Background: A baseline/1 hour rule-in/rule-out acute myocardial infarction (AMI) algorithm using high sensitivity cardiac troponin T (hs-cTnT) measurements is detailed in the 2015 European Society of Cardiology (ESC) non-ST-elevation myocardial infarction (NSTEMI) guidelines. The accuracy of the positive and negative predictive values for diagnostic testing plays a key role in physician therapeutic decision making, especially for acutely ill patients.

Purpose: To determine the ESC recommended baseline/1 hour AMI rule-in (hs-cTnT at 0 hour > 52 or a 1 hour delta ≥ 5 ng/L) positive predictive value (PPV) in the REACTION-US (Rapid Evaluation of Acute Myocardial Infarction in the United States) study and to compare it to that reported in the TRAPID-AMI (High Sensitivity Cardiac Troponin T Assay for Rapid Rule-out of Acute Myocardial Infraction) international multicenter trial.

Methods: Patients presenting with any symptoms, regardless of duration, suspicious for an acute coronary syndrome (ACS) to the emergency department (ED) of a single US tertiary care urban center were enrolled. Baseline (within 60 minutes of triage ECG) and 1 hour blood samples were obtained and later analyzed for hs-cTnT (Roche Diagnostics: 99^th percentile 14 ng/L, level of detection 5 ng/L) measurements at an independent core laboratory. AMI diagnosis was independently adjudicated by 2 physicians after reviewing all available 30 day clinical data and the hospital’s serial cardiac troponin I (Siemens: 99^th percentile 40 ng/L) levels over 3 hours in accordance with the 3^rd Universal Definition of AMI.

Results: Of the 569 enrolled subjects 44 (7.7%) had AMI: 26 type 1 (59%) and 18 (41%) type 2. After analyzing the baseline/1 hour ESC rule-in algorithm in the 542 patients with hs-cTnT values available at both times, 69 (12.7%) were placed in the AMI rule-in zone. The resulting 1 hour AMI rule-in PPV was 42.0% (95% CI: 30.2%-54.5%). In the TRAPID-AMI trial 184 (14.4%) patients were placed in the rule-in zone and with a 1 hour AMI rule-in PPV of 77.2% (95% CI: 70.4%-83.0%). The PPV for the 1 hour rule-in AMI was significantly lower (p < 0.001) in the US ED population.

Conclusions: The PPV was significantly lower when the ESC guidelines AMI 1 hour rule-in were applied to the REACTION-US study as compared to the TRAPID-AMI international trial. This was likely the result of broader troponin ordering and enrollment of some dialysis patients (5.0%), which may have resulted in an increased overall number of elevated hs-cTnT measurements. The current ESC 1 hour rule-in AMI guidelines PPVs are inadequate to initiate early NSTEMI therapy in US and international ED patients as many individuals will receive unnecessary anticoagulation/additional cardiac testing. Further studies are needed to determine the optimal cut points/blood draw timing for a rapid AMI rule-in guideline resulting in much higher PPVs.

 

 

 

Henry Ford Health System, Roche Diagnostics

Background: Type 1 acute myocardial infarction (AMI) is caused by coronary artery obstruction leading to decreased myocardial blood flow with myocyte necrosis while type 2 is related to non-coronary disease causing imbalance between myocardial oxygen supply/demand resulting in myocardial injury with necrosis. Accurate clinical differentiation can be difficult but is needed as specific acute therapies for each AMI type differ.

Purpose: The objective of this study was to determine whether the N-terminal pro B-type natriuretic peptide (NT-proBNP)/high sensitivity cardiac troponin T (hs-cTnT) ratio could help in AMI type identification in the Emergency Department (ED).

Methods: Patients presenting with any symptoms suspicious of an acute coronary syndrome (ACS) to the ED of a single US tertiary care urban center were enrolled. Baseline (within 60 minutes of triage ECG), 30, 60 and 180 minute EDTA blood samples were obtained and later batch analyzed for NT-proBNP (pc/ml) and hs-cTnT (99^th % 14 ng/L, level of detection 5 ng/L) measurements at an independent core laboratory. AMI diagnosis was independently adjudicated by 2 physicians after reviewing all available 30 day clinical data and the hospitals serial cardiac troponin I (Siemens: 99^th percentile 40 ng/L) levels over 3 hours in accordance with the 3^rd Universal Definition of AMI.

Results: Of the 569 enrolled subjects 44 (7.7%) had AMI. Twenty six (59 %) had a type 1 while 18 (41%) type 2. Receiver Operator Curves (ROC) were plotted and the area under the curve (AUC) used to evaluate the ability of the NT-proBNP/hs-cTnT ratios to predict type 1 from 2 AMI and the optimal cut points (OCP) determined. The AUC and OCP values at baseline, 30, 60 and 180 minutes were 0.7650 (95% CI: 0.611-0.919), 14.8; 0.7756 (95% CI: 0.627-0.925), 13.0; 0.7770 (95% CI: 0.621-0.933), 26.0 and 0.7449 (0.568-0.922, 11.0. The AUC for the changes in the NT-proBNP/hs-cTnT ratios from baseline to 30, 60 and 180 minutes were 0.5299, 0.6127 and 0.5884.

Conclusions: The ROC AUC NT-proBNP/hs-cTnT ratio values were moderate when assessed at each of the 4 sample time points but poor when looking at the changes from baseline to 30, 60 and 180 minutes. Our results can be explained as type 2 AMI results from cardiac supply/demand mismatch caused by non ACS disease resulting in increased cardiac wall stress with earlier and larger amounts of NT-proBNP, thus increasing the ratio. Further studies are needed to determine the validity of these results and how to use them to direct optimal ED AMI care

Henry Ford Health System, Roche Diagnostics

Introduction:

Affirming the diagnosis of Generalized tonic-clonic seizures (GTCS) at arrival in the emergency department without seeing the seizure is difficult. In case of doubt, the French Society of Neurology recommends dosing creatine kinase (CK) four hours after the seizure. Several studies have looked at earlier markers such as lactate. The objective of this study was to evaluate and compare the interest of the lactate and CK assay in the diagnosis approach of GTCS at the arrival of the patient in an emergency department.

Material and methods:

We carried out a prospective, observational, single-center study in the emergency department of our universitary hospital from November 2016 to July 2017. An ethical opinion was obtained (CPP South-East VI) and a statement of clinical trials was carried out (NCT03163719). Patients over 18 years old with a proven GTCS were included.

Results:

Thirty four patients were included. The mean age was 48.1 +/- 20.8 years old and most of the patient were male (60.6%). The number of positive lactate dosages at arrival (H0) was higher than the number of positive CK four hour after arrival (H4) (respectively, 70.6% vs 41.2%, p = 0.008). Lactate levels decreased between H0 and H4 (respectively, 5.9 ± 5.2 vs 1.2 ± 0.4, p <0.001) while CK level increased (respectively, 308.6 ± 627.4 and 404.5 ± 615.5, p <0.001). In addition, the number of positive lactates at H0 was significantly higher than those at H4 (respectively, 70.6% vs. 2.9%, p <0.001).

Conclusion:

Our study showed the value of lactate dosing at patient arrival for suspected Generalized tonic-clonic seizures compared to the recommended four hours CK dosage. To our knowledge, this is the only prospective study describing the kinetics of lactate and CK levels at arrival and at four hours in the same patient with a strong suspicion of Generalized tonic-clonic seizures. However, other studies seem necessary to refine the lactate positivity threshold and the factors that can influence them.

Clinical trials registration: NCT03163719

Background: Endothelial glycocalyx is a network of proteoglycans and glycosaminoglycans that cover the endothelial surface of the vessels. This structure plays a role in controlling vascular permeability, migration of inflammatory cells and platelet aggregation.  Virus respiratory infection, mainly secondary to influenza virus, can cause acute respiratory distress syndrome (ARDS) in adults mostly during outbreaks. The mechanisms responsible for this injury are not entirely known. We hypothesized that endothelial glycocalyx damage could contribute to ARDS installation after respiratory virus infection.

Methods: We included patients with flu-like symptoms admitted to emergency department divided into two groups: patients with ARDS according to the Berlin definition (Group 1) and patients without ARDS (Group 2) during influenza A seasonal outbreak period. A control group of healthy individuals was included for comparison (Group 3). During the hospital admission, a venous blood sample was collected and stored at -70 degrees. Biomarkers of endothelial glycocalyx damage (hyaluronan, syndecan-1, thrombomodulin) and cytokines (TNF-alpha, IL-6, IL-1beta) were measured through commercial ELISA Kits (R&D, Minneapolis, USA). The values were shown as mean ± standard error of the mean.

Results: We included 22 patients in the group 1 (44±17 years-old, 54% male, symptoms duration: median of 5 days, intra-hospital mortality rate: 45%, IgM positive for influenza A: 30%), 33 patients in the group 2 (34±17 years-old, 45% male, symptoms duration: median of 4 days, intra-hospital mortality rate: 00%, IgM positive for influenza A: 15%) and 26 healthy individuals in the group 3 (43±10 years-old, 35% male). The hyaluronan levels were significantly higher in the group 1 (34±6 ng/ml) about the group 2 (12±4 ng/ml) and group 3 (8±4ng/ml); p<0.0001. The syndecan-1 levels were higher in the group 1 (80±18 ρg/ml) in relation to the group 2 (49±11ρg/ml), p=0.003, however, there weren’t observed a difference between group 2 and group 3. The thrombomodulin levels were significantly higher in the group 1 (1687±181ρg/ml) and group 2 (1019±143ρg/ml) in relation to the group 3 (175±116 ρg/ml); p<0.0001. In respect to the cytokines levels were not observed differences among the groups: TNF-alfa (92±49ρg/ml, 88±36ρg/ml, 200±76ρg/ml; p=0.56), IL-1beta (76±32ρg/ml, 79±25ρg/ml, 69±28ρg/ml, p=0.99) and IL-6 (114±39ρg/ml, 102±30ρg/ml, 147±49ρg/ml; p=0.73) respectively for the group 1, 2 and 3.

Discussion & Conclusions: Elevation of biomarkers of the glycocalyx endothelial damage was observed in the early phase of ARDS secondary to probable virus infection regardless of the cytokines levels suggesting the possibility of a direct virus lesion of this structure, which could have a pivotal function in ARDS development in this setting.  These biomarkers, mainly hyaluronan, could be used to select among patients with flu those with a higher risk of developing ARDS at the emergency department.  

Funding Information: FAPESP-Fundação de Amparo a Pesquisa do Estado de São Paulo-2016/22147-1

Background. Dyspnea is a major cause of presentation at the emergency department (ED) with a broad spectrum of underlying conditions. The prognosis varies from benign to life threatening and is difficult to determine in the acute setting. The soluble urokinase Plasminogen Activator Receptor (suPAR) is an unspecific inflammatory biomarker of disease severity and a predictor of negative outcome. Objectives. The aim of this prospective study was to investigate whether suPAR can provide clinically meaningful prognostic information for 90 day mortality in patients with acute dyspnea. Method. Blood samples and vital parameters were collected from 620 patients upon admission at the ED in Malmö, Sweden. suPAR was related to 90-day mortality with Cox proportional hazard models adjusted for established risk factors; age, sex, oxygen saturation, respiratory rate, C-reactive protein concentration, smoking history, kidney function, and METTS-score. Discrimination was determined with Receiver Operating Characteristics (ROC) and accuracy by measuring Area Under the ROC-curve (AROC). Further, both category-free and categorical Net Reclassification Improvement (NRI) was computed to assess prediction increment. Results. Seventy-five deaths (12.1%) were recorded within 90 days. suPAR conferred a Hazard Ratio (95% confidence interval) of 1.59 (1.30-1.93, p<0.001) for 90-day mortality per 1-SD increment. Adding suPAR on top of the established risk factors increased the AROC from 0.735 (0.680-0.791, 95% CI) to 0.763 (0.706-0.820, 95% CI) and the continuous NRI was 0.48 (0.27-0.78, 95% CI; p<0.001). Conclusion. suPAR independently improves risk prediction in unselected patients with acute dyspnea. However, more studies are needed to define its role in clinical practice.

The study was supported by research grants from the Knut and Alice Wallenberg Foundation, Göran Gustafsson Foundation, the Swedish Heart- and Lung Foundation, the Swedish Research Council, the Novo Nordisk Foundation, Region Skåne, Skåne University Hospital and the Swedish Foundation for Strategic Research (IRC).

Background: The management of acute stroke throughout the United Kingdom has been networked since 2007. A patient with positive Face Arm Speech Test (FAST) will by-pass their local hospital and be brought to a specialist hyper-acute stroke unit (HASU) as a ‘Stroke Call’.

Upon arrival, the patient will undergo further assessment to determine the diagnosis. Patients may be found to be FAST negative: false FAST positive. After further assessment, patients may be found not to have had a stroke: stroke mimic (SM). The number of SM patients at our HASU was noted to be high and we wanted to explore the relationship between the patient’s FAST assessed by the ambulance personnel and the ED staff, national Early Warning Score (NEWS) and the final diagnosis to aid the early diagnosis of stroke and non-stroke and improve the specificity of FAST. We were unable to find any previous research in this area.

Method: We performed a retrospective observational study by reviewing the medical records of Stroke Call patients brought to our HASU September 2017 to March 2018. We calculated their NEWS on arrival, FAST and the final diagnosis. We calculated the diagnostic accuracy of FAST and looked for a statistically significant difference between the distribution of NEWS with the Kruskall Wallis Test. We looked at the relative risk of an increase in NEWS on the chance of stroke using a Multinomial Logistic Regression analysis. We compared patients who were true FAST positive vs. false FAST positive, ischaemic stroke (IS) vs. SM vs. haemorrhagic stroke (HS).

Results: We included 407 patients; 198 SM, 169 IS and 40 HS. 334 were true FAST positive and 73 were false FAST positive. The sensitivity and specificity of FAST was 92.8% (95% CI: 88.4%-95.9%) and 29.3% (95% CI: 23.1-36.2%) respectively. Kruskal Wallis Test; the difference in NEWS between the SM and IS groups was not statistically significant (p>0.05), the difference in NEWS was significant between the SM and HS groups (p=0.003) and the IS and HS groups (p=0.017).

Multinomial Logistic Regression; NEWS was not a predictor of having an ischaemic stroke in the IS group when compared to the SM group (p>0.05). A higher NEWS was a significant predictor of having a haemorrhagic stroke when compared to the SM group (odds ratio 1.20, 95% CI: 1.07-1.35). A higher NEWS was a significant predictor of having a haemorrhagic stroke when compared to the IS group (odds ratio 1.16, 95% CI: 1.03-1.29). For both the IS and HS groups; being true FAST positive significantly increased the chance of stroke compared to the SM group (odds ratio ischaemic 5.44, 95% CI: 2.80-10.54; haemorrhagic 5.31, 95% CI: 1.55-18.18).

Discussion & Conclusions: NEWS has limited utility in assessing whether a patient is more likely to have suffered haemorrhagic stroke than either ischaemic stroke or no stroke (stroke mimic) when presenting as a stroke call. We conclude that the specificity of FAST in our group is low and its diagnostic accuracy cannot be improved by the use of NEWS.

ABSTRACT

Background: Delays and crowding can increase mortality in emergency departments (EDs). Previous research has demonstrated that risk stratification can be strengthened using prognostic biomarkers, but the impact on patient prognosis is unknown. The aim of the TRIAGE III trial was to investigate whether the introduction of the prognostic and nonspecific biomarker: soluble urokinase plasminogen activator receptor (suPAR) in the emergency department reduces mortality in acutely admitted patients.

Methods: The TRIAGE III trial was a cluster-randomised interventional trial conducted at EDs in the Capital Region of Denmark. We included EDs with acute medical and surgical patients and no previous access to suPAR measurement in twelve cluster-periods of three weeks alternating between intervention and control. Patients were allocated to the intervention if they arrived in interventional periods, where suPAR measurement was routinely analysed at arrival. In the control periods, suPAR measurement was not performed. The primary endpoint was all-cause mortality ten months after admission. Secondary outcome was 30-day mortality.

Results: We enrolled a consecutive cohort of 16,801 acutely admitted patients; all were included in the analyses. The intervention group consisted of 6 cluster periods with 8,900 patients, and the control group consisted of 6 cluster periods with 7,901 patients. The receiver operating characteristics curve analyses showed a prognostic ability of suPAR for 30-day and 10-month mortality corresponding to an area under the curve (95% CI) of 0.83 (0.81 to 0.84) and 0.80 (0.79 to 0.82), respectively.

After a median follow-up of 362 days, death had occurred in 1,241 patients (13.9%) in the intervention group and 1,126 patients (14.3%) in the control group.

The weighted Cox model found a hazard ratio of 0.97 (95% confidence interval, 0.89 to 1.07; P=0.57). This result was consistent in all subgroups. Analysis of 30-day all-cause mortality showed similar results (HR, 0.98; 95% CI, 0.84 to 1.16; P=0.84).

Conclusions: We detected no significant difference in mortality according to use of soluble urokinase plasminogen activator receptor as a prognostic biomarker in the emergency department

 

Trial registration: clinicaltrials.gov. Identifier: NCT02643459. Funding: ViroGates A/S

ABSTRACT

Background: Early and accurate identification of patients at low risk of serious illness may improve flow in the emergency department (ED) by classifying these patients as non-urgent or even suitable for discharge. This would allow for better utilisation of limited staff and resources and could potentially translate into improved patient outcomes. Blood-based prognostic biomarkers measured at admittance can be used for this purpose. One of these biomarkers is the nonspecific soluble urokinase plasminogen activator receptor (suPAR). In this substudy of the TRIAGE III trial, we hypothesised availability of suPAR might lead to a higher frequency of early discharges from the ED.

Methods: In this post hoc substudy, we used data on the same consecutively included and unselected population as in the TRIAGE III trial, which was a randomised interventional trial investigating the introduction of suPAR as a routine biomarker in the ED. As early discharge based on suPAR would require the availability of the suPAR level, we compared patients with a valid suPAR measurement at admission to those without, regardless of whether patients arrived in interventional- or control periods. The primary endpoint was the proportion of patients discharged alive from the ED within 24 hours. In addition, we compared length of hospital stay and the number of readmissions within 30 days.

Results: We included 26,653 acute admissions of 16,801 unique patients. The suPAR level was available at the index admission in 7,905 patients (suPAR group), and no value was available in 8,896 (control group). The proportion of patients who were discharged within 24 hours of admittance was significantly higher in the suPAR group compared to the control group: 50.2% (3,966 patients) vs. 48.6% (4,317 patients), P=0.04). Furthermore, the mean length of hospital stay in the suPAR group was significantly shorter during the index admission compared to the control group (4.3 days (SD 7.4) vs. 4.6 days (SD 9.4), P=0.04). In contrast, readmission rate within 30 days was significantly higher in the suPAR group: 10.6% (839 patients) vs. 8.8% (785 patients), P<0.001. However, there was no difference in mortality (1.3% vs. 1.8%, P=0.09) or readmission rate (8.5% vs. 7.7%, P=0.18) in patients discharged within 24 hours, for the suPAR group and control group respectively.

Conclusions: These post hoc analyses demonstrate that the availability of the prognostic biomarker suPAR was associated with a higher proportion of discharge within 24 hours, reduced length of stay, but more readmissions. There was no difference in mortality or readmission rate within 30 days in those discharged within 24 hours.

Trial registration: clinicaltrials.gov. Identifier: NCT02643459. Funding: ViroGates A/S

Background : We aimed to assess the potential association between vascular endothelial growth factor A (VEGF-A)  and early stage chronic kidney desease (ESCKD).

Methods : In a cross-sectional study  we included 81 patients with ESCKD with estimated glomerular rate filtration (eGRF ) >30 ml/min/1.73m², divided into two groups : G1 patients with eGRF2 (G1, n=49) and G2 patients with eGRF≥90ml/min/1.73m² (G2, n=32).Estimated glomurular filtration was calculated with  CKD-EPI Creatinine Equation (2009).In all patients we collected demographic and clinical data as well as VEGF-A serum levels   measured by ELISA commercial kits.

Result : The mean of eGRF in G1 was 78 ml/min/1.73m² (IQR,70-85 ml/min/1.73m² ) and in G2 was 103.6 ml/min/1.73m² (IQR,95-108 ml/min/1.73m² ) so there was a signifiant difference between the two groups with p≤10^-3  .There was a signifiant difference in both groups  in the serum VEGF-A (183.7 pg/ml versus 278.7 pg/ml respectively for G1 and G2 ;p=0,02) .

Conclusion : In this study we  showed  that ESCKD  is  associatiated with lower serum levels of  VEGF-A .Our findings indicated that VEGF-A can help to ESCKD  detection. 

BACKGROUND

Medically unexplained symptoms (MUS), defined as physical symptoms for which no organic pathology can be found, are a common presentation in the emergency department. It has been estimated that up to 45% of ‘moderate frequent attenders’ (5-10 ED visits per year) are patients with MUS, making up 4% of all ED attendances annually. The standard management of these patients following extensive investigation to rule out organic pathology involves reassurance or simple explanations of their symptoms, for example in relation to stress. A significant body of research examines interventions for such patients within a primary care setting, finding moderate benefits for some psychological treatments. However, much of this research is not transferrable to the ED where doctors are under time constraints and extended treatment courses lasting weeks to months are not feasible. We conducted a literature review to determine if there was any intervention that could be offered to these patients within an ED setting to reduce their re-attendances and improve their symptoms.

METHODS

We searched the MEDLINE, EMBASE, and PsycINFO databases from their earliest limits until March 2018 using terms such as “unexplain*”, “somatoform” and “functional”, as well as terms for more specific syndromes such as “non-cardiac” to capture the ill-defined concept of MUS. Studies were included if they considered adult MUS within an ED setting, and used any specific intervention whilst measuring rates of attendance or symptom severity. We also only included studies designed as RCTs or pre-post intervention studies. Studies were excluded if they considered frequent attenders who had biological disease.

RESULTS

The search identified 1612 unique citations. Titles and abstracts were screened resulting in 32 articles for full text retrieval and finally 6 articles were selected for data extraction. 3 of the 6 articles were published only as conference abstracts. As a whole, the studies were heterogeneous in terms of the participants involved, interventions tested, and conclusions drawn. Three studies tested CBT, ranging from a single 60-minute session at the bedside to 4 sessions over several days, in patients with MUS or non-cardiac chest pain (NCCP) with two finding a reduction in ED attendance and the third showing no change. Other interventions tested included phone-based coaching for self-management of NCCP, intensive short-term dynamic psychotherapy for MUS, and confirming a diagnosis of psychogenic non-epileptic seizures using inpatient video and EEG telemetry to reassure and educate patients.

DISCUSSION

Despite the fact that patients with MUS represent a large proportion of attendances and healthcare costs for EDs, the evidence concerning interventions for patients with MUS is limited and of a variable quality. It seems CBT could be a promising treatment option for this patient group, a result in keeping with the findings from general practice, yet it remains unclear whether short, intensive treatment is efficacious. Further research is required to determine the best intervention for this challenging patient group.

 

Background: Difficult and failed tracheal intubation (TI) procedures occur more frequently in emergency settings than an operating room environment. Notably, glottis identification is difficult with copious salivation, vomiting, or bleeding in the oral cavity, complicating TI. Video-laryngoscopes such as the PENTAX-AWS (AWS, NIHON KOHDEN), with a tube-guiding groove in an L-shaped blade, and McGRATH MAC (McG, Covidien), with a Macintosh-shaped blade, have been developed to facilitate TI under various conditions, including emergency settings. However, the AWS provides only indirect viewing, while a direct view of the glottis as well as indirect viewing via a monitor are possible with the McG, making it advantageous for glottis identification in cases with vomiting. We examined success rate, intubation time, and difficulty with those devices used for simulated TI with oral cavity vomiting.

Methods: This was a randomized crossover manikin study. Twenty-five TI certified ambulance crews were enrolled after each member provided written consent. Using a manikin with a clumped bronchus and esophagus, vomiting was simulated by pouring rice gruel into the oral cavity, then laryngoscopy procedures were performed. With the AWS, suctioning was done with an 18-Fr suction catheter inserted via the tracheal tube (TT) set into the tube-guiding groove of the blade, with subsequent TT advancement. With the McG, conventional suctioning using the same size catheter and subsequent TT advancement were performed. Intubation attempts were randomly performed with each device by the crews. Success rates as well as time required from device insertion to glottis visualization (T1), glottis visualization to tube passage through the vocal cords (T2), and tube passage through the vocal cords to ventilation (T3) were noted. The crews scored each TI attempt for difficulty using a visual analog scale (0-100 mm, very easy to very difficult). Values are shown as the mean ± SD, with Fisher’s exact test or Student's t-test used for analysis.

Results: Success rates with the AWS and McG were 100% and 96%, respectively (not significant). There was no significant difference between the AWS and McG for T1 (33±15 vs. 35±25 seconds), while T2 and T3 with the AWS were significantly shorter (9±9 vs. 20±20, 9±2 vs. 13±6 seconds, respectively). Overall time for TI with the AWS was also significantly shorter (51±17 vs. 69±36 seconds), whereas difficulty was not significantly different between the devices (33±24 vs. 37±25 mm).

Discussion & Conclusion: The AWS required less time to complete intubation as compared to the McG, while time to glottis visualization, difficulty, and success rate were similar. The AWS is equipped with a blade molded to fit the oropharyngeal anatomy, enabling even less experienced operators to obtain an optimal view for TI without requiring airway axis alignment. Furthermore, suctioning with the catheter inserted via the TT set into the tube-guiding groove of the AWS enables focused decontamination around the glottis. These features may explain the main differences between the devices in this study. In conclusion, using a simulated vomiting scenario, more prompt TI was achieved with the AWS as compared to the McG video-laryngoscope. 

Trial registration: This study was not registered as a trial because there were no patients involved. Funding: No specific funding was received in regard to this study.

Study objective: The goal of this study was to compare first-pass success rates in patients undergoing emergency intubation with direct laryngoscopy (DL) vs video laryngoscopy (VL).  We also compared success rates in pediatric vs adult patients and trauma vs medical indications with sub-analyses for the major indications in each category.  We hypothesized that VL would be superior to DL during endotracheal intubation in emergency departments (EDs).

 

Methods: This was a retrospective analysis of prospectively collected data entered into the National Emergency Airway Registry (NEAR) during a 12 month period. Twenty-two academic EDs in the United States recorded intubation data onto a web-based data collection tool. After each intubation, the operator completed a standardized data form evaluating multiple aspects of the intubation, including patient characteristics, indication for intubation, device(s) and medication(s) used, difficult airway characteristics, number of attempts, and outcome of each attempt. The primary outcome was first-pass success.

 

Results: Twenty two centers participating in NEAR met the 90% compliance standards.  We report on 5071 emergency intubations during 2016 (additional data for 2017 will be available soon).   A total of 338 (6.7%) intubations were performed on pediatric patients (age <15) with a first pass attempt by DL (n = 179, 52.9%) vs VL (n = 152, 45.9%).  The remainder of the intubations, 4733 (93.3%) were performed on adult patients with DL as the preferred initial device (n=1796, 37.9%) vs VL (n=2915, 61.8%). Nearly 75% of intubations (3697 out of 5071) were for medical indications with 39.9% (1474) performed using DL and 60.1% (2218) performed using VL.   For trauma indications (1339 pts), 37.4% (501) of intubations were performed using DL vs 62.6% (838) by VL.  For first pass success, VL appeared superior to DL for both medical and traumatic indications except for burn/inhalation injury where using DL resulted in better first pass success (92.3% vs 86.5%).  The largest differences in DL vs VL first-pass success rates were seen for the following medical indications: overdose (80% vs 92.2%), seizure (80.5% vs 92.7%), septic shock (79% vs 92%) and cardiac arrest (76.5% vs 85.8%). Among trauma indications the largest differences were seen for head injury without ICH (68.6% vs 92.5%), polytrauma (73.3% vs 84.3%), chest trauma (82.1% vs 91.5%), and traumatic arrest (77.6% vs 83.6%).

 

Conclusion: VL has a higher first-pass success rate compared to DL when used for emergent intubation for both trauma and medical indications in this large, multi-center airway registry database involving academic institutions.  These findings are not concordant with other studies that have found equivalence between DL and VL and occasionally superior performance with DL. There are many possible explanations for this, but it is clear there has been a movement toward the use of VL over DL in academic institutions. This will have a large and important impact on current and future airway training and will hopefully lead to the increased availability of VL in the community setting.

Background: Computed tomography (CT) is increasing used to evaluate trauma patients and substantial numbers of incidental finding (IF) have been reported. Although these IF are often benign, their presence must always be communicated to patients. Clinically relevant IF needs referral or even consultation. This study was designed to evaluate the prevalence of IF revealed by trauma CT and status of communication. We also evaluate patient characteristics associated with the presence of IF.

 

Methods: This is a retrospective, cross-sectional study. We collected all patients who received CT scans for trauma evaluation at our Emergency Department in 2016. Duplicated scans and patients with missing data were excluded. Official CT reports were examined and basic demographics were reviewed. Scans with IF prompted detailed review of medical records to determine the clinical significance and the follow-up. Incidental findings were divided in 3 categories: category I (potentially severe condition, in-time diagnostic workup and management are required), category II (not urgent, needs follow-up), and category III (of minor concern, required no specific follow-up). Prevalence and status of follow-up of IF were reported. Multivariable logistic regression models were fitted to determine whether certain patient characteristics were associated with the presence of IF. A P value less than .05 is considered statistically significant.

 

Results: There were 4,173 CT scans performed for trauma evaluation. After excluding 20 duplicated scans and 61 scans with missing data, 4,092 scans were enrolled. Incidental findings were identified in 649 (15.9%) scans; 13 (2.0%) of them were category I, 306 (47.1%) were category II, and 330 (50.8%) were category III. Patients with IF were older than those without (P < 0.001); however, no sex difference was found (P = 0.667). Near 2/3 (61.5%) scans were done for head; however, abdomen had the highest prevalence of IF (26.2%), followed by chest (20.2%), head (15.3%), neck (10.5%) and extremity (2.6%). Although 46% patients with category I IF received consultation of corresponding specialists, no documentation about IF could be found for the majority of patients with IF (category I 31%, category II 91.9%, category III 97.0%). Every year of Increasing age was independently associated with a higher prevalence of IF (Odds ratio, 1.019; 95% CI 1.015-1.024). A higher risk (Odds ratio, 1.035; 95% CI 1.028-1.041) of aging was observed in Category I & II IF.

 

Discussion & Conclusions: Incidental findings were identified in 15.9% of our trauma CT scanning. These lesions were common in the abdomen and chest and showed an increased prevalence with increasing age. Follow-up was poor, even for potentially serious findings. A delicate effort of communicating to the patient, referring to the primary care physician or corresponding specialist, and documentation is beneficial to both the patient and the healthcare provider.

OBJECTIVES: We evaluate intubation methods and associations with adverse events (AEs) and first pass success in over 5,000 Emergency Department (ED) intubations.

METHODS: Academic EDs in the USA recorded 5,071 ED intubations at 22 Institutions in 2016 (25 institutions/7,500 intubations in 2017 are scheduled for release at the end of April 2018).  These intubations were collected prospectively through a web based tool (StudyTRAX) for the National Emergency Airway Registry (NEAR).  EDs had to have a 90% compliance rate to be included in the registry.  We discuss associations between intubation characteristics, AEs and first pass success.  The intubation characteristics are method used (Rapid Sequence Intubation{RSI}, sedation only or no medications), device used (video laryngoscopy{VL} vs direct laryngoscopy{DL}),  induction agent used (etomidate, ketamine, propofol), paralytic used (rocuronium, succinylcholine, vecuronium), and intubator (resident, faculty). Logistic regression analysis will be used to compare these variables with first pass success and AEs.

RESULTS: First pass success has remained at 85% since the 1990's.  VL has surpassed DL as the predominant mode of intubation in this study.  This change is associated with different AEs.  Earlier studies showed esophageal intubations were the predominate AE.  In this review of NEAR esophageal intubations accounted for less than 1% of the AEs.  The main AEs were hypoxia and hypotension comprising more than 90% AEs. AEs occurred in 13% of patients overall, of which hypoxia accounted for 7-8% and hypotension accounted for 4%.  The remainder of AEs for this study had a total of less than 1% occurrence rate.  No intubation characteristic came to predominate with any of the AEs.  An increased rate of AEs was found in medical patients (over trauma patients) and in patient with certain characteristics (body habitus and predicted difficult airway).  While the AE rate was similar with either VL or DL, the VL use resulted in a higher first pass success rate across the majority of intubations. In this data higher rate of hypoxia and hypotension were found with ketamine as induction agent.  Ketamine has become an agent of choice in patients with unstable haemodynamics.   This higher rate of AEs is likely due to a sicker subset of patients.  Although the infamous succinylcholine versus rocuronium debate has not been laid to rest, this data does not suggest that either agent has a statistically increased association with any of the AEs.  Certain AE rates were shown to be more prominent in the medical group (esophageal intubations), though numbers were very low (<1%).  

CONCLUSIONS: This data shows that while the device utilized (VL or DL) has changed, the rate of AEs is similar between the two groups despite an associated higher first pass success with VL.   When faced with a difficult intubation in the ED it is paramount that the intubation characteristics reviewed here are not the factors associated with AEs in the hands of trained ED providers.  These findings suggest areas of further study in order to improve patient oriented outcomes and allow the intubator to make informed decisions when intubating critically ill and injured patients.

Prospective observational study about efficiency of reduced core temperature and complications in the period of 72 hours after treatment from heat illness in military personnel.

Intharachat Suthee , Department of Trauma and Emergency Medicine, Phramongkutklao Hospital, Bangkok, Thailand

Background: Heat related injuries including Exertional heat stroke (EHS) and heat exhaustion (HE) are life-threatening conditions with high mortality rate and permanent organ system dysfunction. Heat related injuries are among the health problems of military concern especially during personnel training and operation. Early recognition, immediate cooling and support of organ system function can reduce the fatality rate. 

Objectives: This study aimed to determine the efficiency of rapid cooling of core body temperature (BT) to reach the goal of less than or equal to 38 degree Celsius in 30 minutes and assessed the factors related to the achievement of body cooling including length of stay in hospital, the organ dysfunction.

Methods: We conducted prospective cohort study among patients who was diagnosed with EHS or HE during May 2015 to July 2016.    

Result: Fifty-two participants were included into this study, 11 participants were diagnosed with EHS and 41 participants were diagnosed with HE. Among 52 participants with a mean (±SD) Body mass index of 25.49±4.6 at baseline (29.21±4.12 in EHS and 23.63±3.69 in HE). The mean age of the patients was 21.65 ±3.2 years. The core BT of the patients on arrival at the emergency departments were 41.08±0.76 degree Celsius and 39.73±0.7 degree Celsius among EHS and HE patients, respectively. The primary outcome of lowering core BT to less than or equal to 38 degree Celsius in 30 minutes after rapid cooling was observed in 50% of the total participants (26 of 52), in 58.5% of the participants (24 of 41) in the HE group and in 18.2% of the participants (2 of 11) in the EHS group. One fatality case was found. The cooling methods used in all participants included ice packing, tepid sponge, massage and 4 degree Celsius cool saline infusion to reduce core BT. We also found that 34.6% of the total participants (18 of 52) used cold water gastric lavage and 23.1% of the total participants (12 of 52) used cold water bladder irrigate to reduce core BT. The initial core BT at emergency department effect the efficacy of rapid cooling core BT (P < 0.001). We found that the patients who achieved the target core BT within 30 minutes had significantly good outcomes (shorten length of stay in ICU and hospital [P=0.019]). The complications after the diagnosis of EHS and HE included renal system (98%) i.e., electrolyte imbalance (hypokalemia and hypophosphatemia: 82.6%), metabolic acidosis and acute kidney injury. 

Conclusion: Approximately one fifth of the EHS cases achieved the target core BT. Rapid cooling down core BT caused better outcomes. Prehospital care was an important factor to reduce the core BT. More effective system to improve the cooling core BT among EHS patients in this population should be implemented. 

Keywords: Heat stroke, rapid cooling, Core body temperature, Military

Background : Airway skills are crucial for emergency physicians. Verfication of endotracheal tube intubation location in critically ill patient is very important. Unrecognized esophageal intubations are associated with significant patient morbidity and mortality. No single confirmatory device has been shown to be 100% accurate at ruling out oesophageal intubations in the emergency departments.Many methods are being used for verification of endotracheal tube location, none are ideal. Quantitative waveform capnography is considered the standard care for this purpose. This feasibility study is conducted to compare an alternative, bedside upper airway ultrasonography to waveform capnography, for verification of endotracheal tube location after intubation.

Methods: This is a prospective, single centre, observational study, conducted at a tertiary care centre between April 2015 to September 2015. It included 60 patients who were intubated for surgeries under general anaesthesia in the department of anaesthesia.

After induction of anaesthesia and neuromuscular blockade, intubation via direct laryngoscopy was performed. This study required 2 performers. One performed the ultrasonography, and the other noted down the time taken by the different methods. Intubation was done by an anaesthesiologist and the emergency physician performed upper airway ultrasonography. During intubations, we placed a high- frequency, linear transducer transversely on the neck at the cricoid level and visualised the endotracheal tube in transverse view. After endotracheal tube placement was confirmed, time taken by each methods was noted down, i.e. dynamic airway, quantitative waveform capnography, lung sliding sign and auscultation.

On completion of this study, the result of bedside ultrasonography was compared with capnography and result of lung sliding scale with auscultation. Duration and accuracy of bedside ultrasonography examination were calculated to determine the accuracy and effectiveness of  its clinical use. Those values were considered to determine the strength of agreement between bedside ultrasonography along with lung sliding scale and waveform capnography and therefore be used as the standard of care.

Result: 

Dynamic airway was found to have a sensitivity and specificity of 100%. Capnography showed a sensitivity of 99.5% and specificity of 92%. Lung sliding sign was found to have a sensitivity and specificity of 100%. Auscultation also revealed a sensitivity and specificity of 100% each. Mean time taken for confirmation of intubation was the least with dynamic airway, followed by capnography, lung sliding sign and lastly, auscultation. An improvement in the time taken by dynamic airway and lung sliding test, both showing a progressive downward trend was observed. The time taken by capnography and auscultation did not show any steady increase or decrease with due course of the study. A statistically significant difference was noted in time taken for detection by the methods of dynamic airway and auscultation. Dynamic airway detected esophageal intubation before other methods.

Conclusion:

This study indicates that the use of bedside upper airway ultrasonography is useful for primary verification of endotracheal tube location. It is feasible, easy, safe and rapidly done.Dynamic airway is one of the fastest techniques to detect accurate endotracheal intubation and avoid esophageal intubation.

Background/Objectives: Boarding of patients requiring hospital admission after emergency department (ED) care is the main cause of ED crowding. ED boarding delays care, increases the risk of patient safety events and increases patient dissatisfaction. The impact of the ED boarding on patient mortality remains unclear. Several studies showed that ED boarding was associated with higher mortality up to 30 days after the ED visit. However, a recent study where statistical analysis adjusted the data with patient characteristics did not confirm this association.1 Our main objective will be to systematically review the literature for evidence on the association between ED boarding and mortality. We hypothesize that patient boarding in the ED increases mortality. Our secondary aim will be to identify an association between ED LOS and mortality, and between ED crowding and mortality.

Methods: Articles selected were focus on the association between boarding and in-hospital mortality (IHM). Literature search strategies used MeSH and text words related to EDLOS. Search was performed on Medline, Embase, Cochrane Library, Web of Science, CINAHL and PsycNET. The selection of articles was done with F1000 software. Two reviewers independently screened the titles and abstracts yielded by the search to identify relevant abstracts. Full articles with title or abstract meeting the inclusion criteria were retrieved and the reviewers selected those that meet inclusion criteria. Data extraction included study characteristics, prognostic factors, outcomes, and IHM.

Results: From 3,577 references screened by the two independent reviewers 135 references were selected. After the first step of exclusion of references that didn’t match with the search, 68 papers were selected. Finally, after a last round of screening the reviewers selected 10 papers. The total number of patients included was 126,243. While Hsieh et al, Cha et al, Singer et al, and Chalfin el al found prolonged boarding to be associated with increased inhospital mortality, McCoy et al, Al-Khathammi et al, and Gilligan et al found no association with inhospital mortality. Junhasavsdi et al found prolonged boarding to be associated with decreased inhospital mortality. Huang el al’s results showed significant increase in mortality with increased time to admission, but did not analyze the results for mortality.

Conclusions: The association between in-hospital mortality and ED boarding was not clear in our systematic review. While some studies showed an increase in in-hospital mortality with ED boarding, other studies concluded no mortality differences or even a decrease in in-hospital mortality. Further studies are needed.

Aim:
Emergency service admittions are increasing every year in our country.Health care services are not able to apply for emergency services within working hours due to the large number of working population. Patients who are not relieved of their complaints are referred to the same emergency or other emergency services. In this study, the rates of patients re-admitted for emergency services were examined.

Methods:
In this study, patients who were re-admitted within 24 hours of Emergency Medicine department between 01.01.2017 and 31.12.2017 were enrolled retrospectively. Patient complaints were recorded. Patients with a consultation case were enrolled in case of first admission. Re-admission times have been recorded.

Results:
There was a total of 100 patients re-visiting the emergency service within 24 hours between 01.01.2017 and 31.12.2017. In the case of recurrent complaints, the diagnosis was 60% fatigue fever and nonspesific pain. 49% of the patients were female and 51% were male. 19% of the patients admitted again in the first quarter of the year, 24% in the second quarter, 17% in the third quarter and 40% in the fourth quarter. 82% of the patients who re-admitted in the first quarter admitted out of working hours. 19,05% of these patients had an internal medicine referral for their first visit and 14,29% for consultation with chest diseases. 47% of the patients admitted between 16:00-24:00 hours. In the second quarter, 54.55% of the patients re-admitted out of the working hours. 13,73% of patients had internal medicine and 11,76% had consultations on chest diseases at the first visit. 50% of the patients reappeared between 08: 00-16: 00. In the third quarter, 56% of the patients re-admitted during the working hours. On the first admission, 30% of the patients had internal medicine consultation. In the fourth quarter, 52% of the patients recruited during working hours. In the first visit, 9,09% internal medicine patients and 9.05% neurology consultation were present. 62.5% of the patients applied between 08:00 AM-16:00 PM .

Conclusion: 
When the data of the emergency department re-admission patients were examined in detail, it was seen that especially the patients with green area constituted the majority. Although it is one of the largest hospitals in the region, informing patients about symptoms that may occur in patients with symptomatic complaints, even with a low percentage of re-admission, will reduce re-admission rates.

 

Introduction

Patients presenting to the Emergency Department (ED) with suspected acute coronary syndromes (ACS) will usually undergo further investigation for at least 3-6 hours to detect any changes in cardiac biomarkers before AMI can be ‘ruled out’ confidently and the patient discharged. Several decision aids can now enable ACS to be rapidly ‘ruled in’ and ‘ruled out’ but all require measurement of blood biomarkers.

A decision aid that does not rely on blood biomarkers could enhance risk stratification at triage and could enable more effective decisions to be made in the pre-hospital environment. We aimed to derive and externally validate the History & Electrocardiogram only Manchester Acute Coronary Syndromes (HE-MACS) decision aid to ‘rule in’ and ‘rule out’ ACS using only the patient’s history, physical examination and electrocardiogram (ECG).

 

Methods

We undertook secondary analyses in three prospective observational diagnostic accuracy studies. We included patients presenting to a total of 3 EDs with suspected cardiac chest pain within 12h of onset. Clinicians recorded clinical features at the time of arrival using a bespoke form. Patients underwent serial troponin sampling and 30-day follow up for the primary outcome of ACS, defined as prevalent or incident acute myocardial infarction, all-cause mortality or coronary revascularization. The model was derived by logistic regression in one cohort and validated in two similar prospective studies. The derivation cohort was powered to derive a rule with 15 predictors, assuming 20% prevalence of ACS with 5% loss to follow up, requiring 790 participants.

 

Results

HE-MACS was derived in 796 patients, of which 179 (22.5%) had ACS. It was validated in cohorts of 474 and 659 patients, of which 80 (16.9%) and 93 (19.6%) had ACS respectively. HE-MACS incorporated age, sex, systolic blood pressure plus five historical variables (sweating, ECG ischaemia, pain radiation, vomiting, smoking status) to stratify patients into four risk groups: immediate ‘rule out’, ‘low risk’, ‘moderate risk’ and ‘high risk’ ACS. The model ‘ruled out’ ACS in a pooled total of 9.4% patients with sensitivities of 100.0% (95% CI 96.1-100.0%) and 98.9% (94.2-100.0%) in the two respective validation studies, giving a pooled sensitivity of 99.5% (97.1-100.0%). In the ‘high risk’ group the prevalence of ACS was 50.0% and 60.0% in the two respective validation studies.

 

Conclusion

Using only the patient’s history and ECG, HE-MACS could ‘rule out’ ACS in 9.4% patients while effectively risk stratifying remaining patients. This is a very promising tool for triage in both the pre-hospital environment and ED. Its impact should be prospectively evaluated in those settings. 

(UK CRN 8376 & UK CRN 18000) The Validation of the Early Vascular Markers of Acute Coronary Syndromes study was funded by a research grant from the Royal College of Emergency Medicine (2010), and was sponsored by Stockport NHS Foundation Trust The Bedside Evaluation of Sensitive Troponin (BEST) study received funding from Abbott Point of Care, European Union Horizons-2020 (via FABPulous BV) and the Royal College of Emergency Medicine, and was sponsored by Manchester University Hospitals NHS Foundation Trust.

Abstract

Objective           To establish the assignment of 12-lead electrocardiography (ECG) for localization of myocardial infarction validated by cardiac magnetic resonance imaging (CMR).

Background       The standard assignment of 12-lead ECG to specific myocardial segment is largely based on clinical experience.

Methods            A total of 349 patients with ST-elevation myocardial infarction (STEMI) who underwent CMR after primary percutaneous coronary intervention were enrolled. ST-elevation of

                        each 12 leads was compared with the presence of late gadolinium enhancement (LGE) using 17 left ventricular myocardial segment model.

Results             LGE was found in 6±3 segments per patient, and in 2,109 (36%) among a total of 5,933 myocardial segments. In overall, 1 out of every 5 myocardial segments with LGE did not match

                       with empirically assigned ECG lead (N=423, 20%). In per lead analysis, there was no myocardial segment 100% matching to a specific ECG lead. Leads I, aVR, and aVL corresponded

                       not only to LGE in lateral but also to LGE in anterior myocardial segments. A newly modified assignment of 12 ECG lead to 17 myocardial segment was developed.

                       It could additionally match a total of 212 myocardial segments (10%) to ECG leads, and increase the rate of matching between 12 ECG lead and 17 myocardial segments from 80% to 90%.

Conclusion        ST-elevation in leads I, aVR, and aVL corresponded both anterior and lateral wall myocardial infarction. A newly proposed ECG assignment could reclassify correctly the location of

                       myocardial infarction in 1 out of 10 myocardial segments. Our result suggests that the current standard assignment of 12-lead ECG for infarction localization may require reappraisal.

Aims: The MEESSI (Multiple Estimation of risk based on the Emergency department Spanish Score In patients with acute heart failure –AHF-) scale is a new tool to stratify AHF patients at the emergency department (ED) according to the 30-day mortality risk. We aimed to validate the MEESSI risk score in a new cohort of Spanish patients to assess its accuracy in stratifying patients by risk and to compare its performance in different settings.

Methods: We included consecutive patients diagnosed with AHF in 30 EDs during January and February 2016 (60 fays). The MEESSI score was calculated for each patient. The area under the curve of the receiver operating characteristic (AUC ROC) measured the discriminatory capacity to predict 30-day mortality of the MEESSI full model (13 variables) and the 7 secondary models (lacking the Barthel Index, troponin or NT-ProBNP, in any combination). Further comparisons were made between subgroups of patients from university and community hospitals, EDs with high, medium or low activity and EDs that recruited or not patients in the original MEESSI derivation cohort.

Results: We analyzed 4711 patients (university/community hospitals: 3811/900; high-/medium-/low-activity EDs: 2695/1479/537; EDs participating/not participating in the previous MEESSI derivation study: 3892/819). The distribution of patients according to the MEESSI risk categories was: 1673 (35.5%) low-risk, 2023 (42.9%) intermediate-risk, 530 (11.3%) high-risk and 485 (10.3%) very high-risk, with 30-day mortality of 2.0%, 7.8%, 17.9% and 41.4%, respectively. The AUC ROC for the full model was 0.810 (95% CI: 0.790-0.830), and ranged from 0.731 to 0.785 for the subsequent secondary models. The discriminatory capacity of the MEESSI risk score was similar among subgroups of hospital type, ED activity, and original recruiter EDs.

Conclusion: The MEESSI risk score successfully stratifies AHF patients at the ED according to the 30-day mortality risk, potentially helping clinicians in the decision-making process for hospitalizing patients.

Introduction: The electrocardiogram (ECG) remains central in the risk stratification of non ST-segment elevation myocardial infarction (NSTEMI). The ST segment depression appears to be the most predictive marker of mortality at day 30 and at one year. Recently, many studies had demonstrated that the sum of ST-segment depression provides much more information than the simple qualitative assessment of ST-segment depression>0.5 mm.
Objective: To study the prognostic value of the sum of ST-segment depression in all ECG leads in the prediction of the mortality at six months in the emergency department (ED).
Methods: A prospective observational study was conducted over five years. Patients were eligible for inclusion if the diagnosis of NSTEMI was made (based on anamnestic, clinical, electrocardiographic and biological criteria). The demographics, co-morbidities, clinical and biological data and in-hospital procedures were collected. We calculated the cumulative sum of the ST-segment depression, in millimetres (mm), in all leads showing ST-segment depression >0.5 mm in the standard 12-lead ECG recorded on admission. The prognosis was based on the evaluation of mortality at six months. The ROC curve was used to determine the cut-off of the sum of ST-segment depression to predict the mortality at six months.
Results: Inclusion of 510 patients. Mean age was 62±11. Sex ratio= 1.72. Comorbidities (%): hypertension (58), Diabetes (44), dyslipidemia (31), coronary artery disease (28). An ST-segment depression was found in 276 patients (54%). The median of sum of ST segment depression was 3 [2,6]. Mortality was 11%. The mean sum of ST segment depression was higher in the non survivors patients comparing to the survivors: 7.15±5.94 vs.3.90 ±3.67 respectively, p <0.001. The sum of ST segment depression was predictive of six months mortality with a cut-off at 7 mm with an area under the curve at 0.67, 95% CI [0.55 to 0.78], p=0.003. Sensitivity, specificity, positive predictive value and negative predictive value are 46, 83, 29, 91% respectively. Liklehood ratio (LR) += 2.7.
Conclusion: In patients with NSTEMI, the sum of ST-segment depression in all ECG leads is a powerful predictor of mortality at six months. It should be considered in future multivariate analyses of the incremental prognostic value of novel biomarkers.

Background: Detection of arterial wall calcification (AC) by computed tomography (CT) scan is a marker of atherosclerosis and is associated with an increased risk of cardiovascular disease (CVD). CT scans performed at the emergency department (ED) for any reason can detect AC. The use of AC as detected by emergency CT scan on reclassification of CVD risk has not been investigated yet.

Aims: To investigate the frequency of AC detected by CT scan performed for non-cardiac conditions at the ED among subjects with presumed low CVD risk, and its impact on CVD risk assessment.   

Methods: A retrospective analysis of 1010 subjects from 18 to 45 years old consecutively admitted to the ED of Hospital Israelita Albert Einstein, from Jan 2015 to Dec 2016, who had a non-coronary CT scan performed for several emergency conditions  and laboratory samples in the last 6 months. Eleven clinical and previous laboratory data were evaluated: gender, age, previous history of diabetes, systolic (SBP) and diastolic (DBP) blood pressure, smoking status, total cholesterol (TC), HDL, non-HDL cholesterol (nHDLc), LDL and triglycerides, and compared between patients without (G1) and with (G2) AC. CVD risk was classified using the European Heart Score risk prediction and management program.  For numerical variables were performed independent t test or multivariate logistic regression. Categorical variables were analysed by qui-square or Fisher´s exact test.

Results: A total of 899 subjects were scored as low CVD risk, of which 141 (15,6%) had AC detected by CT scan. Thirty patients had more than one emergency department evaluation. Comparisons between G1 and G2 patients, respectively, showed:

Age 36±7 vs 39 ±5 years, p<0,001. TC 180,8 ± 37,5 vs 179,5 ± 33,6 mg/dl, p=0,480. LDL106,2 ± 32,24 vs 104,5 ± 30,5 mg/dL, p=0,674. HDL 53,5 ±15,3 vs 52,1 ± 16,6 mg/dL p=0,716. SBP: 122 (±17) vs 125(±18), p=0,697. DBP: 77 (±13) vs 80 (±15) mmHg, p=0,01. Gender: male 277(36,5%) vs 52(36,8%) p=0,939. Smoking: 2 (1,41%) vs 25 (3,29%) p=0,939. After adjustment for confounders, DBP did not remain associated with AC, but each year increase in age was independently associated with a 10,8% higher risk of AC (95% confidence interval [CI] 1,073-1,145)

CT scans were performed at nineteen different sites. No differences related to AC detection were found among CT sites.

Conclusions: In this study almost 16% of low cardiovascular risk subjects presented AC. Age and diastolic blood pressure was associated with AC. These  data rise the importance to discuss if subclinical atherosclerosis in extra-coronary territory, detected by CT scan, may reclassify low risk patients.

Introduction: The management of ACS is a challenge for physicians. One of
the most important goal of this management is the evaluation of the prognosis of
the disease. The TIMI score can be used as a tool to predict the short-term
prognosis of the ACS, but it remains insufficient. By combining the TIMI score
with other non-invasive (NI) methods, we can hope to improve its prognostic
performance. The aim of this study is to evaluate the contribution of NI
measurement of the endothelial function (EF) by EndoPAT in predicting the
prognosis when associated with TIMI.
Methods: This is a prospective study conducted from March 2016 to September
2017, enrolling patients presenting to the emergency department for non-
traumatic chest pain with suspicion of ACS (n = 515). We excluded patients
with hemodynamic instability, myocardial infarction requiring emergency
revascularization and parkinsonian syndrome. For each patient the demographic
and clinical data were collected, the TIMI score was calculated and the
measurement of the EF (Endo-PAT) (Tunisian Health Tonics Device) 
proceeded. Endothelial dysfunction is defined by an HRI (Hyperemia Reactive
Index) &lt; 67%. During a follow-up period of one month the onset of major
cardiovascular events (MACE): (myocardial infarction, stroke, angina, death)
was noted.
Results: A total of 153 patients (29.7%) were diagnosed with ACS. The mean
age was 56 years with predominantly male patients (62.7%). The mean TIMI
score was 1.6. MACEs were observed in 42 patients (27.45%). A TIMI score
&lt; 2 had a sensitivity of 59; specificity of 57; PPV and NPV respectively of 12
and 93. The combination of the HRI to the TIMI score improved his sensitivity
and NPV that have gone respectively from 59 to 88 ([74-96]; 95% CI); 93 to 96
([91-98]; 95% CI).
Conclusion: These findings suggest that the Endo-PAT improve the TIMI score
short-term prognostic performance in ACS by increasing the sensitivity and the
NPV.

BACKGROUND:

There has been a significant increase in the incidence of Targeted Automobile Ramming Mass Casualty attacks (TARMAC) worldwide since 2010. Terrorist groups including ISIS and Al Qaeda have published TARMAC instructions for their followers to use, and non-terror TARMAC attacks are increasing as well. The dramatic increase in incidence warrants special attention to the unique pattern of injury associated with such attacks. The injuries expected from such an attack are unlike any other type of intentional mass casualty attack. The goal of this study was to characterize injuries inflicted during a TARMAC attack in Charlottesville, VA in 2017 treated at the University of Virginia Health System, a single, urban, level one trauma center.

METHODS:

The emergency department records from the primary receiving trauma hospital on the day of the attack were reviewed. Victims of the ramming attack were identified, and their demographics and injuries were entered into a database for pattern analysis. Inpatient medical records of admitted patients were reviewed to determine further operative needs and length of stay.

RESULTS:

There were 19 total TARMAC victims treated in the UVAHS Emergency Department on the day of the attack. The majority were female (68%) and had an average age of 29.4 years (range 13 – 72 years). Disposition data showed 7 ICU admissions, 4 acute care admissions, and 7 discharges to home. There was 1 immediate fatality and the specific injury data was unavailable. The majority of the injuries were orthopedic: lower extremity fractures (n=7) [2 open], upper extremity fractures (n=7), axial skeleton fractures (n=6), and a facial fracture (n=1). Arterial injuries occurred requiring interventional radiology treatment (n=1) or observation (n=2). Organ injuries included a Grade 1 spleen laceration (n=1) and a pneumomediastinum (n=1). 6 victims required one or more operative interventions during admission: emergent procedures (n=6) and delayed procedures (n=4). In the Emergency Department 2 bony reductions were performed, 5 lacerations were repaired, and 1 thoracotomy was performed. Injury Severity Scores were calculated (mean=11.5; median 6; range 1-75)

CONCLUSIONS:

Due to the mechanism of injury, TARMAC attacks inflict a unique wounding pattern. Intentional mass blunt trauma is previously unknown to emergency medicine. Vehicle variables including weight, speed, and bumper height affect the injury location and severity. This vehicle, a low-height sports car, inflicted primarily lower extremity injuries. Mortality rates have been higher in attacks involving taller, heavier vehicles, as seen in France, Germany, and Sweden. Analysis of victim data from TARMAC attacks will help emergency medicine physicians, surgeons, and disaster medicine specialists to prepare, train, and mitigate against this increasingly frequent tactic.

 

This study did not require specific registration nor is there an appropriate registry for such research. This study did not receive support from any form of funding. The authors have no conflicts of interest to disclose. The review received approval from the Institutional Review Board at the University of Virginia Health System.

Introduction: With a dense petrochemical industry and several nuclear installations Flanders is at risk for CBRN (Chemical Biological Radionuclear) incidents. The Brussels bombings revealed the risk for terror attacks and the region is prone to natural disasters as floods. Ambulance personnel will be the first to be confronted with the care for victims of these incidents but are the trained to do so?

Material and methods: An online survey looking for demographic parameters, self-reported risk, knowledge and willingness to work on 8 potential scenarios was presented to Flemish ambulance personnel through their professional organization, federal health inspection and cross societies. Self-reported scores were correlated with a set of practical and theoretical questions on the subject.

Results: As we’re still collecting data preliminary results on the first 1324 respondents are presented. Male/Female ratio was 80/20 and 34% of the respondents reported that they were professional ambulance personnel. Mean age was 21 years and 32% stated they had some disaster courses before. 78% found it absolutely necessary to include this training in the basic ambulance curriculum. 32% worked on a fire department or civil protection-based ambulance. 46% stated that they had any links with a fire department apart from their ambulance activities, 8% with the military, 5% with the civil protection, 7% with CBRN-industry and 50% with critical hospital departments. 73% had a practical training in the use of personal protective equipment and 43% in decontamination, the majority was trained by their employer. 86% could use a tourniquet, 65% military hemostatic bandages and 36% radiodetection equipment.

Self-estimated risk for incidents to occur ranged from 3.9/10 for floods to 6.25/10 for mass shooting incidents. Self-estimated knowledge varied from 3.38/10 for biological incidents over 3.5/10 in nuclear incidents, 3.81/10 for Ebola outbreak to 5.69/10 in mass bombing incidents and 5.73/10 in mass shooting incidents. Willingness to work scores higher from 5.81/10 in nuclear incidents and 5.82/10 in Ebola outbreak over 7.1/10 in biological incidents to 8.1/10 in mass shootings and 8.57/10 in mass bombing attacks.

The practical/theoretical case mix revealed a high confidence in Iodium tablets: 46% believes they protect against external radiation, 12% will use them as first step in nuclear decontamination and 11% believe that they will limit radiation damage the most over distance and shielding. 37% directs potentially contaminated victims into the advanced medical post and 12.5% will intervene in a potential chemical hazard accident without prior fire department clearance.

Discussion: Although the knowledge scores are rather low, our study population scores better than their Dutch colleagues who have a longer and more severe basic training. We think that the impact of the links with the fire department, military and civil protection in a large proportion of our population could promote their preparedness. This has to be evaluated in the statistics on the definite study population.

In conclusion we can state that the knowledge and basis training on disasters of Flemish ambulance personnel can be improved. There is a clear perceived need to incorporate it in the basic ambulance curriculum.

No funding