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

Introduction

Triage seeks to bring order and rationale to a potentially chaotic clinical environment. The most widely practiced method of Emergency Department (ED) triage in Europe is the Manchester triage system (MTS) that was introduced in 1997. It is reported that “the validity of the MTS is moderate to good”, however it is our experience that too many Majors patients are assigned to category 3 and that clinical granularity is lost. With rising numbers of frail elderly patients attending the ED and the increasing frequency of access block, this lack of differentiation between ‘true’ category 3 patients and physiologically well ‘condition specific’ category 3 patients has become more clinically relevant.

Our new triage system combines a validated physiological early warning score (NEWS), clinical trigger systems (e.g. sepsis 6), condition specific fast track pathways (e.g. fractured neck of femur) and most importantly, the clinical gestalt of our nursing staff.

This system has been piloted and fully implemented in Glasgow Royal Infirmary ED (GRI-ED).

 

Methods

The new triage system commenced 1^st July 2017. The twelve-week study period started on 31^st July. Seasonal variation was removed by comparing the same three-month period in 2016.

Records of all attendances at EDs across NHS Greater Glasgow & Clyde were obtained from Trakcare (Intersystems 2014) during the study period.

 

Results

A total 47,335 patient attendances at GRI-ED were available for analysis.

Two 12 week sample groups were analysed (2016 n=23,660) (2017 n= 23,675)

The median number of patients seen per day in these periods was similar (257 versus 259 for 2016 and 2017 respectively).

More patients were assigned to triage categories 4 (12% pre and 42% post change) (p<0.001) and 5 (0.23% pre and 15% post) (p<0.001), while significantly fewer were assigned to categories 0 (13% pre and 1% post) (p<0.001), 2 (14% pre and 9% post) (p<0.001) and 3 (57% pre and 28% post change) (p<0.001).

Only category 1 remained relatively unchanged (2.7% pre and 3% post).

Interestingly, there was no overall difference in median time to first assessment between the two samples (71 minutes and 71 minutes in 2016 and 2017 respectively) (p = 0.377 by Wilcox test). However, there were significant changes in time to first assessment within each triage category, particularly category 3 (92 mins pre and 82 mins post)(p<0.001). There was no overall difference in median length of stay between the two samples (157 minutes pre and 159 minutes post) (p = 0.59), however the median length of stay increased in the lower triage categories: 4 (130 mins pre and 154 post) (p<0.001) and category 5 (69 mins pre and 127 mins post) (p<0.001).

Despite the absence of a significant change in median length of stay, a significant improvement in compliance with ‘the four-hour target’ (89.8% in 2016 period versus 93.1% in 2017 period) (p < 0.001). Importantly, admissions fell significantly, from 35% in 2016 to 32% in 2017 (p < 0.001).

 

Conclusion

This simplified triage system has empowered our nurses, improved compliance with the 4 hour target and reduced admissions. 

Background & aim statement

More than 90% of head injuries (HI) presenting to emergency departments (EDs) are minor HIs. Over-utilization of computed tomography (CT) scans in the ED results in exposure of patients to unnecessary radiation and increases health-care resource utilization, including patients’ length of stay (LOS) in the ED. Using recommendations of the Choosing Wisely Campaign (CWC) and quality improvement (QI) methodology, we developed a local initiative with an aim to reduce the CT scan rate for patients presenting with HIs by 10% over a 6-month period at two academic EDs. This was felt to be both achievable and meaningful by our stakeholder group.

 

Measures & design

Baseline CT scan rates for patients with HIs were determined through a local 10-month retrospective cohort review. We used stakeholder engagement and provider surveys to develop our driver diagram and PDSA cycles, which included: 1) Assessing and improving provider knowledge about the CWC recommendations; 2) Testing, refinement and implementation of a Canadian CT-head Rule modified checklist in the ED; 3) Developing and giving patients CWC-themed handouts pertaining to HI best practice; 4) Bimonthly reporting of CT scan rates to providers (both medical and nursing). Our primary outcome measure was the number of CT scans performed for patients with HIs. Process measures included the number of checklists completed and patient’s ED LOS. Our balance measure was return visits to the ED within 72-hours for this patient population.

 

Evaluation/results

Baseline rate of CT scans prior to our interventions was 47.9%. Our QI initiative resulted in a significant ‘shift’ in the run chart of the weekly proportion of CT scan rates, associated with the second PDSA cycle cluster. We observed a 16% relative decrease in CT scans at 3 months (47.9% to 40.5%) and 10.4% at 8 months (47.9% to 43.1%). ED LOS for HI patients decreased by 12 min (237min to 225min). 33% of total checklists were completed. There was no immediate increase in 72-hr return visits following implementation of our initiative, but a small increase of 0.16% was observed during the 8-month study period (4.0% vs 4.16%).

 

Discussion/impact

Our local QI initiative was successful in decreasing CT rates both in the short- and long-term for patients presenting with HI. The decrease in effect at 8 months suggests the need for continued feedback and reminders to ensure ongoing sustainability. Other centres could use similar QI methods, as well as the materials we developed, to achieve similar results of improved evidence-based utilization of diagnostic tests.

Background

Patients present to the emergency department (ED) with a variety of symptoms. The assessment of symptoms at presentation offers readily available information, which is of great importance for clinical workup and possibly for outcomes. The predictive power of certain individual symptoms, such as dyspnoea, is well known. However, research has mainly focused on the investigation of single chief complaints, neglecting the fact that patients usually present to the ED with more than one symptom. A recent study showed that the number of symptoms reported at triage was 2 median (range 0-25), with women reporting significantly more symptoms. Knowledge on combinations of symptoms has great potential in the process of risk stratification.

We therefore aimed to identify the most common combinations of symptoms in an all-comer ED population and to report their related outcomes, such as hospitalisation, admission to the intensive care unit (ICU), and mortality.

 

Methods

A consecutive sample of all patients presenting to the ED of the University Hospital Basel was included over a time course of 6 weeks. The presence of 35 predefined symptoms was systematically assessed upon presentation, by a dedicated study team asking patients whether or not the symptom was present at the very moment.

 

Results

3960 emergency patients (median age 51, 51.7% male) were included. Hospitalisation occurred in 1237 (31.2%), ICU admission in 219 (5.5%) of all cases, and 55 (1.4%) patients died during hospital stay. Out of 3733 patients with complete one-year follow-up, 215 (5.8%) died within one year of presentation. The three most frequent combinations of two symptoms were headache and dizziness in 281 (7.1%) patients, fatigue and weakness in 275 (6.9%) patients, and weakness and dizziness in 200 (5.1%) patients, respectively. As for combinations of more than two symptoms, weakness, fatigue and dizziness (n = 106, 2.7%), and weakness, fatigue, dizziness and headache (n = 62, 1.6%), were reported most frequently. Three combinations of two symptoms were found to be significantly associated with in-hospital mortality; fatigue and weakness (Odds ratio (OR) = 2.59), headache and weakness (OR = 3.31), fatigue and dizziness (OR = 2.94), whereas several combinations were predictive for the outcome of hospitalisation.

 

Discussion & Conclusions

Several combinations of symptoms are frequent at presentation to the ED. Nonspecific complaints, such as weakness and fatigue, are among the most frequently reported combinations of symptoms, and are associated with adverse outcomes. The higher the number of symptoms reported, the higher the prevalence of nonspecific complaints, making it harder to come up with a working diagnosis that leads to focused clinical workup. Systematically assessing symptoms may add valuable information on the prognosis and may therefore influence triage, work-up, and disposition.

No trial registration occurred. Study protocol was approved by the local ethics committee (236/13, www.eknz.ch). This study did not receive any specific funding.

Objectives

Delayed recognition is the major cause of disability and mortality in sepsis. Since sepsis is not only an ICU problem, we aimed to compare the performance of qSOFA, NEWS and SIRS for identifying patients with community-acquired sepsis in an all-comer emergency department (ED) cohort.

Methods

In this prospective observational study, we included all consecutive patients presenting to the ED over a period of 3 weeks. We excluded patients with end stage dementia, those with ongoing life support and patients who declined to participate. Vital parameters, mental status and triage category were recorded at the time of ED arrival by triage clinicians. Demographics, laboratory measurements, microbiology tests and outcome variables were obtained from the hospital’s electronic health record. We defined “suspicion of infection” as the start of a course of antibiotics in the ED or the draw of a microbiological test within 24 hours after ED presentation.

Two independent experts retrospectively assigned a gold-standard diagnosis of sepsis and septic shock according to Sepsis-3 criteria. Patients eligible for review had a sepsis-related ICD-10 code at discharge or positive blood cultures drawn within 24h after ED presentation.

We calculated the discriminative performance of the scores using receiver operator characteristic (ROC) curves with area under the curve (AUC) analysis for sepsis and septic shock. We tested performance criteria for various cut-offs. We used suspicion of infection as a control variable.

Results

2930 patients presented to the ED in the study period, of which 2523 (86.1%) were included in the final analysis. Suspicion of infection was found in 634 patients in the hospital database: antimicrobial therapy in the ED was given to 186 patients, and 592 underwent microbiological testing within 24 hours presentation. The chart abstraction resulted in 68 charts being reviewed, of which 6 patients were classified as sepsis and 10 as septic shock due to community-acquired infections. AUC for early sepsis or septic shock was 0.76 (95%CI 0.63-0.89) for qSOFA, 0.88 (95%CI 0.78-0.99) for SIRS and 0.90 (95%CI 0.84-0.95) for NEWS.

Conclusion

While qSOFA may serve as a valuable tool for the identification of increased risk of adverse outcomes, we found that it performed poorly as a screening tool for early identification of sepsis in the emergency department.

The study was registered at the local ethics committee (236/13, www.eknz.ch). We received no external funding for the realisation of the study.

Objectives: The objective was to compare the performance of “informal triage” with the Emergency Severity Index (ESI) in an all-comer emergency population.

Background: Triage remains one of the key-tasks in emergency patients. A reliable and valid triage is crucial to prevent unnecessary deaths, morbidity and waste of medical resources. The ESI is a well-established triage tool, used emergency departments across the US but also in Europe.

Triage tools are being discussed controversially. Mainly because they differentiate not well in lower acuity.

Patients at risk can be identified using a first clinical impression, also called “Informal Triage”. We wanted to assess whether “Informal Triage” can outperform ESI theoretically in terms of identifying critically ill patients and in predicting mortality. If useful, this simple tool could help to save resources.   

Methods: Prospective data of 7131 patients collected in the emergency departments of the university hospital of Basel, a tertiary-care university hospital. We assessed if informal triage could theoretically replace formal triage by registering data regarding the question “how ill does this patient look?” as rated by physicians. Our primary endpoint was in-hospital-mortality and 30 day-mortality. Other endpoints included admission to hospital and ICU-admission.

Results: During a time span of three weeks each in the years 2013, 2015 and 2017 we included a total number of 7’131 patients. A total of 293 patients with a missing ESI-Score or a lacking informal triage score were excluded. 6’858 patients could be analysed using a complete dataset.

The Area under the Curve (AUC) for 30d mortality rate was 82.8% with a confidence interval (CI) of 78.6%-86.9% for the informal triage by a senior doctor. The AUC of the ESI triage was 75.3% with a CI of 71.2%-79.5% (P-Value < 0.001).

We received similar results for hospitalization: AUC of informal triage 80.5%, (CI: 79.4-81.5%) and AUC of ESI-triage 77.7% (CI: 76.7-78.7%), (P-Value < 0.001), for ICU admission: AUC informal triage 84.0% (CI: 82.1%-85.9%) AUC of ESI-triage 81.5% (CI: 79.7%-83.4%), (P-Value = 0.018), as well as for the in hospital mortality rate: AUC informal triage 85.9% (CI: 81.9-89.9%), AUC of ESI-triage 81.6% (CI: 77.8-85.3%), (P-Value = 0.012).

Conclusions:

Triage by physician by first clinical impression (“informal triage”) was theoretically able to predict various outcomes more precise than the Emergency Severity Index.

Background

Nearly 10% of patients who are admitted to an acute hospital die during the course of their admission, many of whom will have passed through an Emergency Department (ED) along the way. Treating ED patients who are dying in the same way as those who have a reversible cause for their illness can not only be futile but also harmful and costly. The aim of this study was to assess the impact of a treatment limitation escalation plan (TELP) in improving care of patients approaching the end of life.

Method

Retrospective case note review of 300 consecutive in patient deaths was carried out to assign them to one of three cohorts:1. Had a DNACPR order only, 2. Had both a DNACPR and a TELP, or 3. Had neither. A power calculation indicated that a sample of 98 patients in each group was required. Case reviewers used the Structured Judgement Review Method to make a determination of occurance of non-beneficial intervention (NBI) or harm. A sample of 20% of the reviews were checked by a second reviewer for quality control and to generate a Kappa value. The primary outcome was to determine if there was a significant difference in the rate of harms between each cohort. Statistical analysis using Poisson regression and comparison of Incidence Rate Ratios was carried out. Limitations were the inability to blind the reviewers to cohort allocation and potential judgement bias of the author who was involved with development of the TELP.

Results

Case notes were available for 289 patients. Numbers of patients in the 3 cohorts decribed above were 155, 113 and 21 respectively. The 'neither DNACPR nor TELP' cohort therefore did not have sufficient numbers to report statistical significance. This is explained by the high number (93%) of patients who had a DNACPR order. Patients in cohorts 1 and 2 were found to be similar in terms of age distribution and ward where they died. Analysis showed significant difference in both the number of NBIs and harms occuring between the cohorts (p<0.01). This was true both for the rate occurring per 100 cases and the rate per 1000 bed days. Kappa scores were favourable for the 4 reviewers involved, ranging from 0.74 - 0.85.

Discussion

In this study we demonstrated that use of a TELP in addition to a standard DNACPR significantly reduced the frequency of NBIs and harms, therefore resulting in significantly better care for patients who are nearing the end of life. Other studies have confirmed a reduction in harms using a TELP. The incidence of NBIs, or under treatment of a patient's palliative care needs has also been well documented.

In the ED, we need to be aware of the high number of patients passing through our care who are nearing the end of life. Where appropriate, we should be putting a TELP in place, not just a DNACPR. 

Not applicable.

Introduction: Systematic care of patients after OHCA and developement of CAC is recommended by the guidelines, but important „contra“ argument is prolonged transport of often hemodynamicly unstable patients in limited prehospital emergency care.
Aim: To determine if prolonged primarily transport of patients after OHCA to regional CAC influence initial hemodynamic parameters after admission, mortality a neurological outcome.
Methods: Analysis from prospective OHCA Registry of regional CAC from 2013 to 2017. Data were divided into 2 datasets: 1) INSIDE - when CAC is the nearest hospital and 2) OUTSIDE - patients transfered to CAC, but in past  would be transferred to one of the 7 another closer hospitals in the region. We observed duration of transport, baseline characteristics ( age, gender, bystander CPR, ROSC, shockable rhythm, acute coronary syndromes (ACS), catecholamins administration during transfer), hemodynamic parameters on arrival to hospital (systolic BP, lactate, pH, SpO2, body temperature and initial doses of vasopressors and inotropics) and final outcomes (30-day/in-hospital mortality,  length of ICU stay, artificial ventilation days, 1 year CPC).
Results: 232 patients were enrolled after OHCA in years 2013 to 2017, 27 were excluded for insuficient data and 19 for secondary transfer to CAC. We analyzed 186 patients, 93 in both groups. We observed no differences in baseline characteristics in both groups: men (66,7% vs. 80,6%, p= 0.29), age (64,51±1.324 years vs. 61.25± 1.443 years , p= 0.1), shockable rhythm (65,6% vs. 74,2%, p= 0.26), bystander CPR (68,8% vs. 72%, p= 0.75), ROSC (median, IQR) :17 (11-26) min vs. 20 (15-30) minutes, p= 0.29, ACS ( 44,1% vs. 48,4%, p= 0.66) and catecholamine administration during tranfer (80% vs. 70%, p= 0.18). We observed no differences in initial hemodynamic parameters in time of  admission in both groups. Systolic blood pressure: (median,IQR): 103 (82-120) vs. 105(82-124)mm Hg, p= 0.6, serum lactate level (median,IQR): 4.6 (2-8.1) vs. 3.5 (2-6.75) mmo/l, p= 0.372, pH (median,IQR): 7.242 (7.122-7.322) vs. 7.286 (7.177-7.318), p=0.159, body temperature: (median,IQR): 35.95 (35.08-36.5) vs. 36 (35.5-36.5), p=0.218 and oxygen saturation (SpO2):(median,IQR): 95 (91-100) vs. 98 (94-100), p= 0.14.
We observed no differences in catecholamins dosages. Norepinephrine (7.54±+1.75 vs. 5.98±1.17 mcg/min), p= 0.46 and dobutamine ( 66.31±45.81 vs. 38.6±15.62 mcg/min),p=0.56. There was no significant difference in in-hospital/30-day mortality between groups ( 44.1% vs. 42.3%, p= 0.88). 1-year good neurological outcome (CPC 1,2) was identical ( 54,2% vs 54.2%, p= 0.999). Median of artificial ventilation duration was without significant difference: (median/IQR) 3 (1-8) vs.5 (1-7.75) days, p= 0.36 and median of lenght of ICU stay was without significant difference: (median/IQR) 6 (2-14.75) vs. 7 (3-12) days, p= 0.74.
Conclusion: Strategy of primary transport of patients after OHCA to CAC significantly prolonged time of transport, but didn´t affect hemodynamic parameters and outcome of patients.

Background: Ideally, prehospital advanced life support (ALS) should be preceded by good-quality bystander cardiopulmonary resuscitation including chest compressions (CCs). This study aimed to investigate how differently quality of bystander-performed CCs on emergency medical service (EMS) arrival and provision of ALS by EMS paramedics affect the outcomes of out-of-hospital cardiac arrests (OHCAs) receiving bystander CPR.

Methods: Prospective observational study with propensity-matched analyses was conducted in Ishikawa Prefecture, Japan during the period of 2012– 2016 after obtaining ethical approval from a local committee. Of 3.088 adult (≥8 years) OHCAs receiving bystander-performed CCs on EMS arrival, CC qualities were determined in 3,004 cases by two EMS personnel including at least one paramedic qualified for ALS on their arrival at the scene, according to the standard recommendations: depth (one-third of chest depth or >5 cm), rate (100–120), proper position and adequate decompression. When two EMS personnel judged all criteria to be met, the quality was recorded as adequate. Primary outcome measure was neurologically favourable one-year survival. Secondary outcomes were sustained (>20 min) return of spontaneous circulation (ROSC) and one-month survival. After analysing the effects of good-quality CCs and ALS on outcomes and their interaction using a stepwise multivariable regression in all 3,004 OHCAs, propensity-matching procedures were applied for CC quality and ALS provision. Propensity-matchings and stepwise multiple regression analyses included CC quality, ALS provision, time intervals, backgrounds and characteristics of OHCAs.

Results: When analysed for all OHCAs, prehospital ALS (adjusted OR, 1.60; 95%CI, 1.28–1.99) but not good-quality of bystander-performed CCs was associated with sustained ROSC. Neither prehospital ALS nor good-quality CCs affected one-month survival. However, good-quality of bystander-performed CCs (3.33, 1.31–14.9) was associated with higher chances of neurologically favourable one-year survival, whereas prehospital ALS (0.20; 0.04–0.52) was associated with lower chances of the survival. There was no considerable interaction between good-quality CCs and prehospital ALS in any outcome measure. Propensity-matched analyses in CC quality- and ALS provision-matched pairs confirmed these findings. The incidence of sustained ROSC in cases with ALS provision was considerably higher than that without ALS provision for ALS provision-propensity-matched pair (N = 968 each, 29.0 vs 24.7 %, 1.32; 1.07–1.64) The rate of neurologically favourable one-year survival in cases receiving good-quality CCs was considerably higher than that receiving poor quality for CC quality-matched pair (N = 636 each, 3.8 vs 1.6 %, 2.81; 1.29–6.59). However, the rate of neurologically favourable survival in cases with ALS provision was lower than that without ALS provision for ALS provision-matched pair (N = 968 each, 1.5 vs 5.1%, 0.20; 0.10–0.39). The rate of 1-M survival did not considerably differ between the two groups in CC quality- or ALS provision-matched pair. Stepwise multivariable analyses for CC quality- and ALS provision-matched pairs revealed that witness status and initial ECG rhythm are other common and major factors associated with the outcomes.

Conclusions: Quality of bystander-performed CCs but not prehospital ALS provision is essential for neurologically favourable survival. Every effort should be made in a commuty to improve the quality of CCs before EMS arrival.

Objectives

Patients suffering from an out-of-hospital cardiac arrest (OHCA) associated with an initial shockable rhythm have a better prognosis than their counterparts. While patients requiring more shocks may be expected to have worse outcomes, the prognostic implications of recurrent or refractory malignant arrhythmia in such context remain unclear. The objective of this study is to evaluate the association between the number of prehospital defibrillations delivered and resuscitation outcomes (survival to hospital discharge and prehospital return of spontaneous circulation [ROSC]) among patients in OHCA.

Methods

Adult patients with an initial shockable rhythm over a 5 year period were included from registry of OHCA in Montreal, Canada. In order to ensure that this analysis would be immediately applicable, the relationship between the number of prehospital defibrillations delivered and the probability of both resuscitation outcomes was first analyzed in a way to reflect the dynamic nature of clinical decision-making such that each level of analysis represents the likelihood of the resuscitation outcome up to that number of shocks. For the alternative analysis, patients were separated in two groups according to the number of prehospital defibrillations they received: less than three or at least three. Resuscitation outcomes (survival to hospital discharge and prehospital ROSC) of the patients included in these two groups were compared using Pearson’s chi-squared tests. In addition, a multivariable logistic regression model was planned using a standard approach adjusting for pertinent variables to assess the independent association between the number of prehospital defibrillations administered and the resuscitation outcomes.

Results

A total of 1788 patients were included in this analysis, of whom 583 (33%) survived to hospital discharge. The probability of survival was highest with at the first defibrillation (33% [95% confidence interval {CI} 30-35%]), but decreased to 8% (95% CI 4-13%) following nine defibrillations. The same is observed for the probability of prehospital ROSC, which begins at 54% (95% CI 51-56%) and lowers to 24% (95% CI 18-30%) following nine defibrillations. Patients having received three defibrillations or more (median number of prehospital defibrillations: 5 [Q1-Q3: 4-8]) were less likely to survive to hospital discharge (22 vs 41%, odds ratio [OR] =0.41 [95% CI 0.33-0.50], p<0,001) and to experience prehospital ROSC (40 vs 64%, OR=0.38 [95% CI 0.31-0.46], p<0,001) than their counterparts (median number of prehospital defibrillations: 1 [Q1-Q3: 1-2]). In multivariable logistic regression models, a higher number of prehospital defibrillations received was independently associated with lower odds of survival (adjusted odds ratio [AOR] = 0.88 [95% CI 0.85-0.92], p<0.001) and with lower odds of prehospital ROSC (AOR=0.85 [95% CI 0.82-0.88], p<0.001).

Conclusions

For patients with OHCA with an initial shockable rhythm, requiring more defibrillations is independently associated with worse outcomes. Despite that requiring more defibrillations is independently associated with worst outcomes in that population, there does not seem to be an evident cut-off that would predict bad resuscitation outcomes and the number of shocks received should not influence treatment decisions alone.

This project received funding from the ‘Fonds des Urgentistes de l’Hôpital du Sacré-Cœur de Montréal’ and the ‘Département de médecine familiale et de médecine d’urgence de l’Université de Montréal’.

Objective: Delirium is a frequent problem among older patients in the Emergency Department (ED) and early detection is important to prevent its associated adverse outcomes. Several screening tools for delirium have been proposed for the ED, such as the Confusion Assessment Method-Intensive Care Unit (CAM-ICU). Previous validation of this tool for use in the ED showed varying results, possibly because they were administered at different or unknown time points. The aim was to study incidence of delirium in older (≥70 years) ED patients using the CAM-ICU.
Methods: Prospective cohort study, in one tertiary care and one secondary care hospital in the Netherlands. Patients aged 70-years and older attending the ED were included. Delirium screening was performed within 1 hour after ED registration using the CAM-ICU. The 6-Item Cognitive Impairment Test (6-CIT) was determined for comparison, using a cut-off point of  ≥14 points indicating possible delirium, which has previously associated with the presence of delirium using gold standard assessment.
Results: A total of 997 patients were included in the study, with a median age of 78 years (interquartile range 74-84). Delirium as assessed with CAM-ICU was positive in only 13 (1.3%) patients. 95 (9.5%) patients had 6-CIT ≥14.
Conclusions: We found a delirium incidence of 1.3% using the CAM-ICU, which was much lower than the expected incidence of around 10% as been frequently reported in literature and what we find when using the 6-CIT. Based on these results, caution is warranted to use the CAM-ICU for early screening in the ED.

This work was supported by the Netherlands Organisation for Health Research and Development (ZonMW project number 62700.4001).

BACKGROUND

Elderly increasingly demand emergency department (ED) care, leading  to crowding.  ED visits have a profound impact on older patients, including high risks of adverse outcomes and loss of independency. The objective of this study was to evaluate  opinions of patients,  caregivers,  general practitioners (GPs)  and ED physicians (EPs) on the preventability of ED visits by older patients.
 
METHODS 

Prospective, observational and qualitative study of 200 patients of ≥70 years visiting a teaching hospital ED in the Netherlands between 24 July and 7 September 2017. Trauma-related visits were only included if a fall was involved. Semi-structured interviews were performed with patients, caregivers and GPs. EPs  were provided with written surveys. Patient data was extracted to determine vulnerability. Primary outcome was the opinion of patients and healthcare providers. Secondary outcomes were consensus on preventability and the qualitative data derived from the interviews. Mann-Whitney U and chi-square tests were used for continuous and categorical variables, respectively. Cohen’s kappa (κ) was used to measure agreement of preventability assessments.
 
RESULTS 

The mean age of patients was 79.6 years, 49.5% was male. The majority of (95%) lived independently before the ED visit; only half the patients reported any form of domiciliary care (51.4%) or a caregiver (50%). Patients deemed 12.2% of visits potentially preventable; caregivers 9%, GPs 20.7% and EPs 31.2%. Consensus on preventability was poor, especially between patients and professionals. Whilst patients most frequently blamed themselves; healthcare providers predominantly mentioned lack of communication and organizational issues as contributing factors.
 

DISCUSSION AND CONCLUSION

Despite being fragile, older patients who visit the ED in the Netherlands usually live independently and have a caregiver in only 50% of the cases. This is the first study to provide insight in the preventability of ED visits in the elderly according to patients, their caregivers, GPs and EPs. Patients consider an ED visit preventable less frequently than professionals. Little consensus was found between patients and healthcare providers, and the perspectives on contributing factors to a preventable visit differ between groups. In order to help improve geriatric ED care, future studies should focus on why these perspectives are so different and aim to align these.

Background:

Providing healthcare services within the care home environment is the most desirable option for care home residents.Advanced care planning tools, such as Anticipatory Care Plans (ACPs) and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) documents, help to provide patient-centred care in this setting. General practitioners (GPs) play a central role in facilitating this care and assessing when transfer to a higher level of care is required. In Aberdeen, the emergency department (ED) provides a medical decision support service for community practitioners through a dedicated phone line. Due to concerns raised by ED staff about the circumstances in which some care home patients were presenting to the ED this audit was primarily designed to review whether advanced care planning tools are being utilised for this patient group. Secondary aims were to understand more about the assessment of care home patients prior to transfer to ED and about their journey through the department.

 

Method:

This was a retrospective audit of routine clinical data extracted from the data management system Trakcare for the 112 care home patients who presented to the Aberdeen Royal Infirmary ED in January and February 2017 from Aberdeen city and Aberdeenshire. Further data was extracted from the ED documentation stored electronically on C-Cube. The audit was registered with the NHS Grampian Clinical Effectiveness Team (ProjID 3866) and ethics approval was not needed. The descriptive data was used to assess the availability of a DNACPRdecision or ACP in the ED, time of admission, reason for admission, duration of stay, and assessment prior to hospital transfer.

 

Results:

Analysis of the data showed that a DNACPR decision was available for 55% of patients and an ACP for 28% of patients. A third of patients had been discussed with or reviewed by a GP prior to hospital transfer and documented use of the ED decision-support service was found in 9% of transfers. Traumatic presentations accounted for the majority of transfers, there were equivalent numbers of presentations in and out of hours and 55% of patients were admitted to the hospital.

 

Discussion & Conclusions:

At a national level there has been considerable activity around advanced care planning and the national Guidance for Health and Care Professionals (2017) recommends that living in a care home should trigger the creation of an ACP. The results of this audit draw attention to an area for improvement in the advanced care planning processes for care home residents in Aberdeenshire. The audit results also highlight that consideration must be given to the barriers to unscheduled GP review for care home patients. Similarly, the infrequent use of the ED decision support service raises questions about how this service can be optimised. Inappropriate transfers to hospital are likely to be reduced by more widespread use of advanced care planning tools and increasing the percentage of care home patients reviewed by a GP prior to transfer to the ED. The result would be improved care for this patient group and more appropriate use of emergency services. 

NHS Grampian Clinical Effectiveness Team (ProjID 3866)

Background: The effect of hospitalisation in emergency department-based short-stay units (SSUs) has not been studied in older patients. We compared SSU-hospitalisation with standard care at an Internal Medicine Department (IMD) in acutely admitted older internal medicine patients.

Methods: We conducted a pragmatic randomised clinical trial. We randomly assigned patients aged 75 years or older, acutely admitted for an internal medicine disease, and assessed to be suitable for SSU-hospitalisation to SSU-hospitalisation or IMD-hospitalisation. SSU-hospitalisation was provided by a pragmatic ‘fast-track’-principle. The primary outcome was 90-day mortality. Secondary outcomes included adverse events, change in Lawton Instrumental Activities of Daily Living (iADL)-score within 90 days from admission, in-hospital length of stay, and unplanned readmissions within 30 days after discharge. All pre-planned analyses and interpretations were performed before the breaking of the randomisation code, but we included an evaluation of health care utilisation post-hoc (use and timing of diagnostic tests and treatments).

Results: Between January 2015 and October 2016, 430 participants were randomised (median age 84 years in both groups). Ninety-day mortality was 22 (11%) in the SSU-group and 32 (15%) in the IMD-group (OR 0.66; 95%CI 0.37-1.18; p=0.16). When comparing the SSU-group to the IMD-group, 16 (8%) vs. 45 (21%) experienced at least one adverse event (OR 0.31; 95%CI 0.17-0.56; p<0.001); 6 (3%) vs. 35 (20%) experienced a reduction in iADL score within 90 days from admission (p<0.001); median in-hospital length of stay was 73 hours [IQR 36-147] vs. 100 hours [IQR 47-169], (p<0.001), and 26 (13%) vs. 58 (29%) were readmitted (OR 0.37; 95%CI 0.22-0.61, p<0.001). Fewer tests and treatments were applied in the SSU-group, and the time to chest x-ray, CT scans, point-of-care ultrasound, and physiotherapy was significantly shorter.

Conclusions: Mortality at 90 days after admission was not significantly lower in the SSU group, but SSU-hospitalisation was associated with a lower risk of adverse events, less functional decline, fewer readmissions, and shorter hospital stay. SSU hospitalisation may be preferable in  acutely admitted older internal medicine patients.

Trial registration: NCT02395718 CS recieved a Ph.d. stipend from Region Zealand and University of Copenhagen for this work (13-53) CS recieved funding for this project from Region Zealand Research Foundation (12-000095)

Background:

International guidelines recommend adapting the classic emergency department (ED) management model to the needs of older adults in order to ameliorate post-ED outcomes among this vulnerable group. To improve the care for older ED patients and specifically prevent unplanned ED readmissions, the URGENT care model was developed. The study aim was evaluating the effectiveness of the URGENT care model.

Methods:

A prospective single centre quasi-experimental study (sequential design with two cohorts, recruited from 1/12/2014 to 31/5/2015 and from 15/10/2015 to 31/5/2016, respectively) was conducted in the ED of University Hospitals Leuven. Dutch-speaking, community-dwelling ED patients aged 70 years or older were eligible for enrolment. Patients in the control cohort received usual ED care. Patient in the intervention cohort received the URGENT care model. The URGENT care model is a nurse-led, comprehensive geriatric assessment based care model in the ED with geriatric follow-up after ED discharge. The interRAI ED Screener^© and clinical judgement of ED staff were used to identify patients at risk for unplanned ED readmission. A geriatric nurse was available during office hours to conduct CGA in at risk patients. Subsequently, a personalized interdisciplinary care plan was made. Discharged at risk patients were offered case manager follow-up. Hospitalized at risk patients received follow-up on a geriatric ward or by the inpatient geriatric consultation team if considered necessary. The effectiveness of the URGENT care model was measured primarily on 90-day unplanned ED readmission rate. Secondary outcome measures were hospitalization rate, ED length of stay (ED LOS), in-hospital length of stay, 90-day higher level of care, 90-day functional decline and 90-day mortality. The required sample size was 751 patients per cohort, making a total of 1502 patients. Cause-specific hazard-ratios, relative risks, logistic regression and a lognormal model were used when appropriate. In all analyses, a propensity model was used to handle the potential difference in patient mix between the cohorts. Bonferroni correction was applied if considered relevant.  

Results:

Unplanned ED readmission occurred in 170 of 768 (22.1%) control cohort (CC) patients and in 205 of 857 (23.9%) intervention cohort (IC) patients (P=.11). Statistically significant secondary outcomes were ED LOS (CC: 19.1 versus IC: 12.7 hours respectively; P=.0003), hospitalization rate (CC: 67.0% versus IC: 70.0%; P=.0.0026) and functional decline (CC: 21.5% versus IC: 26.6%; P=.0.023). ED LOS and hospitalization rate remained statistically significant after Bonferroni correction.

Conclusions:

The URGENT care model shortened ED LOS and increased the hospitalization rate, but did not prevent unplanned ED readmissions.

 

Trial Registration: The study protocol was registered retrospectively with ISRCTN (ISCRCTN91449949). Funding: The (Flemish) government agency for Innovation by Science and Technology funded this study (file number: 135182). Ethical approval and informed consent: The Medical Ethics Committee of University Hospitals Leuven (B322201422910) approved this study.

Adherence to Geriatric Emergency Department guidelines in routine care

Introduction Older people visiting the emergency department (ED) are at risk of adverse outcomes. Since the number of older people presenting to EDs increases, there is growing interest in the complex health care needs of this patient group. Geriatric Emergency Department (GED) guidelines provide recommendations on how to improve care for these patients. The aim of this study was to describe adherence to GED guidelines for older ED patients.

Methodology This was a prospective observational cohort study including ED patients aged 70 years or older, during two months from 8am till 11pm. The following recommendations of the ACEP GED Guidelines were observed in a two-months inclusion period as a proxy for guideline adherence: use of urinary catheters, family presence, use of hospital bed instead of ED gurney and provision of food during ED stay. The degree of a stressful environment was measured by counting the number of involved care providers and the number of door movements of the treatment room.

Results In total 998 older patients visited the ED, of which 605 (60.6%) were observed during their ED stay. Urinary catheters were used in 6.8% of all older patients. For 88.8% of patients family was present, 35.6% of patients were nursed on a bed and 7.4% of patients received food during their ED visit. The mean number of involved care providers was 8 (SD=3.7) and the median number of door movements of the treatment room during ED treatment was 41 (IQR=24-62).

Conclusions Geriatric Emergency Department Guidelines adherence is low. The use of urinary catheters and presence of family in the ED seems good, but there is room for improvement of hospital bed use, presence of food and stressful environmental factors. To make sure that routine care follows guidelines, interventions such as education programs and environmental changes seem necessary.

During the conference this data will be compared with data after implementation of a system improvement program.

Background

 

Music has been shown to have a beneficial effect in patients with dementia for managing specific effects such as agitation, and improving communication. We hoped to demonstrate that using patient or carer selected playlists could improve the ED experience for patients with dementia and facilitate care.

 

Methods

 

We looked at a case series of consecutive patients presenting to the ED with a known diagnosis of dementia, who were displaying features of distress such as increased agitation. Music was delivered via an MP3 player with either headphones or a mini speaker depending on patient preference. Patients and/or carers selected a playlist of around 30 minutes. A number of musical genres including hymns, folk songs and others were available. The response was assessed using a simple evaluation tool with visual categories for mood assessment, and looking for presence of positive and negative behaviours and indicators such as smiling, eye contact etc.

 

38 “playlist episodes” in 24 patients were reviewed. Mood was scored from 1 (happy, represented by a smiling emoticon) to 3 (distressed, frowning emoticon) at the beginning and end of the playlist. Mood was assessed by the patient where they were able to communicate, or by carers. Witnessed behaviours were indicated by tick boxes, and carers were able to add comments if wished. 

 

Results

 

Of the 38 episodes, 2 had no post music score recorded. Average “mood score” prior to playlist for the completed 36 episodes was 1.842, post playlist was 1.054 (P value <0.00001). No patient was more distressed after than before, and the majority showed an improvement. A total of 86 positive behaviours and 5 negative behaviours were recorded. There were a number of positive comments from carers and family members.

 

No patients were recorded as refusing/unable to participate when music was offered.

 

Discussion

 

The fastest growth in ED attendances in the UK is for patients over 65. Studies report the incidence of cognitive impairment in these patients as between 21% and 40%. There is an increasing body of evidence that patients with dementia are vulnerable to adverse outcomes of hospitalisation. 

 

A review of behavioural disturbances in the ED showed that in elderly patients with cognitive impairment, behavioural disturbances were both more frequent and more severe. These patients have an increased risk of developing acute delirium while in the ED, and delirium has been shown to worsen outcome.

 

Music has been shown to be helpful in patients with dementia in a number of studies, including recently in the context of residential care, improving symptoms of depression and agitation. There are no reported negative consequences in the available literature.

 

Our study suggests that music can be beneficial in modifying the stressful experience of an ED attendance for these patients. It is easy to deliver, has no demonstrated adverse effects and involves minimal resource allocation or staff training. We intend to continue to use this intervention in our department and would recommend it to other EDs who manage patients with dementia.

With grateful thanks to www.playlistforlife.com who provided the MP3 player and initial music downloads

Background: The Bacterial meningitis score (BMS) accurately identifies children with pleocytosis at low or high risk of bacterial meningitis. To include new biomarkers (procalcitonin [PCT], C reactive protein [CRP]) may be helpful to design a more accurate decision support tool.

Objective: To design a more accurate decision support tool to distinguish bacterial from aseptic meningitis in children with cerebrospinal fluid pleocytosis.

Design/Methods: We carried out a multicenter, retrospective cohort study including children aged 29 days to 14 years who presented with cerebrospinal fluid pleocytosis at 25 Spanish participating emergency departments (ED) between 2011 and 2016 to develop a Meningitis Score for ED (MSE). We excluded critically ill patients, those non-previously healthy, those with purpura and those who had received antibiotics previously. To select the variables of the score we included those with an area under the RUC curve higher than 0.90; to select the optimal cut-off point we used the Youden index; finally, variables independently associated with bacterial meningitis were ranked according to the magnitude of the beta-coefficient.

Results: We included 819 children with pleocytosis (758 aseptic meningitis, 61 bacterial meningitis) The MSE was developed attributing 3 points for serum PCT (>1.2 ng/mL), 2 point for CSF protein (>80mg/dL) and 1 point for serum CRP (>40 mg/l) and CSF absolute neutrophil count (>1000 cells/mm3). The negative predictive value of a MSE value of 2 or higher for bacterial meningitis was 100% (95% CI 99.5-100; vs 99.3%; 95% CI 98.4-99.7% of a BMS value of 2 or higher). Of the 758 children diagnosed with aseptic meningitis, 639 had a MSE value = 0 (84.3%, 95% CI 81.5-86.7; vs 390, 51.4%, 95% CI 47.9-55.1% children with BMS=0).

Conclusion(s): The MSE accurately distinguishes bacterial from aseptic meningitis in children with cerebrospinal fluid pleocytosis. To include PCT and CRP increases the performance of the BMS.

Background
Life threatening hemorrhage accounts for 40% of mortality in trauma patients worldwide. Trauma is therefore the leading cause of death in patients aged 1-44 and in both civilian and military setting the most common cause of preventable death. After bleeding control is achieved, volume loss has to be restored. The positive effect of early in hospital transfusion of blood or blood components in equal proportions (1:1:1) is already proven but the scientific proof for the efficacy in the prehospital setting is still absent as a result of lack of randomized control trials.

Objective
Prove that prehospital transfusion of blood products is safe and effective on patients with extensive blood loss

Methods
Four databases have been searched: CINAHL, Cochrane, EMBASE and Pubmed in the period 1988 till March 2018.  After manually removing duplicates 2573 articles were screened on title and abstract by at least 2 reviewers. Articles were excluded when complied with the following exclusion criteria: no blood or blood products administered, animal study, no prehospital setting and no original data. 240 articles were subsequently screened on full text. Finally, a total of 48 articles have been included. Data was analyzed by meta-analysis for mortality.

Results
There was no significant difference in total mortality OR 1.09, 95% CI  [0.89, 1.33] or 24-hour mortality OR 0.93; 95% CI [0.64, 1.34]  for patients who received prehospital blood products, compared to standard care with crystalloids. A total of 4739 patients were transfused and 3 of them developed a complication which was possible the result of the transfusion (0.07%). Thirteen included studies advice the use of fluid warmers before transfusion.

Conclusion
The administration of blood products in the prehospital environment is safe, seems feasible but proof of efficacy is lacking.  Blood products have to be administered in equal proportions and heated before transfusion to minimize the risk to worsen hypothermia. Larger and randomized studies are required to demonstrate a statistically significant effect of the use of combined use of blood products.