Background

Critical care delivery has been defined by the American Medical Association and Current Procedural Terminology (CPT) as a physician's direct delivery of medical care for a critically ill or critically injured patient. Critical care is decision making of high complexity to assess and support vital organ systems to prevent further life-threatening deterioration of the patient's condition. To our knowledge, there has been no study to describe the prospective incidence of critical care, illness and injury in an Irish/European paediatric emergency department (PED) setting. 

Primary Objective

To establish the incidence of critical care delivery for illness or injury in an ED in Ireland’s largest tertiary academic paediatric hospital over 1 year.

Methodology

A prospective observational study from 1/4/17 to 31/03/2018 with consecutive enrolment of patients who required critical care (e.g. ≥2 20ml/kg bolus) , a critical care intervention (e.g. rapid sequence induction) or procedure (e.g. chest drain) in the ED delivered by emergency, anaesthetic, intensive care or surgical specialties. Data was triangulated from charts, electronic (ED information system –Triage category 1 & 2/ PICU admissions) and registry (Pharmacy and Resuscitation logbooks) sources. Cases were screened for inclusion criteria. Inclusion criteria were determined by definitions from national and international guidelines (e.g. British Thoracic Society for asthma). Critical care interventions and procedures were agreed by consensus. The study was approved by the research and ethics committee.  

Results

The annual census was 37471 patients, with 285 (0.8%) receiving critical care. A total of 6280 (17% of annual census) were category 1 & 2 (Irish Children’s Triage System) cases.  The mean age of presentation was 4 years with a range from 1 week to 18 years. Of the 285 cases, 92 (32%) were triaged as category 1 (most critical) upon presentation. A total of 153 (54%) patients presented during regular working hours (8:00 to 18:00) with 196 (69%) arriving by personal transportation. Significant pre-existing co-morbidities were present in 105 (37%) cases. The top 5 clinical presentations were sepsis 32 (11%), laryngotracheobronchitis 28 (10%), gastroenteritis 27 (9%), seizures 21 (7%), and bronchiolitis 21 (7%).  

Intraosseous vascular access was secured in 4 (3%), central venous access in 2 (1.5%), and peripheral intravenous in 249 cases (87%). Interventions were performed by emergency, intensive care and surgical doctors. 

A total of 171 (60%) patients required 2 or more critical care interventions including 10 (3%) endotracheal intubations, 27 (9%) high flow O₂/CPAP, and 2 (0.7%) chest drain insertions. There were 76 (27%) patient transfers to PICU and 4 (3%) out of hospital cardiac arrests pronounced dead in the ED and 2 (0.7%) children died within 7 days of admission to PICU.

 Conclusion

This is the first study to describe prospectively the incidence of critical care delivered in an Irish tertiary paediatric emergency department. Encountering critical care in the PED translated to an intensive care admission in only 27% of cases. This study informs the provision of local education (e.g. simulation), departmental manpower and hospital-wide critical care provision.

Objective                                               

We have previously validated a practical method for identifying shock in critically ill patients in emergency department (ED) patients. The aims of this study were to investigate the correlation between USCOM-derived cardiac output (CO) and systemic vascular resistance (SVR) and the shock assessment tool, and to investigate whether USCOM-derived CO and SVR predicts 30-day mortality.

Method

In a prospective, longitudinal study conducted in an ED in Hong Kong, patients aged ≥18 years presenting to the resuscitation room or high dependency unit were recruited. Patients were classified into one of five shock groups and assessed using USCOM. The primary outcome measure was 30-day mortality.

Results

Patients with warm peripheries shock and normal peripheries shock had a significantly elevated mean CO and lower mean SVR compared with patients with possible shock. Mean SVR/SVRI was also significantly lower in patients with cold peripheries shock. There were significant differences in all outcomes across the groups, with the highest 30-day mortality (46.9%) occurring in the cold peripheries shock group, and the highest composite outcome (80%) occurring in the warm peripheries shock group. In patients with a temperature ≥37.2℃, the mean CO and CI were significantly higher, and mean SVR and SVRI significantly lower than in patients with a temperature < 37.2℃ (P<0.05). Logistic regression analysis shows that for each 100 d.s.cm^-5.m²increase in SVR or SVRI, 30-day mortality decreases by 8.6% (95%CI 0.8%~15.8%, P<0.05) and 5.8% (95%CI 1.2 %~10.3%, P<0.05) respectively.

Conclusions

USCOM-derived CO and SVR correlated with shock in the ED, and SVR and SVRI in particular predicts 30-day mortality.  USCOM may have a role in detecting shock and risk stratification in the ED.

Objectives: Passive leg raise (PLR) is a reversible self-fluid challenge used to predict fluid responsiveness (FR). Combining PLR with non-invasive cardiac output monitoring may be a useful tool for stratifying patients into those who may benefit and those who could be harmed by fluid therapy in emergency department (ED). We aim to evaluate the feasibility and accuracy of PLR test to predict the haemodynamic response to fluid bolus in ED.

Methods: A prospective experimental study was conducted on ED patients. We included a convenience sample of patients ≥18 year-old planned to receive a fluid bolus and able to consent and excluded patients whose clinical condition prevents performance of PLR. Patients were monitored using thoracic electrical bioimpedance (TEB) monitor (Niccomo, Medis, Germany) using 2 pairs of electrodes to the sides of the neck and lower chest. A 3-minute leg raise test (PLR 1) was performed (semi-recumbent to 45° leg raise) followed by a fluid bolus. A second test (PLR 2) was carried out 10 minutes after fluid infusion. The average stroke volume (SV) during PLR and by the end of fluid bolus was calculated and FR was defined as ≥ 10% increase in SV from baseline. Assuming that the prevalence of fluid responsiveness is 60% and the expected sensitivity and specificity of PLR test is 85% and 90% respectively, a sample of 105 will be required assuming that 20% of patients will have missing data (alpha= 0.05, beta= 0.80).

Results: We enrolled 17 patients with median age of 56 years (Interquartile range, IQR 53-76) and 10 (59%) were males. The median TEB signal quality was 51% (IQR 28-62%) throughout the monitoring sessions. At baseline, median mean arterial pressure (MAP) was 88 (IQR 78-101), heart rate 111 (IQR 84-128) and lactate 1.8 (IQR 1.2-4.4). Seven patients (41%) were fluid responsive with PLR1 compared to 11 patients (65%) with fluid bolus and only 3 patients (18%) in PLR2. The median SV change with PLR1 was -2% (IQR -12-14%) compared to 24% (IQR -3-30%) with fluid bolus. PLR1 had a sensitivity of 55% (95% confidence interval, CI 28-79%) and specificity of 83% (95% CI 44-99%) in predicting FR. PLR1 had a Positive likelihood ratio of 3.27 and a negative likelihood ratio of 0.55.

Conclusion: These pilot data show that PLR was feasible with adequate monitoring quality in ED. The test showed lower accuracy in predicting FR than reported in critical care literature, which raises questions about the applicability in non-paralysed spontaneously breathing patients in ED. About one third of patients did not show a SV response to fluid loading, suggesting a place for haemodynamic monitoring in ED to prevent over-treatment.

Background:

Cardiogenic shock (CS) often requires catecholamine use in intensive care unit or in the emergency department. The epinephrine place remains debated because of its potentially side effects.

Methods: 

Meta-analysis based on the individual study data was performed on a systematic search of Medline, Cochrane and Web of Sciences database using search terms about CS and catecholamine or vasopressors. Thus, 16 studies included 2583 patients with CS all causes and received epinephrine alone or in association with other catecholamine, were assessed using a pre-specified protocol (PROSPERO registration number CRD42017082370). Importantly, studies were selected for analysis in at least 15% of patients treated with epinephrine. Patients with post cardiac arrest were included in the analysis. The primary outcome was short-term mortality rate. 

Results:

Short-term mortality rate for the all population was 45% (21% to 55%). 52% of patients were male. In this meta-analysis, CS causes were acute coronary syndrome (ACS) in 66%, post cardiac arrest patients in 45%. 947 patients received epinephrine (36.6%) alone or in association with others vasopressors or inotropes and an association between epinephrine and mortality was found at D30 (OR 3.33 [2.81-3.94]). This result is confirmed with the adjusted-analysis for confounding factors (OR [4.68 3.43-6.39]. We performed also a propensity score (338 patients in each group) which highlighted the consistent harmful epinephrine effects (OR 4.22 [2.99-5.96]).

Discussion: 

Our study highlights the adverse effects of epinephrine in cardiogenic shock. The mechanisms of its toxicity remain unclear. It is probable that the increase in oxygen consumption due to tachycardia is partly responsible. On the other hand, the major alteration of the microcirculation (e.g. for the renal function) can precipitate a multi-organ failure. Lastly, all the studies in our meta-analysis, find an association with mortality suggesting that it would be desirable to use other inotropes and/or vasopressors to replace adrenaline.

Conclusion:

In this study including 2583 patients with CS all causes, the epinephrine use were associated with an increase in short-term mortality rate.

Purpose: The aim of this study was to evaluate diagnostic accuracy of biomarkers in identifying LV and RV systolic dysfunction during sepsis.

Methods: We included patients diagnosed with severe sepsis/septic shock and admitted in our ED-High Dependency Unit between August 2012 and February 2018, in whom an echocardiogram was performed within 24 hours from admission. We evaluated LV systolic function using Global Longitudinal Strain (GLS, > -14% diagnostic for LV systolic dysfunction) and RV systolic function with Tricuspidal Annular Plane Systolic Excursion (TAPSE, <16 mm diagnostic for RV systolic dysfunction). We divided our population in three subgroups: patients with normal LV and RV systolic function (G1), those who had either LV or RV dysfunction (G2) and those who had biventricular dysfunction (G3). Biomarkers levels were measured both at the time of admission (T0) and after 24 hours (T1), considering them both as continue and dichotomized values (TnI: ≤0.1 or > 0.1 µg/L; NTproBNP: > or ≤ 7000 pg/mL). Day-28 mortality was our primary end-point.

Results: we included 238 patients (mean age 73±15 years, male sex 58%, T1 SOFA score 6.0±2.9), 41% with septic shock, 28-day mortality rate 27%. Troponine (T0: 0.59±2.19 vs 1.7±8.2 ug/L; T1: 0.68±2.04 vs 1.52±5.08 ug/L) and NTproBNP levels (T0: 12421±19511 vs 24346±44189 pg/L; T1: 16760±60038 vs 26666±33423 pg/L, all p<0.05) were similar in survivors and non-survivors. Conversely, Troponine level was significantly higher in patients with impaired GLS, both considering continuous values (T0: 1.21±5.67 vs 0.23±0.67, p=0.04; T1: 1.21±3.81 ug/L, p=0.002) and dichotomized values (T0: Troponine ≥0.1 in 31% of survivors and 56% of non-survivors; at T1, 42 vs 61%, all p ≤0.01). T0 NTproBNP was significantly higher in patients with reduced TAPSE (26341±44025 vs 17127±64910 pg/L), while T1 levels were comparable between the subgroups. An NTproBNP>7000 pg/L was more frequent among patients with RV dysfunction (T0: 64 vs 38%; T1 67 vs 41%, all p <0.01) than in patients with LV dysfunction (T1: 55 vs 37%, p=0.018). By an analysis with ROC curves, Troponine (T0: Area under the curve, AUC, 0.64, 95%CI 0.56-0.71; T1: AUC 0.65, 95%CI 0.58-0.73, p≤0.001) and NTproBNP (T0: AUC, 0.68, 95%CI 0.60-0.77; T1: AUC 0.68, 95%CI 0.60-0.76, all p<0.001) showed a fair discriminative value, respectively for impaired GLS and TAPSE. We compared biomarkers level among subgroups with increasing cardiac dysfunction: T0 troponine levels were comparable while T1 levels were higher in G3 compared with other subgroups (G1: 0.30±1.28; G2: 0.68±2.28; G3: 2.32±9.81, p>0.05 between G1 vs G3 and G2 vs G3). A Troponine >0.1 prevalence increased in different subgroups (respectively 29%, 55% and 52% at T0, p=0.005; 41%, 58% and 61% at T1, p=0.06). T0 NTproBNP was higher in G1 than in G3 (9164±15134 vs 27448±29116, p<0.05), while T1 levels were comparable between subgroups; an NTproBNP>7000 prevalence significantly increased in different subgroups (33%, 45% and 72% at T0; 33%, 48% and 75% at T1, p≤0.001).

Conclusions: Biomarkers levels were significantly higher in patients with impaired LV and/or RV systolic function, with a fair to good diagnostic accuracy.

Background: the aim of this work was to evaluate diagnostic performance of inferior vena cava collapsibility index and echo-monitored change in cardiac output induced by passive leg raising, in fluid responsiveness assessment of critically ill patients in the Emergency Department.

Methods: this prospective study enrolled a non-selected population of critically ill patients admitted to the Emergency Department High-Dependency Unit (ED-HDU) of Careggi University-Hospital from January 2015 to January 2018. An ultrasonographic examination was performed assessing the inferior vena cava collapsibility index and variations in aortic velocity time integral (VTI) after a passive leg raising (PLR) maneuver.

Patients were classified as fluid responder if having an inferior vena cava collapsibility index ≥ 40% and/or an aortic VTI increase ≥ 10% during PLR. Based on this, a therapeutic strategy was chosen (e.g. fluid replacement, diuretics, inotropes and vasopressors) and it was subsequently reassessed during the next 12 hours. 

Results: we evaluated 60 patients, with mean age 63±14 years, 58% male, mean SOFA score 5.6±3.0. The most common diagnoses were sepsis/septic shock (78%) and acute exacerbation of COPD (8%). Mean left ventricular dimensions were within the normal range (EDV 73±30 ml), as well as left and right ventricular systolic function (EF 50±14%; TAPSE 17±6 mm).

In 16 patients the only inferior vena cava collapsibility index could be assessed, with 14 patients resulting non-fluid responder; a change in therapeutic strategy during the following 12 hours was performed in 6 of them.

In 17 patients only the aortic VTI after PLR could be assessed; 10 patients were non-fluid responder and a change in therapeutic strategy after 12 hours performed for 1 case in both responder and non-responder groups.

In 27 patients an integrated evaluation with the two methods could be performed: 12 patients resulted non-fluid responder and 15 patients fluid responder. The two methods were discordant in 9 patients: in 8 of them the IVC collapsibility index was < 40% with a positive PLR (and a change in therapeutic strategy in one case), conversely in one case the IVC collapsibility index was > 40% with a negative PLR and therapeutic strategy changed after 12 hours.

Based on these results, we evaluate the diagnostic performance of the two methods.

For the inferior vena cava collapsibility index, sensitivity was 46%, specificity and positive predictive value were 100%, and the negative predictive value was 59%. It should be noted the absence of false positives and the significant number of false negatives. For the variations in aortic VTI after PLR sensitivity, specificity, positive predictive value and negative predictive value were all 91%.

Conclusions:

Diagnostic performance of passive leg raising in fluid responsiveness assessment in critically ill patients is excellent.

On the other hand, the evaluation of inferior vena cava collapsibility index is a reliable method in predicting fluid responsiveness only when >40%, with relevant false negative results for smaller values.

Background

Emergency department (ED) staff frequently see patients with potentially modifiable risk factors for acute, chronic or subsequent illness. Health promotion interventions delivered in the ED have been advocated for these patients but delivery remains suboptimal. Studies report brief interventions in the ED increase smoking cessation rates and reduce injury recurrence following alcohol misuse. The support of clinical staff is essential to provide effective screening programmes and brief interventions for ED patients. This study aimed to compare the perspectives of doctors and nurses in the emergency department (ED) in order to recommend improved strategies and opportunities for health promotion interventions.

Methods

A multicentre, qualitative study was conducted in three EDs in Scotland in 2017. All ED staff at one large teaching hospital and two general hospitals were approached during hand over meetings. All staff who provided direct patient care were eligible for the study (n=273) and offered a multicomponent survey. The primary outcome was self-reported rates of current practice and perceived barriers to practice. Secondary outcomes included methods to improve health promotion delivery and beliefs on patient prioritization for brief interventions in the ED. Two pilot phases of the survey to refine questions were conducted before department role out. The second pilot survey was tested on eligible staff and data included in overall results. Tests for significant differences between doctors and nurses were conducted using chi-square statistics and 95% confidence intervals.

Results

197 of 273 staff responded, representing a 72% response rate. Of the 197 respondents, 79 (40%) were doctors and 118 (60%) were nurses. More doctors (86.1%, CI [76.8-92.1]) than nurses (51.7%, CI [42.8-60.5]) report offering health promotion interventions and specifically for alcohol misuse, smoking, drug misuse and sexual health interventions. A higher rate of doctors (94.4%, CI [87.7-98.0]) reported their role involved brief interventions compared to nursing staff (72.0%, CI [63.3-79.3]). Time constraints (n=172, 87.3%) and a lack of health promotion infrastructure (n=100, 50.7%) in the ED were found to challenge widespread delivery (groups not mutually exclusive). Over 91% (n=180) of staff perceived the delivery of health promotion interventions be a shared responsibility amongst all ED staff.  Staff felt patients whose presentation was directly related to smoking and alcohol/drug misuse or patients with new-found hyperglycemia should be prioritised for brief interventions in the ED.

Discussion & Conclusions

This is the first staff perspective study in the UK and shows encouraging rates of heath promotion intervention being reported by ED staff, exceeding those previously reported in US and Australian studies. Staff acknowledge the benefit of health promotion, in agreement with other studies, but time constraints and insufficient ED resources are unanimously recognised as barriers to practice. Despite a much improved response rate to previous studies (30-67%), results may overestimate the true proportion of staff supporting ED interventions due to the rate of non-completion. Staff require additional training in brief intervention techniques and treatment options to enhance their management of patients presenting to the ED with potentially modifiable risk factors

Background: Most foreign bodies (FB) pass the digestive tract without causing lesions. Their impaction at the esophagus, stomach or duodenum's level requires endoscopic evaluation and treatment. The study's main aim is to evaluate the patients with FB in the upper digestive tract and to assess the possibilities and limits of endoscopic treatment.

Methods: There were prospectively studied 110 patients with voluntary or involuntary ingestion of FB and suspicion of impaction at the upper digestive tract level, that have performed upper digestive endoscopy (UDE) at the Institute of Gastroenterology and Hepatology Iasi between 1st of January 2017 and 1st of January 2018. The following parameters were considered: age, sex, presence and type of FB, symptoms, radiological examination, the impaction place, associated lesions, success of endoscopic treatment.

Results: From the 110 patients, the UDE confirmed the presence of FB in 84 of them (76.36%). 69% of the patients were men and the medium age was 56 years old. 72.61% were alimentary foreign bodies (meat, bones, pips) the rest of them being "real": 15 were voluntarily swallowed (wires, spoons, nails) by prisoners and patients with psychiatric problems and 6 accidentally: needles, dental prostheses. There have also been 2 cases of iatrogenic FB: naso-gastric sonde impacted in a suture of a patient with operated stomach and an esophageal band in a cirrhotic patient with upper digestive bleeding. Simple radiography identified FB in only 19 of the patients (22.6%). The main symptoms were dysphagia, chest pain, odinophagia, sialorrhea. Concerning the place of impaction, 49 (58.3%) were esophageal FB, 28 gastric and 9 duodenal. In case of voluntarily swallowed FB, only 2 patients (13.3%) had associated lesions: resected stomach, reflux esophagitis; in case of impaction of alimentary FB, 41 patients (67.2%) had associated lesions: peptic stenosis, postcaustic stenosis, esophageal rings, hiatal hernia, achalasia cardia, esophageal cancer. Endoscopic treatment was successful in 90.47% of the cases. 8 patients were sent to surgery: 2 refused repeated examinations, 2 had FB longer than 12 cm and 4 patients had sharp FB, impacted in the mucosa. The complications were minor: ulcerations of the mucosa, autolimited upper digestive bleeding, fever. There were no cases of perforation or death.

Conclusion: UDE only reveals FB at 3/4 of the patients with positive anamnesis. Impacting FB is more common in men and the elderly. Most FB are alimentary, they affect the esophagus and are associated with pre-existing lesions. Most of the "real" FB are voluntarily swallowed by prisoners or people with psychiatric problems. Even though American guides assert the necessity of endoscopic treatment in only 10-20% of the cases, in our study over 70 % of the patients had endoscopic treatment. Endoscopic treatment is effective in the majority of patients.

Introduction: The use of epinephrine auto-injectors as treatment for anaphylaxis is not always intuitive and accidental self-injection is not a rare event. Studies on accidental digital epinephrine auto injection reported that all patients had complete resolution of symptoms; however, when signs of ischemia are present, pain and sensory problems are described to last up to 10 weeks in untreated cases.

Objectives: To review the time to relief of symptoms after treatments used in cases of accidental digital epinephrine auto injections reported in the literature to date.

Data sources: A systematic review was performed. Embase, Medline Cochrane central and Web of science databases were searched by title and abstract to identify reports of unintentional digital injections from epinephrine auto-injectors.

Study selection: Publications were selected for inclusion based on title, abstract and full text. Articles were excluded when not written in the English or Dutch language or when full text of the publication was unavailable and reviews were excluded.

Results: In 33 reports we found 49 cases of digital auto injection with epinephrine of which 46 had signs of ischemia (pain, pallor, coldness, decreased capillary refill or loss of sensibility). The age of cases ranged from 5 to 68 years with a median of 30 years. 56.1% of cases was female. In 7 cases gender was not reported. All described auto-injections were localized in the volar aspect of thumb or index finger.

The median time from auto-injection till the start of treatment was 60 minutes ranging from 1 minute to 6 hours. In 49 cases 96 treatment options were reported. Patients underwent zero to five consecutive treatments, mostly due to absence of satisfactory results in the treatments chosen first. The order in which these treatments were given varied from case to case. The more frequently reported treatment options included: Application of nitroglycerin paste or patches in 30.2% of cases, warm water immersion in 17.7% of cases, local phentolamine infiltration with or without local anesthetics in 11.5% of cases, infiltration of phentolamine with or without local anesthetics proximal to the site of injury in 9.3% of cases, local infiltration of terbutaline in 6.3% of cases and a combination of local infiltration of phentolamine and Infiltration of phentolamine with or without local anesthetics proximal to the site of injury in 5.2% of cases. No treatment was started in 3.1% of cases.

The median time from initiation of the final treatment to relief of al symptoms was 240 minutes, and ranged from 480 minutes after warm water immersion to 5 minutes after local infiltration of phentolamine with local anesthetics.

Conclusions: In patients with signs of ischemia after accidental digital auto-injection with epinephrine a plethora of (serial) treatment options are used. Local infiltration of phentolamine relieved most patients of all symptoms in a matter of minutes. Addition of local anesthetics may facilitate an even quicker relief of symptoms but may interfere with testing the return of sensibility.

Background

According to British Association of Urological Surgeons the standard for investigation of renal colic is non-contrast computed tomography kidney, ureter, bladder (CT KUB) which is highly sensitive (97%) and specific (95%). X-ray kidney, ureter, bladder is less sensitive and specific (44-77%) detecting approximately 60% of calculi. It is not recommended when CT KUB is available but may be helpful for comparison during follow-up.

Our local renal colic policy recommends that all patients with renal colic undergo CT KUB and XR KUB prior to discharge irrespective of whether the stone is visible on CT KUB scout image. This is in anticipation of repeat XR KUB for stone tracking at follow up. We aimed to determine whether CT KUB scout view was sufficient for stone detection thereby negating the need for XR KUB and further radiation.

Methods

Retrospective observational study of 50 consecutive patients between October and November 2017 who underwent CT KUB for investigation of suspected renal colic whilst in the Emergency Department (ED). Patients identified by searching the Patient Archiving and Communication System (PACS) and electronic clinical record.

Primary outcome was to determine whether any renal stones were detectable on CT KUB scout view by the reporting radiologist. In addition we identified patients who also underwent XR KUB and whether stone was identified.

Further data collected included patient demographics, final diagnosis based on radiology report and electronic patient record and whether any other significant abnormality was detected on CT KUB.

Results

50 patients included in the study, 72% were male. Age range was 17-80 years, mean of 39. All patients underwent CT KUB for investigation of suspected renal colic.

27 (54%) of the CT’s conducted were positive for renal calculi, of these 10 (37%) had a visible renal stone on scout view. The total number of patients with confirmed renal calculi on CT who went on to have XR KUB was 13 (48%). 5 of these patients had calculi visible on CT scout imaging, 4 (80%) were still visible on XR KUB and 1 (20%) was not. The remaining 8 patients did not have visible stones on CT scout views, of these 5 (62.5%) were visible on XR KUB and 3 (37.5%) were not.  

23 CT KUB’s were negative for renal calculi. 15 patients were diagnosed with minor conditions such as musculoskeletal pain or UTI. 8 patients had other significant findings on CT including gynaecological and urological malignancies.

Discussion & Conclusion

Our results indicate that use of CT KUB scout image alone is not reliable for stone detection in place of XR KUB, 62.5% of stones not visible on CT scout view that were visible on XR KUB.  There is arguably a role for XR KUB following CT KUB to assist with tracking of calculi at follow-up. The numbers of patients with renal calculi who had both CT KUB and XR KUB in this study were small (13). A larger study of patients who have had both modalities of imaging would be required to validate our results.

Purpose:

Most fractures of the clavicle have a good prognosis; patients have few or no residual symptoms once the fracture has healed. Plain radiography is the method for diagnosing the fracture of the clavicle. In this study we aimed to discuss the diagnostic success of ultrasonography versus x-ray.

Methods:

This study was a prospective evaluation of a diagnostic accuracy study which was performed between January and September 2016 at the Emergency Department (ED) of a tertiary care hospital. All patients admitted to the ED with a shoulder trauma were investigated for their eligibility to be included in the study. A standardized US performed by the same investigator to vizualise clavicle from sternal junction through acromial junction. After US, plain radiography was performed.

Results:

The mean age was 45.53 (min=18; max=86; SD=18.791) years and 72.7% were male. Among all 99 patients, 42 clavicula fractures were detected via graphy and 26 (62%) were seen in males and 60 patients with no clavicle fractures.  

The sensitivity of US to radiographically detected fracture was 88.1% (95% CI = 74.37% to 96.02%), and the specificity was 100% (95% CI = 93.73% to 100%). The positive PPV was 91.94% (95% CI = 83.35% to 96.29%) and the NPV was 100% (95% CI = 87% to 99%).

Conclusion:

Ultrasonography is a good alternative for diagnosing clavicle fracture.  Future studies should examine the use of ultrasonography as a method for diagnosing of clavicle fracture by emergency physicians with only basic ultrasonographic training. 

Background: Despite of preventive measures, the incidence of lower extremity deep venous thrombosis (DVT) in intensive care unit (ICU) patients is estimated to range from 5-31%. While clinical diagnostics is unreliable, ultrasound compression test (UCT) has proven to be a highly sensitive and specific investigation for its recognition. Delegating this competence to ICU nurses can increase UCT availability and enable preventive DVT screening. Thus, we decided to perform a clinical study to evaluate the validity of UCT performed by general nurse in ICU patients compared to an investigation by ICU physician certified in ultrasound. We hypothesize that general nurses are able to reach at least 75% sensitivity and specificity of DVT screening by UCT.

Methods: Prior to the study, each nurse participating in the study completed one-hour training in UCT and examined 5 patients under supervision. Then, ICU patients without known DVT underwent UCT in the femoral and popliteal region of both lower extremities performed by trained general nurse. On the same day, the examination was repeated by an ICU physician. The results of the examinations of each patient were blinded to each other for both investigators until both tests were performed. The validity parameters of the test performed by general nurse were calculated in comparison with the examination by a specialist.

Results: A total of 115 patients were examined. The prevalence of DVT of 7.8% has been found. The validity parameters of the overall UCT examination performed by general nurses were as follows: the sensitivity 88.9%, the specificity 99.1%, positive likehood ratio 94.2, negative likehood ratio 0.11, positive predictive value 88.9%, negative predictive value 99.1%, accuracy 98.3%.

Discussion & Conclusions: The results of our study have shown that general nurses are able to perform bedside screening of DVT by ultrasound compression test with a high degree of reliability after a brief training. We conclude that following appropriate education, this competence may be entrusted to them.

Introduction: Transthoracic echocardiography (TTE) is practised in emergency departments by emergency physicians at the patient’s bedside as a routine special investigation procedure following a detailed physical examination. The purpose of our study is to evaluate the performance of TTE in emergency departments by emergency physicians by comparing the finding obtained to those given by an echoDoppler proficient cardiologist. 
Material and methods: This randomised prospective study was carried out in the emergency department during three months inclusive. It included all patients aged > 16 years in whom there was an urgent need to practice a TTE. The patients in the study had to undergo a double echocardiographic examination: an initial echocardiographic investigation carried out by an emergency physician who had previously received a three-month training in Doppler echocardiography, followed by a subsequent investigation performed by an echo-Doppler proficient cardiologist. 
The concordance of the findings obtained by both readers was evaluated by Kappa concordance test. The evaluation considered the global visual estimation of the left ventricular ejection fraction (LVEF), the presence or absence of pericardial effusion (independently of the site), and the diameter and compliance of the inferior vena cava (IVC). 
Results: Forty-four patients were involved in the study. Mean age was 52 + 13 years, sex ratio 5 males/7 females. 
The concordance of the findings obtained by the emergency physician and the cardiologist for the visual estimation of the LVEF was Kappa = 0.82 [95% IC 0.63-1] with an agreement = 0.90 [95% IC 0.74-0.99]. 
The concordance for measurement of the diameter of the IVC was Kappa = 0.95 [95% IC 0.63-1] with an agreement = 0.95 [95 % IC 0.64-0.99] and for assessment of its compliance it was Kappa=1 with an agreement = 1. 
The concordance of the findings obtained for the diagnosis of pericardial effusion was Kappa=0.86 [95% IC 0.71-1] with an agreement = 0.92 [95% IC 0.64-0.99] and the concordance for the detection of echocardiographic signs of compressive effusion was Kappa = 1 with an agreement =1. 

Conclusion: The concordance of the findings obtained by both operators was excellent. Emergency physicians should then be encouraged to practise TTE at the patient’s bedside. A prior training of 3 months in Doppler echocardiography is nevertheless necessary. 

Background: Peripheral intravenous (PIV) cannulation is a fundamental procedure in Emergency Department (ED).  It is usually a routine procedure; however, establishing a PIV catheter may turn out to be a difficult challenge. Difficult venous access (DVA) risk factors include: intravenous drug use, obesity and chronic illness.

 Several attempts with subsequent distress to patients is usually the case. Alternatives include external jugular vein (EJV) cannulation or central access. Using ultrasound (U/S) in peripheral cannulation is another rising fashion with limited evidence in literature.

There is a gap of knowledge needs to be filled. Will the use of U/S, compared to the traditional method, result in better success rate of cannulation and less procedure time in patients with DVA?

Methods: In this randomised controlled study, 300 patients with DVA presenting to Alexandria Main University Hospital ED, over a period of one year, were included. Inclusion criteria: At least two trials of cannulation using the conventional approach by a senior staff in the ED and/or history of DVA with no palpable or visible veins. Patients in a state of hemodynamic instability were on the exclusion list.

After local ethical committee approval, consenting patients and enrolment, DVA patients were individually randomized to two groups; the U/S guided PIV (study) group and the conventional (control) group. Regarding the study group, U/S guidance was performed in real time using 1-person technique in the intravenous placement. In the control group, veins were identified using palpation and visual inspection.

Primary measured outcome was the success of cannulation; infusing 5cc bolus fluids without infiltration, more than two attempts was interpreted as failure. Procedure time “from tourniquet placement to cannulation” was another outcome. Exceeding 15 minutes was a failure.

Statistical data was analysed using IBM SPSS software. Qualitative data was described using number and percent. The Kolmogorov-Smirnov test was used to verify the normality of distribution. Quantitative data were described using range, mean, standard deviation and median. Significance of the obtained results was judged at 5% level. Statistical tests were used when appropriate.

Results: Both groups were homogenous with no statistical difference at baseline regarding patients’ gender, age, body mass index and the reason for DVA. In the control group 71 patients (47.3%) had successful cannulation compared with 118 (78.7%) in the U/S group which was statistically significant (p<0.001). The procedure time was significantly less (P value <0.001) in traditional group (4.19 ± 1.76 minutes), while U/S use led to prolongation of cannulation with mean time 9.01 ± 3.31 minutes. No serious adverse events recorded.

Discussion & conclusions: U/S guidance is established as standard of care for central venous access but research has failed to develop gold standard for PIV access. Cumulative studies in literature tried to use U/S in PIV access, results were inconclusive making further studies warranted. In this study, U/S guided PIV in patients with DVA showed higher success rate over blind technique. However, procedure time was prolonged. U/S guided vascular access is a skill that needs mastering by the Emergency Medicine staff.

Objective

This study examined the trends in incidence and socio-demographic, organizational, academic, and clinical risk markers of student drinking associated with Emergency Department (ED) visits and incident reports from the University Incident Management Response System (IMRS).

 Methods

 A prospective cohort study of students enrolled in a U.S. public university from 2010/11 to 2015/16 was conducted. Student enrollment data were linked to primary healthcare data and subsequent ED visits with alcohol intoxication identified using ICD codes, and linked to alcohol-related incidents that occur on and off grounds recorded in the IMRS system within one year following the first (index) enrollment of each year. Incidence rate per 10,000 person-years for each of the 2 hazardous drinking outcomes was calculated, and annual trends in the incidence were analyzed using Poisson regression. Cox proportional hazard regression was used to provide adjusted hazard ratios (HR) (95 % CIs) for the association between student characteristics and each of the hazardous drinking outcomes studied.  

 Results

The cohort consists of 204,423 students, 56% males, after excluding 5,675 students (2.7%) with missing data on covariates. A total of 1041 students had at least one ED visit with alcohol intoxication and 5,359 students had at least one alcohol-related incident within one year after the index enrollment; the overall incidence rate was 59/10,000 person-years and 311/10,000 person-years, respectively. There were a total of 455 students in both groups (7.6% of total students encountered).

 In the first 6 years from 2009-10 to 2014-15, incidence of student alcohol intoxication associated with ED visits increased linearly from 45/10,000 person-years to 71/10,000 person-years (p<0.001). Similarly, incidence of alcohol-related incidents increased linearly from 249/10,000 person-years to 361/10,000 person-years (p<0.001), but to a lesser extent (by 45% vs. by 57%). In the last 2 years of the study period, incidence of both types of hazardous drinking showed a decline from 72 to 65/10,000 person-years (9%) and from 361 to 318/10,000 person-years (12%), respectively.

 These two  hazardous drinking outcome measures share common risk markers, including: males (versus females),  below 20 years of age (versus 25-30 years),  Hispanic (versus Asian) students, parental tax dependency, Greek life member, undergraduate (versus graduate students), first time enrolled students, and having an existing diagnosis of depression and/or anxiety. In addition, African American, White, and multiracial students were at higher risk for alcohol-related incidents, while students who transferred from a prior institution were at lower risk. Past year alcohol use was significantly associated with higher risk for ED visits with alcohol intoxication. Being a member of a university athletic team appeared to be protective against alcohol intoxication associated with ED visits, but this protection was lost for alcohol-related incidents. 

 Conclusions

Data on student hazardous drinking captured in ED clinical data and the IMRS showed consistent trends in the period studied. Linking student admission data with ED clinical data and IMRS data can more fully capture and monitor student hazardous drinking behaviors and identify student groups at higher risk who subsequently can be targeted for intervention efforts. 

Background: Alcohol withdrawal syndrome (AWS) is recognized to be a common complication of hospital admission in patients with alcohol use disorder. Despite the frequency with which it occurs there is a paucity of epidemiological data in the literature regarding the effects of inpatient AWS on mortality and patient outcomes. The aim of the present study was to examine the relationship between clinico-pathological characteristics, GMAWS, length of hospital stay (LOS) and one and three year mortality rates.

Methods: A retrospective case note review of all patients admitted via the Emergency Department at Glasgow Royal Infirmary between the 1st-31^st of January 2015 was performed with each attendance where notes were available being recorded as a unique admission (n= 2,105). In NHS Greater Glasgow and Clyde patients at risk of AWS are managed using the  Glasgow Modified Alcohol Withdrawal Scale (GMAWS) which quantifies the severity of a patient’s symptoms and guides frequency and dosing of benzodiazepine treatment. Notes were screened for presence of a GMAWS chart indicating the patient was felt to be at risk of AWS by a healthcare professional during that admission.

Results: GMAWS assessment was performed during 166 of the 2,105 admissions. In those patients who had GMAWS performed, one year and three year mortality was 15% and 32% respectively. Using LOS >7 days as an endpoint, age >65 years (p<0.0001), sex (p=0.518), deprivation as categorized by the Scottish Index of Multiple Deprivation (SIMD) (p=0.996), highest GMAWS (p=0.093) and requirement for active treatment (p=0.394) were examined as determinants. On binary logistic regression analysis both age >65 (p=<0.001) and highest GMAWS (p=0.051) were independently associated with LOS >7 days. Using one year mortality as an endpoint age >65 (p=0.230), sex (p=0.720), SIMD (p=0.335), highest GMAWS (p=0.091) and LOS>7 days (p=0.03) were examined as determinants. Both highest GMAWS (p=0.026 and p=0.212) and LOS >7 day (p= 0.01 and p=<0.001) were independently associated with one year mortality. Only LOS>7 days was independently associated with three year mortality.

Discussion/Conclusions: Both age and highest GMAWS were independently associated with LOS >7 days. Highest GMAWS and LOS >7 days were independently associated with one year mortality. LOS >7 days was also associated with three year mortality, however highest GMAWS was not. GMAWS is a useful measure of the severity of alcohol withdrawal and predicts prolonged hospital stay and one year mortality.

Background: Between 1991 and 2013, there was a three-fold increase in prescribing of opioids in the United States. According to the Substance Abuse and Health Services Administration, there were 182,748 visits to emergency departments (ED) related to oxycodone products in 2010. Between 2009 and 2014, there has been a 49% decrease in the initiation of oxycodone misuse according the National Survey of Drug Use and Health. This study aims to examine the national trends in oxycodone exposures reported to U.S. poison centers (PCs).

Methods: The National Poison Data System (NPDS) was queried for all closed, human exposures to opioids from 2011 to 2017 using the American Association of Poison Control Center (AAPCC) generic code identifiers for oxycodone. We identified and descriptively assessed the relevant demographic and clinical characteristics. Oxycodone reports from acute care hospitals and EDs were analyzed as a sub-group. Trends in oxycodone frequencies and rates (per 100,000 human exposures) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2011) were reported with the corresponding 95% confidence intervals (95% CI).

Results: There were 119,263 oxycodone exposures reported to the PCs from 2011 to 2017, with the calls decreasing from 19,165 to 14,859 during the study period. Among the overall oxycodone calls, the proportion of calls from acute care hospitals and EDs increased from 46.2% to 55.6% from 2011 to 2017. Multiple substance exposures accounted for 54.1% of the overall oxycodone calls and 70% of the calls from acute care hospitals and EDs. The most frequent co-occurring substances reported were benzodiazepines (21.2%), and hydrocodone (5.1%). Residence was the most common site of exposure (94.2%) and 59.2% cases were enroute to the hospital when the PC was notified. Tachycardia and respiratory depression were the most frequently demonstrated clinical effects. Naloxone was a reported therapy for 19.9% cases, with this therapy being performed prior to PC contact in most cases. Demographically, 54.9% cases were females, and the most frequent age groups were 20-39 years (32.6%) and 40-59 years (28.6%). Suspected suicides (36.7%) and intentional abuse (11.4%) were commonly observed reasons for exposure, with these proportions being higher in cases reported by acute care hospitals and EDs (57.5% and 13.4%, respectively). Approximately 20% of the patients reporting oxycodone exposures were admitted to the critical care unit (CCU), with 10% of patients being admitted to non-CCU. Major effects were seen in 6.1% cases and the case fatality rate for oxycodone was 1.3%, with 1,476 deaths reported. There were 546 deaths reported within acute care hospitals and EDs during the study period. The frequency of oxycodone exposures decreased by 22.5% (95% CI: -24.2%, -20.8%; p<0.001), and the rate of oxycodone exposures decreased by 14.1% (95% CI: -22.6%, -5.3%; p=0.009).

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

Background

The burden of acute poisoning in Scotland is sizeable.  Studies around acute poisoning, however, are relatively rare.  The time immediately following an admission with self-poisoning can be distressing, and there are concerns regarding patients consenting to research at this acute stage.  This impacts upon study design, and ethical approval procedures.  There is a need to quantify the numbers of patients willing and able to consent, and compare these with acute general medical controls.  This study aims to address this by identifying: 

1. The proportion of acute adult toxicology admissions with capacity to consent into research studies
2. The proportion of eligible patients willing to participate in study designs of increasing complexity compared to the general medical population
3. The principal barriers and potential facilitators affecting recruitment

Methods

The study followed a matched case-control design.  A random sample of patients were screened and recruited from Edinburgh Royal Infirmary (RIE) Emergency Department (ED) or Acute Medical Unit (AMU) between 24/07/2017 and 06/10/2017.  The treating team were consulted regarding patient suitability and written consent sought from the patient.  Patients were eligible if admitted with any form of acute poisoning, aged over 16, safe to approach, able to provide informed written consent, and not requiring immediate clinical attention.  Age (within 5 years) and gender-matched controls were sourced from the acute general medical cohort.  All patients completed a questionnaire through a one-to-one interview.   No follow-up was required.   All documents were reviewed by a patient representative, registered as an audit with the ED quality improvement team and ethical approval granted by Edinburgh University.   All study data was anonymised and statistically analysed using SPSS.

Results

Of 149 acute toxicology admissions assessed, 109 were excluded for not meeting the inclusion criteria or consenting.  The remaining 40 patients were matched with controls.   The most common reason for exclusion was the patient being too unwell or inappropriate to approach (35.8%).  36.2% of patients were suitable for recruitment and, of these, 74% agreed to participate.  Overall recruitment rate was 26.8%.

Study population was 55% female, median age 40yrs (IQR = 31-75, Range = 18-76), median SIMD quartile 2 (IQR = 2-4.25, Range = 1-5). Paracetamol (58%) was most frequently taken in overdose and 50% of cases involved alcohol.

Statistical analysis demonstrated no statistical significance (using 95% confidence intervals) between the willingness of acute toxicology patients and medical controls to participate in any type of research study.  Waste sample and patient data studies were the most acceptable study designs, and drug trials the least.  Analysis by demographic group demonstrated no statistical difference.  The most common barrier identified was time pressure, the most common facilitator the option to participate from home.  

Discussion and Conclusions:

The sample was demographically representative of acute toxicology admissions in Scotland; mostly young, female, socio-economically deprived and admitted with paracetamol overdose. These results suggest that recruitment among toxicology patients is similar to other medical patients in the acute setting for all study designs and is approximately 26.8%.  Barriers to participation and potential facilitators are also similar. 

Background: Heroin use has been steadily rising according to The Substance Abuse and Mental Health Services Administration (SAMHSA). The past year prevalence of heroin use was 0.3 per 100 persons in 2015. There has been a 6.2-fold increase in the total number of deaths due to heroin between 2002 and 2015. We sought to characterize heroin exposures reported to the U.S. National Poison Data System (NPDS).

Methods: The NPDS was queried for all human exposures to heroin reported to the U.S. Poison Centers (PCs) between 2011 and 2017. We descriptively assessed the relevant demographic and clinical characteristics. Heroin reports from acute care hospitals and EDs were evaluated. Trends in heroin frequencies and rates (per 100,000 human exposures) were analyzed using Poisson regression methods. Percent changes were reported with the corresponding 95% confidence intervals (95% CI).

Results: There were 38,717 heroin exposure calls made to the PCs from 2011 to 2017, with the number of calls increasing from 3,152 to 8,676 during the study period. Single substance exposures accounted for 51.7% of such heroin exposures. Of the total heroin calls, the proportion of calls from acute care hospitals and EDs increased from 69.6% to 76.4% from 2011 to 2017. Multiple substance exposures accounted for 49.4% of the overall heroin calls from acute care hospitals and EDs. Approximately one-fifth of the patients reporting heroin exposures were admitted to the critical care unit (CCU), with 39.8% patients treated and released. Residence was the most common site of exposure (74.8%), and 85.5% of these cases were enroute to the hospital via EMS when the PC was notified. Among the patients, 67.1% were male, with individuals between ages 20 and 39 years (67.7%) predominantly reporting heroin exposures. Intentional abuse (65.3%) and suspected suicides (14.6%) were commonly observed reasons for exposure, with these proportions being 62.5% and 16.9%, respectively, in cases reported by acute care hospitals and EDs. During the study period, the proportion of heroin abuse exposures cases increased (62.2% to 68.5%), while suspected suicides decreased (16.1% to 11.9%). Major effects were seen in 16.7% cases and the case fatality rate for heroin was 3.3%. Notably, there was a 2-fold increase in the number of deaths due to heroin. The most frequently co-occurring substances associated with the cases were benzodiazepines (15.5%) and cocaine (9.6%), while the most common opioid was methadone (2.0%).  Coma (22.1%) and respiratory depression (21.8%) were commonly observed clinical effects. During the study period, the frequency of heroin exposures increased by 175.2% (95% CI: 164.2%, 186.7%; p<0.001), and the rate of heroin exposures increased by 203.9% (95% CI: 150.2%, 269.2%; p<0.001).

Conclusion: There was a significant increase in the reports of heroin exposures reported to the PCs during the study period. The alarming increase may be a result of multiple factors including the cheaper cost of heroin and the growing restrictions on the prescribing of prescription opioids. Greater intervention and awareness initiatives are needed considering the increasing contamination of heroin with fentanyl as well as the severity and rising number of overdose deaths.

Background:

Many studies have shown that carbon monoxide poisoning (COP) is a cause of mid-term neuropsychic sequelae. Hyperbaric oxygen therapy (HBOT) has been proposed as the method of choice to avoid these outcomes. The indications for HBOT remain controversal due to the lack of randomized studies.

The aim of the study was to evaluate the efficacy of HBOT compared to normobaric oxygen therapy (NBOT) within one month after COP.

Methods:

Prospective study over 13 months from january 2017 to February 2018. Inclusion of patients admitted to emergency department for COP with indication of HBOT. The indications of HBOT were: loss of consciousness, seizures, pregnancy and acute chest pain suggesting of myocardial infarction. Demographic, clinical and biological data were collected. Comparison of two groups: group HBOT = patients who underwent HBOT and group NBOT = patients with indicated but not performed HBOT (main reasons for impossible HBOT were : patients inability to cover HBOT’s cost or technical problems). Patients of both groups had NBOT for 12 hours. Follow-up after one month of index visit. All patients had telephonic interview to detect neuropsychic sequelae: sleep disorders, memory problems, headaches, seizures or depression.

Results:

Inclusion of 113 patients.  Mean age: 37±14 years with female predominance (80%). Poisoning source (%): gas water heater (64.3), brasero (20), gas heater (13).

Group HBOT : n=33. Group NBOT : n=80. The comparative study didn’t show any significant differences between the groups: mean age 39 versus 37 years , median of time of exposure : 64 versus 80 minutes, median of consultation delay  81 minutes versus 80 minutes and mean of Glasgow coma score  14 for both groups.

Significant differences were observed in: mean carboxy-hemoglobin 25±11% versus 19±12% (p=0.055) and lactate concentration: 3.3±2.2 versus 2.4±1.3 (p= 0.06).

No differences were observed between two groups in term of occurrence of insomnia, memory disorders, headaches, seizures or depression.

Conclusion:

Our results didn’t show any differences between HBOT and NBOT in term of occurrence of neuropsychiatric signs after one month. This conclusion suggests continuing the follow-up in order to detect delayed signs. Prolonged NBOT prevents neuropsychiatric complications.

Background: There exists a critical unmet need to improve the assessment and management of traumatic brain injury (TBI), a leading cause of injury, death and disability throughout the world.  Despite growing recognition of the importance and potential of biomarkers for TBI, there has been no FDA approved blood tests for TBI or concussion.  Ubiquitin C-terminal hydrolase-L1 (UCH-L1) and glial fibrillary acidic protein (GFAP) are two novel biomarker candidates that are highly brain specific and are detectable in the serum shortly after TBI.  In this pivotal clinical study, the utility of measuring serum levels of UCH-L1 and GFAP was evaluated in a population undergoing head CT for the evaluation of mild TBI. 

Methods: A total of 2011 subjects were enrolled in this prospective multi-center study conducted in the United States (67%) and Europe (33%).  Subjects presenting to the ED with suspected TBI underwent blood draw and head CT within 12 hours of injury.  A Neuroimaging Review Committee consisting of three board-certified neuroradiologists conducted an independent, blinded review of each CT scan to determine whether the subject was CT-positive or CT-negative with respect to acute intracranial lesions.  Serum samples were tested for the presence of UCH-L1 and GFAP at 3 independent laboratories blinded to the subject’s diagnosis and clinical status.  Of those enrolled, 1920 had a GCS of 14-15 with a valid head CT and serum sample biomarker result.  A total of 113 of the 1920 (5.9%) had a traumatic intracranial injury on head CT.  The concentration of each target analyte was calculated and reported as below or above the cutoff value for each analyte.  The analyses were performed using a pre-specified multivariate algorithm that combined UCH-L1 and GFAP scores into a single qualitative result.

Results: In those who presented with a GCS of 14 or 15, the assay sensitivity (95% lower CI) and Negative Predictive Value (NPV; 95% lower CI) were determined to be 97.3% (92.4%) and 99.5% (98.7%), respectively, which allowed acceptance of the study alternative hypothesis.  Assay specificity was determined to be 36.7% (34.5%).  Assay performance demonstrated 100.0% sensitivity (N=5) in the neurosurgically manageable lesion (NML) subgroup.   

Conclusion: The results demonstrated the UCH-L1 and GFAP blood test is characterized by both high sensitivity and NPV, which supports clinical utility for ruling out the need for a CT scan in patients with suspected TBI and a negative assay result.

Background

Mild head injury is a common presentation to the emergency department and patients taking Direct Oral Anticoagulant medications (DOACs) present a management challenge to clinicians. International guidelines currently recommend computed tomography (CT) head scanning of these patients, regardless of symptoms or signs; but note a lack of evidence to support management decisions.   

This systematic review aimed to identify, appraise and synthesise the current evidence for the risk of adverse outcome in patients taking DOACs following mild head injury.

Methods

A protocol was registered with PROSPERO (CRD 42017071411) and review methodology followed Cochrane Collaboration recommendations. Studies of adult patients with mild head injury (GCS 14-15) taking DOACs, which reported the risk of adverse outcome (death, disability, intracranial lesion) following the head injury were eligible for inclusion.

A comprehensive range of bibliographic databases and grey literature were searched using a sensitive search strategy. Selection of eligible studies was performed by two independent reviewers. Data extraction and risk of bias (using an established critical appraisal tool) was conducted by a single reviewer and checked by a second. A random effects meta-analysis was conducted to provide a pooled estimate of the risk of adverse outcome. The overall quality of evidence was assessed using the GRADE approach.

Results

4185 articles were screened for inclusion in the systematic review, of which four cohort studies, including 162 patients, met inclusion criteria. All studies were at moderate or unclear risk of bias secondary to selection bias or inaccurate outcome assessment. Estimates of 30 day adverse outcome ranged from 0% to 7%. A random effects meta-analysis showed a weighted average adverse outcome risk of 3% (95% CI 1-5%, I²=0).

The overall quality of the body of evidence was low due to imprecision, risk of bias and heterogeneity.

Conclusions

There is limited data available to characterise the risk of adverse outcome in patients taking DOACs following mild head injury.

A sufficiently powered prospective cohort study is required to validly define this risk,  identify risk factors for adverse outcome, and inform future head injury guidelines.

BACKGROUND:

Traumatic Brain Injury (TBI) is an important public health challenge but Europe currently lacks robust epidemiological information, with most studies focusing on hospital admissions and ignoring TBI patients discharged from the emergency department (ED). The CENTER-TBI Registry addresses this deficit by including all patients presenting to study centres across Europe.

METHODS:

We prospectively recorded demographic, physiological, injury and outcome data of survival after discharge from the clinical records of TBI patients presenting to 55 participating centres across 18 European countries from 2015 to 2017. This registry is part of the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER TBI) study. Patients were stratified for the purpose of between-group comparisons within the registry. These being; the “ER stratum” where TBI patients were evaluated solely in the ED and discharged post-computed Tomography (CT) scan without admission, the “admission (ADM) stratum” where patients were admitted to hospital post CT but not to intensive care and the “ICU stratum” where TBI patients were admitted directly from ED or other hospital to the Intensive Care Unit(ICU).

RESULTS:

18 879 TBI patients were enrolled in the registry-9087 (48%) patients in the ER stratum, 6490 (34%) patients in the ADM stratum, and 3302 (17%) TBI patients in ICU stratum.

The median age was 55 years (IQR 32-76 years) on presentation overall, with patients in the ADM strata being older (64 years (IQR 40-81)) than patients in the ER and ICU strata (51 years (IQR 29-73, IQR 32-68)). Patients were predominantly male (60% (95% CI 59.7-61.1)) overall, specifically ICU patients (73%). Low level falls were the most common mechanism of injury (Overall 39%; ER 39%; ADM 46%) and road traffic collisions were commonest in ICU strata patients (36%).

Patients presented with full or slightly impaired consciousness based on the median Glasgow Coma Scale (GCS) on arrival at the ED (15 (IQR14-15)) overall as well as in the ER and ADM strata. ICU stratum patients presented with lower conscious levels (median GCS (IQR) 12(4-15)). Non-reactive pupils were recorded in only 2.4% (95% CI 2.2-2.6) of the cases overall whereas patients in the ICU stratum had the highest rates of non-reactive pupils (11.6% (95% CI 10.5-12.7)). 71.4% (95% CI 70.8-72.1) of CT scans were normal overall while the ICU stratum patients largely had abnormal CT findings (80.7 %(95% CI 79.4-82.1).

Survival to hospital discharge was 95% overall and lower in the ICU stratum (81%).

CONCLUSION:

 Our study has identified that Traumatic Brain Injury currently presents to hospitals in Europe as two diseases: i) Low energy TBI resulting from ground level falls in patients fully conscious at presentation predominates - with older adults often requiring hospital admission; ii) High energy TBI occurs less frequently affecting mainly younger males presenting with impaired consciousness and life- threatening injuries requiring critical care.  This has major implications for clinical training and Trauma Network configuration. 

Introduction :

Post-trauma haemorrhagic shock is the second leading cause of death in severe trauma patients (ST) and evolution can be rapidly cataclysmic.Hereby early assessment is needed to evaluate blood loss and detect patients at risk in time. Advanced Trauma Life Support (ATLS) has been offering clinical classification for four stages in this context. However, there is a subclass of clinically stable "Borderline ST" with silent infraclinic tissue hypoperfusion that might be missed by the ATLS classification. The goal of this study was to explore the incidence and the profile of borderline severe trauma patients among clinically stable patients with stages 1 and 2  in the ATLS classification.

Methods  :

We conducted a monocentric prospective study over 33 months. Inclusion of the ST admitted to Emergency resuscitation room depening on high velocity criteria and clinical elements, and classified as ATLS1 and / or ATLS 2. A ST has been classified Borderline (BDL +) if fullfillment of : Injury Severity Score (ISS) ≥15 and Base Excess ≤- 4 mmol /l. Comparison of patients (BDL +) and (BDL-). Univariate study was underwent for mortality at day 7 after trauma.

Results :

Inclusion of 379 patients. Median age was 39 ± 18 years. Sex-ratio was 3. Ninety-three trauma patients (24%) were classified Borderline severe trauma. The groups (BDL +) and (BDL-) were comparable for demographic data. However, borderline patients were more severe as demonstrated by the subsequent significantly more frequent need to cirulatory optimization with use of tranexamic acid (Exacyl®), vasoactive drugs and intubation, and a significantly higher Injury severity score in the (BDL +) vs ( BDL-); p <0.001.The univariate analysis of mortality at day 7 after Trauma was  significant (p<0,001) with respective Odds Ratios and Confidence Intervals CI[95%] :  of 2,86 [2,86-4,6] for intubation; 6,4[3,7-11] for the use of vasoactive agents and 3,7[1,9-7] for Tranexamic acid use.

Conclusion :

Patients classified ATLS 1 or ATLS2 are shown to be  clinically stable. However in this study one in four of them required subsequent aggressive resuscitation attitude using vasoactive drugs, Exacyl, and intubation. ATLS alone is insufficient and subsequently not safe to estimate severity in Borderline severe trauma. More studies are invited to explore such patients and to reevaluate clinical tools used to assessment.

Introduction :

Pain is the most common complaint in the emergency department (ED).The provision of adequate, safe, and timely analgesia is a core component of patient care. At subdissociative doses,ketamine maintains potent analgesic effects with preservation of protective airway reflexes,  spontaneous respiration, and cardiopulmonary stability .

Objective of the study :

To evaluate the efficacy and safety of early administration oflow-dose intranasal ketamine analgesic agents in patients with moderate to severe pain in the ED in reducing the need for opioid or class III analgesic agents.

Materials and Methods :

It is a randomized, prospective, double blind, controlled, multicentric trial. The trial was conducted in three community teaching hospitals over two years.The study includes patients aged 18 to 60 years who presented to the ED with acute limb trauma pain and visual analogic scale (VAS) of 5 or more.

In the triage area, each patient received 0.3 mg/kg of intranasal ketamineor intranasal placebo. At ED admission we collected vital signs, demographic,clinical data. VAS was measured at 15, 30, 60, 90, and 120 minutes.

Primary end points includedpain resolution defined as a decrease of VAS more than 50% of baseline values 30 minutes following protocol treatment administration. Secondary endpoints included need for rescue analgesia,and adverse events rate.

Results

The study enrolled 1079 patients with median age of 37years and sex ratio (M/F) 1.32. Overall, there was no statistical difference between the 2 groups for initial VAS. Pain resolution was obtained in261 patients (50%) with intranasal ketamine versus 236 patients (42%)with placebo (p=0.012).Rescue analgesia by morphine was higher in the placebo group compared to ketamine group (6% vs2.9 %; p=0.03). Dizziness was more frequent in ketamine group( 21.5% vs 12.7% ; p<0.01); as disorientation ( 5.7% in ketaminegroup vs 0.4% in placebo group ; p<0.01).

Conclusion: 

This study suggests that intra nasal ketamine, can significantly reduce the need for opioids in the treatment of acute pain.