an abnormal dilatation of the aortic root area between the aortic valve annulus and the sinotubular ridge, and can be either congenital or acquired. Vasculitis is one of the etiologies of acquired SOVA. The patient has Bechcet’s disease, which is an immune-mediated vasculitis affecting vessels of all sizes, may be the reason why he has SOVA. BD can be recognized only by clinical finding, and the International Study Groups for BD criteria (oral ulcer plus any two of recurrent genital ulcer, typical eye lesions, cutaneous lesion, or a positive skin pathergy test) is the most commonly used diagnostic tool. Therefore, detail history taking and physical examination are very important for diagnosing BD. BD with involvement of the heart is called Cardio-BD, and James et al. demonstrated SOVA was the leading causes of death. Non-ruptured SOVA is usually asymptomatic, but 30% to 50% of SOVA is associated with significant AR. The patient had lung infectious symptoms, which might exacerbate the symptoms of AR. Surgical intervention is recommended for SOVA with significant AR or a ruptured SOVA. Surgical mortality ranges from 1.9% to 3.6%, and survival rate is closed to 90% after 15 years. Therefore, early surgical intervention should be considered before worsening symptoms.

Yu Ying LIAO (Tainan, Taiwan, China), Hung-Sheng HUANG
00:00 - 00:00 #23428 - A case of A Giant Abdominal Aortic Aneurysm.
A case of A Giant Abdominal Aortic Aneurysm.

Giant Abdominal Aortic Aneurysms are  defined as having a diameter of more that 13cm. This is a case report of a patient presenting a 19cm AAA to the Emergency Department. Only few cases have been described in the literature before, this can be ascribed to the high rupture rate of 30-50% yearly.

A 93yo male presented to the Emergency Department with 1/7 history of left sided abdominal pain associated  with nausea and vomiting. His medical history include hypertension, heart failure, atrial fibrillation and diverticulosis. He was on Apixaban for his atrial fibrillation. Patient further had history of AAA for which he had EVAR (right to left fem-fem cross over) done in 2005 with realignment 2012. At his last review in the Vascular Surgery Clinic in October 2018, aneurysm size was 12 cm with stable endovascular leak. The decision was made at that time that the patient was not for any further surgical intervention after discussion with the patient and his family.
During the current presentation patient had persistent left sided abdominal pain despite analgesia. Vitals were stable with a blood pressure of 121/61, pulse 50, temperature 36.2 C, respiratory rate 20, saturation on room air 97% and blood glucose 8.2. Physical examination revealed patient to be jaundiced with mild pallor. On abdominal examination he was found to have a large, hard abdominal mass which was diffusely tender but non pulsatile. Laboratory tests showed haemoglobin 9.7 (13.3 – 16.7), haematocrit 0.310 (0.390 -0.5), platelets 126 (144 – 138), International Normalised Ratio 1.3, Total Bilirubin 46 and C Reactive Protein 30.2. A CT Abdomen revealed a massive abdominal aortic aneurysm measuring up to 19cm in diameter with high density fluid adjacent to the aorta suggestive of an acute leakage. His scan was discussed with the vascular surgery team at the University Hospital the decision was made that the patient was not for surgical intervention, patient and his family was counselled regarding the expected course of his disease. He was treated for his persistant pain and referred for Palliative treatment. The patient was discharged into the care of his family. He passed away 5 days after discharge.

Endovascular repairs of abdominal aortic aneurysm (AAA) and endoleaks have been reported in 20 to 50% of patients.  It is usually diagnosed with CT on regular follow up or completion  CT arteriography immediately after EVAR. Management of Endoleaks can be difficult and challenging. Intervention is not warranted for endoleak persistence alone.

This a unique case of a patient with known endovascular leak following initial EVAR in 2005 and revision in 2012. His last scan showed AAA increased to 12cm. He now presented with a giant AAA measuring 19cm following acute leakage.   Despite this the patient was haemodynamically stable and only complaining about abdominal pain .Given the long time the patient survived despite the ongoing endoleak, more considerations should be given to the expectant management of endoleak following EVAR for AAA instead of intervention. 

Sunel ODENDAAL, Suleiman ALTAYEB, Kiren GOVENDER (Galway; Ireland, Ireland)
00:00 - 00:00 #22183 - A case of acute facial edema caused by superior vena cava syndrome mimicking angioedema.
A case of acute facial edema caused by superior vena cava syndrome mimicking angioedema.

This is a 78 years old man who had old cerebral infarction with left hemiparesis and stayed in the nursing home for few years. He was discovered acute facial edema by the caregiver one day in the morning and brought to our emergency department and was told normal last night. He had mild shortness of breath without cough, and didn't take any new medication or new foods recently.

Physical examination revealed edematous change of his face, eyelid, and lips. There were no distended jugular vein or itching skin rash. He had normal breathing sound on auscultation. There were no edema of extremities.

We treated him as angioedema, however, we still took blood exam and chest radiograph because of irrelevant history of angioedema. The lab data was insignificant, but chest radiograph showed widened mediastinum and right upper lung hazziness. This made us to do further image study; we performed point of care ultrasound (POCUS) first and found distended right external jugular vein with echogenic thrombus, few B lines in the right upper lung and minimal right side pleural effusion. Then the subsequent computed tomography(CT) disclosed a huge mediastinal tumor, by whiich the superior vena cava(SVC) was encased. So the acute facial edema was caused by SVC syndrome not angioedema. After admission, the CT guided biopsy proved small cell lung cancer.

What we’ve learned from this case is that typical signs expected in the SVC syndrome such as distended neck veins, distended chest wall vein collaterals, upper extremity swelling were not seen in our case. It was the irrelevant history and lack of other dermatologic signs in angioedema that made us to do more tests.

POCUS helped us to detect distended external jugular vein with thrombus, which weren't seen on the physical examination. It strenghthened and proved our thought about SVC syndrome. We think in case of acute facial edema, more tests should be done when the diagnosis is in doubt, and POCUS may be a good choice.

Borhen WU (Taipei, Taiwan, China)
00:00 - 00:00 #23381 - A Case of Adult Laryngotracheobronchitis -Adult Croup, Presence of Steeple/Wine Bottle Sign.
A Case of Adult Laryngotracheobronchitis -Adult Croup, Presence of Steeple/Wine Bottle Sign.

Case presentation

A 29 years old female presented in the emergency department with one day history of increasing short of breath, difficulty in breathing, increased dust reported in house. Since last night patient complaint of increasing coughs spasms with barking element, couldn’t handle at home in current situation. Used Becolomethasone inhaler (as ventolin ran out). Called ambulance ,received salbutamol with no improvement.

SHe has background history of asthma, on becolomethasone and Ventolin inhalers, with mitrzapine for depression.

On examination, she was sitting upright in bed, visible short of breath, using her accessory muscles, evident severe barking cough with bronchospasms. Hoarse voice noted no evident stridor on presentation.

Looks tired and lethargic, maintaining her oxygen saturation of 95% on RA. Pulse 105, BP 135/70.Temp 36C. Chest fine expiratory wheeze. No visible swelling of Uvula or visible pharynx noted. Rest systems were unremarkable

ABG on Room air showed PO2 of 13, PCO2 was 3.68 and Ph was 7.48, lactate was 1.2. All routine bloods including inflammatory markers sent. Chest and neck x-ray requested to see any inflammatory changes and to see suprglottic tracheal narrowing.(steeple sign).

Patient was treated initially with routine nebulisers, steroids and oxygen. Showed no improvement. Then treated with Epinephrine nebuliser and humidified oxygen.( Heliox not available). Very ShortlyAfter last treatment patient showed marked improvement in her presenting symptoms, especially. Her severe bronchospasms, barking cough,and hoarse voice, improved markedly. Work of breathing (acessory muscles)has been reduced greatly. Medical, intensive care and ENT teams consulted for backup plan. Patient was very satisfied with treatment provided to her in the emergency department.

Her inflammatory makers, UE’s were all within normal limits, Chest x-ray was normal and AP neck x-ray revealed “steeple or wine bottle sign” (fig1).Para influenza A & B were both negative.

Patient was then admitted under medical team for further management and investigations.

Patient didn’t require further escalation of treatment to intensive care unit, after treatment given in the emergency department. Seen by ENT consultant later (after treatment in the emergency department) for her airway assessment and it was found to have  resolution of subglottic oedema which was seen earlier on AP neck x-ray. During stay in medical unit, she was on regular nebulisers, steroid, humidified oxygen and close observations. With Complete resolution of her symptoms next day, she was discharged home on steroids, her routine inhalers to continue and RAST allergen test results to follow. Further Viral screening didn’t performed by medical team as it won’t change the treatment.

Patient been called next day about her condition after discharge from hospital, she was feeling very good and was very happy with the treatment given to her in the emerency department.

 

Educational/Clinical Relevance: Croup is not common in adult age group patients.Our case will be edition to previous reported cases of adult croup, Excellent history ,examination and differential help us differential her presentation from routine asthma presentation.

Muhammad Zeeshan AZHAR (Barrow in Furness, ), Paul GROUT, Asish CHATTERJEE, Mohamed SHIRAZY, Raj KONDRAGUNTA, Julius MANOHARAN
00:00 - 00:00 #21735 - A case of bottle gourd (Lagenaria siceraria) juice poisoning.
A case of bottle gourd (Lagenaria siceraria) juice poisoning.

A 52 year old woman presented to the ED with complaints of severe upper abdominal pain, multiple episodes of vomiting and fresh blood in vomitus since the morning.  She presented with weak pulse with a rate of 70/minute, systolic BP recorded was 70 mmHg, respiratory rate of 18/ minute, Saturation of 100% on room air, Temperature of 980F, random sugar of 100 mg/dL. Her abdomen examination revealed a soft abdomen with epigastric tenderness. No organomegaly was appreciated. Rest of the systemic examination was unremarkable. 

The episode had begun after she had consumed Bottle gourd juice. Patient was given intravenous Omeprazole, Ondansetron and Hyoscine. She was given 2 litres of isotonic normal saline and a Ryle’s tube was inserted for Gastric lavage. After adequate fluid resuscitation the blood pressure was recorded as 140/100 mmHg. The patient underwent emergent endoscopy which revealed Grade – A Esophagitis with pangastritis with severe duodenitis. The patient was managed by the Gastroenterology team with intravenous fluids, antibiotics, antiemetics, antacids and discharged in a stable condition after 4 days. In Ayurveda, bottle gourd is advocated for treatment of diabetes mellitus, hypertension, flatulence,cooling properties, liver diseases, weight loss and other associated benefits. In recent times it has been unearthed that Bottle gourd juice which becomes bitter can cause severe toxic reactions and lead to symptoms such as pain abdomen, vomiting, diarrhea, hematemesis, hematochezia, shock and death. It is important not only for the general population but for Emergency medicine physicians too, to be aware of this uncommon presentation and recognize it without delay especially in our country where traditional medicine is widely prevalent

Ankur VERMA, Shivani SARDA (Delhi , India, India), Sanjay JAISWAL
00:00 - 00:00 #23227 - A case of Cavernous sinus thrombus in an immune thrombocytopenia (ITP) patient , uncommon complication and atypical presentation.
A case of Cavernous sinus thrombus in an immune thrombocytopenia (ITP) patient , uncommon complication and atypical presentation.

Severe headache in a case of immune thrombocytopenia with low platelet count on presentation, CT images showed cavernous sinus thrombosis which is related to (Eltrombopag) the medication that she is taking to increase the platelet synthesis, the management options included IVIG, steroids and heparin infusion along with platelet transfusion, the patient improved and was discharged after 15 days of admission to our hospital.

Adel Ahmed Fraij ZAHRAN (Doha, Qatar), Mohamed Yassin MITWALLI
00:00 - 00:00 #23379 - A case of late-diagnosed congenital hip dislocation.
A case of late-diagnosed congenital hip dislocation.

A 30 years old patient presented to our Emergency Department for chronic left hip pain. The patient described a problem of limping which was persistent since childhood, and which had been attributed to an injection having caused a neuromuscular lesion. The clinical examination showed a depression at the level of the left buttock, with a loss of substance, and pain at the mobilisation of the left hip. The X-ray film showed an hypoplasia of the left pelvis, a disappearance of the femoral head, and a complete hip dislocation with dysplasia of the acetabular rim. The patient has been subsequently referred to the Orthopedics department of our Hospital. A dislocated hip is not always apparent during the initial newborn screening examination, and a followup is normally necessary when a hip dislocation is suspected. With early detection and treatment, most of the affected children will develop functionally and radiologically normal hips, however it is still possible to encounter congenital hip dislocations that have not been correctly diagnosed during childhood.

Gaia BAVESTRELLO PICCINI (Brussels, Belgium), Jean-Christophe CAVENAILE
00:00 - 00:00 #23310 - A case of severe bronchospasm induced by human metapneumovirus in an adult.
A case of severe bronchospasm induced by human metapneumovirus in an adult.

Consent:

Informed written consent to publish this case report with maintaining the anonymity has been obtained from the patient 

Case Presentation:

A 66-year-old truck driver, presented with severe shortness of breath and inability to complete a sentence. He had a cough for two days before the presentation. Regarding his past medical history, he had hypertension, and hypothyroidism for which he was taking Levothyroxine however; he was not on any antihypertensive medications.

On examination, he was alert, the airway was patent, the chest was severely wheezy bilaterally, SPO2was 93% on room air, and respiratory rate was 35 breath/ minute. Additionally, his blood pressure (BP) was 210/110 mmHg, heart rate was 110 beats/ minute, capillary refill time was 1 second, and the temperature was 36.8 degrees Celsius. 

Intravenous access was inserted and blood was collected for FBC, U&Es, LFTs, and troponin. Besides, throat and nasopharyngeal swabs were sent for film array respiratory panel.

The patient was managed as acute severe asthma versus hypertensive induced cardiac asthma. Accordingly, back to back nebulisers with salbutamol and ipratropium bromide, intravenous hydrocortisone, and magnesium sulphate in addition to glyceryl trinitrate (GTN) intravenous infusion were administered.

Chest x-ray showed bilateral clear lung zones with normal mediastinum.

After forty minutes the patient settled down. Follow up examination revealed BP 150/89 mmHg, heart rate 87 beats/ minute, respiratory rate 20 breaths/minute, SPO2 100% on room air and the wheezes resolved.

However, blood results were within the normal range, the film array respiratory panel detected human metapneumovirus.

The patient was then admitted to the acute medical unit under the diagnosis of severe bronchospasm induced by human metapneumovirus.

Clinical relevance:

This case describes a rare and atypical presentation of severe bronchospasm in adults induced by human metapneumovirus.

Human metapneumovirus is a common cause of upper and lower respiratory tract infection that can induce severe bronchospasm.

 

Mohamed SHIRAZY (Armagh, United Kingdom), Raj KONDRAGUNTA, Muhammad AZHAR
00:00 - 00:00 #23466 - A case report of bilateral quadriceps tendon rupture.
A case report of bilateral quadriceps tendon rupture.

Patient consent obtained.

Brief clinical history
A 63-year-old male was brought to the Emergency Department (ED) with suspected bilateral patella dislocation. While stepping out of a water pond requiring a leg elevation of approximately 18 inches, his right leg gave way and whilst placing his left leg out to catch himself, it too gave way. He described a ‘snap’ followed by bilateral anterior thigh pain.

His history preceding the event was unremarkable; he denied previous leg pain or injury and he had not sustained any dislocations or tendon injuries in the past. He had no past medical history, including no regular medication and no allergies. He worked as a refrigerator repair technician; notably this involved spending long hours on his knees. He was a current smoker with a 20 pack/year history and consumed two units/day of alcohol and denied using illicit drugs.

On examination his observations were normal. He had a slightly raised body mass index (BMI) of 25.7kg/m2. Both patellas were central and not displaced with a distinct palpable gap superior to the patellas which was made more prominent with attempted quadriceps contraction. He was unable to perform knee extension. Otherwise, he had a normal neurovascular examination in both lower limbs; plantarflexion and dorsiflexion of both ankles were intact. Other systems were unremarkable on examination and no other injuries were identified. A bilateral quadriceps tendon rupture (BQTR) was suspected and supported by x-ray findings. He was subsequently referred to orthopaedics who confirmed the diagnosis.

Misleading elements
A diagnosis of tendon rupture was initially not considered as the primary diagnosis given that the mechanism of injury was of minimal trauma in a previously fit gentleman. Quadriceps tendon rupture in itself is a rare diagnosis, and the presentation of bilateral rupture is exceedingly rare. The patient had none of the recognised risk factors for BQTR which include obesity, diabetes and chronic renal failure.

Helpful details
The crucial factors that lead to the correct final diagnosis for this unusual presentation were a thorough examination, keeping wide differential diagnoses and x-ray imaging confirming BQTR.

Differential and actual diagnosis
The paramedics initially suspected bilateral patella dislocation. Other differential diagnoses included patella fracture, tendon or ligamentous injury. The final diagnosis was confirmed intraoperatively as complete BQTR.

Educational and clinical relevance of the case
BQTR is often missed, leading to delayed surgical repair and a poorer prognosis. Magnetic resonance imaging (MRI) is recognised as the gold standard imaging modality for tendon rupture however in ED, ultrasound (US) is readily accessible and also offers a high sensitivity. Whilst there are recognised risk factors, it is important to keep in mind that the presentation of BQTR often occurs with minimal trauma in previously well patients.

Miguel Jose RIBEIRO DA COSTA (London, United Kingdom), Natalie Strachan MURRAY
00:00 - 00:00 #22753 - A case report of posterior shoulder dislocation: an uneasily indentified disease.
A case report of posterior shoulder dislocation: an uneasily indentified disease.

Brief clinical history

A 37-year-old female presented to our emergency department after motorcycle crash into a dog in the evening. The event happened because she couldn’t stop the motor while the dog suddenly ran into the road. The crash threw her off the motorcycle and then her left shoulder directly hit to the ground. On arrival, her vital signs were as follows: body temperature 36.5℃, heart rate 89 beats/min, blood pressure 106/68 mmHg, and respiratory rate 18 breaths/min. She was conscious and oriented but complained of pain and inability to move left shoulder. She denied the history of initial loss of consciousness, vomiting or alcohol intake. She had no medical history. Left posterior shoulder dislocation was diagnosed and then close reduction was performed. Afterward, she was discharged with sling fixation.

 Misleading elements:

Non-standard radiographic view.

 

Helpful details 

The physical examination showed tenderness and restriction over left shoulder, an obvious palpable gap over left glenohumeral joint, and multiple abrasions over both of forearms, knees and right lower leg. Other system examination was unremarkable. Antero-posterior radiograph of both clavicle view revealed positive lightbulb sign on left humeral head. Left scapular Y view showed equivocally abnormal position between humeral head and glenoid and also revealed left acromion linear fracture.

 

Differential and actual diagnosis

Contusion of shoulder.

Anterior shoulder dislocation.

Rotator cuff tear.

Posterior shoulder dislocation.

 

What is the educational

The shoulder dislocation is the majority of dislocated diseases presenting to hospital.  Most of them are anterior shoulder dislocation, which is common and easy to indentify. However, posterior shoulder dislocation which accounts for 2-4% of total shoulder dislocation cases is occasionally undiagnosed on initial presentation by inexperienced doctors. Doctors could use several special radiological signs to determine if patients have posterior shoulder dislocation. An axillary radiographic view is the idea image to make out a posterior dislocation, although patients sometimes do not follow the special position. Lightbulb sign is one of radiographic sighs of posterior dislocation to show lightbulb shape on the head of the affected humerus while the radiography is done from antero-posterior view. A normal scapular Y view shows the image which the humeral head overlies the glenoid and is located at posteriority of the glenoid. However, the scapular Y view of a posterior shoulder dislocation is an image that humeral head uncovers but instead of is more posterior from the glenoid. Other special radiolographic views, including of trough line sign, loss of normal half-moon overlap sign, rim sign, and etc., could indentify posterior shoulder dislocation as well. As emergency physicians, posterior shoulder dislocation should be kept in mind.    

Hung-Sheng HUANG (Taiwan, Taiwan, China), Chien-Chin HSU, Yu-Ying LIAO
00:00 - 00:00 #22444 - A case series report of post traumatic infarct- diagnosed in ED with repeated clinical examination.
A case series report of post traumatic infarct- diagnosed in ED with repeated clinical examination.

ABSTRACT

Post-traumatic cerebral infarction (PTCI) is one of the most severe secondary insults after traumatic brain injury (TBI), and is known to be associated with poor outcome and high mortality rate.Seven patients presenting to our ED with h/o RTA had a normal CT brain on initial evaluation and within 4-7hours patient had clinical symptoms of hemiplegia and repeat CT brain post 6 hrs of the initial CT showed acute infarcts. HENCE We assessed the practical incidence and risk factors for the development of PTCI in patients with normal CT brain in initial evaluation followed by ED residents to repeat clinical CNS examination and finding out the presence of classical symptoms and signs of CVA which was absent in the initial evaluation.

INTRODUCTION

Posttraumatic cerebral infarction (PTCI) is a known complication of craniocerebral trauma. A variety of mechanisms may account for this complication, including cerebral vasospasm, vascular compression, or attenuation due to adjacent mass effects producing cerebral displacement/herniation, direct vascular injury, embolization, and systemic hypoperfusion. Infarction of the occipital pole following compression of the posterior cerebral artery (PCA) by the herniating medial temporal lobe is perhaps the most well-recognized mechanism leading to PTCI . The precise frequency with which cerebral infarction complicates craniocerebral trauma and its influence on mortality are not well established.

METHODOLOGY

In The months of august to january - 7 patients presented to our ED  were diagnosed with post traumatic infarct these  patients underwent initial computed tomography (CT) in the Emergency Department, and then they underwent subsequent CT surveillance during admission. The admission CT revealed no abnormality and the subsequent low-density area is compatible with patients showing an acute onset of corresponding clinical signs and symptoms. We analyzed also neurological status in terms of Glasgow coma scale (GCS) score,repeated  cns examination and signs of brain herniation and duration from accident to onset of cerebral infarction.

OBSERVATION

All patients were evaluated and treated according to the guidelines for the management of severe head injury. Neurological assessment was performed using the GCS score, pupil size and reaction. And repeated cns examination by the residents while the patient is in ed was one of the diagnostic criteria for the patient to undergo repeat ct even though there was no decline in gcs of the patient has lead to the diagnosis of acute infarct in post traumatic patient.

CONCLUSION

seven patients presenting to our ED with h/o RTA had a normal CT brain on initial evaluation and within 4-7hours patient had clinical symptoms of hemiplegia and repeat brain imaging post 6 hrs of the initial CT showed acute infarct. HENCE We assessed the practical incidence and risk factors for the development of PTCI in patients with normal CT brain in initial evaluation followed by ED residents to repeat clinical  examination and finding out the presence of classical symptoms and signs of CVA  which was absent in the initial evaluation

Solaipandian MADHUMATHI, Dr Jena NARENDRA NATH (MADURAI, India)
00:00 - 00:00 #23226 - A cloudy noise in your heart.
A cloudy noise in your heart.

A 61-year-old male patient with no history of interest. He came to the emergency department for presenting a 20-day evolution evening fever, as well as night sweats. Polyarthralgias and anorexia appeared over the days. No cough or expectoration. No abdominal pain, no voiding syndrome. No general discomfort (had not stopped working). No dental interventions or recent trips. New couple for the last 2 months.

Physical examination. Vital signs:Tª39ºC,HR 112 bpm, BP 139/83,SpO2:98%

Physical exam: Conscious and oriented, isocoric and normoreactive pupils. Cranial pairs without alterations. Cardiac auscultation with a systolic murmur IV / VI in aortic focus, not irradiated (not known or present in previous reports). Preserved vesicular murmur. Abdomen: Soft and depressible, no pain. No lymph nodes were palpable in the neck or armpits.

 

With this symtoms and signs the history of a new partner, an infectious cause is considered: infectious endocarditis, sexually transmitted disease, neoplasms such as lymphoma or connective tissue diseases, especially systemic lupus erythematosus.

Clinic history. Treatment and action plans:

Complementary Tests

- General analytics. Hemogram, coagulation and renal and hepatic function with 9.48 mg/dL of CRP.

- Urine sediment. Normal.

- Chest radiography: Normal.

- Blood and urine cultures were performed.

 

Paracetamol is prescribed and the patient improved. We decided admission because we had  high suspicion of  bacterial endocarditis.

We started antibiotic treatment with ceftriaxone 2 grams per vein while waiting for culture results. The day after, blood cultures were positive and they showed us  growth of S. sanguinis. After that a transesophageal echocardiogram was performed with images of vegetations in the aortic valve. Surgical intervention is performed with correct evolution.

Conclusions

It is so important that the emergency physician in the clinical history and in the differential diagnosis with symptoms that can be explained by patients in the emergency department. All of these, add to signs and vital signs, can be use to do a good diagnosis and the best treatment in all situations.

The diagnosis of bacterial endocarditis is significant because its complications. We must think about it with any finding of unknown fever in the last days, without focus and with a new onset murmur.

A good medical history and a good physical examination is essential for a wide differential diagnosis and to be able to guide patients in the best possible way and to admit if it is necessary.

Juan ORTEGA PÉREZ (PALMA DE MALLORCA, Spain), Meritxell VIDAL BORRÀS, Bernardino COMAS DÍAZ
00:00 - 00:00 #23214 - A comparison of the clinical features of patients with severe influenza and severe COVID-19: A retrospective study.
A comparison of the clinical features of patients with severe influenza and severe COVID-19: A retrospective study.

OBJECTIVE The clinical characteristics of COVID-19 and influenza are similar. We aimed to explore the differences in clinical characteristics between severe COVID-19 and influenza to help early screening of these two diseases.

Methods In this retrospective studysevere laboratory-confirmed cases of COVID-19 from January 31 2020 to February 25 2020 and severe influenza cases from December 31 2016 to January 20 2019 in Sichuan Province (China) were included. The primary outcome was the mortality rate, and the secondary outcomes were clinical, laboratory, radiological features.

Results 62 patients with severe COVID-19 and 784 patients with severe influenza were included. 29 (46.8%) patients with COVID-19 and 227 (36.5%) patients with influenza were female. Patients with influenza [6048-74]were older than patients with COVID-19[4937-65]       P=0.000, and the percentage of people over 65 years old was much higher in patients with influenza [42.8% vs 22.6%, P=0.002]. there was no difference between the distribution of the underlying diseases in two groups [P0.05], while hypertension was the most common disease in both groups. Clinical symptoms of COVID-19 and influenza were mainly respiratory symptoms, and the most common clinical manifestations at onset of COVID-19 and flu include fever [51.6% vs 77.3%, P=0.000], Upper respiratory symptoms [3.2% vs 18.0%, P=0.003], respiratory symptoms [64.5% vs 90.7%, P=0.000]. 251 patients (40.4%) with influenza had extra-pulmonary symptoms, which was much higher than cases with COVID-19 [7 (11.3%)]. As for the laboratory parameters, parameters like CRP, WBC, LYMPH%, RBC, BUN were not significantly different (P0.05). The results of chest CT scans were significantly different in exudation (78.8% vs 17.7%, P=0.000), consolidation (18.8% vs 0, P=0.000), nodule (36% vs 0, P=0.000), effusion (21.7% vs 1.6%, P=0.000). The mortality was 4.5% in patients with influenza, while this figure for COVID-19 infected patients was 4.8% (P=1.000).

Conclusions Compared with patients with influenza, patients with COVID-19 have a better physical condition and fewer respiratory symptoms. There is no difference between the mortality rate of severe COVID-19 patients and patients with influenza.

Keywords: SARS-CoV-2, COVID-19, influenza, clinical feature, mortality

Yang HUAN (Chengdu, China)
00:00 - 00:00 #23495 - A COVID-19 screening clinic to manage patients surge during the pandemic: The experience of an Italian emergency department.
A COVID-19 screening clinic to manage patients surge during the pandemic: The experience of an Italian emergency department.

Background: The Veneto was among the first regions in Italy struck by the COVID-19 pandemic at the end of February 2020. The first steps to increase hospital surge capability were immediately enacted, providing each emergency department (ED) in the region with separated tracks and alternate care sites to deal with the forecasted surge of potentially infected patients. We describe the activation of nurse-led, screening clinic for patients presenting to our ED with symptoms consistent with COVID-19.

Methods: Our ED (60,000 visits/year) is part of a Level II Trauma Center with 413 in-patient beds. The hospital’s crisis unit was activated on February 23rd, and from March 8th patients that presented with fever or respiratory symptoms were diverted by the triage nurse to this alternate care site that was adjacent to the ED. In this retrospective study we included patients from the opening of the clinic to April 7th. Patients aged ≤ 4 years and with a NEWS score ≥ 5 were sent to the ED for medical attention, and thus excluded from this study. In the clinic, a chest x-ray was performed and blood samples were collected to analyze a standardized panel including CBC with differential, liver and renal functions, lactate dehydrogenase (LDH), procalcitonin, and c-reactive protein (CRP). Due to changes in regional testing policies, the nasopharyngeal swab for SARS-CoV-2 was performed from March 13th. Patients were then sent home and called back 5-6 hours later by an emergency medicine physician: to seek their general practitioner’s attention in case of no lab test or chest x-ray abnormalities; to come back for medical evaluation in case of abnormal findings. Patients were then phone-called back 15 days later to check for survival as primary outcome, and the following secondary outcomes: access to any ED; admission to any hospital or ICU; need for ventilatory support. Data are presented with median and IQR in case of quantitative data, whilst qualitative data were described through their distribution frequency.

Results: a total of 171 patients were included in our sample, and none of them was deceased at the follow up call. Their age ranged from 8 to 90 years old (median = 48 [32.5 – 58.5] years old), 52.0% were female, and 90,6% scored ≤ 3 points on NEWS score. Of the 134 patients with no abnormal exams after the workup, 10 reaccessed the ED for reasons other than COVID-19 and three of them were admitted (only two for COVID-19). On the other hand, 37 patients were asked to come back and receive medical attention; during the follow-up, 6 patients accessed the ED a second time, and 4 of these were admitted (all testing positive to COVID-19 swab). None of the admitted patients needed ventilatory support or was treated in an ICU.

Discussion and conclusions The creation of this nurse-led screening clinic had no negative effects on patients’ survival at 15 days, and missed few patients who needed a second evaluation or a hospital admission, while preserving ED resilience by diverting the surge of potentially infected patients.

Matteo PAGANINI (Padova, Italy), Michele PIZZATO, Eric WEINSTEIN, Elena VECCHIATO, Caterina COMPOSTELLA, Pierfrancesco TRICARICO, Caterina ONESTO, Andrea FAVARO
00:00 - 00:00 #23228 - A Covid19 patient Medevac from remote site in Amazonian area.
A Covid19 patient Medevac from remote site in Amazonian area.

French Guyana is located at the north of South America neighbor of Brazil and Surinam. The main part of this French territory is covered by the amazonian tropical forest without any ground access to reach remote areas. Over 30% of the population is living there and the only way to carry patients out is by helicopter. The Mobile Emergency and Resuscitation Service (MERS) 973 is accountable for the transportation of patients from remote areas to the most appropriate health facilities. 

 

Locally, the first cases of Covid19 have been identified on March, the 4th of 2020. Due to the mode of contamination and to prevent the spread of the virus into the cabin of the chopper within the one-hour flight, our teams are using an isolation stretcher with negative pressure and biological filters. 

 

That kind of medical transport requires a specific technicity and training. This is valid only for patients with steady medical condition because the isolation stretcher doesn’t suit with resuscitation practices within the flight. By the way, the medical team must particularly pay attention to the disinfection of the asset in order to not expose a third party within the transfer. 

Alexis FREMERY (Cayenne), Pierre CHESNEAU, Aurélia STANISLAS, Pierre SALLERIN
00:00 - 00:00 #23600 - A cross-sectional study investigating the habits of healthcare professionals regarding isolation procedures (including personal protective equipment) in a time with COVID-19.
A cross-sectional study investigating the habits of healthcare professionals regarding isolation procedures (including personal protective equipment) in a time with COVID-19.

Background

The importance of appropriate management of personal protective equipment (PPE) and hand hygiene has been clarified due to multiple consequences following covid-19 contamination. Several studies indicate that contamination in relation to PPE frequently occurs during removal of PPE, why this study at the moment is highly relevant. Hence the aim of this study is to test the quality of isolation procedures among healthcare professionals, regarding management (applying and removal) of PPE as well as hand hygiene.

 

Methods

In this cross sectional study, nurses and doctors with different age, gender and experience participated during a 3 week period in April 2020. The participants were selected randomly according to their working schedule at Zealand University Hospital Emergency Department in Koege. A premade structured checklist was performed based on national and regional guidelines and used in a Direct Observation of Procedural Skills setting (DOPS). Supervision via video Zoom links were used. Results for each participant were classified in performance categories as either correct, acceptable or insufficient based on criterias established by the researchers. The assessment was made respectively for each protective equipment, for doctors and nurses, and finally as a total judgment for the management of PPE. Conclusively all participants received individualized feedback on their performance.

 

Results

This study included 45 females and 27 males. The occupational groups were students, registered nurses, interns, residents and attending consultants. The results are calculated as percentages of participants in each performance category. An overall insufficient management of PPE was revealed at approximately 95% of the participants. 4% were categorized as acceptable and 1% correct. A tendency of better management was found regarding applying PPE (56%) compared to removal (93%). Even though decontamination of equipment is a pitfall in 72% cases, when excluding this step, the total evaluation remained almost unaffected. Second to decontamination of equipment, hand hygiene and removal of masks were problematic, as 60% achieved insufficient status in each of these PPE categories. In general nurses tend to perform better than doctors except for hand hygiene and masks.

 

Discussion & conclusions

Despite a common denominator of posters and video-material allocated to staff-members prior to the COVID-19 pandemic, qualifications among healthcare professionals differs. Adequate education is fundamental, although practical experience is needed for handling the procedures safely. A fact that maybe is reflected in the observed safer management of PPE among nurses compared with doctors. The survey was made as a simulated clinical setting, yet nothing indicates that real-life settings would be an improvement. Contamination within the healthcare system is an issue as consequences are multiple, including dissemination to patients and understaffed hospitals due to contamination of staff. The aim of this study was to test the quality of isolation procedures among healthcare professionals, in which insufficient management of PPE and hand hygiene was observed. To achieve an adequate procedure, the educational passive focus, e.g. videos, may require a shift to a more real-life setting with individualized feedback. A prospective suggestion could be a mandatory accreditation course when hired or as an annual course.

Karina NYGAARD-KJELDAL (Køge, Denmark), Gitte Bech GARFIELD, Elisabeth Kjems PETERSEN, Anne Grethe MØLBAK
00:00 - 00:00 #23142 - A fatal case of Aluminium Phosphide Poisoning in a 16-year-old patient in the pre-hospital setting.
A fatal case of Aluminium Phosphide Poisoning in a 16-year-old patient in the pre-hospital setting.

Abstract: Aluminium phosphide (ALP) is a widely used pesticide particularly in developing countries with high mortality rates post-acute exposure caused by cellular damage and cardiorespiratory failure. We report the case of intentional acute aluminum phosphide poisoning in a 16-year-old girl that encountered a regional emergency department (ED) in the city of Boumerdes in Tunisia. The intervention of Emergency Medical Services (EMS) was needed in order to provide the patient with advanced care in the University Hospital of the city of Mahdia. The patient developed a cardiogenic shock during the pre-hospital intervention and died despite appropriate circulatory and ventilatory support.

Ensaf MISSAOUI, Dr Ahmed MAHMOUDI (Sousse, Tunisia), Haifa BRADAI, Mounir NAIJA, Khaoula RAMMEH, Cherifa BEN CHEIKH, Naoufel CHEBILI
00:00 - 00:00 #22802 - A Machine Learning Model for Prediction of Unscheduled Return Visits in Emergency Department.
A Machine Learning Model for Prediction of Unscheduled Return Visits in Emergency Department.

Background:

An unscheduled return visit (URV) in emergency department (ED) is an important quality indicator of performance for the delivery of emergency care. Machine learning (ML) techniques have been developed in healthcare system for clinical research and practice in these decades. Collaborations between researchers from artificial intelligence (AI) and medical systems have created novel solutions for better patients care and more efficient healthcare systems. Our aim is to develop an AI tool which is more powerful and more suitable for Asian countries to predict URV and improve ED healthcare quality.

Methods:

In this project, we use data of 160,189 patients visit in China Medical University Hospital between 2017/01-/2017/12 and excluded patients who left ED due to missing data, against medical advice and patients aged less than 18 years old. To avoid any kind of anomalies or repetitions, cross-validation was used to obtain an answer as accurately as possible.

First, the dataset is pre-processed on the dataset by creating synthetic examples of the class “return” (URV of ED patient). Next, we apply the feature selection process where we rank the variables of the dataset according to their information gain and select the subset with the highest gain. Totally 12 factors were selected as input factors pool for outcome measurement. Finally, we examine different machine learning models with XGBOOST, Random Forest, and evaluate their performance using the two main methods, hold out 80/20 and 10-fold cross-validation, based on different evaluation metrics. F-scores were measured for output feature importance.

Results:

Three input factors: patients’ complaint; stay time and cost are associated with higher rate of URV within 72 hours in ED by using machine learning with XGBOOST method. We developed prediction criteria based on these rules that differentiate the revisit patients from the rest of the patients with predictive accuracy 70.6%.

Discussions & Conclusions:

By machine learning approach, the patients’ complaint, cost and stay time in ER were predicting factors for unscheduled return visit within 72 hours in ED. Clinicians can use these prediction materials as a decision-making tool for URV prediction.

Yen-Jung CHU (Taichung City, Taiwan, China), Charles C.n. WANG, Shao-Hua YU, Jiao-En WU, Hong-Mo SHIH, Yu-Shin CHANG, Chih-Yu CHEN
00:00 - 00:00 #22730 - A multi-centre, non-interventional, observational study into the expectations of adult patients attending a tertiary centre Emergency Department.
A multi-centre, non-interventional, observational study into the expectations of adult patients attending a tertiary centre Emergency Department.

It appears there is a disconnect between expectations of patients attending Irish Emergency Services and facilities available to Emergency Physicians. We hope that through studying these perceptions and expectations we can better understand how to interact with, and manage, our patients, and ensure more closely aligned objectives. Frequently Emergency Physicians are presented with chronic patient complaints which may have had, or are undergoing, investigation which cannot be furthered in the Emergency setting, barring acute change in patient condition. Such interactions, often ending in patient frustration and disappointment, can create negative impact on public perception of Emergency Services, whilst affecting job satisfaction when occurring regularly for Physicians. The objective is to gain insight into expectations of patients attending Emergency Departments (ED), especially focussing on patient perspective of presentation appropriateness, foreseen waiting times based on presenting complaint and mode of arrival, and assumptions about referral pathways from ED for immediate and outpatient advanced imaging and specialist medical/surgical team reviews.

 

This observational study recruited a volunteer patient sample using an anonymous survey with associated patient information leaflet. Eligible patients included adults attending ED, or accompanying next-of-kin in patients lacking capacity to partake, who had yet to be seen by a Physician/Advanced Nurse Practitioner, and whose care would be uncompromised by participation. All twelve survey questions were in checkbox format with brief elaboration sought depending on answer to certain questions. Minimal demographic data was also requested. Prior to public engagement, surveys were trialled for transparency and ease of understanding amongst non-medical hospital staff, and appropriate editing made to facilitate broad patient population engagement. Patients were invited to partake at ED registration; at main Reception, or at Triage if arrival was via ambulance. Completed forms were collected in one of three ‘postbox’-style boxes located in the main Waiting Area, main Nursing Station, and Minor Injuries Unit. Although not required, ethical approval was pursued.

 

Data collection is currently underway in two Irish tertiary EDs, and will be complete at time of EUSEM conference; abstract to be modified with results and discussion of same for conference presentation, if accepted.

 

Data is entered onto a coded Microsoft-Excel spreadsheet where total numbers and percentages for each question and variable are calculated, after which we analyse figures using Chi-Squared methodology and t-testing to determine numbers needed to recruit to assess any statistically significant differences between patient mode of arrival, mode of referral, or presenting complaint, and patient illness duration, waiting time expectation, and expectation of investigations. We are using hospital Information Technology programmes to obtain actual waiting times per presenting complaint, to ascertain crossover point between patient expectation and reality in this regard.

 

There is no individual patient follow up. Findings are to be presented at departmental teaching for ED staff education, compiled in a letter to local General Practitioners aiming to manage patient expectation at Primary Care, and displayed on a poster in Waiting Areas of the EDs to inform patients of emergency services available regarding investigations and feasability of urgent specialist team review, and rationalisation of waiting times.

Chloe DORAN (Dublin, Ireland), Hugh MCGOWAN
00:00 - 00:00 #22374 - A novel ecoguided central venous access in emergencies.
A novel ecoguided central venous access in emergencies.

Brief clinical history: 52-year-old-woman addicted to parenteral drugs, stage HIV-C3 with 2 weeks duration fever. On arrival had malaise, hypotensive, febrile, tachycardic...

Misleading elements: it was not possible to catheterize a peripheral vein we performed a central line cannulation: ultrasound-guided infraclavicular axillary vein. Less arterio-venous overlap and a greater distance between artery and vein, and from vein to rib cage, should provide an increased margin of safety for this central venous cannulation. We will describe step by step, accompanied by images, the steps necessary to achieve infraclavicular axillary vein cannulation.

Helpful details: After performing the analysis and radiographs, the presence of bilateral pneumonia was detected, presenting the patient with leukocytosis with neutrophilia, together with an increase in acute phase reactants. After initiating hemodynamic support measures, together with non-invasive mechanical ventilation and empirical antibiotic therapy, the patient improved all her hemodynamic parameters, admitting to the infectious diseases department.

Differential and actual diagnosis: The differential diagnosis of sepsis should initially be considered with other causes of systemic inflammatory response syndrome such as severe acute pancreatitis, polytrauma, large burns, systemic diseases in the acute phase (vasculitis, primary antiphospholipid syndrome or autoimmune diseases); postoperative period of cardiac surgery with extracorporeal circulation, extensive tissue necrosis or immunological lesions. We must also take into account other situations of shock such as cardiogenic or hypovolemic.

Educational and/or clinical relevance: Currently, the cannulation of a central venous line is usually necessary to critically ill patients in the emergency department, and therefore is a basic skill that must be mastered by emergency physicians. Its main indications include the need for rapid fluid resuscitation, central administration of drugs, and hemodynamic monitoring of critical patients. Like any procedure, central venous access is associated with a risk of complications. With the advent of ultrasound and the experience in its use in critically ill patients, it appears that the overall incidence of complications accessing central lines is lower. The internal jugular cannulation guided by ultrasound reduces complications and increases the accuracy of the technique. The cannulation of the subclavian vein is popular, but is less accessible to the ultrasound. The axillary vein, a direct continuation of the subclavian vein, is an alternative. In a large study of central venous access guided by ultrasound in a group of complex patients, carried out by O'Leary et al, most patients undergoing axillary vein cannulation did successfully and safely, demonstrating a low rate of complications. Therefore, the axillary vein access ultrasound-guided appears to be a very safe and effective alternative.

Ultrasound-guided axillary approach offers a number of potential advantages over others central line cannulation. The anatomy favours ultrasound guidance and less complications. Manual compression of the axillary artery or surgical access is possible if arterial damage is caused. The puncture site is further away from potential sources of infection in patients with tracheostomy, central chest wall burns or sternotomy wounds. Once mastered, this is a safe, useful, and reliable technique for central venous access, so the axillary vein is an useful alternative for central venous cannulation.

Alberto Ángel OVIEDO-GARCÍA (DOS HERMANAS (SEVILLA), Spain), Margarita ALGABA-MONTES, José RODRÍGUEZ-GÓMEZ, Francisco Jesús LUQUE-SÁNCHEZ
00:00 - 00:00 #22801 - A pilot observational study on point-of-care biomarkers: spontaneous intracerebral hemorrhage in the emergency department.
A pilot observational study on point-of-care biomarkers: spontaneous intracerebral hemorrhage in the emergency department.

Background: Stroke is a worldwide leading cause of death and disability, and intracerebral hemorrhage (ICH) continues to pose a significant economic and social impact, despite the recent efforts made towards documenting outcome-bettering acute interventions. This study aimed to assess the enrolment process in a prospective study concerning point-of-care (POC) biomarkers on spontaneous ICH (sICH), conducted in a Romanian emergency department (ED).

Methods: Patients suffering from acute (less than 8 hours from symptom onset) sICH were enrolled in this study over 18 months. Patients presenting a Glasgow Coma Scale score lower than 8, secondary ICH, seizures, recent ischaemic events, known thromboembolic disease or anticoagulant treatment, severe pre-stroke disability, terminal disease, scheduled neurosurgical intervention of hemostatic treatment were excluded. Demographic and baseline clinical characteristics have been collected upon enrolment, in the ED, along with troponin, D-dimer, and C reactive protein sampling.

Results: Thirty-nine patients were included with an inclusion rate of 2.16 patients/month. Of the 375 potentially eligible patients, 36% (134 patients) had a secondary ICH, and 63% of the sICH patients did not meet the inclusion criteria mainly due to late presentation, severely altered mental status, current oral anticoagulant treatment or lack of study team activation. The median age of the cohort was 72 years, with a slight predominance of males (female:male = 19/35). Hypertension was the most common documented risk factor (77%), along with diabetes (~29%) and ischaemic heart disease (31%). Additionally, one-third of the hypertensive patients did not undergo any blood pressure-lowering treatment. Mean baseline values were documented for white blood cells (WBC - 9.30×109/L (6.80 to 10.95)), hemoglobin (13.60 mg/dL (12.70 to 14.85)), and glycemiae (146 mg/dL (124 to 166)). The median time from symptom onset to ED presentation was 128 minutes (Q1 to Q3) = (96 to 239), {min to max} = {35 to 346}, with 21 of the 35 patients having presented within the first 3 hours from ictus. All patients had a diagnostic CT scan performed in the ED, with a median time of 170 minutes (Q1 to Q3) = (126 to 317), {min to max} = {59 to 507} between symptoms’ onset and CT scan and a median of 25 minutes (17 to 62) between presentation time and CT scan. The median time from patient’s ED presentation to complete blood count (CBC) result was 12 minutes (Q1 to Q3) = (6,5 to 20), {min to max} = {1 to 365}, with 21 of the 35 study participants having the results available within 15 minutes from ED arrival.

Discussion & Conclusions: ED-based research is a feasible instrument not only for epidemiological data collection but also for developing risk stratification strategies using novel tools such as POC biomarkers.

Eugenia - Maria MURESAN (Cluj-Napoca, Romania), Adela GOLEA, Sorana D. BOLBOACA, Lacramioara PERJU-DUMBRAVA
00:00 - 00:00 #23075 - A quantitative survey to assess the impact of a high-fidelity ex-vivo simulation model on the confidence level of participants on performing ultrasound guided regional nerve blocks.
A quantitative survey to assess the impact of a high-fidelity ex-vivo simulation model on the confidence level of participants on performing ultrasound guided regional nerve blocks.

Background: Ultrasound guided regional nerve blocks are increasingly being utilised in the emergency and anaesthetic departments to increase patient care and safety. High-fidelity ex-vivo simulation model, such as salt solution‐embalmed whole-body human cadavers, is important in safe and effective teaching and training of procedural skills. The aim of this study was to assess the impact of utilising such model in ultrasound guided regional nerve blocks pilot course on the confidence level of the participants.

Methods: All the Yorkshire and Humber deanery Acute Common Care Stem (ACCS) and Anaesthetic Trainees were invited by email to book onto the pilot of the course in September 2019 on first come first serve basis. The one-day course was held at the University of Leeds cadaver laboratory that has thiel embalmed fresh whole-body human cadavers as a high-fidelity (1-3). There were four main stations with 2:1 candidate to faculty ratio with GE Healthcare Venue 50 ultrasound machines: arm/brachial plexus, serratus plane, and femoral nerve/fascia iliaca compartment. There was a fourth extra station as Focused Assessment with Sonography for Trauma (FAST)/Focused Assessment for Free Fluid (FAFF) in none traumatic cases to improve the basic understanding of ultrasound and probe handing. All participants had the opportunity to perform the procedures and scans on the relevant body parts in real time with injecting normal water as a simulation for local anaesthetic agent. At the end the candidates were asked to anonymously complete confidence level scale, on a paper-based feedback form pre- and post-course. The confidence scale was 1-5, with 1 indicating unconfident and 5 fully confident. The median and interquartile range of the candidate confidence level was calculated as the primary outcome.

Result: All the 14 participants completed the confidence level scale pre- and post-course. The median improvement levels were 2, 3, and 1.5 (all interquartile range 1) for arm/brachial plexus, serratus plane, and femoral nerve/fascia iliac compartment respectively.

Discussion and Conclusion: Thiel embalmed whole-body human cadavers as a high-fidelity ex-vivo simulation model has been shown to improve surgical skills (1-3). As ultrasound guided regional nerve blocks are increasingly being utilised in the emergency and anaesthetic departments, a similar model is required. This is the very first pilot course of its kind. This course has demonstrated that utilising such simulation models could be useful for training/education and improve the confidence levels trainees performing ultrasound guided regional nerve blocks in their clinical practice with less supervision level.

References

1.     Benefits and Pitfalls of Cadavers as Learning Tool for Ultrasound-guided Regional Anesthesia S. Chhavi, L. Sanjeev, R. R. Bikash, S. Sumit, K. Abhyuday, Anesth Essays Res. 2017 Jan-Mar; 11(1): 3–6.

2.     Cadaver models for regional anaesthesia training J. P. Seeley   Anaesthesia Volume71, Issue11. November 2016 Pages 1372-1372.

3.     Cadaveric training – the solution for ultrasound‐guided regional anaesthesia? A. K. Gupta Anaesthesia Volume71, Issue8. August 2016 Pages 874-878. 

 [LA1]increasingly being

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Nick MANI (Leeds, United Kingdom), Jennifer FIRTH-GIEBEN, Veena DAGA, Mohit ARORA, Gilbert PURUSHOTHAMAN
00:00 - 00:00 #22963 - A rare and frightening effect of a commonly used drug.
A rare and frightening effect of a commonly used drug.

Amiodarone is an anti-arrhythmic drug used to treat supraventricular and ventricular arrhythmias. We report a rare adverse effect following IV infusion, excruciating severe whole body pain.

A 67 year old male presented at the emergency department (ED) for recent onset palpitations. He was diagnosed as having atrial fibrillation (AF), without signs or symptoms of haemodynamic instability, pulmonary congestion or myocardial ischemia. He reported a previous episode of AF, successfully treated with amiodarone. IV loading of amiodarone (300 mg over 30 minutes) was started. After 5 minutes, the patient complained acute, severe low back pain associated with flushing and pre-syncope. The pain rapidly spread to the whole body. Infusion was stopped. Vital signs, clinical examination and ECG were unchanged. Bedside echo excluded an acute aortic syndrome. High sensitive troponin I (hs-TnI) and d-dimer (XDP) were tested, while paracetamol 1000 mg infusion was started. Symptoms resolved within 5 minutes.

 Chronic amiodarone use is limited by side effects (pneumonia, pulmonary fibrosis, disthyroidism, hepatotoxicity, peripheral polyneuropathy, optic neuritis, skin disorder, bradycardia), related to drug accumulation. Amiodarone infusion can cause hypotension, usually related to infusion velocity. Polysorbate-80, an excipient for parenteral amiodarone, might play a role in amiodarone-related hypotension, through vasodilation. Moreover, it has been linked to other immunological and non-immunological reactions.

 Similar cases have already been reported, with pain usually located at the lower back. The physiopathology of this reaction is unknown, although some have advocated a vasodilatory - vasospasm mechanism, possibly related polysorbate-80. Interestingly, switching from iv to oral administration was not associated with back pain in a 2010 case, supporting the role of one of the solvent.

In our patient the first infusion of the drug had been well tolerated, suggesting that a kind of hypersensitivity reaction. Our patient also reported a flushing sensation that can be associated with hypersensitivity reactions. However, in most reported cases the first administration of amiodarone caused severe pain, supporting an idiosyncratic aetiology. In some reports, pain was associated with urticaria, complicating the clinical picture.

It should be highlighted that in two reports, patients of the same Unit developed symptoms in a restrained range of time, raising questions on production batch defects. 

 In all cases, the pain was very severe but of brief duration and completely self-resolving few minutes after stopping the infusion. We used IV paracetamol as analgesic, that might have helped. No analgesics were used in the other cases reported, except for IV hydrocortisone 250 mg iv, given to one patient because of urticarial rash.

 Our patient was subsequently given IV flecainide 150 mg iv, with restoration of sinus rhythm. Hs-TnI and XDP levels were normal. Given a Wells score of 0 and a negative CUS of the lower limbs, the patient was not investigated for pulmonary embolism, and was discharged after 3 hours of observation.

 This unusual adverse effect of amiodarone infusion can be frightening, given its intensity, and may lead to unnecessary exams, such as contrast enhanced CT scan for pulmonary embolism or aortic dissection. Hence, ED physician must be familiar with it.

Alessio MARRA (Bergamo, Italy), Lorenzo DELLA BELLA, Roberto COSENTINI
00:00 - 00:00 #22666 - A RARE CASE OF PSEUDOANEURYSM WITH PULMONARY THROMBOEMBOLISM... OPTIMAL TREATMENT OPTIONS.
A RARE CASE OF PSEUDOANEURYSM WITH PULMONARY THROMBOEMBOLISM... OPTIMAL TREATMENT OPTIONS.

A RARE CASE OF PSEUDOANEURYSM WITH   PULMONARY THROMBOEMBOLISM...  OPTIMAL TREATMENT OPTIONS.

 

ABSTRACT -

BACKGROUND -                

 Pseudoaneurysm is rare, but with pulmonary thromboembolism is very rare with asymptomatic presentation, Clinical suspicion and imaging techniques are the cornerstones of timely diagnosis and appropriate management of the condition. We report a case of 30-year-old man who suffered a traumatic femoral artery pseudoaneurysm, that was diagnosed in ED and treated surgically. He was also found to have asymptomatic saddle pulmonary thromboembolism.

CASE REPORT –

          A 30-year-old male, presented to ED with complaint of pain with swelling present over the right thigh since 5 days’ duration followed by alleged history of accidental occupational injury over the right thigh by a penetrating sharp object 5 days back. Patient was vitally stable with a sutured wound over the right thigh. On evaluation, duplex ultrasound showed femoral artery pseudoaneurysm with wells’ score of moderate risk for pulmonary thromboembolism, CT aorta and bilateral lower limb angiogram suggestive of saddle thrombus seen in the main pulmonary artery extending into right and left branches. Large pseudoaneurysm measuring about 5.3 x 4 cm of right femoral artery. USG guidance proximal compression of femoral artery and Inj.Human thrombin 500 IU injected into the pseudoaneurysm. Due to recanalization, surgical resection of the pseudoaneurysm of the femoral artery with femoral artery repair was done followed by anticoagulation therapy was given for pulmonary thromboembolism.

CONCLUSION –

          This patient had a post traumatic pseudoaneurysm of right femoral artery with asymptomatic saddle pulmonary thromboembolism. The possibility of thrombus formed is by compression of the pseudoaneurysm of the femoral artery over the femoral vein leading to form saddle thromboembolism. Patients with asymptomatic saddle pulmonary embolism can be successfully managed, with conventional treatment for pulmonary embolism without any aggressive measures. The patient was managed by a trial of ultrasound guided thrombin injection into the pseudoaneurysm, due to its recanalization, surgical resection was done and post procedure anticoagulants was initiated for pulmonary thromboembolism and discharged with oral anticoagulant. Early diagnosis with appropriate decision for surgical resection and anticoagulant therapy for pseudoaneurysm with pulmonary thromboembolism will bring good outcome.

Praveen J, Dr Nath Jena NARENDRA (MADURAI, India), Gaurav SINGH, Mukuntharajan T
00:00 - 00:00 #21713 - A rare case of stroke.
A rare case of stroke.

Brief clinical history:We report a case of pheochromocytoma in a 46-year-old man with a history of hypertension and GERD.  The patient presented with intractable hypertension, headache, paroxysmal vomiting, cardiac dysfunction and vision impairment. 

Misleading elements: First head CT scan and coronarography showed no abnormalities. 

Helpful details: As far as the neurolgical symptoms became more severe we repeted head CT scan, which showed subacute cerebral infarction. Computed tomography scan of the abdomen and evaluation of catecholamine levels confirmed pheochromocytoma. Surgical resection of a right adrenal mass quickly resolved the patient's hypertension. 

Differential and actual diagnosis: Subarachnoideal haemorrhage vs ischaemic stroke due to pheochromocytoma

Educational relevance: Although pheochromocytoma has rarely been reported in the presence of severe, temporary cardiac dysfunction and ischaemic stroke, it should be included in the differential diagnosis when a patient is presenting with cardiac dysfunction and a cerebrovascular event that have no obvious cause.

Júlia HÉGER (Kaposvár, Hungary), Veronika DEÁK, Csaba Balázs NAGY, Csaba VARGA
00:00 - 00:00 #22939 - A retrospective analysis to compare five ways on predicting pre-hospital mortality among adult victims in earthquake.
A retrospective analysis to compare five ways on predicting pre-hospital mortality among adult victims in earthquake.

Background

When natural disasters like earthquakes occur, facing with a huge number of patients, rescuers need to divide patients into different types according to the severity of their injuries to improve rescue efficiency and reduce casualties. At present, there are several triage methods being widely used all over the world such as START triage method (START), Sacco triage method (STM), Prehospital Index (PHI), CRAMS (Circulation, Respiration, Abdomen, Motor, and Speech) and Injury Severity Score (ISS). However, which one of them is the most accurate for adult patients, has not been proved yet.

Methods

A retrospective study was conducted on 21985 cases of adult patients whose age was between 18 and 65 from the Earthquake Casualty Database of West China Hospital of Sichuan University. Every patient was assigned to different triage scores by START, STM, PHI, CRAMS and ISS individually. All of the triage methods were evaluated based on cases of death with receiver-operator curve (ROC) using Medcalc version 18.11.3.

Results

For death cases, the AUC of START, STM, PHI, CRAMS and ISS reflected as 0.754(95% confidence interval 0.749 to 0.760), 0.874(95% confidence interval 0.869 to 0.878), 0.877(95% confidence interval 0.872 to 0.881) , 0.867(95% confidence interval 0.863 to 0.872) and 0.535(95% confidence interval 0.528 to 0.541). P value of each group reflected as 0.0255, 0.0209, 0.0199, 0.0235 and 0.0308.

Discussion & Conclusions

For adult patients, all the five triage methods were statistically significant in predicting death cases in mass casualty incident. STM, PHI, and CRAMS were more accurate compared with START and ISS. And above these five triage methods, PHI has the best predictive power for death.

Aoyu WANG (Chengdu, China), Mengjiao TAO, Hai HU
00:00 - 00:00 #23511 - A retrospective cohort study of patients diverted from the emergency department during a major incident.
A retrospective cohort study of patients diverted from the emergency department during a major incident.

Background

High attendances at Accident and Emergency departments ( A&E ) cause stress on health care providers. Overcrowding is due to the lack of primary care, its access to people and patients presenting with non-urgent complaints. This study aims to review a specific major incident and consider changes to reduce reliance on Accident and Emergency departments.

 

Methods

A retrospective cohort study was done at the Royal Albert Edward Infirmary, Wigan (RAEI) after the Wrightington, Wigan and Leigh NHS Trust declared a major incident on 5th February 2020 till 6th of February externally due to failure of internal systems including PACS (imaging) and HIS ( electronic patient record). The Trust continued to operate on an internal major incident as part of the recovery phase until 11th February. During this a total of 93 walk-in patients were advised to seek care elsewhere. These patients were contacted by the A&E department and the Clinical Audit Department regarding where they had sought care after being diverted. Amongst this group, 23 patients did not answer, 10 patients had no available contact numbers and 6 patients had provided incorrect details. All these patients were contacted thrice. One patient could not recall attending. The Patient Advice and Liaison Service (PALS) were also given the patient details.

 

Results

Of the 53 patients who were able to recall their A&E visit and provide information, 2 patients were reviewed at Wigan Infirmary and discharged. 8 patients presented to their GP whilst 2 self-treated at home. 5 patients went to Leigh Walk-In Centre and 2 patients were noted to return to WWL A&E the following day. One patient was referred to the Fracture Clinic at Wigan Infirmary. One patient was referred to the Urgent Treatment Centre. 32 patients went to a total of nine alternative trusts (60%) amongst which 38% went to Royal Bolton Hospital. 29 out of 32 patients were discharged from the A&E departments. Three patients were admitted. One patient was admitted at a psychiatric hospital and 2 patients were admitted at Royal Bolton Hospital. None of the 53 patients died. The purpose of collecting these details was to ensure patient safety and to check if any complaints were made. PALS were given the names of the 93 patients. There were no complaints made through PALS till 28th February 2020.

 

Discussion and Conclusions

Many patients presenting to the A&E have non-emergency conditions and require only advice. Results were similar to those observed during major sporting events and the COVID-19 pandemic. Urgent care centers can prove to be cost effective alternatives to hospital emergencies for people with non-life-threatening complaints. Patient education and awareness regarding their use will be crucial in determining their positive impact. Considering our results, where 40% of our patients did not require hospital intervention, we recommend urgent care centers alongside the Emergency departments to reduce congestion and overcrowding.

 Ethical Approval

Not needed

 

Ayaz ABBASI (Manchester, United Kingdom), Hamzah Khawar KHOKHAR, Hadeed ABBASI, Raenah Hamzah KHOKHAR
00:00 - 00:00 #23536 - A retrospective descriptive cohort study of drowning victims in two hospitals near the Dutch coast.
A retrospective descriptive cohort study of drowning victims in two hospitals near the Dutch coast.

Title: A retrospective descriptive cohort study of drowning victims in two hospitals near the Dutch coast  


Authors:
E. van der Vinne1, R. Barendse2, L. Scholtens1, I.T.B. Berg2, B.G.F. Verweij1, H.E. Elsenga3, J.J. Bierens4

Affiliations:
1.
Haga Hospital, The Hague, The Netherlands
2. Haaglanden Medical Center (HMC), The Hague, The Netherlands
3. Reinier de Graaf hospital (RdGG), Delft, The Netherlands
4.
Research Group on Emergency and Disaster Medicine, Medical School of the Vrije Universiteit Brussel (ReGEDiM Brussel), Belgium

Introduction
Few studies have focused on the clinical course and management of non-fatal drowning patients presenting to the emergency department (ED). The aim of this study is to describe the clinical characteristics of drowning patients presenting to the ED of two coastal hospitals of The Hague. The primary outcome of our study was the number of patients presenting to the ED’s and their clinical characteristics. Secondary outcomes were patient mortality, morbidity, ED and in hospital management, time of observation at the ED (in hours) and time to discharge from the hospital (in days.

Methods All consecutive files of patients admitted between 1-1-2014 to 31-12-2019 to the Emergency Department (ED) of 2 hospitals in The Hague (a coastal city) with a drowning related International Classification of Disease-10 (ICD10) code were studied. Data included patient characteristics, vital signs, blood gas analysis, radiographic findings, hospital admission or discharge from the ED, complications, and mortality.

Results
In the Haga Hospital 42 drowning patients (60% male; average age 9.5 years) presented to the ED. Of these 19 (51%) were younger than 4 year of age and 37 (88%) younger than 18 years. On ED presentation thirty-two patients (76%; average age 7.8 year) were asymptomatic, with normal lung sounds, no altered mental status and a pulse oximetry >95% without oxygen support. Twenty-three (72%) of these patients were discharged from the ED within ten hours. Patients who were admitted for observation to the general ward showed no adverse events or deterioration and were safely discharged the next day. Two persons were admitted to the ICU and survived hospital discharge.

The detailed patient characteristics and results of the HMC will be presented during the conference. In case we can resubmit the abstract with all data, this would be very much appreciated.

 
Conclusion
Drowning patients presenting to the ED in The Hague are predominantly children. Most patients are asymptomatic and discharged directly from the ED. All patients that were admitted for observation were discharged the next day.

Evelien VAN DER VINNE (The Hague, The Netherlands), R. BARENDSE, L SCHOLTENS, I.t.b. BERG, B.g.f. VERWEIJ, H.e. ELSENGA, J.j. BIERENS
00:00 - 00:00 #23005 - A Retrospective study about violence and verbal abuse against staff in Accident and Emergency Department.
A Retrospective study about violence and verbal abuse against staff in Accident and Emergency Department.

 A definition of violence and verbal abuse against staff in accident and emergency department:“Any incident, in which a person working in the healthcare sector is verbally abused, threatened or assaulted by a patient, member of the public or a member of staff arising out of the course of their work.

 

 This study     aimed  to determine the incidence of verbal abuse and physical violence in Southend  Accident and Emergency (A&E) Department  and  the extent of provision of security measures and instructions for staff on how to deal with these problems

Methodology : A retrospective study  between 1st of September2018 until 1st of September 2019 with a Sample size of   103 000 was conducted in Southend  Accident and Emergency (A&E) . Data was collected from   the software departmental system(’’Medway ‘’)and from A&E database for  all the patient who had a red card or a yellow card

This was a pilot study/ index study on violence to Southend  ED Staff .   The risk of being a victim of violence as a member of staff in A&E  Southend University Hospital NHS Foundation Trust is  4% , compared with 15 % in NHS. During one year 9 cases were related with physical violence(red carded) and 75 (89.28%)   being verbally abusive / physically threatening(yellow carded)

Conclusion:

 

The risk of being a victim working in A&E  Southend  is  4%. Underestimated compared with national data. We considered that there is an under-recording of these incidents.  89.28% resulted in no physical injury, patient being verbally abusive / physically threatening

We highlighted Individual staff responsibilities 1)Be familiar with Trust Managing Abuse and Violence Policy which details guidance on prevention and management of violent and abusive incidents.2)Document each episode of unacceptable behaviour in the patient’s medical record and complete an incident report.3)Be aware of how to escalate issues with unacceptable behaviour.4)Report incidents through Datix

Ionut Sorin NEGREA (Southend-on-Sea, ), Dalip KUMAR, Michael ACIDRI
00:00 - 00:00 #23494 - A service evaluation of potential impact of major trauma triage tool on emergency departments in the clyde region.
A service evaluation of potential impact of major trauma triage tool on emergency departments in the clyde region.

Background

Since the inception of the NHS, ambulances transported patients to the nearest ED without specific consideration as to the capability or capacity of that department. However, it has been shown that this leads to great inequality of the level of care that patients receive. In order to reduce inequality, organizations such as the Scottish Trauma Network have sought positive changes to improve the standard of service especially in respect to improvement of the triage of patients to the most suitable ED. A new regionalised trauma system in Scotland has been devised to address this issue. These new trauma systems will result in centralization of specific services at specialised EDs. This study is to evaluate the potential effects of regionalization of orthopaedic trauma care from Inverclyde Royal Hospital ED to the Royal Alexandra Hospital.

 

Method

A retrospective service evaluation of all adult (>16 years) orthopaedic trauma cases that presented to Inverclyde Royal Hospital (IRH) ED between 1st January 2019 until 30th June 2019 who were admitted to the orthopaedic ward at IRH was conducted. This period was chosen as covered two seasons of the year to give a wide representation of expected orthopaedic trauma and increased the potential to include a larger number of patients for the evaluation. These patients were identified by being admitted to ward” K North” which is the dedicated orthopaedic ward at IRH. Patient clinical details of their admission were collated from NHS Greater Glasgow and Clyde clinical portal and gender, age, date of presentation, diagnosis and short description of any procedure noted. Further to this, orthopaedic trauma injuries were categorised into upper, lower and spinal/neurological trauma with each of these then recorded as either fracture or non-fracture trauma. Additionally all neck of femur fractures and patients transferred from rural locations were recorded.

 

Results

A total of 357 patients were admitted to “K North” ward from IRH ED with orthopaedic trauma. Of those, the largest proportion of admissions was due to lower limb trauma which accounted for 235 (66%). Upper limb trauma had 55 (15%) admissions and spinal/neurological had 67 (19%). The mean age for a patient admitted with an orthopaedic injury was 69 years old and two-thirds of the patients were female 231(65%). There were 224 (63%) fractures injuries with 78 (34%) of them neck of femur fractures. A total of 202 (57%) procedures were carried out on patients who were admitted to IRH.

 

Discussion

The evaluation shows the potential for an additional 714 patients requiring treatment at RAH which will impact the ED as well as orthopaedic ward capacity and will incur additional expense for that RAH on already stretched budgets. This will impact patient experiences too with patients requiring to be transferred from IRH to RAH which could be delayed due to a lack of ambulance prolonging time to surgical procedure required. Overall, a full assessment of its benefits and drawbacks in the Clyde region can only occur once the Major Triage Tool has been implemented to identify further service improvements  needed.

 

 

 

Lynn POOLE (Glasgow, ), Afnan MSHIHADANI, Monica WALLACE
00:00 - 00:00 #23721 - A spontaneous imminent aortic aneurysm rupture: a case report.
A spontaneous imminent aortic aneurysm rupture: a case report.

Introduction:

An aortic aneurysm is defined as a dilation of the subdiaphragmatic aorta diameter greater than 3cm. Aneurysm rupture represents the most feared complication. When aneurysm rupture, themortality increase to more than 80%; that's why efforts have been made toward early detection.

 

Case report

In this observation, we report a case of a 65-year-old male with a history of non-obstructivecoronary artery disease, hypertension, who came to the emergency department withabdominal pain. His medication included aspirin 125mg, amlodipine 5mg daily. He describedan aching pain in the lower abdomen. He denied fever, melena, diarrhea, or urinary sign. Thepatient's vital signs were within normal ranges. On physical examination, the patient was feeling pain. The pain measurement scale was 10. The patient's abdomen was tense anddistended, his pulses were intact and symmetrical in the upper and lower extremities. An abdominal CT scan was performed and revealed an infrarenal aortic aneurysm measuring

70*57*60 cm with an aortic wall hematoma. A giant left retroperitoneal hematoma measuring

10*6*20 cm with active bleeding was noticed. Within the 30 min of the scan, the patient wasunconscious and pulseless, and cardiopulmonary resuscitation was initiated. The patient wasintubated, a central venous line was placed, norepinephrine was initiated and permissivesystolic blood hypotension around 70-80 was respected. The cardiovascular surgeon was called,but the patient died after an unsuccessful resuscitation effort.

 

Conclusion:

Aortic abdominal aneurysm rupture is a critical event with a high mortality rate. A thoroughinvestigation of the risk factors and clinical presentation of impending rupture allows physicians togive adequate therapeutic behavior.

Wiem DEMNI (TUNIS, Tunisia), Asma JENDOUBI, Amira BAKIR, Aymen ZOUBLI, Maaref AMEL, Youssef BEN BRAHIM, Abdelaziz BEN TAHAR, Wafa SLEIMI, Hamed RYM
00:00 - 00:00 #23080 - A survey on the recognition of child maltreatment in emergency departments in Europe: we should do better.
A survey on the recognition of child maltreatment in emergency departments in Europe: we should do better.

Background: Early recognition of child maltreatment and subsequent intervention is crucial to minimize the negative impact of child abuse on individuals as well as on society. Child maltreatment is a major public health problem and responsible for a huge socio-economic burden. However, child maltreatment remains difficult to identify. Policies such as systematic screening for child maltreatment at the emergency department (ED) using a screening tool, recognizing (parental) risk factors in patients admitted at the ED, and training of hospital staff has shown to increase the detection rate of child maltreatment. We questioned to what extent such policies were used in European EDs. Hence our aim was to evaluate the organization of different policies used to recognize child maltreatment in EDs in Europe in order to define areas of improvement to detect child maltreatment.

Methods: A survey was conducted on the recognition of child maltreatment in EDs in European countries with a focus on screening methods, parental risk factors and hospital policies regarding child maltreatment. The survey was distributed through different key members from REPEM, the EuSEN and the EUSEM and at the EUSEM congress 2018. Responses from unknown hospitals and non-scorable surveys due to missing data were excluded. The NICE guideline on child abuse and neglect was used to develop a ‘NICE-score’ reflecting to what extend European EDs met NICE guideline recommendations on 1) detection of child maltreatment, 2) recognition of parental risk factors and 3) hospital policy by categorizing EDs into meeting few (<50% of maximum score), some (50-75% of maximum score) or most (≥75% of maximum score) of the NICE guideline recommendations.

Results: We analysed 185 completed surveys, representing 148 hospitals from 29 European countries. Of the respondents, 50.8% had a standardized hospital policy for the detection of child maltreatment, 28.6% used a screening tool, and 52.3% had no guidelines on parental risk factors. A total of 42.2% respondents did not follow training on the recognition of child maltreatment based on child characteristics, nor did 57.6% on parental characteristics. A total of 71.9% indicated that there was a need for training. Extrapolating survey results to NICE-scores revealed that, of the EDs in Europe, 25.6% (34/133) met most, 22.6% (30/133) met some and 51.9% (69/133) met few of the NICE guideline recommendations on child maltreatment.

Discussion & conclusions: There is a high variability in policies for child maltreatment detection and only a quarter of the EDs met most of the NICE guideline recommendations., This first study on the organization of the recognition of child maltreatment in different European EDs identified the need for the use of screening tools, the need for training of ED staff and the need for implementation of local hospital policies in order to improve early recognition of child maltreatment.

Patrycja PUIMAN (Rotterdam, The Netherlands), Feline HOEDEMAN, Andrea SMITS, Mariëlle DEKKER, Hester DIDERICH-LOLKES DE BEER, Said LARIBI, Door LAUWAERT, Rianne OOSTENBRINK, Niccolo PARRI, Luis GARCIA-CASTRILLO RIESGO, Henriëtte MOLL
00:00 - 00:00 #23657 - A way to avoid COVID-19 spreading within the Emergency Department and the whole Hospital.
A way to avoid COVID-19 spreading within the Emergency Department and the whole Hospital.

The novel corona virus pandemic started in China around the end of November 2019 and progressively spread throughout many countries, especially in the temperate zone of the boreal hemisphere. It is possible that the virus was already circulating in Italy from the second half of January, but the first cases were diagnosed only a month later.

The health emergency due to the massive influx of patients with acute respiratory syndrome related to COVID-19 pandemic has led the Italian National Healthcare System to a deep reorganization such as the implementation of ICU beds and respiratory semi-intensive care unit beds and even in ED, which was still assisting patients affected from other serious illnesses, such as AMI, Stroke, Trauma, etc.

This impacted locally all health facilities, even in our ED; it was necessary to rethink patients care pathways to try and reduce effectively the contamination among patients and between patients and health workers. Our Hospital has 400 beds and has all different specialties, except Neurosurgery, Cardiac Surgery Ward and the Burn Unit and moreover is hub for Strokes and AMIs. The ED has a short stay observation of 10 beds, where patients can stay for a maximum of 48 hours, before being hospitalized or discharged.

The ED was drastically changed through the ingenuity and effort of the health professionals that work here, following the regulations of the Ministry of Health. The solutions introduced by us allowed to redefine the patients management guaranteeing their safety and a prompt response.

A triage point was made at the door” to make a first filter, followed by a dirty” or clean” pathway. Other isolation spaces have been identified in ED to guarantee the correct care to fragile and/or critical patients in addition to the four marquees installed outside the ED by the Civil Protection Department.

Our Observation Unit has been closed because is an open space, unsuitable for this type of patients, since everyone can be contagious because we don’t know who is positive or not.

A COVID-Observation Unit was put in place, with 23 isolated beds, previously dedicated to other care units, in which it was possible to start early high flow oxygen therapy, CPAP and NIV while waiting safely for the exams result, for the best outcome for the patient. In this Unit we treated 331 patients from the 10th March to the 29th April of which only 4 died.

All of this required the development of human and technological resources, that were changed in a short period of time to increase the level of care.

This high levels of protection garanted only few COVID-19 cases within healt workers (4 cases on around 80 employees) and no contagious cluster within patients.

The patient’s average time in the ED decreased from around 16 hours, in the first phase, to around 2 hours after the introduction of the COVID-Observation Unit, increasing patients comfort and at the same time accelerating the access to the right treatment.

Francesco PRATTICO' (Verona, Italy), Carmen TOZZO
00:00 - 00:00 #23269 - AAA case of swallowed button batteries.
AAA case of swallowed button batteries.

Introduction: The National Poison Data System received notice of 56,535 button battery ingestions from 1985–2009. Most pass through the GI tract without incident but fatalities have increased seven-fold over the last decade.

Case: A 24-year-old male with a history of mental health issues presented to the ED having swallowed a handful of button batteries.

He has discomfort to the upper abdomen and has vomited. An abdominal x-ray shows a collection of button batteries in the stomach.

Case discussion:

Batteries lodged in the oesophagus are a medical emergency and must be removed within 2 hours to avoid serious, delayed complications including local necrosis, perforation or death. Symptoms may not be present initially.

The National Capital Poison Center and the National Poisons Information Service offer helpful advice.

Due to the potential risk of electrical burns this patient went for endoscopy. 25 batteries were removed from the stomach, the tissues looked normal.

An xray image with patient consent form is available to support the case report.

Charlotte ELLIOTT (Liverpool, United Kingdom)
00:00 - 00:00 #22907 - Abdominal pain following low-energy impact pubic rami fracture.
Abdominal pain following low-energy impact pubic rami fracture.

We report the unusual case of a 70 year old man who sustained vascular injury following a low-energy minimally displaced pubic rami fracture. 

Patient presented to the Emergency Department from a rehabilitation centre with severe right hip pain after a fall from standing. He sustained an intra-cerebral haemorrhage two months earlier from which he was recovering well. His background history included previous DVT-PE for which he had an IVC filter in situ and was receiving Tinzaparin.

 

 

On arrival in the Emergency Department, primary survey was unremarkable and initial radiographs showed a minimally displaced right superior inferior pubic rami fractures which was treated conservatively.

 

Forty-eight hours post fall he developed severe abdominal pain and re-attended the Emergency Department. He was found to be hypotensive with a drop in his haemoglobin level.

 

Physical examination revealed tenderness and guarding in the suprapubic region and right iliac fossa.

After resuscitation with blood products and reversal of the LMWH, abdominal and pelvic CT showed a large extraperitoneal haemorrhagic collection in close proximity of the known right sided ramus fracture. This prompted an urgent arteriogram of the right common iliac artery which didn’t demonstrate active extravasation of contrast. The patient was transferred to ICU for further care.

 

 

 

Learning points:

Vascular injury following low-energy trauma should be considered into the differential diagnosis of elderly patients presenting with acute abdominal pain following pubic rami fracture.

A high index of suspicion in high risk patients such as those on anticoagulants can be life-saving.

 

 

Conclusion:

Pubic rami fracture are common injuries in elderly patients following low energy falls.

These fractures are considered stable and treated conservatively.

Delayed bleeding as a consequence of low-energy minimally displaced pubic rami fracture is uncommon but can be life-threatening if undetected.

Signs of bleeding may develop late after the injury and patients and their families should be instructed to return to the hospital if any sign of shock occur.

 

Consent


Written informed consent was obtained from the patient for publication of this case report.

Irene GROSSI (Bristol, United Kingdom), Damien RYAN
00:00 - 00:00 #23370 - About a case: Hyperosmolar hyperglycemia.
About a case: Hyperosmolar hyperglycemia.

Breves detalles cliniales: Mujer de 86 años, institucionalizada, independiente para las actividades de la vida diaria. Antecedentes de carcinoma medular de tiroides, presión arterial alta, artroplastia de rodilla derecha. Tratamiento real con prednisona 30mg cada 12 horas horas los últimos 6 meses, bemiparina 3500U cada 24, deltius, ranitidina horas y enalapril. Se refirió al Departamento de Emergencias para el mioclono en la parte superior de la pierna derecha con disminución del nivel de después de las horas de evolución. Se sospecha una crisis parcial. Se administra clonazepam intravenoso. Sonolent, Glasgow 9, anamnesis adecuada y examen físico limitado no es posible debido a la condición y gravedad del paciente. No hay deshidratación de la piel o las membranas mucosas. Bradypneic. Auscultación cardiopulmonar: bradicárdico sinusal. Nada de murmullos. Hipofononia de soplo vesicular.

Tocada profunel del cerebro: edema. Análisis de sangre: glucemia capilar 1215mg/dl, osmolaridad plasmática 367 mOsm/kg. Orina sistemática: glicosuria, ketonuria. ECG: ritmo sinusal a 52 latidos/minuto. Se inicia la insulina). Ingresada a Medicina Interna donde murió dos días después.

Elementos engañosos: Los miembros de lafamilia son cuestionados: no hay datos sobre la diabetes mellitus, clínico ni clínicos típicos. Sin desconstestar. Análisis de sangre anterior una semana antes: cifras de glucosa en sangre de 123mg/dl. Clínica neurológica. Ausencia de parámetros bioquímicos de infección.

Detalles útiles: Criterios diagnósticos de la Asociación Americana de la Diabetes: glucosa en sangre por encima de 600mg/dl, osmolaridad plasmática porcima de 320 mOsm/kg y ausencia de cetoacidosis significativa. CT-cerebro: edema, posible responsable de la clínica neurológica.

Diagnóstico diferencial y real: Clínica neurológica: Estado epiléptico, tumor o proceso metastásico, evento cerebral isquémico o hemorrágico, traumatismo craneal sin visto. Hiperglucemia hiperosmolar: Debut diabético. Pobre control diabético. Abuso/intoxicación de diuréticos o corticoides. Infección interocurrente. Thyrotoxicosis. Diagnóstico final: coma hiperosmolar con hernia cerebral secundaria.

¿Cuál es la educativa y/o clínica del caso?

Una de las peores complicaciones de la hiperglucemia h yperosmolar es el edema cerebral, que causa un rápido deterioro del estado general y puede conducir a com-comprobables, cambios pupilares, bradicardia, hernia del tallo cerebral y paro respiratorio. El estado de hiperosmolaridad no se requiere la formación de edema cerebral, causando la muerte en casos, haciendo que la situación dependa del tiempo. Por lo tanto, es importante tener siempre en cuenta las manifestaciones clínicas producidas por la hiperglucemia, la determinación de la glucemia capilar a su llegada a los Servicios de Urgencias del Hospital en pacientes con Diabetes Mellitus, pero aquellos en que presente s oluciónmos compatibles con el aumento o disminución dela glucosa ensangre.

Rubén PÉREZ GARCÍA, Ana RAMOS RODRÍGUEZ (Valladolid, Spain), Beatriz MARTÍN PÉREZ
00:00 - 00:00 #22827 - ACCOMPLISHMENT OF CHRONIC OBSTRUCTIVE PULMONAR DISEASE CLINICAL GUIDELINES RECOMMENDATIONS AT THE EMERGENCY DEPARTMENT.
ACCOMPLISHMENT OF CHRONIC OBSTRUCTIVE PULMONAR DISEASE CLINICAL GUIDELINES RECOMMENDATIONS AT THE EMERGENCY DEPARTMENT.

INTRODUCTION: 

Chronic Obstructive Pulmonary Disease represents around 1-2% overall services at the Emergency Department. 

OBJECTIVE: 

To describe the characteristics of the attention to the patients with Chronic Obstructive Pulmonary Disease with exacerbation (acute) and to know the adequacy of the actual guideline’s recommendations  related to the pharmacological treatment prescribed to the patients. 

MATERIAL AND METHODS: 

Retrospective descriptive observational study performed to patients diagnosed with COPD exacerbation seen between January-August 2019 at the emergency department in La Ribera University Hospital (Alzira-Valencia-Spain).

The variables used for the study were: sex, age, assigned priority of care, place and time of care, request of additional test, eosinophil value, prescribed treatment and adequacy of the same regarding to the recommendations. 

RESULTS: 

111 patients were studied having the males ,with a mean age of 73,13 ± 11,764 years, a much higher percentage.

The assigned priority level ranged between P2 and P4. The patients were attended mainly in the consultation area and stayed 315,25 minutes on average.

Main pharmacological groups administered were 80,2% LABA and 72% LAMA.

Most frequent combination used was LABA-LAMA-ICS in a 32,43% of the cases followed by LABA-LAMA- in a 28,83% of the cases.

The eosinophil value was equal to or superior to 300 cells/ul in  26 patients, and 17 of them recieved inhaled corticosteroids following GOLD guidelines recommendations.  

CONCLUSIONS: 

It was observe a treatment regimen not in accordance with the recommendations in 34,6% of the patients

It is essential to carry out and update protocols in the emergency department on prevalent pathologies that adapt to the latest recommendations and guidelines such as GOLD for the care of the patient with Chronic Obstructive Pulmonary Disease.

 

Luis MANCLUS, María CUENCA (Alzira, Spain), Asier BENGOECHEA, Sergio NAVARRO, Alicia GIMENO, Ricardo MUÑOZ
00:00 - 00:00 #22996 - ACCOMPLISHMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE CLINICAL GUIDELINES RECOMMENDATIONS AT THE EMERGENCY DEPARTMENT.
ACCOMPLISHMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE CLINICAL GUIDELINES RECOMMENDATIONS AT THE EMERGENCY DEPARTMENT.

BACKGROUND:

 

Chronic Obstructive Pulmonary Disease exacerbations represents around 1-2% overall services at the Emergency Department.

 

OBJECTIVE:

 

To describe the characteristics of the attention to the patients with Chronic Obstructive Pulmonary Disease with exacerbation (acute) and to know the adequacy of the actual guideline’s recommendations  related to the pharmacological treatment prescribed to the patients.

 

MATERIAL AND METHODS:

 

Retrospective descriptive observational study performed to patients diagnosed with COPD exacerbation seen between January-August 2019 at the emergency department in La Ribera University Hospital (Alzira-Valencia-Spain).

The variables used for the study were: sex, age, assigned priority of care, place and time of care, request of additional test, eosinophil value, prescribed treatment and adequacy of the same regarding to the recommendations.

 

RESULTS:

 

111 patients were studied having the males ,with a mean age of 73,13 ± 11,764 years, a much higher percentage.

The assigned priority level ranged between P2 and P4. The patients were attended mainly in the consultation area and stayed 315,25 minutes on average.

Main pharmacological groups administered were 80,2% LABA and 72% LAMA.

Most frequent combination used was LABA-LAMA-ICS in a 32,43% of the cases followed by LABA-LAMA- in a 28,83% of the cases.

The eosinophil value was equal to or superior to 300 cells/ul in  26 patients, and 17 of them recieved inhaled corticosteroids following GOLD guidelines recommendations.

 

 

CONCLUSIONS:

 

It was observe a treatment regimen not in accordance with the recommendations in 34,6% of the patients

It is essential to carry out and update protocols in the emergency department on prevalent pathologies that adapt to the latest recommendations and guidelines such as GOLD for the care of the patient with Chronic Obstructive Pulmonary Disease.

 

Luis MANCLÚS, María CUENCA (Alzira, Spain), Asier BENGOECHEA, Alicia GIMENO, Ricardo MUÑOZ
00:00 - 00:00 #22811 - Acute Aortic Dissection presenting with Inferior STEMI : A Chilling Reminder.
Acute Aortic Dissection presenting with Inferior STEMI : A Chilling Reminder.

Brief Clinical History

A case is presented of a 60 year old gentleman with background of Hypertension who presented with sudden-onset chest pain that radiated to the right shoulder and was associated with feeling hot and clammy. Pain was described as a 6/10 severity and self-resolved after two minutes. On presentation to the Emergency Department, ST elevation was noticed in the inferior leads (III, aVF) with reciprocal ST depression in I, aVL, V5 and V6. A diagnosis of Inferior ST-Elevation Myocardial Infarction was made and a referral made to the regional Cardiac Centre. Moreover, the first Troponin assay was raised, further confirming that the patient had an Acute Coronary Syndrome. It was advised that the patient is not for Primary PCI and advice was given to treat the patient medically for an Acute Coronary Syndrome (ACS). Aspirin, Clopidogrel and Fondapurinux were given as per local protocol for management of ACS. 10 hours after admission, the patient had an urgent echocardiogram that showed a dilated aortic root. An urgent CT Aorta was done that confirmed a Type-A acute aortic dissection. Patient was urgently transferred to the local Cardiac Surgery Unit and was operated on. Unfortunately, patient did not recover, and died on the operating table.

 

Misleading Elements

ST changes on the ECG, background of Hypertension and a raised troponin all were in keeping with the diagnosis of an Inferior STEMI.

 

Helpful details

The history of a short burst of chest pain that self resolved is mentioned as a "classic" early sign of an acute aortic dissection. An early Echocardiogram alluded to the diagnosis that was confirmed by a CT Aorta. However, diagnosis was delayed by almost 12 hours from the admission of the patient to the Emergency Department.

 

 Educational Relevance

Acute Aortic Dissection is an extremely severe condition having high mortality.Moreover, there can be coronary malperfusion, more commonly to the right coronary artery making it an increasingly more dangerous presentation. This means that while uncommon, Acute Aortic Dissection can present as an Inferior STEMI. European guidelines also mention that Acute AD is a cause of troponin rise. This is important to consider, especially as standard ACS treatment would be contraindicated in an Acute Aortic Dissection and literature indicate increases mortality in patients with Acute AD. The aim of this case report is to learn from the case and avoid the same pitfalls as has happened here. Early investigations, such as Echocardiography, and even laboratory tests such as d-dimer could be considered in patients with an Inferior STEMI as a potential "rule-out" category for Aortic Dissection.

Raiiq RIDWAN, Mawra SUZAR (Chelmsford, United Kingdom)
00:00 - 00:00 #22990 - acute aortic syndrome.
acute aortic syndrome.

introduction: Delayed presentation of acute aortic syndrome is plagued by high mortality and morbidity

A 42-year-old  man with medical history of asthma  came to emergency department for  shortness of breath. examination on admission showed 90% saturation tachaycardia at 120 beats per minute  systolic arterial pressure at 170 mmHg and diastolic arterial pressure at 90mmHg the patient was apyretic  and conscious . Physical examination : at pulmonary ausculation there are wheezing rales and a systolic murmur at cardiac auscultation  no signs of heart failure no peripheral signs of shock, a 12-lead ECG showed sinus tachycardia without evidence of ischaemia. the case was treated as a severe asthma attack.

 A  chest radiograph  showed a aortic button protrusion and a bedside a heart ultrasound showed pathognomonic findings of acute type A aortic dissection (figure). The patient underwent urgent repair of the aortic root. the patient died during transport for the operating room.  The location of the intimal tear in acute type A aortic dissection is in the immediate vicinity of the sinuses of Valsalva 65% of the time ant it’is an intense surgical emergency.

Conclusion:  The sensitivity of cardic ultrasound is between 78% and 100%; its specificity ranges from 87% to 96%. Cardiac ultrasound  is a valuable diagnostic tool in cases when more sensitive techniques (transoesophageal echocardiography, CT, magnetic resonance angiography) are not readily available or are impractical.

Asma KHALFALLAH (Mahdia, Tunisia)
00:00 - 00:00 #23779 - Acute aortitis in Emergency department: A rare cause of chest pain.
Acute aortitis in Emergency department: A rare cause of chest pain.

Introduction :

Acute aortitis is a rare life-threatening  condition caused by several distinct systemic rheumatologic diseases or infectious diseases.

There are several idiopathic and autoimmune inflammatory conditions that may affect the aorta, including systemic lupus erythematous, rheumatoid arthritis, ankylosing spondylitis, sarcoidosis, Reiter syndrome, and Behcet disease.

It is caracterised by different and non specific clinical finding making this condition under-diognosed.

Observation :

A 54-Year-old male with a history of COPD presented to emergency department with  recurrent chest pain with posterior irradiation that began from one week. The chest pain was substernal and heavy but did not worsen with deep inspiration, change of position, or palpation.

The physical examination showed a conscious patient, he was algic with profuse sweat. Blood pressure was 200/100 mmHg symmetrical on both arms the heart rate was 100 per min and we found paraplegia with a D4 sensitive level. Cardiac enzymes were within normal limits and EKG was normal.

Aortic dissection was suspected and a CT angiography was performed that allowed  to rule out an acute aortic affection and showed  a  circonferential mural thickening of both  thoracic and abdominal aorta. Guillain-Barré syndrom was also suspected but a lumbar puncture was normal.

A lumbar MRI imaging has showed an ischemic myelitis.

The patient recieved  steroide therapy and was tranferred to reanimation.

Conclusion :

Aortitis is a pathological term designating inflammation of the aortic wall, regardless of its cause. The clinical presentation of aortitis is non specific and variable.  Prompt recognition, correct diagnosis and appropriate treatment are essential in order to avoid life-threatening complications.

Imen MEKKI (Tunis, Tunisia), Dhekra HOSNI, Anissa CHAMSI, Aymen ZOUBLI, Hana HEHDLI, Safia OTHMANI, Rym BEN KADDOUR, Rym HAMED
00:00 - 00:00 #22739 - Acute cerebral ischemia after wasp stings : A rare neurological complication.
Acute cerebral ischemia after wasp stings : A rare neurological complication.

Hymenopterans are common insects around us, which cause about 100 million stings worldwide every year. Stings may cause local symptoms such as itching, swelling and pain as well as systemic symptoms such as hypotension and anaphylaxis. Neurologic complications such as encephalitis, cerebral edema, cerebral hemorrhage, and infarction are rare. We report a case of cerebral infarction in a healthy male after multiple wasp stings. A 28-year-old man was stung in his neck during the removal of the hive and transferred to hospital. He complained of itching, facial swelling and difficulty of breathing. There was no loss of consciousness and focal neurological deficits. About 30 hours after visit, he suddenly complained weakness of his left extremity. Magnetic resonance imaging was performed, and a cerebral infarction was found in the right middle cerebral artery territory. Carotid duplex ultrasonography, electrocardiography, and lipid profile test were performed to exclude other causes of cerebral infarction. No specific findings were found. Treatment with aspirin, atorvastatin and sufficient hydration were performed. Exercise rehabilitation was also performed. At discharge, he was better than the first, but the left upper arm weakness still remained. The pathophysiology of neurological complications such as stroke is clearly unknown. Cerebral infarction after wasp sting may be caused by hypotension which is following by anaphylactic reaction. It may be caused by vasoconstriction and platelet aggregation due to venomous poisoning. There is also the possibility of triggering by  systemic immune response and thrombus formation. Generally, the treatment of life-threatening anaphylaxis after wasp stings is similar to other anaphylactic treatments. Above all, stabilization of airway, breathing, and circulation is important. Injection of epinephrine, intravenous infusion, antihistamine and steroid use are also needed. Neurological complications are rare but can occur after wasp stings, which is caused to allergic and toxic reactions by hymenopteran venom. In this case, it is important to stabilize the hemodynamic state, and steroids and antihistamines should be used. Although there are no guidelines for specific strokes yet, if there is any suspicious symptom of stroke, management should be done in accordance with stroke treatment.

Woo Han JUNG (Uijeongbu-si, Korea, Republic of), Hyun Ho JEONG
00:00 - 00:00 #22391 - Acute Coronary Syndrome in the Pre-hospital Care of EMS Prague: Men versus Women.
Acute Coronary Syndrome in the Pre-hospital Care of EMS Prague: Men versus Women.

Background:

According to definition of European Society of Cardiology, acute coronary syndrome presents itself as a typical chest pain with iradiation to certain locations with other additional symptoms. The patients of EMS Prague consist of the population of Prague, where a total of 638,009 men and 670,623 women live4.

 

Method:

We conducted a retrospective data analysis of 344 patients with diagnosis of acute coronary syndrom (I21 and I24) between 21/12/2018 and 21/12/2019.

 

Results:

Diagnosis of ACS in pre-hospital care was more frequent in men, in a total of 247 cases, compared to 97 women. Males were younger with an average age of 61.4 years, the average age of females was 73.4 years. A total of 85% of men and 70% of women with ACS experienced typical chest pain, without significant differences between sexes. Women were more likely to complain about less typical symptoms such as back pain (12.3% women versus 5.2% men), nausea (26% women versus 20% men) or vomiting (14.4% women versus 8.9% of men).

 

Conclusions:

These findings suggest that there are differences in the incidence and presentation of ACS depending on gender. Our results correlate with the results of the 2017 Ali Ali Khesroha study "Gender differences between patients with acute coronary syndrome in the Middle East" 5, suggesting that women with ACS are older and present less typical symptoms of ACS such as atypical pain or heart failure symptoms.

Tereza KRSKOVA (Prague, Czech Republic), Katarína VESELÁ, Ondrej FRANEK, Miloslav LOUCKA
00:00 - 00:00 #23596 - Acute coronary syndrome with healthy coronaries in a young subject after cannabis use.
Acute coronary syndrome with healthy coronaries in a young subject after cannabis use.

Introduction:

Cannabis is the most frequently used drug in the world mainly for its euphoric and hallucinogenic effects.

Its cardiovascular effects are currently well identified. However, few data are available concerning its involvement in the occurrence of acute coronary syndromes (ACS) We report 1 case of acute coronary syndrome with ST elevation occurring in a young patient aged 21 years, heavy user of cannabis.

Observation:

Mr. EM aged 21, without medical history, smoking and cannabis smoker, admitted for angina pains with profuse sweating for an hour .

The interrogation found a catch of cannabis 7 hours ago, that is 6 hours from the beginning of pain.

The clinical examination was normal. The electrocardiogram showed an inferior basal shift with an anterior mirror image. The management was to put it under anti thrombotic treatment and to proceed to the primary angioplasty. The coronary angiography showed healthy coronaries and the trans thoracic ultrasound was without abnormalities.

Discussion:

Cannabis is a mild drug derived from a plant (Cannabis Sativa). rapidly absorbed by the lungs with a plasma half-life of around 20 to 30 hours

The cardiovascular effects of cannabis come from sympathetic activation and the decrease in the activity of the parasympathetic system. There is an increase in the synthesis of carboxyhemoglobin and a decrease in oxygen supply therefore a mismatch between increased needs in oxygen and reduced intakes which can favor the occurrence of ACS.

Coronary spasm has also been implicated in the occurrence of ACS linked to cannabis consumption, especially that they are often patients with healthy coronaries as is the case with our patient.

The most likely explanation is that of endothelial dysfunction induced by the consumption of cannabis with a reduction in the level of nitric oxide. It is produces vasoconstriction which is potentiated by the activation, adhesion and aggregation of platelets thus releasing other vasoconstrictor agents.

The formation of intra-coronary thrombi following the consumption of cannabis was recently described with very variable coronarographic anomalies.

Conclusion:

Cannabis use should be systematically sought in young patients suffering from ACS, especially in the absence of a classic cardiovascular risk factor.

The Coronary spasm and the formation of intra-coronary thrombi seem to be the two main mechanisms involved.

Maroua TALBI, Dr Dorra LOGHMARI (sousse, Tunisia), Rabeb MBAREK, Ghada SHILI, Chrifa BENCHIKH, Nouhel MZID, Farrouk DOUMA, Mounir NAIJA, Naoufel CHEBILI
00:00 - 00:00 #23350 - Acute coronary syndrome without coronary alterations.
Acute coronary syndrome without coronary alterations.

51-year-old woman. Hyperthyroidism under treatment, no other personal or family history of interest or toxic habits. Appendectomy. She went to the hospital emergency department for sudden onset epigastric pain radiating to the jaw and shortness of breath not related to physical exertion. No accompanying vegetative courtship. Refers dizziness and palpitations for days that had been related to work stress.

Description of the relevant abnormalities

On arrival: Heart rate: 133 beats/minute. Respiratory rate: 21 breaths/minute. Oxygen saturation 97%. Blood pressure: 127/84. Tachypneic, skin pallor. Auscultation cardiopulmonary: rhythmic and tachycardic without murmurs or extrasystoles. Vesicular murmur preserved. Electrocardiogram: sinus rhythm 121 beats/minute, ST elevation in V3-V5 and negative T waves in the same. Troponin I series: negative. Coronariography: no alterations. Final diagnosis: Tako-tsubo syndrome.

Why this image is clinically or educationally relevant?

Long-Axis cardiac magnetic resonance (four chambers), Cine Steady-State Free Precession, with high sensitivity detecting abnormalities in the myocardium after suspicion of an acute coronary syndrome with normal coronaries. Basal and mid-segment dyskinesia/kinesia, apical hypercontractility and ventricular thickening at the expense of the left ventricle are observed. Absence of late realization with gadolinium administration.

Ana RAMOS RODRÍGUEZ (Valladolid, Spain), Muñoz San José JUAN CARLOS, Héctor GARCÍA PARDO
00:00 - 00:00 #23757 - Acute decompensated heart failure in the emergency department : Interest of the MEESSI score in predicting the prognosis.
Acute decompensated heart failure in the emergency department : Interest of the MEESSI score in predicting the prognosis.

Introduction:Acute heart failure (AHF) in the Emergency Department ED is associated with high morbidity and mortality. Despite the existence of well-identified prognosis factors, the risk stratification remains difficult and often requires hospitalization. Hence,prognostic scores are important to guide the emergency physician in the management and orientation of such patients.
Objective:
Study the usefulness of the MEESSI score in predecting mortality on day30 of AHF  patients admitted to the  EM. Mortality classes were compared using ANOVA test

 Methods: A prospective observational study was conducted over six months. Inclusion of  patients admitted for AHF based on clinical criteria. Patients were classified into 3 clinical scenarios (SC) according to  the systolic blood pressure (SBP) in mmHg : SC1 ( SBP > 140), SC2 ( SBP  ≤ 140 ), SC3 ( SBP Results:Inclusion of 61 patients. Mean age was 69 ± 12 years with sex ratio of 1.34. Comorbidities N (%): hypertension 44 (72.13%) , diabetes 30 (49.18%) , coronary artery disease 21 (34.43%) ,  chronic  heart failure  23 (37.7%) , chronic renal failure  26 (42.62%).The CS distribution was N(% ): CS1  26 (42.63%), CS2 18 (29.5%), CS4 15 (24.6%) and  CS 3 = 2 (3.27%).The MEESSI score founds N (%) : a low risk  18 cases (29.5%), an intermediate risk 28 cases (45.9%), a high risk   7 cases (11.47% ) and a very high risk 8 cases (13.11%).The overall mortality rate was 9.83%. Two thirds of mortality rate were associated with a very high risk MEESSI score = 4 (6.5%). Mortality rates were statistically different with ANOVA test.

Conclusion: The MEESSI score showed its effectiveness in predicting acute heart failure patients’prognosis. However, multicentric validation isnecessary.

Rim DHAOUEDI, Rim DHAOUEDI (Tunis, Tunisia), Imen MEKKI, Hana HEDHLI, Badr FERJEOUI, Rym BEN KADDOUR, Anissa CHAMSSI, Hamed RYM
00:00 - 00:00 #22182 - Acute facial edema caused by superior vena cava syndrome mimicking angioedema.
Acute facial edema caused by superior vena cava syndrome mimicking angioedema.

This is a 78 years old man who had old cerebral infarction with left hemiparesis and lived in the nursing home for few years. He was discovered to have facial edema by the caregiver one day in the morning and was normal last night. He complained of mild shortness of breath without cough, and didn't take any new medication or new foods recently.

Physical examination revealed edema of his face, eyelid, and lips, but no edema of extremities. There were no distended jugular vein or itching skin rash. He had normal breathing sound on auscultation.

We treated him as angioedema initially, however, we still took blood exam and chest radiograph because of irrelevant history of angioedema. The lab data was insignificant, but chest radiograph(CXR) showed widened mediastinum and right upper lung hazziness. This made us to do further image study; we performed point of care ultrasound (POCUS) first and found distended right external jugular vein with echogenic thrombus, few B lines in the right upper lung and minimal right side pleural effusion. Then the subsequent computed tomography(CT) disclosed a huge mediastinal tumor, by whiich the superior vena cava(SVC) was encased. So the acute facial edema was caused by SVC syndrome not angioedema. After admission, the CT guided biopsy proved small cell lung cancer.

What we’ve learned from this case is that typical signs expected in the SVC syndrome such as distended neck veins, distended chest wall vein collaterals, upper extremity swelling were not seen in our case. It was the irrelevant history and lack of other dermatologic signs in angioedema that made us to do more tests. POCUS helped us to detect distended external jugular vein with thrombus, which weren't seen on the physical examination. It strenghthened and proved our thought about SVC syndrome. We think in case of acute facial edema, more tests should be done when the diagnosis is in doubt, and POCUS may be a good choice.

Borhen WU (Taipei, Taiwan, China)
00:00 - 00:00 #23765 - ACUTE HEPATITIS A: ABOUT 22 CASES.
ACUTE HEPATITIS A: ABOUT 22 CASES.

BACKGROUND

Hepatitis A is a communicable disease of the liver caused by the hepatitis A virus. It is usually transmitted through the fecal-oral route or consumption of contaminated food or water. Most people recover completely and do not have lasting liver damage. In rare cases, Hepatitis A can cause liver failure and death. In Tunisia, the prevalence of acute hepatitis A in children still high and epidemics can be explosive. The aim of this study is to describe clinical and biological properties and risk factors for this infection in order to find preventive strategy.

METHODS

This is a retrospective observational study including all patients presenting to the emergency department with acute hepatitis A during the period from 2012 to 2017 and  hospitalized on pediatric wards. We analyzed patient’s demographics, clinical characteristics, biological characteristics, medication and evolution.

RESULTS

22 patients were included. The average age was 7 years with sex ratio of 1,7 .One case of familial personal contact was noted. The symptoms of hepatitis A included especially jaundice in 100% of cases, abdominal pain in 9 cases ( 40,4%), asthenia in 8 cases ( 36,6% ) ,darkcolored urine in 7 cases ( 31%) , vomiting in 6 cases ( 27,2% ), fever over 38 °C in 5 cases (22,7%), and pale stools in 4 cases (18%) . Elevated liver enzyme and high bilirubin level was detected in 100% of patients. Prothrombin time test was < 50% in one case. The specific diagnosis of hepatitis A infection was based on the detection of HAV-specific Immunoglobulin G (IgM) antibodies in the blood, in all patients. An acute liver failure with death was observed in 10 years old child.

CONCLUSION

In general, prognosis of hepatitis A is excellent with a lifelong immunity. However, patients could die from fulminant hepatitis. Improved sanitation, food safety and immunization are the most effective ways to combat this infection.

Sondess MAGHRAOUI, Fatma HEBAIEB, Rania HMAISSI, Nadia ZAOUAK (Tunis, Tunisia), Boutheina AMMAR, Fadoua KHALFAOUI, Neila MAAROUFI
00:00 - 00:00 #23060 - Acute ischemic stroke thrombolysis in elderly patients.
Acute ischemic stroke thrombolysis in elderly patients.

Introduction: Cerebrovascular Accidents (CVA) is a severe, invalidating and increasingly frequent condition with the aging of the population. CVA represents a challenge in terms of public health, particularly in elderly patients. About 30% of Acute Ischemic Strokes (AIS) occur in patients over the age of 75. The prognosis is more severe in elderly patients when it comes to mortality and functional and cognitive sequela 

Materials and Method: A retrospective single-centred study based on our CVA registry. We included all patients admitted to the emergency department with CVA and underwent thrombolysis. Our study population is divided into two groups based on age with a limit of 75 years. We noted the clinical, demographic and biological data of each patient. The statistical analysis was conducted with SPSS 18.

Results: Our study population included 80 patients of which 30 patients were over the age of 75 years. The majority of our patients were female with a sex ratio M/F of 0.77. The table below shows the evolution of NIHSS from H0 to H24 in the two groups

 

NHISS 0

NHISS 24 Hours

P

 

 

 

 

≥75 years

12±6.9

9.39 ±6

0.001

<75 years

8.8±10

5.87±4

0.02

Our results reveal that patients over the age of 75 year who underwent thrombolysis do not have a higher risk of intracranial haemorrhage or death as compared to those under the age of 75 years. We note that the functional outcomes at 3 months were less favourable than in patients under this age limit. That being said, this observation seems to be related to the worse prognosis of CVA in elderly patients and not to the ineffectiveness of the thrombolysis.

Conclusion: The age limit of 75 years alone should no longer be considered a contraindication to thrombolysis.

Mohamed Hedi AHMED, Hajer YAAKOUBI (sousse, Tunisia), Salma BEN SAID, Lotfi BOUKADIDA, Ahmed Amin ABRI, Houda BEN SALAH, Asma ZORGATI, Riadh BOUKEF
00:00 - 00:00 #23347 - Acute liver failure: a case report.
Acute liver failure: a case report.

A variety of reasons can cause abdominal pain and vomiting. What medicine is the most common to cause liver damage and the aforementioned symptoms?

Case report: A 20-year-old female was brought to the Emergency department, complaining of abdominal pain, nausea and vomiting. The pain began 3 days ago soon followed by nausea and voming more than 10 times. As the pain increased, and upon the patient seeing what she thought was some blood in the vomit, the patient decided to seek medical help. The patient mentioned she had consumed some dairy products and fried pork, day before the symptoms started. There was no previous history of gastrointestinal or any other chronic diseases, surgical treatment or known allergies. Upon physical examination the patient presented with no fever, pale, clammy skin, mild tachycardia (102 bpm), right upper quadrant abdominal pain, with no signs of peritonitis, or enlarged liver, no melena was observed. An infectious cause, or acute gastritis were considered primarily. Also, Mallory-Weiss, or a peptic ulcer bleed as possible complications. Antiemetics and fluids were administered. Nausea and vomiting subsided consequently; abdominal pain had not decreased. Abdominal ultrasound appeared normal. EGD was ordered as well. Complete blood count was normal, with no indication of infection. CRP – 12.3 mg/l, electrolyte, glucose, urea and creatinine levels were within the normal range. ALT – 6036 U/l, AST –  >7000 U/l, bilirubin – 66.3 umol/l, GGT – 21 U/l, AP – 73 U/l. APTT – 43 s, PT/INR – 1,98. Upon receiving the blood panel, acetaminophen poisoning came up as a possible reason, and after the patient was repeatedly asked if they had consumed any pain medications,  she admitted to have taken more than  30 tablets of acetaminophen with a can of cider as a suicide attempt. The dose of acetaminophen was assumed to be 15 to 30 grams, and blood acetaminophen was measured to be 2.3 mg/l. 21 g of intravenous N-acetylcysteine was administered during the first 21 hours and the patient was admitted to the intensive care unit. The patient was transferred to a psychiatric unit on day 7, after blood tests revealed her PT/INR had lessened to 1,03, AST 101 U/l, ALT – 1211 U/l, no jaundice developed and abdominal pain had subsided. The patient was discharged at day 10 with a referral to an out-patient counseling, with blood PT/INR 1,02, AST – 35 U/l, ALT – 311 U/l.

Conclusion: Even though acetaminiphen poisoning is usually unintentional and chronic, a physician should never forget acute acetaminophen poisoning as one of the causes for acute liver dysfunction. Most patients can recover without any chronic liver damage if treatment is started promptly.  

Deima EITMONTAITĖ (Vilnius, Lithuania), Pranas ŠERPYTIS
00:00 - 00:00 #23717 - Acute polyradiculoneuritis at the emergency department.
Acute polyradiculoneuritis at the emergency department.

Introduction :

Acute polyradiculoneuritis develops due to an inflammatory reaction that affects spinal and cranial nerve roots and peripheral nerves, which can be observed in all ages and may cause hemodynamic and respiratory instability.This neurological condition may be difficult to diagnose at an early stage in the emergency department and remains a challenge for the emergency physician.

 

Observation :

we report a case of a 48-year-old man, with no medical history, who came to the emergency department with muscle weakness and walking ability disorders with gradual worsening over three days, associated with swallowing problems and dysphonia.

Upon clinical examination, the patient was apyretic and hemodynamically stable. He was eupneic, oximetry pulse was at a level of 92% on air and pulmonary auscultation was normal. Glasgow coma scale (GCS) score was 15, there was a flaccid tetraparesis predominant in both lower limbs and on the left. The standing position was impossible. Walking was possible with help showing a steppage. There was hyperreflexia in all limbs and positive bilateral Babinski sign. He had dysphonia, swallowing problems, and ineffective coughing. A blood test showed: WBC=18300/mm ³, CRP=0.3mg/dl, créatinine=68 µmol/L ,Na+/K+=140/3.6 mmol/L ; serum calcium levels=2.25 mmol/L, blood gas analysis (in ambient air) : pH=7.43 PaO2=62mmHg paCO2=41 mmHg HCO3-=27.2 mmol/L SaO2=92%, lactates=1.6mmol/L (with A-a oxygen gradient at 36.7 mmHg)

A cranial computed tomography and a cranial and spinal MRI were performed, but there were no abnormal signs. Lumbar puncture examination showed clear cerebrospinal fluid, with normal cell count, normal protein level, and normal glycorrhachia.

On electrophysiological diagnosis, acute demyelinating polyradiculoneuritis with severe secondary loss of axons was objectified. The patient was managed with non-invasive ventilation initially, but his respiratory state had quickly deteriorated and required mechanical ventilation.

Treatment with intravenous immunoglobulins was started, and the patient was transferred to the intensive care unit for additional care. No etiology was retained after an initial investigation.

 

Conclusion:

GuillanBarré Syndrome is a serious, potentially deadly condition, its diagnosis is not always obvious. Atypical forms are common, electromyography and nerve conduction studies are essential to confirm the diagnosis and to determine the prognosis.

Wiem DEMNI (TUNIS, Tunisia), Asma JENDOUBI, Hana HEDHLI, Montassar BHOURI, Amira BAKIR, Dhekra HOSNI, Houyem ZOUARI, Hamed RYM
00:00 - 00:00 #22206 - ACUTE PULMONARY EMBOLISM: ARTERIAL BLOOD GAS TEST’S ROLE IN IDENTIFYING POPULATION WITH MASSIVE AND SUB-MASSIVE PULMONARY EMBOLISM.
ACUTE PULMONARY EMBOLISM: ARTERIAL BLOOD GAS TEST’S ROLE IN IDENTIFYING POPULATION WITH MASSIVE AND SUB-MASSIVE PULMONARY EMBOLISM.

Purpose of the study: to evaluate if ABG gas exchange’s impairment could detect subpopulations of patients presenting massive or sub-massive pulmonary embolism (PE), organ damage or with high-risk of short-term mortality or shock, therefore patients presenting right ventricular enlargement and myocardial enzyme elevation. We eventually examined if the latters showed a correlaton with worse outcomes, defined as greatere sPESI index and the need of ICU hospitalization.

Methods: observational monocentric study, we enrolled all the patients who received acute PE diagnosis in the period going from 01/01/2016 to 31/12/2018. We analized the following ABG measures: pH, pO2, pCO2. An expert radiologist examined CT-scans and identified organ damage as dilation of right heart chambers, pulmonary artery dilation and pulmonary infarction.

 

Results: In the electronic database, we enrolled 113 patients identified as elegible to partecipate in the study, as they matched previously listed criteria. Patients’ mean age is 68 years, ranging from 19 to 98. Female represent 53,10% of the total. pH showed no utility in detecting the examined subpopulations, neither was found more impaired in the subpopulations with worse outcomes.

pO2 measure showed to be more easily impaired in patients with organ damage (p = 0,041) and in patients with right ventricular enlargement myocardial enzyme elevation, therefore the patients with high-risk of short-term mortality or shock (p = 0,041). pCO2 measure didn’t show utility in detecting the examined populations and wasn’t more impaired in the populations with the worse outcomes considered. Although it showed to be more impaired in typical simptoms presentation. (p = 0,005).

Conclusions: ABG’s low values od pO2 may help to detect the subpopulation considered at high-risk of short-term mortality or shock, therefore presenting right ventricular dilation and myocardial enzyme elevation and therefore needing close monitoring and eventual thrombolysis at the worsening of clinical features.

Dr Gabriele SAVIOLI (PAVIA, Italy), Iride Francesca CERESA, Sarah MACEDONIO, Paolo MAGGIONI, Viola NOVELLI, Mirko BELLIATO, Michele PAGANI, Federica MANZONI, Massimiliano LAVA, Maria Antonietta BRESSAN, Giorgio Antonio IOTTI
00:00 - 00:00 #22252 - ACUTE STROKE AND THE DEATHLY HALLOWS: THE RISK FACTORS IN A LARGE COORTE OF ELDERLY PATIENTS UNDERGOING THROMBOLYSIS.
ACUTE STROKE AND THE DEATHLY HALLOWS: THE RISK FACTORS IN A LARGE COORTE OF ELDERLY PATIENTS UNDERGOING THROMBOLYSIS.

AIM: Analyze among patients aged 75 and over who have acute stroke and have thrombolysis in our emergency room for a consecutive year (May 2017-May 2018) the distribution of risk factors in the global population and depending on the presentation symptomatic framework..

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: Elderly patients diagnosed with strokes in our emergency room (May 2017 to May 2018) and subjected to thrombolysis for a total of 49 patients were analyzed. These had an average age of 83.7 aa on equal distribution between the sexes (24 M, 25 F). This population has a high incidence of risk factors: 94% had at least one risk factor, 63% of the study population had at least two risk factors, and 30% had 3 or more. By far the most represented risk factor in this population is high blood pressure in 73.5% of cases. The prevalence of atheromasia superortic trunks present in 32.6% of patients, ischemic heart disease 26.5%, atrial fibrillation 26.5% and diabetes mellitus 20.4% follow with substantially overlapping prevalence. with slightly lower percentage of ical disease 22.4%; while cigarette smoking habit has a lower incidence in this population (4%). We then divided the population of thrombolysis patients into clinical syndromes: patients with motor, sensory, language and nonspecific symptoms. 85% had motor symptoms, 30% sensory symptoms, 61% speech disorder, 28% atypical symptoms. The 4 symptomatic groups were found to be overlapping by age, sex distribution, and hospitalization outcome. The four symptomatic groups were shown to be substantially overlapping in the number and distribution of risk factors with regard to high blood pressure 73-77%; cigarette smoke 4-7%;  ateromasia superortic trunks 20-29%; previous ischemic heart disease (20-29%) and diabetes mellitus 16-23%. Differently, previous ictal disease is less represented in patients with sensory symptoms (7%) compared to other subgroups (20-23%), atrial fibrillation is less represented in the subgroup with atypical symptoms, representing 15% (atypical symptoms) respectively, compared to 23-29% in the other subgroups.

Conclusions: it is clear that in the subpopulation of elderly patients who are candidates for thrombolysis, high blood pressure is the widely represented risk factor, while cigarette smoking is poorly represented.  Particular attention should be given to all the other risk factors under consideration. Patients with atypical symptomatic cadres, on the other hand, have a lower prevalence of FA, suggesting that in these cases the rate of heart disease pathogenic stroke is reduced.

Dr Gabriele SAVIOLI (PAVIA, Italy), Iride Francesca CERESA, Anna CAVALLIN, Alessandra MARTIGNONI, Alessandra PERSICO, Dr Alba MUZZI, Mirko BELLIATO, Fabio SCIUTTI, Elvis LAFE, Francesco GERACI, Chiara GAGLIARDONE, Andrew WIMER, Viola NOVELLI, Maria Antonietta BRESSAN
00:00 - 00:00 #23598 - Acute temporo-parietal encephalopathy in heavy cannabis users: about one case.
Acute temporo-parietal encephalopathy in heavy cannabis users: about one case.

Acute disturbances in consciousness or behavior are relatively common grounds for pre hospital care. Among the causes to be mentioned apart from head trauma, meningo encephalitis and metabolic causes, one must think of intoxication.

Cannabis use is increasing worldwide despite the various health effects of this substance.  It is the most frequently used drug in the world mainly for its euphoric and hallucinogenic effects.

Methods:

We report one case of acute hippocampal encephalopathy in heavy cannabis users (>10

joints/day). 

Results:

In 23 years old male patients, acute encephalitis was suspected. Brain MRI sequences showed evidence of symmetrical bands of signal anomalies in ribbon concerning the cerebral cortex at bilateral temporo-parietal level and semi-oval centers which appear in discrete hypo signal T2 FLAIR and diffusion with peripheral enhancement lepto meningeal.

Patients had rhabdomyolysis and inflammatory syndrome. Investigations showed no evidence of infectious or autoimmune encephalitides.

Clinical and biological acute abnormalities improved within 48 hours. New exposition to cannabis yielded a new episode of encephalopathy. 

Conclusions:

Health professionals should be aware of this cannabis-related syndrome given its severe and

long-lasting effects.

Bouhoula ASMA, Dr Dorra LOGHMARI (sousse, Tunisia), Sondos LAAJIMI, Abir OUEDERNI, Khaoula RAMMEH, Sourour BRIKI, Wissem CHAOUCH, Mounir NAIJA, Naoufel CHEBILI
00:00 - 00:00 #23534 - Acute type B aortic dissection: an unlikely diagnosis in the systemically well patient.
Acute type B aortic dissection: an unlikely diagnosis in the systemically well patient.

Brief Clinical Details

Sixty-nine year old fit and well male presented with sudden-onset dull central chest pain while doing press-ups (a usual daily routine). The pain initially originated between the scapulae, leading the patient to think this was a muscular pain associated with exercise. Patient was haemodyncamically stable on arrival with equal blood pressures and radial pulses bilaterally. ECG showed global ischamia. The decision was made to CT to rule out aortic dissection prior to anticoagulation and transfer to PCI centre. 

Description of Relevant Abnormalities 

Type B acute aortic dissection, terminating in the internal and external iliac arteries bilaterally. Femoral arteries are patent and spared from dissection.The false lumen supplies an accessory left renal artery and the IMA. Suspicion of developing areas of infarction within the left kidney. Coelic axis and SMA show involvement but both are patent and supplied predominantly by the true lumen. 

Why is this clinically or educationally relevant?

This diagnosis was surprising in a patient without any significant co-morbidity, who was fairly well on presentation. Although the patient did not describe typical ‘tearing’ intrascapular pain, this case highlights the importance of history taking as the site and onset of the pain was the only  justification for the scan.

Images awaited. 

Aimee THOMPSON (Glasgow, )
00:00 - 00:00 #23178 - Adherence to primary care physician follow-up among geriatric head trauma patients after hospitalization.
Adherence to primary care physician follow-up among geriatric head trauma patients after hospitalization.

BACKGRUND: Primary care physicians (PCP) serve as the cornerstone for care transition in high-risk geriatric patients who are discharged from the hospital. The PCP can help patients understand care plans and adhere to medication regimens. Unintentional falls are one of the most common geriatric presentations to the ED, with over 250,000 annual visits for traumatic brain injury in the US. Given the high risk of repeat head injury in these patients, it is crucial that post‐discharge PCP follow‐up is completed. The aim of this study is to assess adherence to PCP follow-up in geriatric head injury patients.

METHODS: This investigation was a prospective cohort study at two level-one trauma centers, taking place from August 2019 to February 2020. Patients age ≥ 65 who suffered head trauma associated with a ground-level fall were included. Adherence to PCP follow-up was assessed during a structured telephone survey 14 days after ED presentation. Analysis by descriptive statistics was performed.

RESULTS: A total of 3,310 geriatric patients who sustained a fall were included in the study. Among the 1,019 (31%) patients who were able to be reached by telephone and agreed to participate, 599 (59%) had followed-up with their PCP since being discharged from the hospital. The mean age was 82 years (SD 8.7), half were female, and 84% were white. Out of the 599 patients contacted, 333 (56%) were patients with ED visits that did not result in hospitalization and 266 (44%) were patients with in-hospitalization stay for an average of 3,1 days (SD 4.3).

CONCLUSION: Six out of ten patients in our study completed follow-up with their primary care physician. Geriatric patients who have suffered a head injury are at high risk for repeat fall and significant injury. Many of these patients do not or are unable to follow-up with PCPs.  This critical follow-up is an important factor for decreasing subsequent morbidity and mortality in these patients.

Gabriella ENGSTROM, Scott ALTER, Richard SHIH (Boca Raton, Florida, USA), Joshua SOLANO
00:00 - 00:00 #23563 - Adherence to the Guidelines for CTKUB scans for Renal Colic in Portiuncula University Hospital.
Adherence to the Guidelines for CTKUB scans for Renal Colic in Portiuncula University Hospital.

CT KUB is the investigation of choice when investigating acute renal colic. It also falls in line with the NICE guidance for acute renal colic, British Association of Urological Surgeon (BAUS) guidelines for acute management of first presentation of suspected acute renal colic, and European Association of Urology (EAUS) guidelines on urolithiasis. MDCT is the most accurate investigation in suspected ureteric colic and a low- radiation-dose CT technique can be used in most cases patients with a high BMI might not be suitable for low dose CT KUB.

This was a retrospective study of 75 CT KUB scans conducted in Portiuncula University Hospital. These were identified and analysed over a period of four months starting from 20th of April to 20th of August 2019. Patient demographics scan request and performance time, clinical details on request and scan result were obtained from National Integrated Medical Imaging System (NIMIS) /PACS system. The study found that the detection rate of renal calculi in PUH was meeting the expected percentage 53% (44 to 64%). The performance of a CT KUB within 24 hours as per guidelines was not met. Only 86% met current guidelines. There were delay in obtaining a CT KUB after hours and weekends. A significant proportion of patients were females (42%), 69% of all females scanned were of child bearing age. 

The results of this study were circulated to all ED and surgical teams in an effort to decrease the number of requests for non-indicated CT KUB. It seems that more scans were ordered with the ease of obtaining these as compared to renal ultrasound, especially in women of child bearing age. Education regarding radiation exposures and pathways of care need to be followed to ensure that access to critical tests are available after hours and on the weekends.

 

Avriel MCDONNELL, Suleiman ALTAYEB, Kiren GOVENDER (Galway; Ireland, Ireland), Farooq OZAIR
00:00 - 00:00 #23129 - Adiponectin Alleviate Inflammatory Response in BV2 Cells After OGD/R by Regulating Nrf2-HO1-HMGB1 Signaling Pathway.
Adiponectin Alleviate Inflammatory Response in BV2 Cells After OGD/R by Regulating Nrf2-HO1-HMGB1 Signaling Pathway.

Background

In the process of ischemia reperfusion injury of brain after cardiac arrest, resting microglia are transformed into activated microglia. M1 phenotype microglia mediate inflammation by releasing TNF-α, IL-6, ROS, etc., while M2 phenotype microglia mainly produce anti-inflammatory factors such as IL-4, IL-10, TGF-β, etc. Current studies have found that microglia polarization is a new mechanism of cerebral ischemia-reperfusion injury, regulating microglia polarization may be a promising treatment for ischemia-reperfusion injury-related diseases. Recent studies have shown that the regulation of Nrf2 and its target genes helps to suppress microglial activation and regulate the microglial phenotype. Nrf2 activation can attenuate the polarization of M1 microglial cells under inflammatory conditions and promote the polarization of M2 phenotype microglial cells. Activated Nrf2 can induce HO-1 to protect cells from oxidative stress. Moreover, HO-1 in microglia has an anti-inflammatory effect, which can inhibit activated microglia from secreting pro-inflammatory factors. Therefore, we constructed a model of microglial glucose deprivation/reperfusion (oxygen glucose deprivation/reperfusion, OGD/R) to simulate the brain injury after cardiopulmonary resuscitation. We hypothesized that adiponectin regulates the polarization of BV2 cells after OGD/R through the Nrf2-HO1-HMGB1 signaling pathway.

Methods

An OGD/R model of BV2 cells was constructed, and the Nrf2 agonist DMF and Nrf2 inhibitor ML385 were used to intervene BV2 cells. After OGD/R, IL-1β, TNF-α, Nrf2, HO-1, and HMGB1 were detected by Western blot, and different phenotypic polarized protein expression in BV2 cells, verify whether adiponectin regulates different phenotypic polarization of BV2 cells after OGD/R through the Nrf2 signaling pathway.

Results

After OGD/R, the CD68 protein expression was significantly higher, while the CD206 protein was lower. After the administration of ML385, the CD68 expression was more higher than APN administration, while the CD206 protein was lower. After OGD/R, IL-1β, TNF-α, Nrf2, HO-1, HMGB1 expression was higher. APN administration increased the Nrf2, HO-1 level and reduced the IL-1β, TNF-α, HMGB1 expression. DMF administration further magnified the APN function, which increased the Nrf2, HO-1 expression and reduced the inflammation and HMGB1 level. After the ML385 administration, we observed the opposite role of ML385 compared with DMF.

Conclusion

APN can alleviate the BV2 cell activation, polarization and inflammation release after OGD/R by Nrf2 signaling pathway.

Wen MA (ChengDu, China), Dr Sheng YE, Yarong HE, Junzhao LIU, Songling TANG, Pr Yu CAO
00:00 - 00:00 #23127 - Adiponectin can alleviate BBB injury after CA-CPR-ROSC by regulating Nrf2-HO1-HMGB1 signaling pathway.
Adiponectin can alleviate BBB injury after CA-CPR-ROSC by regulating Nrf2-HO1-HMGB1 signaling pathway.

Background

For patients surviving cardiac arrest (CA), the blood-brain barrier (BBB) disruption is an important cause of long-term neurological disorder. The brain ischemia reperfusion (I/R) related the inflammatory response is an important cause of BBB injury. The microglial cells become activated and polarized towards the M1 phenotype after I/R, secreted a large number of pro-inflammatory factors which can lead to injury of BBB. Nuclear factor erythroid 2 related factor 2 (Nrf2) is the key mediator of the endogenous defense system against oxidative stress. Activation of the Nrf2-HO1 signaling pathway can promote the polarization of microglia from the pro-inflammatory M1 phenotype to the anti-inflammatory M2 phenotype to reduce the inflammatory cascade. Adiponectin (APN) is a cytokine secreted by adipocytes which can reduce the expression of TNF-α and IL-6 in brain after ROSC. Therefore, we established a CA-CPR-ROSC mice model to explored whether adiponectin can regulate different phenotype polarization of microglia after ROSC. We hypothesized that adiponectin regulates polarization of microglia through the Nrf2-HO1-HMGB1 signaling pathway, thereby reducing the cerebral cortex inflammation response and attenuating BBB damage.

Methods

Twenty-five C57 BL/6 mice were randomly divided into 5 groups: sham group (n=5), CPR group (n=5), CPR + APN group (n=5), CPR + APN + DMF group (n=5), CPR + APN + ML385 group (n=5). observing the basic status and resuscitation indicators of the mice in each group, and the mice were sacrificed 3 hours after ROSC treatment, and brain tissue was taken Store in formaldehyde and liquid nitrogen. The expression of tight junction proteins occludin and claudin-5, IL-1β, TNF-α, Nrf2, HO1, and HMGB1 of each group of mice were detected by Western blot and immunofluorescence. Immunofluorescence was used to detect the polarization of different phenotypes of cerebral cortex microglial cells in each group.

Results

Compared with the CPR group, the APN intervention increased occludin and claudin-5 protein expression, Nrf2 and HO-1 expression, reduced HMGB1, IL-1β, TNF-α level, microglia activation and M1 type polarization. Compared with APN, the administration of DMF further magnified the APN effect, which increased Nrf2 and HO-1 expression, reduced HMGB1, IL-1β, TNF-α level, microglia activation and M1 type polarization, and alleviated the BBB injury. While the ML385 intervention had the opposite effect, reduced the Nrf2 and HO-1 expression, aggravated the HMGB1, inflammation level and BBB injury.

Conclusion

Adiponectin can reduce the inflammation level and decrease the microglia activation and polarization to alleviate BBB injury after CA-CPR-ROSC by regulating Nrf2-HO1-HMGB1 signaling pathway.

Junzhao LIU, Tingyuan ZHOU (ChengDu, China), Yarong HE, Dr Sheng YE, Pr Yu CAO
00:00 - 00:00 #23100 - Adiponectin improves outcomes via regulated microglial polarization after cardiac arrest and cardiopulmonary resuscitation in mice.
Adiponectin improves outcomes via regulated microglial polarization after cardiac arrest and cardiopulmonary resuscitation in mice.

Background

Cardiac arrest (CA) causes blood-brain barrier damage that frequently leads to severe loss of neurological function in survivors. The inflammatory response exacerbated by activation of microglial after cardiac arrest provides a potential therapeutic target. Adiponectin (APN) is a cytokine with anti-inflammatory effects secreted by adipocytes, but whether it can reduce the inflammatory, maintain blood-brain barrier integrity and improve outcomes after cardiac arrest is unknown. We tested the hypothesis that adiponectin would modulate microglial polarization, attenuate inflammation, improve neurological function and survival rates after cardiac arrest in rats.

Methods

Adult wild-type C57BL/6 and adiponectin-deleted (APN-/-) mice were subjected to electroe-sophageal stimulation-induced CA for 5 minutes and subsequently resuscitated. Ten minutes after the spontaneous circulation recovery, wild-type mice were randomized to receive adiponectin 10ug, or saline as placebo. Neurological score and survival rate with wild-type mice were evaluated seven days after cardiopulmonary resuscitation. Blood-brain barrier permeability was assessed using Evans Blue (EB) leakage. Immunohistochemistry, immunofluorescence and western blotting was performed on cerebral cortex tissue to assess cortex inflammation, microglial polarization and tight junctions (TJs) damage with blood-brain barrier.  

Results

A significantly elevated Evans-Blue leakage was detected in the cerebral cortex of the mice model after cardiac arrest, especially at 3h after return of spontaneous circulation (ROSC). Furthermore, microglia were markedly proliferated and the expression of IL-1β and TNF-α protein were elevated at the same time. More importantly, Administration of adiponectin attenuated neurological function impairment and improved 7day-survival in wild-type mice after CA/CPR (75% in APN group versus 41.7% in CPR group; log rank P=0.002). Relative to CPR group, adiponectin improved the expression of tight junction proteins (Occludin and Claudin-5) with the blood-brain barrier, reduced the expression of inflammatory proteins (IL-1β and TNF-α) in the cerebral cortex, and promoted polarization of microglia from the M1 phenotype to the M2 phenotype. Meanwhile, adiponectin-deleted further increased the cerebral cortex inflammation response, aggravated the destruction of the blood-brain barrier tight junction, and reduced the polarization of microglia to the M2 phenotype in APN-/- mice after ROSC.

Conclusions

   Inflammatory induced by microglial proliferation to M1 phenotype leaded to further damage with blood brain barrier after CA/CPR. Adiponectin maintained blood brain barrier stability, improved neurological prognosis and survival rates via regulated microglial polarization and reduced inflammatory response after CA/CPR in mice. Our observations suggest that adiponectin is a novel therapeutic drug to improve outcomes after CA/CPR.

Dr Sheng YE, Songling TANG (ChengDu, China), Yarong HE, Peng YAO, Junzhao LIU, Di HAO, Pr Yu CAO
00:00 - 00:00 #23625 - Adolescent self-harm in the Emergency Department: an observational study from the Royal Berkshire Hospital, UK.
Adolescent self-harm in the Emergency Department: an observational study from the Royal Berkshire Hospital, UK.

It is well established that young people who have self-harmed report negative experiences of Emergency Department (ED) treatments. Commonly ED staff also describe not knowing the best way to help.

Young people who have self-harmed probably differ in multiple respects from others attending the ED with two major implications. First we need to know more about these differences to inform ED care. Second there may be characteristics of adolescents who self-harm that explain how they experience being in the ED.

In this study we set out to examine these topics with a unique design in which young people were administered a questionnaire pack soon after arrival in the ED, and again at least 2 hours later, thus capturing their expectations and pre-existing characteristics, and their experience. Adolescents attending for suspected fractures served as the control group.

The study was paused because of COVID-19, at which time the numbers for the arrival questionnaires were, N = 25 self-harm, N= 60 control, and numbers also with second questionnaires, N = 17 self-harm and N = 41 control.

We report here from a subset of adolescent report measures on Expectations of Care  based on items from a widely used measure the Parental Bonding Instrument, Borderline Personality Disorder features using a standard measure for adolescents, Attachment needs using the Reading Attachment Behaviour Questionnaire devised for this study, and a standard measure of Patient Satisfaction. We also administered parallel questionnaires to parents which are not reported here.

All the measures showed satisfactory psychometric properties with internal consistencies (alpha) of over .75.

The self-ham and control groups differed markedly in several respects.  Mean scores for Borderline Personality disorder features were 1 .s.d higher (p = .001), and mean attachment security scores 0.8 s.d. lower (p = .004) in the self-harm than the control group.  The control group had more positive expectations of care from ED staff than the self-harm group, but that difference was not significant.

Young people who had self-harmed reported more dissatisfaction with their treatment than those with suspected fractures, with a difference in means of 1 s.d. (p = .001).

However, dissatisfaction was also predicted by Borderline Personality Disorder features (r = .37, p = .004), lower positive expectations (r = -.27, p = .042) and lower attachment security scores (r = -.43, p = .001). Numbers are at the moment insufficient for joint examination in multiple linear regression and so we cannot yet say whether these pre-existing characteristics explain the elevated dissatisfaction scores in the self-harm group.

The findings underline the distinctive needs of young people who self-harm and the way they may affect how they experience the ED. Implications for further work are that there may need to be a distinctive ED pathway for adolescents who self-harm taking account of these psychological and interpersonal needs, and that studies of patient satisfaction have to account for these differences when attempting to estimate the impact of the ED experience. 

Sarah WILSON (Slough, United Kingdom), Liza KEATING, Jonathan HILL, Tauseef MEHDI, Thomas MANTELL, Dominic JONES
00:00 - 00:00 #22457 - Against better knowledge: why are infants in the paediatric emergency department still receiving bronchodilators?
Against better knowledge: why are infants in the paediatric emergency department still receiving bronchodilators?

Introduction: There is good evidence that bronchodilator treatment of infants with bronchiolitis carries no significant benefit. The same applies to performing chest x-rays and starting antibiotics. Despite clear guidance from the National Institute for Health and Care Excellence (NICE, NG9) this continues to be common practice in paediatric emergency departments and in this qualitative study we tried to explore the reasons behind this.

Methods: All infants (aged less than 12 months) with bronchiolitis severe enough to require inpatient admission from the paediatric emergency department were identified from the electronic medical record system (EPIC) and confirmed as meeting inclusion criteria. This was limited to infants presenting during the month of December 2019. The individual patient notes were assessed for investigations, bronchodilator therapy and other therapeutic interventions including antibiotics and respiratory support. The ordering physician was identified. A non-validated, anonymised questionnaire was used, describing a common bronchiolitis scenario, exploring physician’s attitudes towards investigations and therapeutic interventions and their knowledge of current guidance.

Results: 129 infants were identified of which 80 fulfilled the inclusion criteria. Ages ranged from 10 days to 11 months (mean 4.3 months, median 3.5 months). 73 infants had the diagnosis confirmed by virus identification, 7 patients were diagnosed on clinical grounds with no alternative diagnosis. 13 patients (16.25%) had a chest x-ray, the same number received antibiotic treatment. 11 patients (13.75%) were given bronchodilators. Ordering physicians included all levels of seniority, ED physicians as well as paediatricians based in the paediatric emergency department. All were aware of the NICE recommendations in relation to the management of infants with bronchiolitis. The main drivers behind ordering chest x-rays and starting antibiotics (usually as part of a septic screen) were unwell appearing children, high fevers and pre-existing medical conditions (especially cardiac and cystic fibrosis). Physicians felt more inclined to trial bronchodilators in infants at the older end of the age range, with evidence of previous positive response to bronchodilators and in infants presenting at the more severe end of presentation, especially in relation to perceived work of breathing.

Conclusion and recommendation: Despite lacking support by the NICE bronchiolitis guideline, infants are submitted to investigations and treatment by paediatric ED physicians, some of whom are very experienced and fully aware of the current guidance. It is plausible that there may well be sub-groups of infants with bronchiolitis that may benefit from these interventions and further research focussing on these specific populations would be welcome.  Other factors influencing physicians’ decision making like ‘ill appearance’ or ‘increased work of breathing’ would benefit from becoming part of more formalised, validated and quantifiable assessment tools like Paediatric Early Warning or Severity of Illness Scores.

Hira HASAN (Cambridge, United Kingdom), Peter HEINZ
00:00 - 00:00 #23012 - Age improves early prediction of 7-day mortality in a Scandinavian triage system, an observational study.
Age improves early prediction of 7-day mortality in a Scandinavian triage system, an observational study.

Background

Early identification and management of critically ill patients is important for the quality and patient safety in the Emergency Department (ED). 

Rapid Emergency Triage and Treatment System (RETTS) is a triage system widely used in Scandinavian EDs, setting a triage priority (TP) from 1 to 5 for the patient, with 1 being the highest priority. The priority level is intended to indicate a risk of deterioration and a need for urgent emergency care and interventions. The process of RETTS evaluation is a structured patient history and status control conducted by a nurse, including respiratory rate, heart rate, systolic blood pressure, pulse oximetry saturation, body temperature and level of consciousness. Patient age or sex is not included in the RETTS algorithm. 

Improving the triage system’s ability to predict adverse patient outcomes could reduce the risk of delayed intervention and delayed care for patients at risk.

Objective

We aimed to evaluate the relative risk and predictive utility of patient’s age and sex in triage in general and in the RETTS system in particular with regard to 7-day mortality (7dM) risk, and whether there was a difference in this regard between patients with specific or nonspecific primary complaints. 

Material and methods

We performed a cohort study on all visits to the EDs for adults of any of the 7 emergency hospitals in the 2 million inhabitants Stockholm region during 2012-2016. A total of 1 816 599 visits were included. Logistic regression (LR) analysis and receiver operating characteristic (ROC) analysis with area under the curve (AUC) were performed with patient’s first triage priority, age and sex as independent variables and patient deceased or not within 7 days as primary outcome. The model was fitted on patient visits in 2012 - 2015 and evaluated on patient visits in 2016.

 

Results

Age was an independent predictor of 7dM also when adjusted for triage priority and sex, whereas sex didn’t make a significant contribution to any model.

Age alone outperformed triage priority in predicting 7dM. The model using only triage priority had an AUC of 0.73 (95% confidence interval [CI] 0.72 - 0.75) and a model with only age had an AUC of 0.85 (95% CI 0.84 - 0.85). The combined model with triage priority and age had an AUC of 0.88 (95% CI 0.87 - 0.89).  Relative risk increased by 8.3% for each year of patient age (95% CI 8.0% - 8.5%), after adjusting for triage priority. We found no significant differences between models for patients with specific vs nonspecific complaints.

Conclusions

Including patient age substantially improves risk assessment for 7dM for patients in the ED triaged with the RETTS system. We suggest that future triage systems consider patient age when setting triage priority.

 

Gustav MALMER (STOCKHOLM, Sweden), Richard ÅHLBERG, Per SVENSSON, Martin HOLZMANN, Eli WESTERLUND
00:00 - 00:00 #23140 - Age-related differences in the prognostic value of sepsis-induced myocardial dysfunction: an observational study.
Age-related differences in the prognostic value of sepsis-induced myocardial dysfunction: an observational study.

Background

The aim of this study was to investigate the presence of age-related differences in the prognostic value of sepsis-induced myocardial dysfunction (SIMD).

Methods

Consecutive patients with sepsis, admitted between July 2012 to September 2019 to our Emergency Department High-Dependency Unit, were included. A complete echocardiographic examination was performed within the first 24 hours. We assessed LV systolic function with Global Longitudinal Strain (GLS) and RV systolic function with Tricuspidal Annular Posterior Systolic Excursion (TAPSE). LV systolic disfunction was defined as GLS > -14%, RV systolic dysfunction as TAPSE

Results

We included 391 patients, 90 in group A and 301 in group B. The 2 groups were similar for gender distribution (male gender 70% vs 55%), sepsis source (mainly respiratory), lactate levels upon admission (2.0 vs 2.3 meq/L), SOFA score [6 (3-8) vs 6 (4-8)] and incidence of septic shock (31% vs 41%). LV systolic dysfunction showed a similar prevalence (57% vs 63%) while RV systolic dysfunction was less prevalent in group A than in group B (18% vs 36%, p <0.001). Mortality was lower in group A compared with group B at Day-7 (6% vs 18%, p 0.01), Day-28 (16% vs 36%, p <0.001) and long-term follow-up (42% vs 69%, p <0.001). For group A, a Kaplan-Meyer survival analysis showed a decreased survival for patient with LV systolic dysfunction at day-7 (90 vs 100%, p=0.04) and no significant difference at day-28 and long-term follow-up (80 vs 86%, p=0.39; 48 vs 68% and p=0.07). For patients in group B, LV systolic dysfunction was associated with decreased survival at Day-7, Day-28 and long-term follow-up (respectively 77 vs 89%, p=0.009; 54 vs 80%, p <0.001; 23 vs 43%, p <0.001). The Kaplan-Meyer analysis for RV systolic dysfunction did not show any difference in survival at day-7 for both groups. At day-28 survival was decreased only in group B (53 vs 72%, p=0.001), while it was reduced for both group during long-term follow-up (group A: 33 vs 63%, p=0.002; group B: 23 vs 36%, p=0.006). We performed a Cox regression analysis and we included in the model LV systolic dysfunction, RV systolic dysfunction, SOFA score and a history of known coronary artery disease. LV systolic dysfunction was an independent predictor of mortality only in Group B, at day-7 (HR 2.02, CI 1.01-4.07, p=0.04), day-28 (HR 2.60, CI 1.57-4.29, p <0.001) and long-term follow-up (HR 1.73, CI 1.27-2.36, p <0.001). RV systolic dysfunction was an independent predictor of mortality only in Group B and only in long term follow-up (HR 2.41, CI 1.16-4.98, p 0.02). 

Conclusions

LV systolic dysfunction is an independent predictor of short and long-term mortality among elderly patients and it is associated with a higher short-term mortality in young patients. RV systolic dysfunction is a long- term prognostic marker, independently associated with an increased mortality only in older patients.

Federico MEO, Francesca INNOCENTI, Vittorio PALMIERI, Dr Michele MONTUORI (Firenze, Italy), Stefano CALCAGNO, Marco CIGANA, Federico D'ARGENZIO, Anna DE PARIS, Valerio Teodoro STEFANONE, Irene TASSINARI, Riccardo PINI
00:00 - 00:00 #23651 - Aggression against the emergency teams in Bulgaria-analysis and ways of limiting it.
Aggression against the emergency teams in Bulgaria-analysis and ways of limiting it.

Background: Verbal and physical aggression against emergency teams is a serious problem, forcing many medics to leave the system of emergency medical care in Bulgaria. An analysis of the frequency and forms of aggression was carried in order to propose measures to limit its impact, taking into account some proposals by the emergency staff itself.  

Methods: Two studies were conducted via social network, among workers in outpatient and hospital emergency care in Bulgaria. The first study, carried in the period 22.02.-22.04.2020,  on the frequency and types of aggression exercised upon emergency teams was conducted among 134 respondents. The questionnaire aimed to determine who, when, how and why exerts aggression over the emergency medics, and gathered suggestions of the medical staff how to protect themselves. The second study was carried in the period 16.02-16.04.2020 among 115 respondents on the need for regulatory measures to prohibit carrying weapons in the presence of an emergency team, as well audio and video footage of the team’s work and its dissemination in social networks and mass media.

 Results: The results of the first study showed that 112 (84%) respondents do not feel safe on duty. According to 122 (91%) aggression is mostly shown by the relatives of patients, and according to 95 (71% ) - by patients under the influence of alcohol or psychotropic substances. Aggression may occur at any time during the medical examination according to 95 (71%) and in case the patient is dissatisfied with the service - 91 (67%). According to 68 (51%) aggression occurs monthly and according to 42 (31%) on daily basis. Over 80% reported as forms of verbal aggression: insults, threats of complaints to institutions and media, audio and video footage. 20 respondents (15%) claim that records made to them at work are distributed without their consent. 97 (72%) were victims of physical aggression and 29 (22%) were threatened with weapons. 129 (96%) are dissatisfied with the existing measures against aggression. Among all respondents in the two studies, over 40% supported measures such as CCTV in emergency departments, panic buttons, physical security. Nearly 70% wanted regulatory changes prohibiting video and audio footage from escorts and patients, as well as banning the carrying of firearms.

Discussion & Conclusions: Aggression against emergency staff remains a serious issue and takes several forms. Some of the Bulgarian emergency medics do not feel safe at work. Emergency medical personnel is not satisfied with the existing measures against aggression and recommends regulatory changes that will contribute to greater security at work. It is highly recommended for health institutions to research deeply this problem and take timely and adequate decisions, because the shortage of staff in the emergency care system increases, lowering the quality of the medical care of the population.

Desislava KATELIEVA (SOFIA, Bulgaria), Lora GEORGIEVA, Teodor TSANKOV
00:00 - 00:00 #23622 - Alcohol and epilepsy seizures correlation.
Alcohol and epilepsy seizures correlation.

Alcohol abuse and its consequences related seizures are Well known in experimental and clinical data. The best Recognized seizures are “alcohol withdrawal seizures” Specific epileptogenesis may underlie seizure unrelated to withdrawal and in this context involves several mechanisms including alterations of excitation/inhibition systems and kindling like effect. Patients presenting with seizures unrelated to any cause other than alcohol are classified in several successive stages of “alcoholic epilepsy”, as solitary and chronic seizure. Epidemiological data have shown that 4 to 7% alcoholics have seizures. There are several possible contexts in which seizures can occur in chronic alcoholics, hypoglycemia, hyponatremia, hepatic en-cephalopathy, thiamine deficient, head trauma cerebral atrophy ,etc.

Methodology:
We have data for 41 patients recovered with diagnoses of epileptic seizure in the emergency division in Regional Hospital Durres Albania in the years 2016 – 2019. Mean age of patients 44.4 years old. 37 are male and 4 are female. The types of seizures observed Generalized tonic-clonic 52%, status epileptic 11%, simple partial seizures6%, simple complex seizures 5 %, 26% un classification seizures. Two causes (female) had the first time of alcohol abuse. The mean times of alcohol abuse for the males were 16.5 years and 2 females 11 years

Conclusion:
In our opinion the classifications of time abuse and the type of seizures can help for drug choice anti-epileptic treatment but, alcoholic epilepsy we think is an epileptic syndrome whose particularity is  in the fact that it is potentially reversible and the therapy can be stopped in cases of free seizures for a long time.

Edlira HARIZI (SHEMSI) (Durres, Albania), Kledisa SHEMSI, Ferid DOMI
00:00 - 00:00 #23566 - ALIMENTARY HABITS IN PROFESSIONAL MASTER’S NURSING STUDENTS.
ALIMENTARY HABITS IN PROFESSIONAL MASTER’S NURSING STUDENTS.

Background and Aims:

Malnutrition, in all its forms, is a global problem.

Worldwide, 1 in 3 people suffer from some form of malnutrition.

Today, almost 800 million people suffer from chronic undernourishment and more than 2 billion people suffer from micronutrient deficiencies. Another 1.9 billion people are overweight, and 600 million of them are obese. A healthy diet helps protect us from malnutrition in all its forms, as well as from noncommunicable diseases, including diabetes, heart disease, strokes and cancer.


Methods:

This is a descriptive study included 27 randomly selected professional master's students in surgical nursing, who completed an online anonymous questionnaire regarding alimentary habits during 15-16 June 2019. The statistical analysis included descriptive statistics.


Results:

The study showed that: 88% was female, the main age 23 years old. 40.7% refer that consume 1 portion of fruit per day, 74.1% consume candy, snacks or industrial dough products once a day, 55.6% consume 1 meal of dairy products a day, 33.3% consume vegetables 3 times a week. 40.7% consume meat 3 times a week, 48.2% consume fish once a week, 44.4% consume chicken once a week, 53.9% consume fast food once a week, 30.8% consume 3 refreshments during the week, 46.2% consume fried foods once e week, 26.9% drink 5-6 glasses of water/day, and 19.3% drink 9-10 glasses of water/day.


Conclusions:

The findings show that the alimentary habits of nursing students need to be improved, and

suggests increasing knowledge and promoting healthy behaviors to go back to our Mediterranean diet.

Llambi SUBASHI, Brunilda SUBASHI (Vlore, Albania), Leonard LIKAJ, Elca GERXHI, Genti KONDO, Ina SHUAIPI, Indrita FEJZAJ
00:00 - 00:00 #23149 - Always suspect COVID-19 in hospitalized patients.
Always suspect COVID-19 in hospitalized patients.

We present the case of a male 74-year-old patient with a personal history of arterial hypertension, dyslipidemia, type 2 diabetes mellitus, immunosuppression because of having received a kidney transplant in 1984 for CKD of unknown etiology and an event compatible with a possible seizure crisis, for which no further details were provided. The patient went to an Emergency Service of the Community of Madrid (Spain) on March 6th, 2020 due to dysthermia in the afternoon prior to his consultation with associated shivering, as well as dizzying symptoms that have caused a fall, having been found by a relative on the floor when visiting his home (he lives alone). The patient said that he had been unable to get up for 3 hours. The patient denied respiratory symptoms (although during the anamnesis he presented a cough that he claims has been for months), gastrointestinal or urinary symptoms. He refused to smoke or drink alcohol and usually goes to a day center for retired people in the afternoons. On physical examination, he presented 37.3ºC with a vesicular murmur preserved after pulmonary auscultation, and an unremarkable abdominal examination. In the blood test, he  presented creatinine 1.25 mg / dL, bilirubin 1.3 mg/dL with ALT 87 IU/L, AST 96 IU/L, GGT 40 IU/L LDH 775 IU/L, CRP 90 mg/L, leukocytes in normal range with mild lymphopenia 900/mm3, platelets 121,000/mm3, coagulation with INR 1.21 and D-Dimer of 1.83 µg/mL. The chest radiograph had no pathological findings. With all these clinical, analytical and radiological data, it was decided hospitalization at the Gastroenterology Unit in an individual conventional room without any measure of isolation, given that an incipient acute cholangitis was suspected at the Emergency Department. Upon arrival at the Unit, the doctor in charge reviewed the data, and in the context of the increasing number of cases of COVID-19 in the region and in particular related to day centers for retired people, it was decided to request a PCR test in order to detect SARS-COV-2, being positive.

We consider this case of interest to highlight the importance of in a pandemic context not to avoid suspecting in oligosymptomatic cases the presence of SARS-COV-2 that has high infectivity with an R0 around 3 that without measures of isolation could cause a high number of infections among healthcare personnel and other hospitalized patients. Early suspicion of the disease is also important to treat the patient as early as possible. An X-ray at the time of the consultation can be normal in up to 50% of cases and a PCR have a sensitivity of around 60%, being the most sensitive test for detection being a chest CT scan (close to 90%) that it was not included in the regional protocols for the diagnosis of new cases at that time, so staying alert and repeating the PCR after 48 hours could increase the sensitivity to detect the disease, maintaining isolation measures in the patient while not completely ruling out its presence.

Santiago BLANCO REY, Vanesa Natalia ISAAC, Ismael EL HAJRA MARTÍNEZ, Elena SANTOS PÉREZ, Antonio Miguel PINTO DA COSTA, Miriam UZURIAGA (Madrid, Spain)
00:00 - 00:00 #22856 - Ambulance patients with acute dyspnoea - experience of symptom and situation.
Ambulance patients with acute dyspnoea - experience of symptom and situation.

Background
Acute dyspnoea constitute a serious prehospital problem, as previous study shows it frequently occurs and is associated with a high mortality. Yet few studies have investigated the patient’s own experience of acute dyspnoea in the prehospital setting. Our aim was the investigate how ambulance patients with acute dyspnoea experience their situation when calling the emergency number and having a following ambulance run.

Methods
Focused ethnography inspired study in the North Denmark Region, with observations from ambulances based at three different locations and patient interviews from two emergency departments in the region.
The region is mostly rural but include urban areas. A prehospital dyspnoea score (scale 0-10) is implemented in all ambulances in the region.

Included a convenience sample of ambulance runs and ambulance patients with acute dyspnoea.

We chose a focused ethnography inspired approach as it combines observation of patients in the acute situation with interviews when the patient is in a more stable phase. Field notes were used for observations, and semi-structured interviews were used for patient interviews.
Data was analysed and interpreted with inspiration from Poul Ricouer. First, it was read and reread naively, to gather an understanding. At the next step, they were analysed and structured according to deduced themes. Finally, the deduced themes were critically interpreted in thematic analysis.

All data was anonymised prior to analysis and NVivo 12.1 PRO (QSR International Pty Ltd, Doncaster, Victoria, Australia) was used.

Results
In total 12 patients were interviewed, and six ambulance runs with dyspnoea patients were observed.
We identified several themes among the acute dyspnoea patients. The severity of acute dyspnoea both in the ambulance and following in the emergency department was immediately evident. As two different patients expressed “People who cannot breathe panic. They always do.” and ”… I could only concentrate on breathing”. The severity was also a prominent theme in the fieldnotes from the ambulance observations, with the observations of the patients’ distress.

However, another prominent theme among several patients, was an expressed relief when being met by ambulance personal who they saw as professional in their work. In addition, the patients noted the communication with the ambulance professionals as positive and reassuring.

The patients expressed difficulties assessing their own dyspnoea, when moderate, i.e. whether they had a dyspnoea score of specifically 6 or 7, but otherwise had little problem assessing.

Discussion & Conclusions
We found patients experienced acute dyspnoea as a severe symptom, which correlates with the oft poor outcome for the patients. The patients experience of relief when met by ambulance professionals, relate with a previous study that found ambulance patients desire reassurance and are further reassured by professional behaviour. The patients were well aware of their own situation, and capable of assessing their intensity of acute dyspnoea. The difficulties with smaller nuances of the dyspnoea score, is well known from other scores, e.g. visual analogue scale for pain.
In conclusion our findings emphasise the severity of acute dyspnoea and stresses the importance of professionalism and communication between ambulance professionals and patients.

Tim LINDSKOU, Stine IBSEN, Birgitte LAURSEN, Ulla WEINREICH, Søren MIKKELSEN, Erika CHRISTENSEN (DENMARK, Denmark)
00:00 - 00:00 #22984 - An abdominal mass in a six year old? How bezoar!
An abdominal mass in a six year old? How bezoar!

We present the case of a 6-year-old girl, who was referred to the emergency department (ED) by her general practioner (GP) with an abdominal mass. She had no past medical history and a normal development to date.

She had attended the out-of-hours GP four days previously with epigastic pain and reduced oral intake. Examination at the time revealed the mass; she was managed conservatively with simple oral analgesia and followed up with her usual GP.  

On arrival she appeared well, vitals were within normal limits and she was pain free. The history revealed she had a three month history of trichotillomania with trichophagia which coincided with the birth of twins in her family. She also had a four day history of halitosis. 

Abdominal examination revealed a large, non-tender, well circumscribed mass in the epigastrium, with some crepitus. Laboratory investigations were normal. An abdominal x-ray revealed a large intra-luminal mass filling most of the stomach. 

She was referred to the surgical team and was subsequently transferred to a tertiary paediatric hospital the next day. She underwent a laparotomy to remove the mass which was confirmed to be a trichobezoar. She had an uneventful post-operative recovery and was discharged after five days. 

During her admission child-psychiatry were consulted regarding her trichotillomania and trichophagia which were diagnosed as being secondary to anxiety. She has since been managed with play therapy and has not had any further instances of trichophagia.

Trichobezoars are ingestional foreign bodies composed of hair. Rapunzel syndrome is the rare form which extends beyond the stomach into the small intestine. Trichobezoars are rare causes of abdominal masses; only three have been reported in Ireland.

Gastric bezoars have a reported recurrence rate of up to 20%; therefore it is critical to treat the underlying cause of the condition.

  

Brian MACCARTHY (Limerick, Ireland)
00:00 - 00:00 #23218 - An abdominal surprise.
An abdominal surprise.

58-year-old female patient with a history of hypothyroidism, dyslipidemia and overweight. He went to the emergency department for presenting a tumor at the abdominal level. He says that this mass was noticed a few days ago when he leaned on a counter. No nausea or vomiting, no diarrhea, no change in bowel movements, or general discomfort. No headache or associated chest pain.

Physical examination. Vital signs:Tª35.5ºC,HR 69 bpm, BP 128/72,SpO2:98%

Physical exam: Conscious and oriented, isocoric and normoreactive pupils. Cranial pairs without alterations. Normal cardiac auscultation. Preserved vesicular murmur. Abdomen: Soft and depressible, painful on deep palpation at the level of the mesogastrium and right vacuum with the presence of a painful mass at this level. When the patient was lying supine, it is palpable less than when she was standing. Airborne noise present. No signs of peritonism.

 

Complementary Tests

- General analytics. Hemogram, coagulation and renal and hepatic function with PCR in normal limits.

- Urine sediment. Normal.

- Venous blood gas: pH 7.37, lactic 0.9, Hb 14.5.

Abdominal hernia, neoplastic tumor as differential diagnosis.

I perform an abdominal ultrasound in which a small discontinuity of the musculature of 0.8 cm was observed on the right flank (where the patient has pain). It could be an abdominal wall hernia.

In this situation, an abdominal CT was requested, which was observed between the aponeurosis of the oblique / transverse muscles and the right anterior rectus muscles, a tumor compatible with Spiegel's hernia. It measured about 3 x 2 x 2.6 cm, with a 1.3 cm neck.

Conclusion:

A Spigelian hernia is the type of ventral hernia where aponeurotic fascia pushes through a hole creating a bulge. This kind of hernias is rare compared to other types. It develops betxeen fascia tissue that connects to muscle, not under abdominal fat.

It is so important to thing about it because it has high risk to become strangulated. The best way to diagnosis is with ultrasound imaging or CT scan. Before these imaging tests we must have a suspected diagnosis and do a correct and systematic exploration.

The emergency physician plays a very important role in the diagnosis of abdominal hernias during the history and examination.

Juan ORTEGA PÉREZ (PALMA DE MALLORCA, Spain), Meritxell VIDAL BORRÀS, Bernardino COMAS DÍAZ
00:00 - 00:00 #22986 - An atrial fibrillation patient with multiple thrombi in left atrium and pulmonary vein after Maze procedure and mitral valve replacement surgery: a case report.
An atrial fibrillation patient with multiple thrombi in left atrium and pulmonary vein after Maze procedure and mitral valve replacement surgery: a case report.

Background 

Left atrial thrombus is a rare clinical condition and is known to be mainly caused by atrial fibrillation (Af) and mitral valve disease. Thrombus can mostly be found in left atrial appendage and in some uncommon cases also involves the pulmonary vein. Moreover, thrombus might also cause systemic thromboembolism to the end-organ, e.g. ischemic stroke or ischemic bowel disease. Anti-coagulant agents can be used to prevent further thrombus formation. Besides conservative treatment for Af, Cox-maze procedure is a surgical treatment for refractory atrial fibrillation. If the lesion comes from antrum of pulmonary vein, the surgery is usually done with complete pulmonary vein isolation. A few case reports [1] revealed that intra-atrial thrombus was found after a maze surgery which was caused by many factors including atrial damage by surgery and recurrent Af. 

Case scenario: 

An 80 year-old male had a medical history of coronary artery disease and ruptured mitral valve chordae. Therefore, the patient underwent coronary artery bypass graft and mitral valve repair with tissue valve replacement. And due to persisting atrial fibrillation, he then took the Maze surgery with pulmonary veins isolation and also took anti-coagulant and anti-platelet agents. The patient was sent to our emergency department (ED) with dyspnea which gradually worsened in the past four days. There were no fever or respiratory tract infection symptoms. Physical examination revealed a wheezing breathing sound over the bilateral lung field, pitting edema over legs and hypoxia with 93% of oxyhemoglobin saturation by pulse oximetry (SpO2). Electrocardiogram (ECG) showed Af. The medical team decided to perform a Point-of-Care Ultrasound (POCUS) and found diffuse lung edema and poor cardiac contractility. Furthermore, a large soft tissue density lesion (3.12 x 4.04 cm) was found in the left atrium and thrombus was suspected. It is rare to find a large thrombus in the left atrium even among Af patients. Besides, clinical and echocardiogram may not be thorough enough to distinguish thrombus from myxoma. A computed tomography scan (CT scan) with contrast was performed and showed there were multiple thrombi in the left atrium which extended to the pulmonary vein causing pulmonary vein narrowing.  In some case reports, pulmonary artery pressure might increase and result in lung congestion with systemic hypotension and low cardiac output. The clinical manifestations could vary, but mainly show a decrease in cardiac function or even cardiogenic shock. In this case, the patient seemed to suffer from acute heart failure with decompensation. Even though this is an Af patient under the anti-coagulant therapy with previous ablation treatment or mitral valve replacement, this case should also be considered as a high risk for thrombus formation in the left atrium. 

Conclusion & perspectives :

Atrial fibrillation is a major cause of left atrium thrombus formation. Although the patient is under anti-coagulant therapy and underwent previous cardiac surgery for ablation or valve replacement, this case should still has a high risk of causing an even more severe thrombus in the left atrium and pulmonary vein.

Wei-Lun CHEN (Taipei, Taiwan, China), Tzu-Yao HUNG
00:00 - 00:00 #23436 - An audit into the investigation of patients presenting to the emergency department with unexplained haematuria.
An audit into the investigation of patients presenting to the emergency department with unexplained haematuria.

Background:

Patients with unexplained haematuria commonly present via the Emergency Department. With cancer accounting for around one third of patients with painless haematuria, it is important that patients are investigated promptly. Lack of a clear referral pathway means that some patients are admitted for investigation while others are referred for outpatient investigation, either directly by the Emergency Department (ED) or via General Practice (GP). We carried out a retrospective analysis of adult patients presenting with unexplained haematuria to the ED of two NHS Greater Glasgow & Clyde (NHS GGC) hospitals over a one-year period, with the aim of identifying any improvements to current practice.

 

Methods:

In this retrospective cohort study, data was obtained for adult ED presentations at the Royal Alexandra Hospital and Inverclyde Royal Hospital during a one-year period from January 2019 until December 2019. Patients discharged with the diagnosis code “haematuria – unexplained” were included. Where patients had multiple presentations, only the first was included. Relevant data was collected from the NHS GGC Trakcare and Clinical Portal IT systems. The patients were then classified into groups according to patient age (i.e. 45 years) and type of haematuria (i.e. visible or non-visible) to allow comparison with the Scottish Referral Guidelines for Suspected Cancer. The data collected was analysed to identify the proportion of cases where patients underwent appropriate investigation, and whether cases were referred for investigation within the recommended timeframe. Mean waiting times for patients requiring urgent outpatient investigation within two weeks were calculated and compared for ED and GP referrals. An unpaired T test was then carried out to determine whether there was a significant difference between the two groups.

Results:

Unexplained haematuria was identified in 159 patients who presented to the RAH and IRH over a one-year period. 128 patients (80.5%) were male and 31 (19.5%) were female. The mean age at presentation was 69 years. 64% of patients were investigated in accordance with the guidelines; 28% were referred appropriately but investigated out with the recommended time period; 8% were not investigated in accordance with the guidelines. 36 patients aged > 45 with unexplained visible haematuria required referral for investigation within two weeks as recommended. 27 (75%) were referred via ED and waited an average 36 days; while 9 (25%) were referred via GP and waited an average 35 days. There was no significant difference between waiting time following ED and GP referral (P=0.92).

 

Discussion & Conclusions:

The majority of patients were referred for investigation in accordance with the guidelines. However, most patients requiring urgent referral were seen out with the recommended two weeks. Further exploration into potential reasons is required to help improve waiting times for outpatient investigation. No significant difference was noted in waiting time between referral via ED and GP, although a small minority of patients were not followed up as recommended when discharged from ED for GP referral. We therefore recommend that patients requiring outpatient investigation are referred directly via ED to help ensure that all patients are referred for investigation, where necessary.

Hannah GILCHRIST (Glasgow, United Kingdom), Jessica COOPER, Monica WALLACE
00:00 - 00:00 #23426 - An Audit of Clyde Emergency Medicine and STAG guidelines on Open Fractures.
An Audit of Clyde Emergency Medicine and STAG guidelines on Open Fractures.

Introduction

According to The Scottish Trauma Audit Group (STAG) Quality Indicators, patients with open limb fractures should receive antibiotic prophylaxis within one hour of attendance at A&E and within three hours of the injury.  STAG guidelines are currently on version three and were last updated in September 2013.

Why antibiotics?

Many studies have proven the importance of prescribing antibiotic prophylaxis as soon as possible as it will reduce open fracture infection rates by a substantial amount.  One in particular found that delaying the administration of antibiotics to 6 or 24 hours had a more profound effect than delaying surgery.

Methods

This retrospective study reviewed patients’ medical notes who had experienced an open limb fracture anywhere except the hands and feet, in the time period of January 2018 to October 2018 and July 2019 to October 2019 at Royal Alexandra Hospital (RAH) and Inverclyde Hospital Emergency Departments in order to determine whether the management was in keeping with STAG guidelines. Data was collected after reviewing doctors notes and medication charts in inpatient records.

We documented the time of patients’ arrival to the ED and the time when they received their first dose of antibiotics.  In addition, we noted the triage category and the time the call for an ambulance was made, as this was the best indicator of time of injury. The main outcome was to assess if the hospitals were following the STAG guidelines. Sample size was limited those who attended the emergency department.

Results

Overall, 38.89% of patients who came to the emergency department were given antibiotics within the 1 hour of attendance target.  53.85% had antibiotics administered within 3 hours of injury time.  

The average time of antibiotic administration from time of presentation either to the ED was 1 hour 28 minutes.  This is considerably higher than the 1-hour guideline from STAG.

The average time of antibiotic administration from time of injury was 2 hours 54 minutes, which is within the three-hour recommendation.

Given these results, it can be concluded that the A&E departments failed to meet STAG guidelines.

Conclusion

The following are recommendations which could help staff to meet the 1-hour and 3-hour targets:

        Training for all staff on open fractures and current STAG guidelines

        STAG guidelines poster on walls around the emergency department

        Encourage paramedics to administer antibiotics at the scene of injury when getting IV access.

        Better documentation of injury details:

        Gustilo-Anderson Classification

        Accurate time of injury

        Accurate time of antibiotics administration

        Creating a proforma for staff to fill out and follow that covers the above documentation suggestions

        Follow up research to see if there are any changes in the proportion of patients who have been treated in accordance to the STAG guidelines

Maria STOKOE, Muhammad PATEL (Glasgow, United Kingdom)
00:00 - 00:00 #23206 - An evil dizziness.
An evil dizziness.

65-year-old male patient with a history of depressive anxiety syndrome treated with paroxetine and diazepam, former smoker for a year. He came to the emergency department for presenting instability to the march for 3 days. He had instability to walk so hard so he needed to be taken home due to the impossibility of ambulation. He denied that this symptomatology has occurred to him previously. No fever or dysthermic sensation. She claimed that he had an unirradiated holocranial headache without photophobia or sonophobia.

Physical examination. Vital signs:Tª36.3ºC,HR 50 bpm, BP 128/68,SpO2:99%

Physical exam: Conscious and oriented, isocoric and normoreactive pupils. Cranial pairs without alterations. No alterations in the confrontation campimetry. Oculomotricity were normal. No diplopia or nystagmus. Lingual motility and velopalatin preserved. He did not give up on Barré or Mingazzini. Overall and symmetrical 5/5 muscle balance in all four extremities. No alterations in sensitivity. There were no differences in finger-nose or heel-knee maneuvers. Negative Romberg. March very unstable, with insecurity to the march and increase of the support base.

Normal cardiac auscultation. Preserved vesicular murmur. Abdomen: Soft and depressible, not painful, without mass palpation or visceromegaly. Ears were normal.

The patient had cervical contracture.

We put dexketoprofeno 50 mg and diazepam 5 mg by vein for the headache and the cervical contracture while we were waiting the results of complementary tests.

Complementary Tests
ECG: Normal.

Blood test: Hemogram, coagulation and liver and kidney function without alterations. PCR of 1.06 mg / dL.

The CT scan of his brain were normal.

Radiography of the chest: Condensation was observed on the right apex which it was not present in the 2017 radiography.

 

With this results we decided to ask for a CT scan of his chest. Tuberculosis, bacterial condensation or neoplastic process were considered as differential diagnosis.

Radiological findings in probable relation with primary pulmonary neoformative process in stage T4N2Mx in upper right lobe.

The patient improves symptoms, could walk without dizziness and without increasing the base of support.

Patohological anatomy showed us adenocarcinoma of the lung.

With this diagnosis, we referred the patient into Pneumology and Oncology for treatment and follow up. The patient received chemotherapy and radiotherapy and was progressing correctly awaiting surgical intervention.

Conclussion:

Adenocarcinoma of the lung is the most common type of lung cancer. The signs and symptoms of this type of lung cancer are similar to other forms of lung cancer, and patients most commonly complain of persistent cough and shortness of breath, not in this case. We can find different kind of symptoms or without them like in our case. The most important thing is to think about it in patients with a history of cigarette smoking.

Juan ORTEGA PÉREZ (PALMA DE MALLORCA, Spain), Meritxell VIDAL BORRÀS, Bernardino COMAS DÍAZ
00:00 - 00:00 #23242 - An important antidote: Methylene blue.
An important antidote: Methylene blue.

Introduction

Introduction:Sodium nitrite may cause methemoglobin formation resulting  indiminished oxygen-carrying capacity. Serious adverse effects may occur at doses less than twice the recommended therapeutic  dose. In this study,  a case is presented with  methemoglobinemia  developed secondary  to overdose sodium nitrite intake suicidally, and the importance of  the treatment of this rarely seen intoxicitation is emphasized.

Case report: A 23-year-old male patient presented  to the emergency department (ED)  with complaint of lassitude, prostration, shivering, shortness of breath, and cyanosis of lips. He had no systemic disease.The general health state of the patient was deteriorated. In inspection he revealed tacypneic pulse (120-130 beats/min) and ciyanotic lips. The patient’s blood pressure (90/60 mm-Hg), respiratory rate (30/min), pulse rate (135 bpm-sinus rhytm), body temperature (37,1 OC), and oxygen saturation (SPO2:65%) were measured. His pulmonary and cardiovascular examination findings were normal. Comple blood count (CBC) and blood chemistry did not reveal any abnormal results. In similar fashion no cardivascular or respiratory abnormality that could explain his real clinical health state was defined. With arterial blood gas (ABG) pH; 7,32, PCO2;12,6, PO2;86,3, HCO3;20, lactate;1,49 mmol/L, and methemoglobin; 78,4% he was prediagnosed as methemoglobinemia. Although the initiation of a saline infusion (100 ml/hour) and oxygen delivery with a mask at a rate of 10 L/min, cyanosis persisted. His treatment  was continued with 10 mg 10% methylene blue and then his methemoglobin level dropped to 0.6%, and  his clinical findings ameliorated. As he was stabilized his detailed anamnesis was obtained by him. In history ıt was learned he was chemistrist and he had intaked sodium nitrite with suicidal intention. Priorly he had attempted twice. He was admitted to the intensive care unit (ICU) for advanced following.

Conclusion:Methenoglobinemia can thrive under the influence of hereditary and acquired factors. A lot of drugs and chemical drugs and substances are known to cause acquired methemolobineimia.Sodium nitrite is amongst these methemoglobinemia-induced drugs.

Mehmet UNALDI (Istanbul, Turkey), Onur KARAKAYALI, Emrah CELIK, Nurcihan Ülkü AYTAŞ, Ozgur SOGUT
00:00 - 00:00 #23486 - An observational study to identify epidemiological patterns in patients admitted via the emergency department to a west london district general hospital with confirmed SARS-CoV-2 infection.
An observational study to identify epidemiological patterns in patients admitted via the emergency department to a west london district general hospital with confirmed SARS-CoV-2 infection.

Background:

SARS-CoV-2 infection presents a significant threat to global health. Little is known about the novel virus, therefore epidemiological information and common trends are important to identify with an aim to reduce transmission and improve management of patients with Covid-19. In this observational study we hypothesised that we may be able to identify clusters of patients with confirmed coronavirus presenting to a London District General Hospital to allow targeted public health measures.

Methods:

This is a retrospective, single centre, observational case series study. All patients requiring admission from 11th March 2020 to 30th April 2020 were screened in the emergency department of West Middlesex Hospital, a district general hospital which sees approximately 160,000 patients per year. All patients with a confirmed diagnosis of Covid-19 either by swab or radiological diagnosis were included. Paediatric patients were excluded (<16 years). Demographic data was collected for each patient including age, sex, accommodation type, postcode as well as co-morbidities, smoking status, radiological, biochemical findings, length of stay and patient outcome. Our primary outcome was to identify potential geographical clusters of patients which may represent widespread local transmission. Secondary outcomes include mortality of patients included in the data and any factors such as ethnicity, socio-economics or co-morbidities which may correlate to Covid-19 severity. An online cloud based mapping analysis was used to map case density against secondary outcome variables.

Results:

Our data collection and analysis is ongoing. By the end of data collection we aim to have 500 patients included within the case series. Using mapping software and postal code location we were able to generate a daily animated time series. Initial analysis suggested there was uniform spread of cases within the local catchment area. However, analysis of secondary outcomes shows a correlation between ethnicity, population density and socio-economic status.

Discussion and Conclusions:

We hypothesised we would see geographical clusters of patients requiring admission to hospital which could then be targeted with public health measures to reduce transmission of SARS-CoV-2 in the community. As discussed within results there was uniform spread within the catchment areas suggesting equal uptake of social distancing and household isolation. On further analysis of secondary outcomes however, overlay maps showed potential socio-economic correlation. Lessons from the first wave of SARS-CoV-2 suggest there may be a role for targeted population specific public health measures to minimise spread within communities in a potential second peak of infection.

Limitations:

This study focused solely on patients admitted to hospitals with Covid-19. Asymptomatic or mild Covid-19 infections not requiring admission were not included. Patients who self-discharged or where the decision was made that despite severe Covid-19 to remain in the community were also not included. Data collection started 11th March 2020 therefore early index cases may have been missed. Further analysis and research would be required to establish whether population density, socio-economic status and/or ethnicity increases SARS-CoV-2 prevalence or predict increased severity. 

Natalie RING (London, United Kingdom), Eleanor HEALD, David SHACKLETON
00:00 - 00:00 #22952 - An uncommon cause of a sore throat and hoarseness.
An uncommon cause of a sore throat and hoarseness.

Brief clinical history

An 89-year-old Caucasian woman was presented to our ED (Emergency Department) because of a possible TBI (Traumatic Brain Injury) after a fall from her bed. Her medical history included a TAVI (Transcatheter Aortic Valve Implantation) because of severe aortic valve stenosis, atrial fibrillation, ventricular pacemaker, brain stem infarction, narcolepsy and goiter. 

 

At presentation she couldn’t remember what exactly happened, but she probably fell out of her bed at night. In the morning she visited her general practitioner and he referred her to the ED because a possible TBI and the use of coumarins.

She reported a sore throat, especially when swallowing, complained about shortness of breath and her daughter mentioned that her voice sounded hoarse. 

At clinical examination there was no swelling of the mouth or throat, and there neither was a stridor. Her neck wasn’t easy to examine because of her short neck with pre-existent goiter. Her pulse oxygen saturation was normal, and her vitals were unremarkable.

 

Because evaluation by the ENT physician showed normal movement of the vocal cords a CT-scan of neck and thorax was ordered with suspicion for a laryngeal fracture caused by a blunt trauma. This showed a large mediastinal hematoma. After intubation a CT angiography of the neck was performed. The hematoma was caused by an arterial bleeding of a branch of the left arteria thyroidea inferior. The bleeding was coiled, and patient was atmitted at the ICU. 

 

Misleading elements

The neck was hard to examine for swelling due to pre-existent goiter.

Although hoarseness was present, there was normal movement of the vocal cords.

Despite of the bleeding the patient was hemodynamically stable at presentation a few hours after her fall.

 

Helpful details

A sore throat, shortness of breath and hoarseness after a fall by an old patient with coumarin use.  

 

Differential diagnosis and actual diagnosis

Differential diagnosis upon presentation includes laryngeal fracture or rupture due to blunt trauma of the larynx, vascular injury of the neck, neck muscle hematoma and traumatic thyroid injury. 

 

Diagnosis is hematoma due to an arterial bleeding of a branch of the left arteria thyroidea inferior.

 

What is de educational and/or clinical relevance of the case?

At presentation after a blunt neck trauma with symptoms of hoarseness, a sore throat and/or shortness of breath we always have to consider a serious laryngeal trauma like a bleeding of one of the arteries in the neck. Even when the patient is hemodynamically stable at presentation a few hours after the trauma and the mechanism might appear trivial. 

Fatma ÇETIN (Rotterdam, The Netherlands), Sorina KRAMPS
00:00 - 00:00 #23380 - An unexpected complication in the treatment of epicondylitis.
An unexpected complication in the treatment of epicondylitis.

A 47 years old patient presented to our Emergency Department during the month of August for a second degree burn at the level of her right arm and elbow, associated to a painful swelling of the right hand. 

The patient had been treating an epicondylitis with topical application of Ketoprofen 2.5% during 7 days. The last 2 days of treatment, the patient noticed paresthesias at the level of the treated region. 

Subsequently, she reported the appearance of an erythema and blisters at the level of her arm and elbow. 

The patient has been treated with cerium nitrate-silver sulphadiazine locally once per day, and a prophylactic antibiotherapy with Clindamycin 600mg 3 times per day. 

The patient has been subsequently referred to the Plastic Surgery department of our Hospital.

Topical NSAIDs are commonly prescribed to patients in the Emergency Department, it would however be important to remind patients that areas of skin treated with Ketoprofen 2.5% gel should not be exposed to direct sunlight, or solarium ultraviolet light, either during treatment or for two weeks following treatment discontinuation, in order to avoid phototoxicity reactions and photoallergy.

Gaia BAVESTRELLO PICCINI (Brussels, Belgium), Jean-Christophe CAVENAILE
00:00 - 00:00 #23161 - An Unexplained Sleepiness and Dizziness may be Early Sign of Cerebellar Infarction.
An Unexplained Sleepiness and Dizziness may be Early Sign of Cerebellar Infarction.

This is case Interesting to recognise the early or pre stage of cerebellar infarction.

Many of literatures mentioned possibility of drowsiness in case of cerebellar infarction. In our case we reported a 47 years old gentleman presented 2 times in our emergency for dizziness and much sleeping . The plain CT brain during first visit showed unremarkable study. After two weeks ,he came back with same symptoms and more deep sleeping and constricted pupil. The second plain CT brain showed cerebellar infarction. The MRI brain Showed: bilateral cerebellar hemisphere infarction, acute thrombosis in  right vertebral artery  , narrowing at proximal basilar artery and  posterior circulation embolic phenomena.  The carotid Doppler US was normal.

The learning points are:  

-          May MRI  is require in central  dizziness or  central vertigo case .

-          Unexplained much sleeping and dizziness sign need further evaluation for vascular  supply of posterior brain circulation and vertebral artery . Like CT angio and Ultrasound Doppler

-          Emergency physician should  be aware about the simple sign and unexplained symptoms may guide to serious disease.

-          Repeated CT scan with comparison between it and the old one may helpful to detect any significant changes with the persistent symptoms.

-          Evidence of depressed conscious level needs immediate clinical attention.

Dr Islam ELROBAA, Dr Islam ELROBAA (Al wakra, Qatar), Mahmoud SAQR
00:00 - 00:00 #23763 - An unusual cause of chest pain.
An unusual cause of chest pain.

Introduction:

Chest pain is one of the leading causes of presentation to the emergency department.  Patients must undergo a rigorous diagnostic processes. We report the case of patient who was at first admitted to our emergency department for an NSTEMI, but further investigations revealed a surprise.

 

Case report:

A 55 year old man presented to the emergency department. He had chest pain during the last week. He has diabetes and hypertension but no history of coronary disease.

At presentation, he complained of a typical angina. He   had an arterial pressure of 130/70mmHg and a pulse of 89 bpm without signs of heart failure. Respiratory rate was 18 cpm and pulse oximetry was 99%.

Electrocardiogram showed no abnormalities

Chemistry blood panel showed troponin level of 53 controlled at 60 ng/l.

The chest pain was persistent despite of an optimal treatment with double anti-aggregation,  anticoagulation and anti-ischemic treatment. However, repeated electrocardiograms were normal. By consequence the diagnosis of aortic dissection was suspected, antithrombotic treatment was withhold, and an aortic angiography scan was performed. It concluded to a superficial aortic ulcer measuring 13*5 mm of the descendant aorta associated to a calcified stenosis of the interventricular coronary artery. The patient was transferred the cardiology department.

Conclusion:

Emergency physician must be alert and constantly evaluate their patients and try to reconsider the diagnosis if necessary.

Montassar BHOURI, Imen MEKKI (Tunis, Tunisia), Aymen ZOUBLI, Rim DHAOUEDI, Badr FERJAOUI, Emna KALLEL, Wafa SLEIMI, Rym HAMED
00:00 - 00:00 #23767 - An unusual hemorrhagic complication of anticoagulant treatment.
An unusual hemorrhagic complication of anticoagulant treatment.

Introduction

Acenocoumarol is an anticoagulant commonly used in many thromboembolic disease. Patients receiving this medication are exposed to hemorrhagic iatrogenic complications which can be life-threatening. We report a case of a women that had an hematoma in an unusual area.

 

Case report

A 56 year old female presented to the emergency department for dysphonia. She receives an anticoagulant medication for a valvular disease.A week before she had an odynophagia for which she took penicillin.

On admission she was conscious, she had a blood pressure of 120/70 mmHg, a heart rate of

100 pm. She had a normal auscultation, pulse oximetry was 99%. She had an ecchymosis on her abdomen and a mandibular ecchymosis with anhematoma on the floor of the mouth.

There were no other apparent bleeding. Blood panel showed an INR of 7.02.

A cervico-thoracic scanner and abdominal scanner showedan important infiltration of the

cervical subcutaneous tissues without hematoma.

Since the upper airway were at risk of obstruction, our patient had 25 UI/kg of PPSB. INR was controlled 30 minutes later, it was equal to 1.56.

 

Conclusion

Our patient presented a therapeutic challenge, she had an artificial mitral valve and must have an INR between 2.5 and 3.5 which exposes her to an hemorrhagic risk. A close clinical and biological surveillance is extremely necessary to avoid thromboembolic and hemorrhagic

accidents.

Rim DHAOUEDI, Rym BEN KADDOUR (Tunis, Tunisia), Hana HEHDLI, Badr FERJAOUI, Safia OTHMANI, Youssef BEN BRAHIM, Aymen ZOUBLI, Rym HAMED
00:00 - 00:00 #23587 - Analysis of metabolic fatigue among health workers working in isolation environments by Covid-19 in the emergency services.
Analysis of metabolic fatigue among health workers working in isolation environments by Covid-19 in the emergency services.

Background:

Since the beginning of the Covid-19 pandemic, isolation environments have been developed where health workers are performing their work. The work is carried out with individual protective equipment which carries a significant physical and emotional burden. 

Aims:

To find out what factors are related to metabolic fatigue among health workers in a hospital emergency department in isolation work environments by Covid-19.

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 (AG): 18-40 and >40 yers; gender, job position: doctor, nurse, assistant, duration of work, presence of smoking, respiratory pathology, hypothyroidism, body mass index: normal, overweight, obesity, physical condition by means of an IPAQ survey: sedentary, active, sportsman, feeling of physical preparation for this work (low, medium, high), feeling of tiredness on entry and exit (low, medium, high). Capillary blood glucose and capillary lactate blood glucose were calculated at the entrance and exit of the Covid-19 zone, using an Accutrend Plus measurement device (Roche Diagnostics, Mannheim, Germany). Metabolic fatigue (MF) has been defined as a worsening of capillary lactic acid by more than 10% between inlet and outlet lactic acid. A descriptive analysis of the sample has been performed. Comparison of qualitative variables using Chi-square and quantitative variables using non-parametric tests. Software: SPSS 24.0. p<0.05.

Results:

N: 84; Median age: 40.01 (9.9) years; GE: 22-40: 41 (48.8%), >40: 43 (51.2%); Female: 65 (77.4%); Doctor: 27 (25.2%), Nurse: 51: 47.7%, ACTS: 29: 27.1%. MF: 26 (31.0%). Average time spent in covid zone: 4:00 (IQI: 3:30-5:03) minutes. Variables and MF: AG: 18-40: 34.1%, >40: 27.9% (p>0.05); sex: female: 29.2%, male: 36.8% (p>0.05); smokers: Yes: 30.8%, No: 31.0% (p>0.05); hypothyroidism: Yes: 42. 9%, No: 29.9% (p>0.05); respiratory pathology: Yes: 37.5%, No: 30.3% (p>0.05); Sedentary: 40.0%, Active: 20.0%, Sport: 35.7% (p>0.05); feeling of physical preparation: medium: Yes: 62.5%, high: 27.6% (p<0.05); MC: normal: 39.4%, overweight: 0%, obesity: 0% (p=0.006); Tired on entry: low: 34. 0%, medium: 33.3%, high: 21.1% (p>0.05); Tired on exit: low: 18.2%, medium: 30.0%, high: 34.0% (p>0.05); Fear of work: low: 27.6%, medium: 21.1%, high 38.9% (p>0.05); average time covid zone FM: 3:50 (IQ: 3:24-4:20) vs No FM: 4:10 (IQ: 3:30-5:15) (p>0.05)

Discussion:

It doesn't seem that working in the covid area generates a significant increase in lactic acid, so there is no significant muscle fatigue. A greater than 10% increase in capillary lactic acid is only associated with the population with a normal BMI. And to a feeling of having a medium physical preparation to work in the covid area of an emergency department. 

Dr Raul LOPEZ IZQUIERDO (Valladolid, Spain), Laura FADRIQUE MILLAN, Virginia CARBAJOSA RODRIGUEZ, Francisco MARTÍN RODRIGUEZ, Ana Maria GONZALEZ FERNANDEZ, Miguel Angel CASTRO VILLAMOR, Candelas GALINDO APARICIO, Irene ALONSO FERRADAL, Villahoz Cancho ISABEL, Vanesa HERNANDEZ BRUNO, Nieto Alvarez LORENA, Gabino MOZO HERRARA, Portillo Rubiales RAQUEL, Esther DURA BALLESTER, Escudero Cuadrillero CARLOS, Henar BERGAZ DIEZ, Maria Jesus GIRALDO PEREZ, Patricia BUSTAMANTE MARCOS
00:00 - 00:00 #22389 - Analysis of Patient Types from Nursing Home to Regional Emergency Medical Center.
Analysis of Patient Types from Nursing Home to Regional Emergency Medical Center.

Purpose

The National Statistical Office predicts that the nation will enter a super-aged society in 2025, where people aged 65 or older exceed 20 percent of the total population. The growing number of elderly patients is increasing demand for nursing homes, but most of them are unable to take immediate first aid. This results in overcrowding of emergency rooms. Therefore, the authors analyzed the types of patients who entered the nursing home from to the local emergency medical center to solve these problems.

 

 

Material & Method

As a follow-up study, this study was conducted on patients who visited the emergency medical center of a university hospital in a large city from January 1, 2019 to December 31, 2019.

 

Result

A total of 7,438 patients came to the hospital from nursing homes or nursing homes, of which 619 (8%) visited the nursing home. The average age was 73.7 ± 12.9, with the majority of elderly patients in their 70s or older visiting, and the gender distribution was 332 (54%), 8% higher than that of women. Analysis results by severity KTAS 1 62(10%), KTAS 2 133(21%), KTAS 3 329(53%), KTAS 4 77(12%), KTAS 5 18(3%) The proportion of emergency cases was higher than non-emergency ones.

 

Conclusion

Patients with chronic and elderly diseases are in a state of extreme deterioration and can be placed in a critical condition, which, if not properly dealt with, could adversely affect the patient's prognosis, and thus the introduction of facilities and systems is necessary.

 

 

Key Words: Long-tear care, Emergency Medical Cente, Nursing Home, KTAS

 

Hyo Jeong CHOI (Bucheon-si, Korea, Republic of), Ho Jung KIM
00:00 - 00:00 #22685 - Analysis Of The Causes Of MajorTrauma In The Population With And Without Trauma Induced Coagulopathy.
Analysis Of The Causes Of MajorTrauma In The Population With And Without Trauma Induced Coagulopathy.

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 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: 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. 

Dr Gabriele SAVIOLI (PAVIA, Italy), Iride Francesca CERESA, Sebastiano GEROSA, Sarah MACEDONIO, Maria Antonietta BRESSAN
00:00 - 00:00 #22221 - Analysis OF THE DIFFERENT DISTRIBUTION IN FLOWS OF PATIENTS AFFECTED BY INFECTIONE DISEASE. FROM TRIAGE AT THE END OF THE PROCESS Comparison OF THE LOW AND THE MEDIA AREA INTENSITY OF CARE.
Analysis OF THE DIFFERENT DISTRIBUTION IN FLOWS OF PATIENTS AFFECTED BY INFECTIONE DISEASE. FROM TRIAGE AT THE END OF THE PROCESS Comparison OF THE LOW AND THE MEDIA AREA INTENSITY OF CARE.

BACKGROUND: the emergency room of the IRCCS Polyclinic St. Matthew of Pavia is divided into areas of intensity of care. At triage therefore not only patients receive a priority code for the medical examination, but are also being inhaled into a stream of care (low-intensity or medium-intensity) that they begin to follow. Obviously if at the medical examination it is considered to change the flow of care this is possible by changing the area to which the patient has been assigned. As a result, therefore, for the same reason of access to Triage, such as the one we consider, namely fever, the patient is evaluated and on the basis of vital parameters, the risk factors taken into account by the Triage grids, is addressed in a care channel.

AIMS: Describe and type the various flows of patients who enter the emergency room for infectious causes determinant fever, in an emergency room divided into areas of intensity of care, with a 5-level triage and provided with short intensive observation. We have retrospectively analyzed patients who have been diagnosed with infectious disease in our emergency room in 10 consecutive months (January 1, 2018-October 31, 2018).

METHODS AND RESULTS: 1636 patients with minimal male prevalence (M 52%). 66% were allocated at the low intensity of care, 34% at the average high intensity of care. The average age of the first group was 59 years, the second was 82 years.

For the former the code of medical severity at discharge was medium low (green and white) in 65% and high (yellow and red) in 35%, for the second group it was medium low (green and white) in 30% of cases and high in 70%. In the first group, 40% were admitted, and 2% were transferred to hospitals with lower intensity of care. In the second group, 80% were admitted and 2% were transferred to hospitals with lower intensity of care. The first group is mainly patients with urinary tract infections, followed by patients with pneumonia (about 25%). The second group sees pneumonia patients as the most represented categories (over 60%) and septic patients (above 20%).

Conclusions: It is evident that the population that comes to the emergency room for infectious causes and is attributed to the average intensity of care is older, more rave and composed mainly of pneumonia and septicaemia. It is therefore important to keep in mind during the flu peaks and the winter period that will be the medium-intensity area of emergency room care to have the majority of the increased workload. Therefore, solutions must be put in place to avoid access blocking and outbound blocking.

Dr Gabriele SAVIOLI (PAVIA, Italy), Iride Francesca CERESA, Dr Alba MUZZI, Elisa BONADEO, Sara CUTTI, Viola NOVELLI, Leandro GENTILE, Maria Antonietta BRESSAN
00:00 - 00:00 #22767 - Analysis of the Treatment-Time Reduction of ST elevation Myocardial Infarction Patients Transferred by Helicopter-based Emergency Medical Services in Korea.
Analysis of the Treatment-Time Reduction of ST elevation Myocardial Infarction Patients Transferred by Helicopter-based Emergency Medical Services in Korea.

Background: ST-elevation myocardial infarction (STEMI) requires timely reperfusion therapy and the first medical contact to percutanesous coronary intervention (PCI) time within 120 minutes is recommended . Hence early recognition and rapid transportation of the STEMI patients to the PCI-capable hospital are important. This study was conducted to analyze the time reduction effect of the STEMI patients who were transferred by helicopter.

Methods: This was a retrospective, single-center study. The study period was from 2016 to 2017. An air ambulance is available with our hospital and 24-hour PCI is capable. We selected STEMI patients who were transferred from other hospitals in 6 regions. We compared the transfer distances, time factors, treatment outcomes between those transferred by helicopter and those transferred by ambulances.

Results: Among total 88 STEMI patients from 6 regions, 38 (43.2%) were transferred by helicopter and 50 (56.8%) were by ambulances. Average transfer distances were longer in helicopter-transfer group (92.7 vs. 82.4 km, p=0.004). Transfer time, call-to-lab time, door-to-balloon time, FMC-to-PCI time were shorter in helicopter-transfer group. The proportion of FMC-to-PCI within 120 minutes were higher in helicopter-transfer group (40.5 vs. 11.4%, p=0.002).

Discussion & Conclusions: The helicopter-transfer reduced FMC-to-PCI time including transfer time and call-to-lab time. Therefore higher proportion of time-targeted treatment was achieved.

Choi HAN JOO (Cheonan, ROK, Korea, Republic of), Han KYOUNG HEE, Choi YONG HYUN
00:00 - 00:00 #23285 - Analysis on the Current Status of Disaster Emergency Medical Response Manuals for Public Heath Center in 23 Cities and Counties in Gyeongsangbuk-do.
Analysis on the Current Status of Disaster Emergency Medical Response Manuals for Public Heath Center in 23 Cities and Counties in Gyeongsangbuk-do.

The main contents of Korea's comprehensive measures for national disaster management are divided into disaster-responsible agencies, disaster-supervising agencies and disaster-support agencies in the event of a disaster. It has shifted from the central government's government-led province to a public-private cooperation check system centered on local sites, and is pushing for the unification of the dualized legal system of natural and human disasters into the basic disaster and safety management law. The Central Safety Management Committee, the highest organization, was launched and the National Fire Agency was established exclusively for on-site response. Comprehensive disaster management information system (NDMS) was established. The standard manual for crisis management consists of 32 types: natural disasters (5) and social disasters (27). It is a manual for responding to major situations (12 kinds). The 32 kinds Action Manual for Field Measures is dedicated to the Ministry of Health and Welfare and the city and county health centers for medical response. The Si/Gun Health Center shall prepare a manual for medical response to disaster situations and an on-site report on disaster situations.
Over the past two years, the government collected manuals from 23 city and county health centers and fire departments in Gyeongsangbuk-do to investigate response procedures, but only made perfunctory comments about all disasters.

Manual analysis : Step1 · Review of manuals by major types · Review of manuals by major types Step2 · Analysis of roles of disaster management agencies, disaster management agencies, and disaster management support agencies given by the top Step3· Verification of roles of agencies concerned Step4 · Reflect of manuals Step5 · Review proposals for insufficient/unreflective fields Step6 · Case analysis by major types Step 7 ·  Recommendation for rewriting the relevant agency's manual was carried out in the order.

In particular, there was no mention of the cooperation of related agencies needed to cope with disasters. There was no survey on medical demand and supply by city or county. In the event of a disaster, actual operation was found to be difficult based on the manual. Revisions are needed in line with actual operations.

Daihai CHOI, Heebum YANG (Seoul, Korea, Republic of), Ho Sung SEO, Gyo Seok SHIN
00:00 - 00:00 #23588 - ANALYTICAL ALTERATIONS AMONG HEALTH PROFESSIONALS WORKING IN COVID-19 ISOLATION AREAS DEPENDING ON THE TYPE OF MASK USED.
ANALYTICAL ALTERATIONS AMONG HEALTH PROFESSIONALS WORKING IN COVID-19 ISOLATION AREAS DEPENDING ON THE TYPE OF MASK USED.

Background:

Since the beginning of the Covid-19 pandemic, isolation environments have been developed where health workers are carrying out their work. Working with personal protective equipment is essential, and analytical alterations among these workers may vary depending on the type of masks used. 

Aims:

To find out if analytical alterations are produced depending on the type of masks used (N95 or FPP2) among health workers who carry out their work in environments of isolation by Covid-19

Material and methods. 

A study of volunteer health care staff who worked in a Covid-19 zone in a Emergency Department and a field hospital designed for this purpose was carried out in April 2020. The demographic variables that were analyzed are: Age, gender, duration of work, type of mask used: N95, PFP2. The following were calculated: haematocrit, venous glycaemia, venous creatinine, PCO2, HCO3, venous lactate both at the entrance and exit of the Covid-19 zone, using a measuring device: epoc® Blood Analysis System and analysis if these parameters rise or not. A descriptive analysis of the sample has been carried out. Comparison of qualitative variables using Chi-square and quantitative variables using non-parametric tests according to age, gender and type of mask used. Software: SPSS 24.0. p<0.05.

Results:

N: 63; Mean age: 35.8 (SD 10.8); Female: 46 (73.0%); Mean working time: 4:13 min (0:33). N95: 37.7%; FFP2: 62.3%. Percentage increase in: haematocrit: 55.6%, glycaemia: 39.7%, creatinine: 33.3%, PCO2: 44.4%, HCO3: 49.2%, lactate: 34.9%. Analysis by mask type, percentage of increase (N95 vs. FPP2): Hematocrit: 65.2% vs. 50.0% (p>0.05), blood sugar: 26.1% vs. 44.7% (p>0.05), creatinine: 39.1% vs 31.6% (p>0.05), PCO2: 60.9% vs 31.6% (p<0.05), HCO3: 47.8% vs 47.4% (p>0.05), lactic: 30.4% vs 36.8% (p>0.05). 

Discussion: 

The use of N95 masks during a prolonged period of time causes significant carbon retention but does not alter the rest of the parameters analyzed. 

 

Dr Raul LOPEZ IZQUIERDO (Valladolid, Spain), Francisco MARTÍN RODRIGUEZ, Laura FADRIQUE MILLAN, Miguel Angel CASTRO VILLAMOR, Virginia CARBAJOSA RODRIGUEZ, Irene ALONSO FERRADAL, Portillo Rubiales RAQUEL, Nieto Alvarez LORENA, Esther DURA BALLESTER, Vanesa HERNANDEZ BRUNO, Escudero Cuadrillero CARLOS, Gabino MOZO HERRARA, Villahoz Cancho ISABEL, Candelas GALINDO APARICIO, Ana Maria GONZALEZ FERNANDEZ, Jesus ALVAREZ MANZANARES, Susana SANCHEZ RAMÓN, Henandez Gajate MARIO
00:00 - 00:00 #23731 - Anti-NMDA receptor encephalitis in the emergency department:Meningitis as a presenting feature.
Anti-NMDA receptor encephalitis in the emergency department:Meningitis as a presenting feature.

Anti-N-methyl D-aspartate (NMDA) receptor (anti-NMDAR) encephalitis is among one of the most common autoimmune encephalitideswhich often occurs as a paraneoplastic phenomenon. A typical presentation is in a young femaleindividual with a viral-like prodrome followed by the development of severe psychiatric symptoms, memory loss, seizures, reduced consciousness and hallucination. Meningitis is a very rare presenting feature of anti-NMDA receptor encephalitis with our literature search only revealing two other reported case. 

Case presentation:

A 26-year-old female without significant history presented to the emergency department complaining of gradual onset pressure-like headache, vomiting and fever. Her family also noted that she had been suffering from unusual behavior. There was no history of substance use or recent travel. In the emergency the patient was notably agitated and confused. On examination, she was febrile at 38 C° with unremarkable systemic and neurological examination.Initiallaboratory studies include a metabolic panel and a blood count were unremarkable. A computed brain tomography was reported as normal. Cerebrospinal fluid (CSF) analysis revealed an elevated white cell (WC) count of 80 WC/mm3 with 70 % of lymphocytosis. Following the lumbar puncture, she received an intravenous acyclovir 15 mg/kg three times a day. Her headache and memory loss didn’t improve, and she developed a generalized tonico-clonic seizure. she went for further investigations. Her magnetic resonance imaging brain showed a cortico-subcortical signal temporal abnormalities T2 with contrast enhancement.CSF repeatedly demonstrated marked lymphocytosis with elevated protein levels, and a normal CSF/serum glucose ratio. Investigations for severalinfections were negative. The MRI retained a typic aspect of anti-NMDA receptor encephalitis. She was transferred to the neurological department for further investigations and  specific treatment.

Conclusion:

Anti-NMDAR encephalitis is a serious, potentially fatal condition. Meningitis is a rare presentation but should be considered in young female patient with negative extensive investigations meningitis.

Dr Fatma MEJRI (Ben Arous, Tunisia), Montassar BHOURI, Safia OTHMANI, Rym BEN KADDOUR, Houyem ZOUARI, Emna KALLEL, Maaref AMEL, Hamed RYM
00:00 - 00:00 #22915 - Antibiotic prescribing and outcomes in cancer patients with febrile neutropenia in the emergency department.
Antibiotic prescribing and outcomes in cancer patients with febrile neutropenia in the emergency department.

Introduction
The benefit of reducing the time of antibiotic initiation in the emergency department (ED) for neutropenic patients is controversial and the research on the impact of antibiotic adherence to international guidelines in the ED is scarce. We aimed to investigate the effect of antibiotic timing and appropriateness on outcomes in patients with febrile neutropenia (FN) and to assess the performance of the MASCC risk-index to risk-stratify such patients in the ED.

Methods
We prospectively identified patients with FN who presented to our ED and assessed their Multinational Association of Supportive Care in Cancer (MASCC) risk-index. The time to parenteral antibiotic initiation and the appropriateness of the antibiotic regimen according to international guidelines were retrospectively abstracted. The performance of the MASCC risk-index in predicting the absence of complication was assessed with sensitivity, specificity and the area under the receiver operating characteristics curve (AUC). We investigated the effect of the time to antibiotic initiation and the appropriateness of the antibiotic regimen on the outcome (ICU admission or death) by logistic regression analyses. The study was approved by the “Comité d’Evaluation de l’Ethique des projets de Recherche Biomédicale (CEERB) Paris Nord” (Institutional Review Board -IRB 00006477- of HUPNVS, Paris 7 University, AP-HP)—number 2019–008.

Results
We included 249 patients. Median age was 60 years and 67.9% had hematological malignancies, 26 (10.4%) were admitted to the ICU and 23 (9.8%) died during hospital stay. Among the 173 patients at low risk according to the MASCC risk-index, 56 (32.4%) presented at least one complication including 11 deaths. The MASCC risk-index had a sensitivity and a specificity of 0.78% and 0.43%, respectively, in predicting the absence of complication and the AUC was 0.67. The time to antibiotic initiation in the ED was not associated with the outcome after adjusting for performance status and shock-index.Conversely, an inadequate ED antibiotic regimen was associated with higher ICU admission or death during hospital stay (OR = 3.50; 95% CI = 1.49 to 8.28).

Conclusion
An inadequate ED antibiotic regimen in patients with FN was significantly associated with higher ICU admission or death during hospital stay.

Olivier PEYRONY (Paris), Camille GERLIER, Imola BARLA, Jessica ELLOUZE, Léa LEGAY, Elie AZOULAY, Sylvie CHEVRET, Jean-Paul FONTAINE
00:00 - 00:00 #23224 - Antibiotic prescription in a hospital emergency department.
Antibiotic prescription in a hospital emergency department.

Objectives: To analyze the prescription of antibiotics in a hospital emergency department (ED) by assessing time elapsed until the first antibiotic dose and adjustment according to the findings for microbiology.


Methods: Patients were included consecutively on receiving a first intravenous dose of an antibiotic in the ED. The patients were followed prospectively while they were on antibiotic treatment.

Results: We included 63 patients. The median time until the first dose was 180 minutes from the time of arrival in the department; the mean time was 218 minutes. The median time from first medical evaluation until the first dose was 120 minutes; the mean time was 135 minutes. Five of the 63 patients had severe sepsis and 1 were in septic shock. In these patients the mean time between physician evaluation and first antibiotic dose was 109 minutes (severe sepsis) and 73 minutes (septic shock). In 82,5% treatment was adjusted based on results of microbiology.

Conclusions: Time elapsed until the first antibiotic dose administered in the ED is longer than recommended even for patients with severe sepsis or in septic shock.

Jose MINGUEZ PLATERO (VALENCIA, Spain), Maria Del Mar LOPEZ IBAÑEZ, Patricia COGOLLOS REDOLAT, Yoshio SILVERO, Juan Carlos MONTALVA BARRA, Ricardo GARCIA BAYO
00:00 - 00:00 #22693 - Antley-Bixler- an orphan medical condition.
Antley-Bixler- an orphan medical condition.

First described in 1975, Antley-Bixler Syndrome (ABS) is an autosomal recessive, exceptionally rare craniosynostosis syndrome characterized by radiohumeral synostosis presented from the perinatal period. Little over 50 cases have been reported. We present the case of CF, male, 2 days old, who was born from cosanguineaous cohabitation between a 16 years old mother and a 20 years old father, unsupervised pregnancy. The patient had multiple deformities as followed: severe exophtalmy, choanal stenosis, arahnodactyly, neonatal teeth, hypospadias. Unfortunately, even with all the best medical treatments, he died three weeks later. Following medicine development, nowadays ABS can be diagnosed prenataly by ultrasound, which may reveal patognomonic findings and also, if there is a know family history of the condition or risk factors involved, targeted genetic testing is available. Unfortunately, there is no cure for the condition, all the treatment is supportive and aimed at managing symptoms.

Ion-Alexandru CIUTA (Timisoara, Romania), Dan Victor CIAPA, Andreea NYCHITA
00:00 - 00:00 #23738 - Aortic stenosis in disguise of an asthma.
Aortic stenosis in disguise of an asthma.

Introduction:  

Aortic stenosis is a common pathology among young adults. The dominant congenital malformation is bicuspidism. The suggestive clinical triad is chest pain, dyspnea and syncope. Echocardiography is the key diagnostic tool.

Observation:

Mr. MA, 46 years old, with a history of asthma, presented to the emergency department for a dyspnea evolving  for two days associated with an episode of hemoptysis and hematuria. The initial examination showed a respiratory frequency at 30 cpm , an SpO2 at 94%,  his blood pressure was 110/60 mmHg , his heart rate at 100 bpm . At the heart auscultation there was a systolic murmur radiating in the left para sternal area. There was no jugular veins distension and no hepatojugular reflux. The ECG showed a regular sinus rhythm at 105 bpm, an axis in DI, a biphasic P wave in V1 and V2 and a Socolow index at 31. The Glasgow score was 15. The patient presented jaundice. The abdomen was flexible, painless, depressed with a liver span measured at 12 cm. The urine test strip showed the presence of hemoglobin and the absence of both protein and leukocytes. The laboratory tests have shown severe hepatic cytolysis (AST/ALT=2924/2517), cholestasis and liver failure (PT=28%). The chest X-ray showed a cardiomegaly. The abdominal ultrasonography was normal. The echocardiography has shown dilated cardiomyopathy (LVEF=38%), Pulmonary arterial hypertension (PAH), SPAP=52mmHg. The patient developed a hepatic encephalopathy that led to a coma then death.

Conclusion:

Aortic stenosis is a pathology which must be taken into consideration in the face of progressive and recent dyspnea in young adults. Treatment includes percutaneous valvuloplasty, valve replacement, and more recently non-invasive treatment with therapeutic ultrasound.

Nisrin SELMAN (Tunis, Tunisia), Imen MEKKI, Saoussen KHIARI, Hamdi DOGHRI, Badra BAHRI, Imen ZAGHDOUDI, Ines SEDGHIANI, Nebiha BORSALI FELFOUL
00:00 - 00:00 #23397 - Aortocolic fistula complicating a sigmoid diverticulosis.
Aortocolic fistula complicating a sigmoid diverticulosis.

A 63 years old patient presented to our Emergency Department for rectal bleeding and abdominal pain. 

The patient had a medical history of intermittent claudication, and of an aortic aneurysm of 37mm which had been discovered accidentally 12 months earlier. Given the size of the aneurysm, there was no surgical indication at the time, and therefore a semestral follow up had been put in place, however the patient had not performed the follow up scheduled at 6 months. 

The patient presented with an arterial blood pressure of 110/60 mmHg, a heart rate of 90 bpm, an oxygen saturation of 96%, and a body temperature of 36.2°C. 

The clinical examination showed a sensibility at the level of the left flanc, but without significant tenderness nor rebond; the peristalsis was normal. 

The blood test showed: Hemoglobin 8.8 g/dl, white blood cells 21 G/L, platelets 550 G/L, and normal coagulation tests. 

A digital rectal examination was therefore performed, and it showed the presence of melena. 

A gastric endoscopy demonstrated the presence of esophagitis, but this finding alone could not be responsible for the overall clinical picture. 

An abdominal CT scan was therefore performed, and it revealed a voluminous aortic aneurysm of 66mmx46mm, and 90mm of length. The sigmoid colon presented thickened walls, in contact with the anterior and inferior wall of the aneurysm. This image was suggestive of a covered rupture of the aneurysm, with probable presence of an aortoenteric fistula with the sigmoid colon but with no active communication. 

The patient underwent a surgery which was conducted by a team of vascular and digestive surgeons. 

The digestive surgeons realized a colostomy according to the Hartmann’s procedure, while the vascular surgeons implanted a vascular prosthesis which had been treated with aluminum salts, and which could therefore be placed in a site at risk for infections. 

The results were satisfying, besides the thromboembolic complications of the surgery which have been treated with low molecular weight heparin. 

Five months after the initial surgery, restoration of bowel continuity was performed. 

Aortoenteric fistulas are a rare complication of aortic aneurysms, and they usually occur at the level of duodenum and small bowel. The classical presentation includes a triad of gastrointestinal bleeding, abdominal pain and a pulsating abdominal mass. The CT scan is the most accurate diagnostic tool to demonstrate the presence of an aortoenteric fistula.

 

Gaia BAVESTRELLO PICCINI (Brussels, Belgium), Jean-Christophe CAVENAILE
00:00 - 00:00 #23223 - Appropriateness of Packed Red Blood Cells Transfusions in Chronic Anemic Patients in the Emergency Department: The TRANSFUS-ED Retrospective Analysis.
Appropriateness of Packed Red Blood Cells Transfusions in Chronic Anemic Patients in the Emergency Department: The TRANSFUS-ED Retrospective Analysis.

Background: Anemia is a common disease, with a significant clinical impact particularly evident in the elderly. Transfusion with packed red blood cells (PRBCs) is the mainstay treatment for acute anemia due to bleeding. Also, patients with chronic anemia can benefit from periodic, scheduled transfusions, while urgent PRBCs administration in this subset of patients has strict indications. Since PRBCs are a limited, perishable, and expensive resource, their use must be outweighed by benefits. However, far too little attention has been paid to PRBCs transfusions in chronic anemics in the Emergency Department (ED), and the aim of this study was to assess the appropriateness of such practice. 

Methods: A retrospective analysis was performed on electronic charts, including patients who accessed the ED of the Azienda Ospedaliera di Padova (Padova, Italy) between 2016 and 2018 and received PRBCs transfusions. Patients aged > 16 years old and with chronic anemia were included, while those with acute anemia or admitted to the hospital after the transfusion were excluded. Chronic anemia was defined as satisfying one of the following in the past medical history from ED charts: diagnosis of chronic anemia (and type); two or more blood samplings demonstrating anemia before the access to the ED; a history of periodic transfusion. As the primary outcome, the appropriateness of transfusions was assessed according to the American Association of Blood Banks (AABB) 2016 criteria. In particular, AABB promotes a restrictive strategy, recommending a threshold of 7 g/dl for adults who are hemodynamically stable, and 8 g/dl for patients with preexisting cardiovascular disease. The secondary outcomes were: the check of hemoglobin between each unit infused; cost analysis; adverse outcomes. 

Results782 records were selected, and 259 were included in the study. According to our criteria, 132 patients (51.0%) were inappropriately transfused. Moreover, in 159 out of 259 transfusions (61,4%), patients received two or more PRBCs without a previous check of hemoglobin levels. Overall, the inappropriately carried out transfusions resulted in an estimated cost of € 26,700 (only for PRBCs). No adverse events were registered. 

Discussion and Conclusions: With this study, we showed that transfusions in chronic anemic patients are a recurrent event in the ED and are frequently inappropriate. A possible explanation could be the lack of a well-structured healthcare network granting periodic transfusions to this subset of patients, available several times per week in a dedicated clinic. Our analyses also showed that hemoglobin was not checked before infusing another PRBC unit in 61.4% of cases, as per AABB recommendations. This strategy could be explained if thinking that emergency physicians tried to reduce the length of stay of these patients in the ED. In the future, implementing and improving patient access to transfusion services through dedicated pathways could reduce the burden of chronic anemic patients transfused in the ED for non-urgent causes, and also reduce the costs related to urgent transfusions.

Federico REBUSTELLO, Fabio RIGON, Vito CIANCI, Matteo PAGANINI (Padova, Italy)
00:00 - 00:00 #23082 - Arboviroses: the difficulty of clinical diagnosis in front of a epidemic.
Arboviroses: the difficulty of clinical diagnosis in front of a epidemic.

Introduction

Arbovirus is the term used to define viruses that have their replication cycle in insects (atropod vectors). The most common in Brazil are: Dengue (DENV), Zika (ZIKV), Chickungunya (CHIKV), and Yellow Fever. Due to the similarity of the initial clinical pictures, complementary exams such as: complete blood count, serology using the MAC ELISA technique, PCR, viral isolation and rapid NS1 test for DENV can help in the diagnosis. This work aims to demonstrate the difficulty in differentiating Arboviruses through clinical diagnosis and to evaluate the evolution of different cytokines in an Arbovirus epidemic.

 

Methodology

A Cross-Sectional Study was carried out. Samples were collected from 03/09/2016 to 05/10/2016. Patients over the age of 12 who sought care at the Ribeirão Preto Emergency Care Unit complaining of fever, general malaise, headache, myalgia, arthralgia and rash were treated and included in the study after signing the free and informed consent form. enlightened. After initial physical examination of the patients, blood samples were collected for laboratory tests recommended by the Ministry of Health (TGO, TGP, blood count), serology and cytokine analysis (performed by the University of Ribeirão Preto). The cytokines evaluated were: IL1, IL2, IL4, IL5, IL6, IL8, IL10, IL12, IL13, IL 17, INF Gamma, TGF beta, TNF alpha.

 

Results

280 samples were collected. Of this total, 78 were discarded because they did not present positive serology. Positive cases (202) are divided into: DENV- 132 (65.02%), ZIKV- 44 (22.16%), CHIKV- 26 (12.80%), with 85.22% of the patients seen at first four days of symptoms. As for the analyzed symptoms, Arthralgia was observed in 81.81% - DENV, 65.90% - ZIKV and 69.23% - CHIKV; Headache in 80.30% - DENV, 93.18% - ZIKV and 96.15% - CHIKV; Myalgia in 98.48% - DENV, 97.72% - ZIKV and 96.15% - CHIKV; Fever in 78.78% - DENV, 75.00% - ZIKV and 69.23% - CHIKV. Regarding the results of cytokines, there was a significant difference in relation to the control. However, among the studied Arboviruses, they did not present significant changes. IL4 and TNF alpha showed no significant change with the control.

 

Discussion and Conclusion

There was a predominance of DENV cases, but the symptoms fever, myalgia, headache and arthralgia were prevalent in the three Arboviruses evaluated. This shows the difficulty in clinical differentiation during an epidemic when specific tests are not available. In Arboviroses, the innate immune system requires a quick response to control the infection. Type I interferons are considered central mediators in protecting against DENV and ZIKV. CHIKV leads to an acute immune response triggered early with an increase in anti-inflammatory mediators such as interferon type II. Regarding the first line of immune response to infection by the evaluated Arboviruses, there was an increase compared to the control. In the presence of more than one circulating virus, differential diagnosis is necessary for better clinical evolution of patients. Thus, quick test exams are necessary.

Reinaldo BESTETTI, Rosemary F DANIEL (ribeirão preto, Brazil), Renata JOVILIANO, Silvia SILVA, Edilson CARITA, Larissa ALEM, Marcus SILVEIRA, Felipe PIRES, Melissa CESARIO, Pollyana SOUZA, Santos LUIS, Marcelo SOUZA, Ana LOURENÇO, Tufik GELEILETE
00:00 - 00:00 #23010 - ARE MEDICAL STUDENTS INTERESTED IN DISASTER MEDICINE EDUCATION?
ARE MEDICAL STUDENTS INTERESTED IN DISASTER MEDICINE EDUCATION?

Background. Considering the dynamics of modern society, man-made or nature-inflicted disasters have marked the recent decades and triggered international response initiatives to alleviate these burdensome situations. Medical students (MS) represent a valuable resource in disasters, if awareness and introductory training are provided. Nonetheless, most European medical universities do not include DM training within their bachelor curricula. The aim of our observational study is to document MSs’ interest in disaster medicine education and generate appropriate learning contexts.

 

Methods. A survey is currently being conducted amongst the 6th year medical students of “Iuliu Hațieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania during their Emergency Medicine (EM) rotation. The questionnaire consists of 11 closed questions and 1 multiple choice question, which was shared both offline and online. Data such as demographics, previous DM educational training, current experience and interest in humanitarian missions and DM courses was collected through this survey.

 

Results.507 MSs have been offered the possibility of enrolling in this survey. The response rate was 57.4%, with a cohort mean age of 25.0 years (SD= ±1.6) and a 1:1.94 male:female gender ratio. The ethnic structure of the cohort was 73.54% Romanians, 13.4% French, 6.19% German, alongside Greek, Italian, British, Irish, Swedish, Canadian. Out of the 291 responders, 75.26% did not have DM training as part of their university curricula. Nevertheless, 97% of them acknowledged that there is a difference between DM and EM, yet only 45.7% knew the definition of a disaster. In almost unanimity, MS rated DM as being important for their education (96%) and consider the need for DM professionalization (92%). 75.6% of the MS intend to collaborate with a Humanitarian Organization in the future, but only 8.93% feel prepared for a disaster response as future medical professionals. Therefore, 86.25% would take part in a DM course, if organized by the university.

 

Discussion and Conclusions. Nowadays, MSs seem to be highly interested in humanitarian missions and contributing to disaster relief. Unsurprisingly, they comprehend the importance of courses and workshops regarding DM, as they believe that every physician should be trained on how to act in case of a disaster, no matter their specialty. Therefore, the necessity of disaster management trainings for MSs arises, becoming an essential part of their bachelor curricula. Trained MSs can contribute to a competent and qualitative response in natural and humanitarian crisis; the present COVID-19 pandemic comes proof, as MS are volunteering to alleviate the situation. Means such as peer-to-peer education, table-top and manikin simulations, and e-learning, visual platforms can be employed inexpensively and with maximal results.

Eugenia - Maria LUPAN-MURESAN, George-Teo VOICESCU, Stefania-Anda POPA (Cluj-Napoca, Romania), Adela GOLEA
00:00 - 00:00 #23559 - Are there cases of psychotic outbreaks in children?
Are there cases of psychotic outbreaks in children?

We are warned by a 14-year-old man for unconsciousness he breathes on public roads. Approximate patient weight 55 kg. Upon our arrival conscious patient breathes. They say that he was taking the preparation for the first communication in the church when he started to feel bad. Upon our arrival conscious patient with resistance to ocular opening. We proceed to introduce him to the ambulance. There he is more communicative with the healthcare team at an initial moment. He says that he has ever been to the psychologist but that he does not take medication for it. Denies consumption of toxins. Subsequently the patient begins to agitate and refers to phrases like "I notice how Satan is inside me", "you are going to die everything" "entering level 3 of evil". Attempts are made to verbally reduce the patient. This being impossible, we proceed to the pharmacological reduction. We proceeded to use 5mg of haloperidol without result, so we repeat the dose. We managed to get to the hospital where they administered chlorpromazine 25 mg. They manage to reduce the patient pharmacologically and proceed to admission. In it, an acute psychotic outbreak is diagnosed.

Psychoses, including schizophrenia, comprise an important group of psychiatric disorders characterized by hallucinations and / or delusions (psychotic symptoms) that alter perception, thoughts, affect and behavior and that can considerably alter development, relationships and the physical health of the child and adolescent. Schizophrenia is estimated to affect 1.6 -1.9 per 100,000 children and its frequency increases from the age of 14.

    Psychosis and schizophrenia in children (under 12 years old) and adolescents (up to 17 years old) are important causes of disability.
     
    They are more severe and have a worse prognosis than when they begin in adulthood, because they disrupt social and cognitive development.
     
    Adolescents with schizophrenia are prone to a shorter life expectancy than the general population, due to suicide, cardiovascular injuries or diseases, the latter in part due to antipsychotic medications.
     
    The late diagnosis of schizophrenia can affect the long-term evolution, so early diagnosis and treatment are essential.

In Spain, the specialty of Child and Adolescent Psychiatry has not yet been created and this implies a deficit of resources to treat this range of population. It is a big problem because there are professionals who do not have specific training and who are working with children without having that specialty, according to medical sources.

Despite this, specific hospitalization units have been created for children and adolescents with psychiatric problems, such as the Psychiatric Hospitalization Unit for Adolescents of the Puerta del Hierro Hospital in Majadahonda (Madrid), an acute care unit for stays of between one and three weeks. Acute decompensations are treated in patients between 12 and 18 years of age.

An early approach and early recognition of psychotic patients is important, especially at such an early age. Hence the importance of training in out-of-hospital medicine as a fundamental element of patient care.

Jose MORA ALCALÁ, Miriam UZURIAGA MARTIN (Madrid, Spain), Natalia VALENCIA GONZALEZ, Santiago BLANCO REY, Cristina BARREIRO MARTINEZ, Vanesa ISAAC, Jordi Arnau MARSÁ DOMINGO, Sara HERNANDEZ MARTINEZ
00:00 - 00:00 #23243 - Aspiration while diving, plausible ?
Aspiration while diving, plausible ?

The patient had an incident whilst diving at a depth of 8 meters, the previous day before presenting to this hospital. She is thought to have aspirated during an uncontrolled ascent, but the patient was not sure if this happened. She recovered following this incident and managed to go diving the day she presented to our ED. However the same event occurred and she became more ill, coughing up frothy pink sputum and was brought into the hospital. On arrival, she was severely hypoxic with a SpO2 of 80%  on 15L.

On examination

A-     Mallampati 1, No loose teeth, A few filling on the molars

B-     Bilateral bibasilar crackles, dyspnoeic, SpO2 80 on 15 lit ABG Po2 5.0 kpa on 15 lit O2

C-     C- unsupported, stable BP 152/ 73 MAP 98 HR 74 warm and well-perfused peripheries

D-    GCS 15/15.

 

 

Investigation

ABG  ph 7.38, pO2- 5.0kpa , PCO2- 5.8 kpA on 100 % O2,

  X-ray chest – bibasilar opacities ( picture 1)

  FBC WBC – 15.1, Neutrophils 13.4

  UE – Urea 4.3 mmol/l, Creatinine 83 mmol/l

  CRP – 110

The patient was started on CPAP 10 mmHg at 40 % O2 which was eventually titrated to 28 %. She was subsequently transferred to ICU and spent 4 days on with high flow oxygen.  

The following differentials were considered:

Immersion pulmonary edema

Aspiration Pneumonitis

She had a repeat X-ray after two days in the ICU ( picture  2) 

Once she was weaned off her high flow she was transferred to the respiratory ward.

The patient's symptoms have greatly improved she was off oxygen and was medically fit for discharge. The patient wasinformed that the likely cause of her hypoxia was immersion pulmonary edema and the likelihood of aspiration was very low as the patient herself is not sure about the same.

We need to rule out cardiac complications. As she is from out of the area we have requested that she go to see her GP to arrange a cardio review to have both an Echocardiogram and myocardial perfusion scan.

She was advised that she does not do any diving until she has been given clearance by a diving specialist who has knowledge of potential cardiac risks. She has her own medications - ferrous sulfate and HRT with her and we advised her to continue taking these medications.

Shankar MURTHY, Asim IJAZ (Lancaster, )
00:00 - 00:00 #22743 - Assessing the survivability of early trauma deaths: a feasibility pilot.
Assessing the survivability of early trauma deaths: a feasibility pilot.

Introduction

Death following trauma is classically described as having a trimodal temporal distribution. The first phase or “early” deaths are often ascribed to unsurvivable injuries. EMRS provide a pre-hospital critical care team to a large area of the West of Scotland, covering rural and urban areas. We aimed to assess the feasibility of analysing the pattern of injuries in a population of patients attended by EMRS, who are “first phase” deaths related to trauma and also assess the feasibility of measuring the reversibility or treatability of the injuries found.

Methods

A convenience sample of six sequential patients who were attended by the EMRS trauma team and were in traumatic cardiac arrest at the time of EMRS team arrival. These data were matched with post mortem results from the regional forensic pathology results. Legal clearance was sought to release the record for medical review.

The post mortem reports for these patients were then examined by an experienced trauma audit coordinator and injuries were coded using Abbreviated Injury Scores (AIS 2005) and an Injury Severity Score (ISS) calculated for each patient.

A multi-disciplinary team consisting of a forensic pathologist, emergency physician, intensive care physician and two retrieval practitioners reviewed the clinical and pathological findings to assess a number of outcomes.

The primary outcome was a 5 point likert scale of survivability in the circumstances of the incident, based on expert consensus.

Secondary outcomes were

5 point likert scale of survivability in ideal circumstances and appropriateness of interventions

Results

A total of 6 patients were included in the study. The median ISS was 43 (range 33 to 57). A summary of AIS codes is given below.

Patient

ISS

Highest AIS

Body area

1

57

5

Thorax

2

45

5

Thorax

3

33

5

Thorax

4

41

4 (x2)

Thorax & Extremity

5

35

5

Head

6

50

5

Thorax

 

Discussion

Our cohort of patients all had significant traumatic injuries, with a high injury severity score, and five out of six patients had at least one injury coded as critical (AIS=5). None of the patients had an injury currently coded as unsurvivable (AIS=6).

 

We have demonstrated the feasibility of identifying a cohort of patients, and working through the legal constraints surrounding post mortem paperwork, and coding the injuries found. Further work is required to assess the context of injuries described to make a judgement on potential survivability.

Price RICHARD, Alasdair CORFIELD (Glasgow, United Kingdom), Jones VICKY
00:00 - 00:00 #23650 - Assessment of breathing in cardiac arrest - a randomised controlled trial of three teaching methods.
Assessment of breathing in cardiac arrest - a randomised controlled trial of three teaching methods.

Background: Agonal breaths are slow and deep breaths, frequently with a characteristic snoring sound, and are present in approximately 40% of victims in the first minutes of cardiac arrest. The importance of early recognition has been emphasised due to increased survival rates if responded to as a sign of cardiac arrest. Teaching laypersons how to recognise breathing patterns is challenging, and agonal breathing is particularly difficult to recognise. We aimed to compare a video- and a simulation-based teaching method to the conventional lecture-based method when teaching laypersons how to recognise normal, no, and agonal breathing.

Methods: In this Danish investigator-initiated, unblinded, randomised controlled trial, adult laypersons (university students, military conscripts and elderly retirees) participating in European Resuscitation Council (ERC) Basic Life Support (BLS) courses were randomly allocated to receive teaching on how to recognise breathing patterns using lecture- (standard practice), video- or simulation-based teaching methods. The primary outcome was the mean proportion of correctly classified breathing patterns in nine videos of actors simulating normal, no, and agonal breathing. We analysed the primary outcome using a logistic regression model and the likelihood ratio test and presented results as odds ratios with 95% confidence intervals (CIs).

Results: 156 participants were included from February 2, 2018 through May 21, 2019; 153 were included in the analyses: 52 in the lecture group, 50 in the video group, and 51 in the simulation group. The mean proportion of correct answers was statistically significantly different between the groups (P=0.013). Compared to lecture-based teaching (83% correct answers), both video- (90% correct answers; OR 1.77, 95% CI: 1.19-2.64) and simulation-based teaching (88% correct answers; OR 1.48; 95% CI: 1.01-2.17) led to significantly more correct answers. Video-based teaching was not statistically significantly different from simulation-based teaching (OR 1.20; 95% CI: 0.78-1.83).

Discussion & Conclusion: Video- and simulation-based teaching methods led to improved recognition of breathing patterns among adult laypersons participating in BLS courses compared to the standard lecture-based teaching method. Video-based teaching is not dependent on instructor skills, does not require specific instructor training, and it can be carried out in plenary. Thus, video-based teaching can be implemented in existing BLS courses without substantial increases in time requirements or costs. Finally, videos may be made available to participants after the course, which potentially can increase learning retention.

Ethical approval and informed consent: The Committee on Health Research Ethics in the Capital Region of Denmark waived the need for further ethical approval (approval number: 17021633). Participation in the trial was optional and voluntary and all participants gave written informed consent.

The trial results are original and have not yet been published.

Niklas BREINDAHL (Copenhagen, Denmark), Granholm ANDERS, Theo Walther JENSEN, Annette Kjær ERSBØLL, Helge MYKLEBUST, Freddy LIPPERT, Anne LIPPERT
00:00 - 00:00 #23727 - Assessment of diagnostic and therapeutic managment in the face of a suspected urinary tract infection in the emergency department.
Assessment of diagnostic and therapeutic managment in the face of a suspected urinary tract infection in the emergency department.

Assessment of diagnostic and therapeutic managment in the face of a suspected urinary tract infection in the emergency department.

 


Introduction: Urinary tract infections (UTIs) are a common reason for emergency department visits. Often the doctor supplements with complementary examinations essentially the urine cytobacteriological  test (urinalysis), and empirically treats a suspicion of UTI. This conduct is sometimes ill-justified and abusive.

 

Aim: To assess our behavior towards patients presenting to the emergency department for suspected UTI and to study the microbiological profile of our patients.

 

Methods: Retrospective study, including patients aged over 14 years consulting Monastir emergency department during 2019 and presenting signs suggesting UTI. The demographic, clinical and bacteriological data of each patient were collected.

 

Results: During 2019, 2257 urinalyses were requested by the emergency department. Our patients had an average age of 45 ± 19 years, predominantly female (60%). 16% were diabetics, 7% had a history of urinary lithiasis and 8% a history of UTI. The symptoms leading our physicians to request an urinalysis are summarized in the table1, the signs objectified to the clinical examination are presented by table 2 and the results of the urinalysis are detailed in table 3.

 

Symptoms

Frequency

Fever

16%

Burning urination

45.5%

Lumbar pain

44%

pollakiuria

9%

dysuria

11%

Table 1: Main symptoms in our population

:

Symptoms

Frequency

Fever

21%

Lumbar sensibility

28%

 positive Giardano

20%

Table 2:The main clinical symptoms in our population

 

Urinalysis results

Frequency

Positive

16.5%

Negative

40.5%

Contaminated

43%

Table 3: Urinalysis results in our population

 


The most isolated germ is Escherichia Coli (E.Coli) (70% of cases). The practice was to prescribe antibiotic therapy in 44% of patients and analgesic treatment in 27% of patients who had a urinalysis. The most prescribed antibiotic was ciprofloxacin. The bacteriological study has shown that E. coli the most isolated germ is resistant to this molecule in 20.7% of cases.

 

Conclusion: The results of this study brings us to the need to review our diagnostic and therapeutic management in the face of suspected UTI.

 

Youssef HASSEN, Mohamed Amine MSOLLI, Kais ZAIDI, Hassen MOHAMED KHALIL, Soumaya SAAD, Khaoula BEL HAJ ALI, Wahid BOUIDA, Hamdi BOUBAKER (Monastir, Tunisia), Semir NOUIRA
00:00 - 00:00 #23632 - Assessment of knowledge of pain treatment methods in pre-hospital: survey for paramedical staff.
Assessment of knowledge of pain treatment methods in pre-hospital: survey for paramedical staff.

Introduction :

Although acute pain is a symptom often encountered in emergency medicine, many studies have highlighted insufficient diagnostic and therapeutic management.

Therefore a certain number of regulatory texts encourage healthcare establishments to set up therapeutic protocols concerning pain management.

The objective of this sudy is to assess the knowledge of paramedics concerning the management of acute pain in pre-hospital  .

Résultats :

This study included 25 paramedics , 64.7% of them were  males .

There was no written protocol for the treatment of pain in 64.7% of the cases.

The intensity of pain was assessed in the majority of cases (70.6%) by an VAS  scale, an NRS scale in 5% of cases, while 35.3% considered that it would depend on age and understanding.

As for the severity of pain, it is defined as unbearable pain in 70.5% of cases, a VAS  > 8 in 5.88% and by other definitions (23.52%).

The use of morphine drugs was : 0.2 mg every 10 min in 5.88% ;  3mg first bolus then 2 mg in 11.76% ;  2mg divided in 5 to 10 minutes in 35.29% of cases

The morphines available at the site of the intervention are Fentanyl for 76% of the responses and Sufentanyl for 17% of the responses.

For the undesirable effects of morphine, they are mainly respiratory distress in 52% of cases, nausea and vomiting in 47% of cases, dependence on morphine in 11.77% of cases and constipation in 5.88% of cases.

Regarding knowledge of the morphine antidote, 64.7% responded with Narcan (Naloxone), 29.9% responded with "I don't know" and 5.88% responded with Ephedrine.

Conclusion :

This evaluation highlights a deficiency in the practice of recommendations concerning the management of acute pain by paramedics of the prehospital emergency unit .

Analgesia treatment protocols should be in place for each prehospital emergency team. A practice assessment should be carried out regularly.

Chrifa BENCHIKH, Dr Dorra LOGHMARI (sousse, Tunisia), Hicheri YASSINE, Rabeb MBAREK, Sourour BRIKI, Chrifa AOUINI, Friji ANIS, Lahouimel MARIEM, Naoufel CHEBILI
00:00 - 00:00 #23017 - Assessment of pre-hospital care of pediatric traumas : a retrospective study from January 2010 to December 2017 in the Haute-Garonne department.
Assessment of pre-hospital care of pediatric traumas : a retrospective study from January 2010 to December 2017 in the Haute-Garonne department.

Assessment of pre-hospital care of pediatric traumas : a retrospective study from January 2010 to December 2017 in the Haute-Garonne department 
Introduction
In order to set up a paediatric trauma centre, we studied the epidemiology of the paediatric traumas in Haute-Garonne from January 2010 to December 2017. The secondary objective was to evaluate the impact of the creation of a mixed (adult and paediatric) trauma centre in 2014 on the management of severe trauma in children.
 
Methods
Our study is an epidemiological, retrospective, descriptive study of severe trauma paediatric victims in Haute-Garonne.
All under-15 (y.o.) patients suffering from a severe trauma requiring treatment in an ICU ward and dealt with by the French pre-hospital Emergency Medical Service (SMUR) (were included). Were included.
 
Results
68 patients were included. A majority of 65 % were boys with a median age of nine years old. The most common traumas were cranial traumatisms (81%), mechanism being mostly domestic accidents (62%) and traffic collisions (28%). 49 % of the traumas happened in summer (May-August). We observed an overall mortality of 12 %, and 73 % of the patients ended up with sequelae, especially hearing loss.
The creation of a trauma centre led to improvement in following guidelines, in particular in terms of fluid resuscitation, but no changes in morbidity and mortality rate.
Discussion
Analysis of the data evolution before and after the setting of the trauma centre in 2014 shows an improvement in care of trauma patients without improving morbidity and mortality rates. Setting up a paediatric trauma centre might enable better care through standardisation of practices and the optimisation of the orientation of those patients.
 
Lola GRIOT (FRANCE), Anne-Laure CHEVRIN, Sandrine CHARPENTIER
00:00 - 00:00 #23003 - Assessment of the decontamination procedure for self-referrals of a chemical mass casualty disaster, through a simulation exercise at the emergency department of a University Hospital in Brussels (UZ Brussel).
Assessment of the decontamination procedure for self-referrals of a chemical mass casualty disaster, through a simulation exercise at the emergency department of a University Hospital in Brussels (UZ Brussel).

Introduction: Recent developments with nerve agents have renewed the interest in public preparedness against chemical incidents. Contaminated wild evacuees are considered an important part of the disaster response chain in chemical incidents, due to their tendency to overrun an emergency department and endanger the people within. This secondary contamination can be prevented with adequate decontamination, but this process is resource-intensive and requires sufficient manpower. To our knowledge, previous research only focussed on one or more subsets of this process. In order to get an all-encompassing view, a live simulation exercise was constructed to estimate the real decontamination capacity of the emergency department.

Objectives:

Measuring decontamination capacity and throughput times of regulation, triage, preliminary treatment, disrobing, decontamination and rerobing.

Analysis of the wet decontamination procedure to identify bottlenecks.

 

Design and setting:

A prospective observational study using a chemical disaster simulation exercise at the emergency department of a tertiary hospital in Brussels.

 

Participants:

24 participants, 5 timekeepers, 6 observers, 2 drillmasters and 8 personnel members carrying out the procedure.

 

Scenario and decontamination procedure:

A chemical incident using Sarin in a nearby metro station was modelled. Adequate recognition was assumed, as well as activation of the hospital chemical incident plan. Mock victims were ambulatory and wore laminated cards with medical information and parameters. The procedure consists of regulation, triage, oxygen application, preliminary antidote treatment, disrobing, showering and finally re-robing. Participants incapacitation was simulated using specific acting instructions, as well as pinhole glasses simulating miosis. Antidote injection was performed on an intramuscular mannequin. Oxygen application was simulated using a simple face mask, while participants carried their own oxygen tank throughout the procedure. Triage was performed using the modified CBRN triage sieve. Clothing was removed by cutting or self-disrobing when able. Wet decontamination time was 5 minutes according to the hospital protocol, and the decontamination unit has 5 available showerheads.

 

Methods:

Time spent in each station was recorded using synchronised digital clocks. Median and average times were calculated per station and across the exercise.

Feedback from all involved was acquired through a structured questionnaire regarding procedures, bottlenecks and communication.

Results:

The decontamination capacity per hour was 24. Median decontamination time was 20 minutes 31 seconds with an interquartile range of 3 minutes 51 seconds. The average decontamination time after exclusion of one outlier was 20 minutes 6 seconds with standard deviation of 2 minutes 36 seconds. The largest bottleneck was the disrobing station and therefore the maximum capacity of the shower was rarely reached. Higher triage codes went faster through the procedure than lower triage codes. Twenty five percent of participants found the communication lacking throughout the procedure.

 

Conclusion:

The decontamination capacity was 24 victims per hour. The bottleneck was the disrobing station. Participants suggested that additional personnel at the disrobing station could significantly improve this capacity.

Lieselot BLOMME (Brussels, Belgium), Sofie PAUWELS, Ruben DE ROUCK, Ives HUBLOUE
00:00 - 00:00 #23145 - Assessment of the effect of a hospital-based simulation exercise about decontamination during a chemical mass casualty incident on knowledge and self-efficacy in emergency staff.
Assessment of the effect of a hospital-based simulation exercise about decontamination during a chemical mass casualty incident on knowledge and self-efficacy in emergency staff.

Introduction:

Recent developments with nerve agents have renewed the interest in public preparedness against chemical incidents. Training and education of emergency staff remains an important topic and can be performed using different methodologies. Live simulation exercises for example are resource- and time-consuming, often raising the question if they are worth it when compared to focussed training. Therefore, such an exercise should have a clear effect on the knowledge and self-efficacy of personnel. A simulation exercise was organised in a tertiary hospital to train personnel in wet decontamination and to identify bottlenecks in the decontamination procedure. In order to estimate the effect of training and a live exercise on knowledge and self-efficacy of participating personnel, a set of questionnaires was designed.

Objective:

Evaluating the effect of a course and a live simulation exercise about decontamination in a chemical mass casualty incident on knowledge and self-efficacy of emergency department personnel.

Design and setting:

An influx of wild evacuees from a chemical mass casualty incident using a nerve agent in a nearby metro station was simulated. Twenty-four volunteers and 10 staff members (4 emergency physicians and 6 emergency nurses) participated in this exercise. All parts of the decontamination procedure were simulated: regulation, triage, rapid stabilisation, disrobing, showering and re-robing.

Methods:

Participants participated in a course with a 3-hour lecture and hands-on training on the use of personal protective environment clothing, 5 days before the simulation exercise. Questionnaire were collected from participating emergency department personnel to evaluate knowledge and self-efficacy: 1 before the course , 1 after the course and 1 after the simulation exercise.

The questionnaire consisted of 11 knowledge-based questions as well as a self-assessment on their own self-efficacy to perform in-hospital decontamination of chemical mass casualty incident victims.

 

Results:

Nine pre-training questionnaires, 10 post-course and 10 post-exercise questionnaires were collected (1 person arrived late to the course ). A one-tailed paired t-test using alpha=0.05 was used to compare the results from before and after the course to the results after the simulation exercise. Eight participants performed better, and two participants performed worse on the knowledge test, both after the course and simulation. Average scores improved with training: 9.5/11 before the course training compared to 10.2/11 after the course and 10.5/11 after simulation. Improvement after the course was borderline insignificant (p=0.11), as well as improvement between before the course and after the exercise (p=0.06). The difference between after the course and after the exercise was borderline statistically significant (p=0.04).

None of the participants felt prepared to perform a chemical decontamination procedure before the course, while 8/10 considered themselves prepared after the course and 10/10 felt ready after the simulation exercise.

Conclusion:

Both focussed training session and live decontamination exercise improved decontamination procedure knowledge and self-efficacy in this small sample. While resource intensive, a live simulation exercise led to a bigger increase in knowledge and self-efficacy.

Lieselot BLOMME (Brussels, Belgium), Sofie PAUWELS, Ruben DE ROUCK, Ives HUBLOUE
00:00 - 00:00 #23025 - Assessment of the SOFA and Harmless scales for the prediction of adverse effects among patients diagnosed with acute pancreatitis in an emergency department.
Assessment of the SOFA and Harmless scales for the prediction of adverse effects among patients diagnosed with acute pancreatitis in an emergency department.

Background.

Acute pancreatitis (AP) is a pathology that presents high morbidity and mortality and is relatively frequent in emergency departments (ED). It is very important to know the prognosis of these patients from the first moment since the diagnosis is made.

Aim:

To know the utility of the SOFA and Harmless severity scales to determine adverse effects among patients diagnosed with AP in an ED.

Material and methods:

Descriptive, retrospective study in an ED. Patients diagnosed with AP in an ED in 2018 have been analyzed. dependent variable: adverse effect (AE), adverse effect was defined: pseudocyst, abscess, necrosis, death in hospital or hospitalization in critical units. The SOFA and Harmless severity scales were calculated, a descriptive study of the sample: age, gender and Charlson index. The area under the curve (AUC) of the receiver operating characteristic (ROC) (95% CI) of different scores was calculated to dependent variable. Univariate and multivariate study using logistic regression and Odds Ratio (OR). Software: SPSS 24.0, p <0.05

Results.

N: 173. Median age: 68.2 (18.4) years Female: 99 (58.2%). Adverse effect: 16 (9.2%). Mean age with AE: 64.9 (17.0) Mean age without AE: 68, 5 (18.5) (p> 0.05). AE according to gender: male: 14.9%, female: 5.1% (p <0.05). High CI: 8%, low moderate: 11.7% (p> 0.05). AE: SOFA  2: 11.9%, SOFA <2: 6.7% (p> 0.05); Harmeless: 0 points: 6.0%, 1-2 points: 11.3% (p> 0.05). AUROC SOFA: 0.658 (95% CI 0.508-807) (p> 0.05), Harmless: 0.608 (95% CI 0.442-0.774) (p> 0.05). logistic regression and odds ratio (OR): age, gender and SOFA: age: 0.98 (95% CI 0.94-1.02) (p> 0.05), gender: 4.97 (95% CI 1.21-20.33) (p <0.05), SOFA : 1.51 (95% CI 1.009-2.28) (p <0.05); logistic regression and OR: age, gender and Harmless: age: 0.99 (95% CI 0.96-1.02) (p> 0.05), gender: 2.77 (95% CI 0.88-8.65) (p> 0.05), Harmless: 1.63 (95 % CI 0.68-3.90) (p> 0.05)

Conclusions:

The only variable analyzed that has been associated with any AE is male gender. Although a SOFA greater than or equal to 2 and a score on the Harmless scale greater than zero has a higher percentage of adverse effects, no statistically significant association has been evidenced. In the logistic regression by age, gender and SOFA: both gender and SOFA are independently associated with adverse effects, something that does not occur when analyzing age, gender and Harmless, in which no varaible is associated with independently with AE. The AUROC of the SOFA and Harmless scales are not significant to predict AE. Of the two analyzed scales, although neither offers great reliability, it seems that the SOFA scale would be more appropriate to assess the appearance of the adverse effects studied among patients diagnosed with PA in ED.

Dr Raul LOPEZ IZQUIERDO (Valladolid, Spain), Castaño Camblor PEDRO, Ingelmo Astorga ELISA, García Vesga VIOLETA, Henar BERGAZ DIEZ, Delgado Alonso LORENA, Rosa Maria CASTELLANOS FLOREZ, Irene CEBRIAN RUIZ, Carlos GARCÍA CALVO, Berta TIJERO RODRIGUEZ, Raquel TALEGON MARTIN, Juan Carlos SANCHEZ RODRIGUEZ, Susana SANCHEZ RAMÓN, Henandez Gajate MARIO, Mª Antonia UDAONDO CASCANTE, Isabel GONZALEZ MANZANO, Inmaculada GARCÍA RUPEREZ, Francisco MARTÍN RODRIGUEZ, Ramos Rodriguez ANA, Helena HERNANDEZ PÉREZ, Fraile Simón JUDIT, Gonzalez Araujo MARÍA
00:00 - 00:00 #23759 - Assessment of therapeutic education in diabetes patients.
Assessment of therapeutic education in diabetes patients.

Introduction :

Mellitus diabetes is a chronic disease with a constantly increasing incidence. Its metabolic and degenerative complications can compromise vital and functional prognosis. Optimal control of diabetes can be achieved by adapting medication and lifestyle to reduce the occurrence of complications.

This study aimed to assess the level of knowledge of diabetic patients and to evaluate their ability to manage their condition.

Methods :

Prospective and descriptive study, including diabetic patients seen in the emergency department over a 3-month period. Data collection was conducted using a questionnaire including epidemiological data, medical history, type of diabetes and its degenerative complications, usual treatment and evaluation of patient therapeutic education knowledge.

Results :

Thirty seven patients were included. The average age was 59 years old [26-96]. The observed sex ratio was 0.48. We noticed that 35.1% of our patients were illiterate. Type 2 diabetes was found in 81.1% and insulin therapy represented 32.4% among usual treatment. The mean duration of diabetes was 9 years [0-41]. We found at least one kind of degenerative complication in 43.8%. Diabetic peripheral neuropathy was the most frequent degenerative complication (38.2%). Blood glucose measurement by glucometer showed that the mean level was 2.53 g/l [0.41-Hi]. The most common acute complications of diabetes observed were: Diabetic ketosis (2.7%), diabetic ketoacidosis (8.1%) and hypoglycemia (13.5%).The number of patients unaware of their last fasting blood glucose level was 24. Denial of disease in diabetes mellitus was observed in 8.1% of patients and patient non-compliance was observed in 18.9% of cases. It was found that 30% of type 1 and type 2 diabetes mellitus patients requiring insulin therapy were unaware of injection techniques. Those who did not have a glucometer at home accounted for 54.1% of cases. We noted that 48.6% of patients ignored the signs of hypoglycemia and 45.9% were unaware of the symptoms of hyperglycemia. Physical inactivity was noted in 73% of cases. Diet for diabetics was not followed in 21.6% of cases and poor foot hygiene was observed in 48.6% of cases.

Conclusion :

Our study allowed us to identify possible gaps in the therapeutic education of diabetics. It is expected that additional efforts will be made to sensitize healthcare professionals to the need to adapt the lifestyle of diabetic patients.

Fatma HEBAIEB, Karim BELGUITH, Nadia ZAOUAK (Tunis, Tunisia), Rania HMAISSI, Imene ABIDA, Fadoua KHALFAOUI, Boutheina AMMAR
00:00 - 00:00 #22899 - Association between acute intracranial hemorrhage and ground-level falls in geriatric patients taking aspirin.
Association between acute intracranial hemorrhage and ground-level falls in geriatric patients taking aspirin.

Background: Ground-level falls are the most common injury seen in geriatric patients, with nearly 25% of people age 65 or older experiencing a fall-related injury annually. Among these patients, aspirin use is widespread due to its many beneficial effects. However, its platelet effects may also increase the risk of intracranial hemorrhage (ICH) in the event of head trauma, which is a major cause of morbidity and mortality. Our study aims to investigate if aspirin use increases the prevalence of acute ICH in geriatric patients who present to the emergency department (ED) after suffering head trauma due to a ground-level fall.

 

Methods: This investigation was a prospective cohort study at two level-one trauma centers, taking place during a 4-month period from August 2019 to December 2019. Included patients were age ≥ 65 who suffered head trauma associated with a ground-level fall. Patients who presented to the ED with a head-related injury greater than 24 hours prior to arrival, transferred from another facility, experienced penetrating injuries, or taking an anticoagulant or antiplatelet medication other than aspirin were excluded. Rates of ICH were compared between patients taking aspirin and those who were not.

 

Results: 1,222 consecutive patients were enrolled. 342 were in the aspirin group and 880 in the non-aspirin group. Mean age was 80.8 years. The aspirin group tended to have patients with higher rates of diabetes, hypertension, coronary artery disease, and atrial fibrillation. ICH was found in 8.8% of the aspirin patients and 12.6% in the non-aspirin patients, which was not a statistically significant difference.

 

Discussion & Conclusions: Aspirin is commonly used for its beneficial cardiovascular effects despite its effects on the hematologic system.  Head injury among older individuals are common and are most commonly caused by ground level falls.  Our study looked at geriatric ED patients who have experienced head trauma from fall and found that preinjury aspirin use did not appear to increase the incidence of acute intracranial hemorrhage.

 

Trial Registration: ClinicalTrials.gov Identifier: NCT04044924

 

Funding: This project was supported by the The Florida Medical Malpractice Joint Underwriting Association Dr. Alvin E. Smith Safety of Health Care Services Grant, RFA 2018-01.

 

Ethical Approval: This study was approved by the Florida Atlantic University Instituitional Review Board