Sunday 13 October
11:30 OPENING REGISTRATIONS
13:00

Sunday 13 October

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A11
13:00 - 14:30

Toxicology
When Nature strikes back
Toxicology

Moderators: Kurt ANSEEUW (Medical doctor) (Antwerp, BELGIUM), Christian HOHENSTEIN (PHYSICIAN) (Madgeburg, GERMANY)
13:00 - 14:30 Mushroom poisonings in Europe. Davide LONATI (MD, Clinical Toxicologist, Invited speaker) (Pavia, ITALY)
13:00 - 14:30 Rare but deadly plant poisonings. Robin FERNER (UK)
13:00 - 14:30 Palytoxin, tetrodotoxin and ciguatera poisoning in Europe. Luc DE HARO (Head of the Toxicovigilance Unit) (Marseille, FRANCE)
CONGRESS HALL

Sunday 13 October

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B11
13:00 - 14:30

Research trail blazers
Research

Moderators: Pr Rick BODY (Professor of Emergency Medicine) (Manchester, UK), Simon CARLEY (Consultant in Emergency Medicine) (Manchester, UK)
13:00 - 13:30 Research is everyone's business. Barbra BACKUS (Emergency Physician) (Leiden, THE NETHERLANDS)
13:30 - 14:00 Is science dead in the era of charisma based medicine? Pr Yonathan FREUND (Emergency Physician) (Paris, FRANCE)
14:00 - 14:30 Evidence and commerce: clash of the titans or a match made in heaven? Colin GRAHAM (Director and Professor of Emergency Medicine) (Hong Kong, HONG KONG)
FORUM HALL

Sunday 13 October

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C11
13:00 - 14:30

EBEEM: Quick review of some topics

13:00 - 14:30 Syncope. Ruth BROWN (Speaker) (London, UK)
13:00 - 14:30 Weakness. Eric DRYVER (Consultant) (Lund, SWEDEN)
13:00 - 14:30 MetHb. Gregor PROSEN (EM Consultant) (MARIBOR, SLOVENIA)
13:00 - 14:30 Abscess. Nikolas SBYRAKIS (Specialty doctor) (Brighton, UK)
13:00 - 14:30 Hemochezia. Cornelia HARTEL (Medical Director of the ED, Consultant in EM, Director of Medical Education in EM) (STOCKHOLM, SWEDEN)
13:00 - 14:30 Kid w/rash. Veronique BRABERS (Emergency Physician) (Mol, BELGIUM)
SOUTH HALL 3AB

Sunday 13 October

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D11
13:00 - 14:30

YEMD - Other countries - other ideas
Important lessons from all over the world
International EM, Young Emergency Medecine

Moderators: Eva DIEHL-WIESENECKER (Physician) (Berlin, GERMANY), Rok PETROVCIC (Resident) (Maribor, SLOVENIA)
13:00 - 14:30 EM far from home. Eva DIEHL-WIESENECKER (Physician) (Berlin, GERMANY)
13:00 - 14:30 First EM residents in croatia. Bojana RADULOVIC (Emergency medicine specialist) (Zagreb, CROATIA)
13:00 - 14:30 Tunisa - daily struggle. Ikhlass BEN AICHA (résidente troisième année medecine d'urgence, étudiante en instance de thèse de doctorat en medecine) (TUNISIA, TUNISIA)
SOUTH HALL 3C

Sunday 13 October

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F11
13:00 - 14:30

ABSTRACTS SESSION

Moderators: Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, GREECE), Felix LORANG (Consultant) (Jena, GERMANY)
13:00 - 13:10 #18128 - OP001 Is there gender discrimination in acute renal colic pain management? .
OP001 Is there gender discrimination in acute renal colic pain management? .

Background: Pain is a widespread problem, affecting both men and women; studies have shown that women in the emergency department (ED) receive analgesic medication and opioids less frequently in comparison with men.
Objective: The purpose of this study was to examine the administration and management of analgesics by the medical/paramedical staff in relation to the patients' gender , and thereby to examine  the extent of gender discrimination in treating pain by  gender

Design: This is a single center retrospective cohort study which included 824 patients. As an acute pain model, we used renal colic, with a nephrolithiasis diagnosis confirmed by imaging. We recorded pain level by visual analog scale (VAS) and number of VAS examinations. Time intervals were calculated between admissions to different stations in the ED. We recorded the number of analgesic drugs given, type of drugs prescribed and drug class (opioids or others).  

Results: A total of 824 patients (414 women and 410 men) participated. There were no significant differences in age, ethnicity and laboratory findings. VAS assessments were higher in men than in women (6.43vs.5.90, p=0.001, respectively). More men than women received analgesics (68.8%vs.62.1%, p=0.04, respectively) and opioids were prescribed more often in men than in women (48.3%vs.35.7%, p=0.001). The number of drugs prescribed per patient was also higher in men compared to women (1.06vs.0.93, p=0.03).  A significant difference was found in waiting time length from admission to medical examination between non-Jewish women and Jewish women.

Conclusion:  We have observed differences in pain management between genders which could be easily interpreted as gender discrimination. Yet, these differences might also be attributed to other factors which are not based on gender discrimination but rather on gender differences.

Clinical implication: The medical and paramedical staff should be made aware that women might experience and express pain differently from men and diagnostic methods and treatment may need to be adapted accordingly.  

Naamany EVIATAR , Shachaf SHIBER (Tel aviv, ISRAEL), Rona ZUKER-HERMAN , Drescher MICHAEL
13:10 - 13:20 #18335 - OP002 Reducing Pain in Emergency Department by Using Veinous Blood Gas Instead of Arterious Blood Gas (VEINART study): a multicentic randomized controlled trial.
OP002 Reducing Pain in Emergency Department by Using Veinous Blood Gas Instead of Arterious Blood Gas (VEINART study): a multicentic randomized controlled trial.

Background: Arterial blood gas (ABG) analysis is integral to the assessment of critical illness, providing information on the etiology and severity of a disease process. Despite low rate of complications, the procedure can lead to major vascular damage such as thrombosis or pseudo aneurysm. Moreover, it is a painful procedure that can be challenging to perform. Due to the lack of evidence of benefit for the patient or the health care team of a venous blood gas rather than an arterial blood gas in the absence of suspicion of hypoxemia, arterial blood gas is currently the standard of care for the analysis of acid-base disorders. Indeed, among the university hospitals affiliated to the Paris Diderot University, 4 of the 5 emergency departments (ED) carry out ABG. Demonstration of the superiority of venous sample over arterial sample regarding pain could substantially modify current practices.

Objectives: The main objective of this study was to show the superiority of venous sampling in arterial sampling with respect to the patient's pain related to the collection of a blood gas in EDs.

Materials and methods: We performed a randomized multicenter prospective study that recruited from 4 emergency departments during two months period. Eligible patients were non-hypoxemic patients with an indication of ABG. The randomization and allocation were computer generated. The primary end-point was the average pain, in millimetres, according to a self-measurement (the Visual Analogue Scale), within 3 minutes of the blood sampling between the arterial puncture group and venous puncture group. The secondary end points were the convenience of the sampler, number of attempts needed to obtain a blood gas sample, number of different operators needed to obtain a blood gas sample and failure of the blood gas sampling procedure

Results: 113 patients were included: 55 in the control group and 58 in intervention group. The median [Q1;Q3] maximal pain felt by the patient within 3 minutes after the sampling, among the Visual Analogue Scale was respectively 40 [21;59] in arterial group and 18 [10.5;30] in venous group. The mean difference was 17.9 [CI95 9.6;26.3] (p<0.0001). The prescriber’s satisfaction in terms of diagnostic profitability of the blood gas did not differ between the two groups (p=0.25). Success on the first attempt was better in venous sampling: 93% (n=53) success versus 80% (n=44) in the arterial group (p=0.073). But the number of sampler change was the same in each arm (n=3, 5%). Almost half of sampler categorized the sampling as easy (n=24, 44%) or moderately easy (n=23, 41%) in the control group. Majority of sampler categorized the sampling as easy (n=30, 69%) or moderately easy (n=16, 28%) in the intervention group

Conclusion: Venous blood gas is less painful for patients, simpler for the health care team and provides sufficient biochemical information for the doctor in comparison with an ABG.

Trial registration: clinicaltrials.gov, NCT03784664. December, 24th 2018

Chauvin ANTHONY (Paris), Ghazali AIHAM, Enrique CASALINO, Nicolas JAVAUD, Sonja CURAC, Jerome LAMBERT, Patrick PLAISANCE, Damien ROUX
13:20 - 13:30 #18503 - OP003 Inhaled versus intravenous opioid dosing for the initial treatment of severe acute pain in the emergency department : pharmacological intermediate results of the CLIN-AEROMORPH french study.
OP003 Inhaled versus intravenous opioid dosing for the initial treatment of severe acute pain in the emergency department : pharmacological intermediate results of the CLIN-AEROMORPH french study.

Background: Intravenous morphine titration (IVMT) is the gold standard for opioid treatment in the Emergency Department (ED). Nebulized morphine titration (NMT) may represent an alternative without venous access. After a preclinical study on healthy volunteers, we test the hypothesis that NMT is at least as effective as IVMT to initially manage severe acute pain in the ED, supported by pharmacologic data. Methods/design: We designed a multicenter (10 French EDs), single-blind, randomized and placebo controlled trial (NCT03257319). Adults between 18 and 75 years with Visual Analog Scale (VAS) ≥ 70/100 or Numeric Rating Scale (NRS) ≥ 7/10 will be enrolled.  850 patients will be randomized in two groups to compare two routes of MT as long as VAS > 30 or NRS > 3. In group A (425), patients will receive an initial NMT during 5 to 25 minutes. In group B (425), patients will receive initial standardised IVMT.  NMT is defined as a minimum of one and a maximum of three 5-minute nebulized boluses of 10 mg or 15 mg (weight ≥ 60 kg), at 10-minute fixed intervals. IVMT is defined as a minimum of one and a maximum of six boluses of 2 mg or 3 mg (weight ≥ 60kg), at 5-minute fixed intervals. In both groups, after 25 min, routine IVMT will be continued until pain relief if necessary. The primary outcome is the rate of relief 1 hour from the start of drug administration. Complete pain relief in both groups will be compared ( non-inferiority design). Secondary outcomes are pain relief at 30 minutes and at 2 hours and median pain relief. We will compare final doses, and study the feasibility and tolerance of NMT (major and minor respiratory, hemodynamic or neurologic effects). In addition, we decided to perform a supplementary pharmacokinetic (PK) and pharmacodynamic (PD) study to assess the NMT characteristics. Thirty patients from group A will be included in a single-center analysis for a NMT modelling objective. Morphine, Morphine-3-betaglucuronide and Morphine-6-betaglucuronide will be measured at minimum 6 and maximum 7 study times (T0-T5-T10-T20-T30-T60-120). A intermediary PK/PD analysis at the tenth patient is provided. Results: The multicentre clinical study is still in progress. The PK/PD intermediary analysis shows that morphine concentration are therapeutic concentrations and are similar than the expected concentration with IVMT, for mean concentrations and dispersion (1-120 ng/mL, 4-19,5 ng/mL for the peak concentration). Metabolites ‘concentrations analysis suggest hepatic metabolism of morphine by this route of administration. Discussion and Conclusion: This trial is the first multicenter randomized and controlled NMT protocol for severe pain in the ED using the titration concept. We propose an original approach of combined titration with an endpoint at 1 hour and non-inferiority design supported by pharmacologic early data that have established the NMT relevance. The PK/PD NMT study highlights the possibility of future organisational improvements for MT access in the ED.

Virginie Eve LVOVSCHI (Rouen), Justine JOLY, Nicolas LEMAIRE, Pauline CANAVAGGIO, Maxime MAIGNAN, Luc-Marie JOLY
13:30 - 13:40 #18806 - OP004 Analysis of bedside determinisms leading to under-prescription of morphine titration in the Emergency Department: EPIMORPH study.
OP004 Analysis of bedside determinisms leading to under-prescription of morphine titration in the Emergency Department: EPIMORPH study.

Background: Morphine Titration (MT) is the gold standard for severe acute pain management in the Emergency Department (ED) in France. Guidelines suggest its ubiquitous use for adults with Visual Analogue Scale (VAS) ≥60/100, or Numeric Rating Scale (NRS) >6/10 at admission. Despite recommendations oligoanalgesia remains problematic and opiate prescription is rare in the ED. Pain management by protocol at ED admission is presented as the best solution. However, physicians’ adherence to protocol, as bedside determinisms of prescription of morphine titration, is poorly investigated. Objectives: 1-Evaluate the prevalence of MT among eligible patients according to French guidelines. 2- Collect real-time data on the reasons for morphine non-titration (MNT) at the bedside, regarding patients, physicians and ED organisation. 3-Evaluate the adherence of physicians to MT protocol outside the care environment 4- Identify factors statistically associated with MNT. Methods: We conducted a 1-month single-centre cross-sectional study in our university ED, including patients with VAS≥60 (or NRS≥6) on initial nurse evaluation. We aimed to evaluate the prevalence of MT and to identify real MNT determinisms among 37 items (from preliminary focus groups and literature analysis). The data collected were divided into 6 subclasses: morphine contraindications, morphine non-indications, decision for other analgesic treatments, decision for reassessment of pain, opiophobia and other prescribing fears, care environment related-issues. In a simultaneous study, to estimate the ideal rate of MT, a real-time blind assessment of the records by non-prescribing senior physicians of the patient was performed. Then a 3-month case-control study was conducted to identify associated factors with MNT. A bivariate analysis was performed involving 8 variables: Age, gender, initial VAS/NRS levels, route of admission and discharge, diagnosis, prescriber’s gender and grade. Results: 164 patients (women 54.2%, mean age 45.9 years) were included in the cross-sectional study with mean VAS 75.5/100 (SD = 13.1). MT prevalence was 6.1% CI95% [2.4-9.8]. The three main reasons for MNT were: subjective physician-reduced VAS (45.7%), priorization for lower analgesic levels (33.5%) or for non-analgesic etiological treatment (12.8%). In the “blind reading” study, the ideal rate of titration was 18.3% CI95% [11.5-27.7]. 50 cases (titrated patients) and 154 controls (non-titrated) were compared: The factors significantly associated with MNT were: personal route of admission (OR = 4.6, p <0.001), discharge home (OR = 8.5 <0.001), physician low grade (OR = 2.0 p = 0.03), and initial low VAS (OR = 1.7, p <0.001). Discussion and conclusion: Physicians demonstrated poor adherence to a ubiquitous MT protocol based on initial nurse VAS or NRS evaluation, even outside care environment considerations (6.1% to 18%). They used other cognitive paths to decide MT prescription: intuitive pain assessment, paracetamol therapeutic tests, first evaluation of etiological treatment. The relevance of systematic MT is particularly challenged by young physicians, and when patients are in ambulatory care pathways. MT is safe and effective for the relief of severe pain in the ED but a single VAS evaluation at admission is not favored by physicians as the main trigger for current decisions of MT.

Virginie Eve LVOVSCHI (Rouen), Karl HERMANN, Hugo MOCELIN, Luc-Marie JOLY, Marie-Pierre TAVOLACCI
13:50 - 14:00 #18973 - OP006 Methoxyflurane in the emergency department; a brief summary of our experiences.
OP006 Methoxyflurane in the emergency department; a brief summary of our experiences.

Introduction

In the Emergency Department at Bedford Hospital methoxyflurane, a halogenated ether aneasthetic agent, has been used as an alternative to procedural sedation since December 2017. This study aimed to evaluate a number of factors relating to its scope of use, efficacy, adverse events and discharge time post procedure.

Method

A convenience sample of patients who received methoxyflurane for analgesia to allow a procedure had prospective data collected by the treating clinician from December 2017 to March 2019. A standard data collection sheet was used, collected and analysed by the researchers. Data collected included pain score prior to administration, at 1 minute after the administration of methoxyflurane started and at 15 minutes. Data on adverse outcomes, success or failure of procedure, administration and discharge times, and user comments was also collected.

Results

60 uses of methoxyflurane were recorded. The most common indication for use was shoulder dislocation (n=19), followed by reduction of colles fractures (n=13) and manipulation of ankle fracture/dislocations (n=10). 6 cases were deemed ‘failure of procedure’. Of these 4 were shoulder relocations, 1 ankle fracture/dislocation, 1 hip dislocation. There was 1 adverse event, with a patient feeling ‘dizzy’.

Pain score was recorded in 55 cases. The mean pain score prior to administration of pentrhox was 8, the mean pain score at 1 minute following the start of adminstration was 5 and the mean pain score at 15 minutes following the start of administration was 2.

Mean time to discharge from adminstration in those cases not requiring admission (n=15), or a second procedure (n=6) was 53 minutes.

Conclusions and Discussion

Although this is a small data set from a single centre, we feel that methoxyflurane has proven itself an effective form of pain relief, allowing for a wide range of procedures to be carried out without the need for  procedural sedation.

The failure rate seems acceptable at approximately 10% whilst it appears to be generally well tolerated by patients, with only 1 minor adverse event in our data set. Discharge post procedue is prompt and the average is below the minimum 1 hour timeframe recommended for procedural sedation

Richard AUSTIN, Lakshmi GANGADHARAN, Dr Nicholas WHITLOCK (Bedford, UK)
14:00 - 14:10 #19255 - OP007 Non-medical Use of Opioids among the Teenage Population.
OP007 Non-medical Use of Opioids among the Teenage Population.

Objectives: The misuse of prescription opioids has evolved into a national emergency in the United States (U.S.). According to the 2017 National Survey on Drug Use and Health, approximately 2 million individuals misused prescription pain relievers for the first time within the past year. According to the Monitoring the Future Survey, among youth ages 12 to 17, 4.9 percent reported past-year nonmedical use of prescription medications. Prescription opioid misuse among teenagers occurs as this population believes that they are safer than illegal substances as they are prescribed by a healthcare professional. This study examines the trends in intentional opioid exposures among teenagers reported to U.S. poison centers (PCs).

Methods: The National Poison Data System (NPDS) was queried for all intentional opioid exposures in patients between 13 and 19 years from 2012 to 2018. We descriptively assessed demographic and clinical characteristics. Calls from acute care hospitals and emergency departments (ACH) were studied. Poisson regression models were used to evaluate the trends in the trends in teen intentional opioid exposures. Percent changes from the first year of the study (2012) were reported with the corresponding 95% confidence intervals (95% CI).

Results: Among 651,882 teen exposures reported to the U.S. PCs during the study period, 39,398 (6%) involved opioids. While the overall teenage exposure calls increased, opioid-related calls decreased (6,211 to 4,487). Among the teen opioid exposures, 72.9% were directly reported by ACH. Cases were predominantly females (62.3%). The residence was the most common site of exposure (91.4%). Multi-substance exposures accounted for 56.2% cases, with the prevalence increasing during the study period (53.9% to 58.7%). Most intentional teenage exposures were attributed to suspected suicides (65.7%) with one-fifth cases reporting abuse. Major clinical effects were seen in 5.3% teen opioid exposures and there were 174 deaths. Among cases, 18.1% were admitted to a critical care unit (CCU) while 22.3% were admitted to a psychiatric facility. The proportion of cases from ACH increased during the study period (65.9% vs 78.6%). Hydrocodone (36.1%) was the most common opioid reported in intentional teen opioid cases followed by tramadol (19.2%). Benzodiazepines were the most common non-opioid co-occurring substance reported for cases (13.5%). The most frequent clinical effect demonstrated was drowsiness (40%), while tachycardia (21.9%) and vomiting (15.7%) were commonly seen. Naloxone was used in 15.7% of cases. In approximately 40% of the cases, these therapies were used after recommendations from the PCs. Intentional teenage exposures decreased by 27.8% (95% CI: -30.5, -25.7%, p<0.001) during the study period.

Conclusions: The current study used data from a national real-time poison system and demonstrated that the teenage opioid exposures due to intentional reasons decreased during the study period. These trends parallel the stabilizing opioid prescribing rates as well as several state and federal public health prevention efforts.  Suspected suicides were the predominant reason for such exposures. The proportion of exposures from acute care hospitals and hospital-based EDs increased. Greater educations efforts, recovery support and behavioral approaches are key in tackling this issue in the teen population.

Saumitra REGE (Charlottesville, VA, USA), Dr Christopher HOLSTEGE
14:10 - 14:20 #19302 - OP008 A randomized, double blind placebo-controlled study of methoxyflurane plus standard of care analgesia versus placebo plus standard of care analgesia for moderate to severe pain associated with trauma (The PenASAP Study).
OP008 A randomized, double blind placebo-controlled study of methoxyflurane plus standard of care analgesia versus placebo plus standard of care analgesia for moderate to severe pain associated with trauma (The PenASAP Study).

Background: Oligo-analgesia is common in the emergency department (ED). Methoxyflurane (Penthrox®), a non-opioid, self-administered, analgesic is approved in Europe for the emergency relief of moderate to severe pain in trauma patients. This study aimed at demonstrating the superior efficacy of Methoxyflurane (Penthrox®) + standard of care (SoC) analgesia (multimodal analgesia) over placebo + SoC for the management, at emergency department (ED) admittance, of moderate to severe pain secondary to trauma.

Methods: A randomised, double-blind, multicentre, placebo-controlled trial conducted at eight EDs in France between May and December 2018. Eligible patients were alert subjects (≥18 years) admitted to ED for pain secondary to trauma [pain score ≥4 on the 11-point numerical rate scale (NRS) at admission]. Patients were randomised to receive either one or 2 inhalers containing each 3 mL of methoxyflurane or 5 mL of matched placebo in association with SoC. Randomization was stratified by gender, centre and pain score at baseline (moderate pain: NRS 4-5; severe pain: NRS 6-10). The primary endpoint was the time until pain relief (PR) defined by the duration between the start of the study treatment (T0) and pain relief (≤ 30 on the visual analogic scale (VAS). VAS was assessed electronically on tablets devices at least at 5, 10, 15, 20, 30, 60, 90 and 120 min.

Results: 359 patients were randomised and 351 were analysed for efficacy (178 Penthrox®; 173 placebo). Baseline characteristics were comparable between groups with a median VAS at T0 of 66 mm and 263/351 (75%) patients with severe pain. Main trauma localisations were upper limb (43%) or lower limb (35%) and main type of injury were contusion (34%), fracture (20%), sprain (19%), or wound (17%). Median time to PR was 35 min (95% CI: 28 to 62) in the Methoxyflurane-SoC group and not reached (NR) in the SoC-placebo group (92 to NR) [HR=1.93 (1.43; 2.60), p <.001]. Efficacy increased in the severe pain subgroup with a hazard-ratio (HR) at 2.52 (1.71: 3.72). The proportion of responders (VAS decrease > 30%) at 60 mn was 76% (n=135/178) in the Methoxyflurane -SoC vs. 55% (n=94/172) in the SoC-placebo group, p<0.01. 67/178 (37.6%) in the Methoxyflurane-SoC group and 47/173 (27.2%) in the SoC-placebo group did not received any SoC analgesia. 6/178 (3.4%) in the Methoxyflurane -SoC group and 9/173 (5.2%) in the SoC-placebo group received strong opioids. Two severe adverse events (AEs) occurred in the Methoxyflurane-SoC group including one that was assessed as related to treatment and most AEs (diziness, feeling drunk, somnolence) were of mild (111/147) or moderate intensity (34/147).

Discussion & conclusions: This double-blind controlled trial demonstrated that Penthrox® in multimodal analgesia is superior to SoC-placebo in achieving pain relief for trauma patients. The results confirm the rapid onset of action of Penthrox®. Treatment efficacy increased in patients with severe pain.

 

Agnès RICARD-HIBON (Pontoise), Nathalie LECOULES, Dominique SAVARY, Eric WIEL, Frédéric ADNET, Marion DOUPLAT, Patrick DESCHAMPS, Karim TAZAROURTE, Laurent JACQUIN
14:20 - 14:30 #19398 - OP009 Procedural sedation and analgesia in a Belgian Emergency Department: an observational cohort study.
OP009 Procedural sedation and analgesia in a Belgian Emergency Department: an observational cohort study.

Aim:

To describe the indications, used medication and safety of procedural sedation in a Belgian University Hospital Emergency Department.

 

Methodes:

We performed a prospective observational cohort study of all patients who underwent procedural sedation and analgesia in a Belgian Emergency Department between April 2017 and April 2018. Standardised forms were used to collect data on patient demographics, indication, performed procedures, used medication and the occurence of adverse events classified by the SIVA adverse event reporting tool.

 

Results:

171 patients were included in the study. Median age was 53 years, 56% were male. 40% of patients were ASA class 1, 37% were ASA class 2 and 22% were class 3 or higher. The majority of the patients underwent procedural sedation for cardioversion (34%), reduction of fractures (30%) or dislocations (26%). Propofol and ketamine were the most frequently used medications. Adverse events occured in 12% of cases, mostly due to apnoea (33%), hypoxia (19%) and emesis (19%). All of the adverse events were transient. None of the patients suffered an adverse outcome.
Logistic regression analysis revealed ASA class 3 or higher as independent risk factor for adverse events.

 

Conclusion:

This Belgian cohort study supports the results of international studies showing that procedural sedation in the emergency department is safe, with a 12% adverse event rate and without occurence of adverse outcomes.

Laurens DE GRIM (Antwerp, THE NETHERLANDS), Hannelore RAEMEN, Koen MONSIEURS
TERRACE 2B
14:30 COFFEE BREAK AND EXHIBITION - E-POSTER SESSION
15:00

Sunday 13 October

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A12
15:00 - 16:30

Emergency ultrasound
HOT TOPIC SPEAKER!, Ultrasound

Moderators: James CONNOLLY (Consultant) (Newcastle-Upon-Tyne, UK), Senad TABAKOVIC (Zürich, SWITZERLAND)
15:00 - 16:30 HOT TOPIC SPEAK! Ultra smart and sound approach to kids. Dr Kasia HAMPTON (Emergency Department Medical Director) (USA/Poland, USA)
15:00 - 16:30 Nerve Blocks that you should learn in the ED - "No pain.. No pain". Dr Nicolas LIM (Intensive Care Fellow) (Dublin, IRELAND)
15:00 - 16:30 Dead or Alive? Ultrasound and fluid responsiveness. David MACKENZIE (co-Director of Emergency Ultrasound) (Portland, USA)
15:00 - 16:30 FAST is not FAST enough for 2019. Pr Joseph OSTERWALDER (Head of Hospital) (St. Gallen, SWITZERLAND)
CONGRESS HALL

Sunday 13 October

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B12
15:00 - 16:30

Sex and the Emergency Department
How the Emergency Physician Can be Involved
Genitourinary

Moderators: Cornelia HARTEL (Medical Director of the ED, Consultant in EM, Director of Medical Education in EM) (STOCKHOLM, SWEDEN), Andy NEILL (Doctor) (Dublin, IRELAND)
15:00 - 16:30 One night stand - post exposure prophylaxis - case scenarios. Pr Christian BACKER-MOGENSEN (Professor) (Aabenraa, DENMARK)
15:00 - 16:30 Techniques that went wrong - challenging procedures for the Emergency Physician. Andy NEILL (Doctor) (Dublin, IRELAND)
16:00 - 16:30 Chemsex. Gareth ROBERTS (Doctor) (Manchester, UK)
FORUM HALL

Sunday 13 October

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C12
15:00 - 16:30

Fake news, fake science, fake quality - true leadership
Leadership and quality in Emergency Medicine
Leadership, Quality, Research

Moderators: Dr John HEYWORTH (Consultant) (Southampton, UK), Dr Barbara HOGAN (Past President of the European Society for Emergency Medicine, EuSEM) (HAMBURG, GERMANY)
15:00 - 16:30 Goal framing from in the Senate of Ancient Rome to the floor of a modern ED. Jan STROOBANTS (Head of the Emergency Department) (Brecht, BELGIUM)
15:00 - 16:30 Abuse of the "science“ label. Colin GRAHAM (Director and Professor of Emergency Medicine) (Hong Kong, HONG KONG)
15:00 - 16:30 Abuse of the "quality" label. Dr Ian HIGGINSON (Emergency Physician) (Plymouth, UK)
SOUTH HALL 3AB

Sunday 13 October

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D12
15:00 - 16:30

YEMD - Doing the basics right
Everything starts with the basics - here you will learn stuff to change your daily practice.
Basics, Burns, Drugs, INTERACTIVE SESSION, Psychiatric, Pulmonary, Young Emergency Medecine

Moderators: Aleks SUSTAR (EM Resident) (Maribor, SLOVENIA), Dr Pieter Jan VAN ASBROECK (Consultant in Emergency Medicine) (Genk, BELGIUM)

15:00 - 16:30 Dealing with IV drug users. Tereza RADL (Doctor) (Prague, CZECH REPUBLIC)
15:00 - 16:30 Out of my mind - psychiatric emergencies. Wilma BERGSTRÖM (Nurse, medical student) (Berlin, GERMANY)
15:00 - 16:30 Oh baby! Rule out PE in pregnany. Dr Thomas MOUMNEH (Fellow) (Angers, FRANCE)
15:00 - 16:30 Treating burns right! Katarina VESELA (doctor) (Prague, CZECH REPUBLIC)
SOUTH HALL 3C

Sunday 13 October

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F12
15:00 - 16:30

ABSTRACTS SESSION

Moderator: Bulut DEMIREL (Emergency Department Chief) (Ankara, TURKEY)
16:20 - 16:30 #19355 - OP010 PAEDIATRIC TORUS FRACTURES OF THE DISTAL RADIUS: AUDIT OF A UNIVERSITY HOSPITAL APPROACH.
OP010 PAEDIATRIC TORUS FRACTURES OF THE DISTAL RADIUS: AUDIT OF A UNIVERSITY HOSPITAL APPROACH.

Background:

Torus or buckle fractures of the distal radius are the most common forearm fractures in children. Because of their inherent stability and few complications, recent guidelines have recommended treatment with non-rigid removable immobilisation devices instead of rigid cast immobilisation. Routine follow-up consultation and radiographic exams are also questioned and deemed unnecessary. This newer approach may have multiple advantages, such as patient and parent convenience, improved wrist functionality and overall cost reduction. The main purpose of this study was to audit a university hospital approach to children with torus fractures of the distal radius, to assess whether recommendations are followed.

Methods:

This study was a retrospective cohort study and evaluated children under 18 years old who presented with a suspected fracture of the wrist or the distal forearm to the emergency department (ED) of the Ghent University Hospital in 2016 and 2017. A subgroup analysis was done for children treated for torus fracture of the distal radius. Diagnosis, treatment and follow-up were evaluated. Proportions of children treated with a non-rigid removable immobilisation device and median numbers of follow-up consultations and x-rays were examined. To explore diagnostic difficulties, inter-observer variability between 2 experienced investigators who reviewed all radiographic images was assessed using kappa statistics. Finally, comparison was done with findings from the literature.

Results:

In total, 205 children with a suspected distal forearm fracture were included. Thirty-nine of them were treated as a torus fracture at the ED, regardless of the correctness of the diagnosis. Diagnosing torus fractures by physicians at the ED had sensitivity, specificity, positive and negative predictive values of 55%, 90%, 56% and 89% respectively. Inter-observer variability assessment between the 2 reviewers showed a Cohen’s kappa score of 0.64 (95% CI of 0.38-0.55), meaning a rather poor or moderate agreement, depending on the guideline. All patients with a suspected torus fracture of the distal radius were treated with a rigid non-removable plaster backslab. Most of them had at least 2 routine follow-up consultations and 1 radiographic exam. Besides prolonged discomfort in 3 patients, no serious fracture-related complications occurred in the torus fracture group. Four patients (10%) however had a material related complication.

Discussion & Conclusions:

This audit of a university hospital approach to paediatric torus fractures of the distal radius showed a conservative approach without the use of non-rigid removable immobilisation devices and with several routine follow-up consultations and x-rays. These findings were also found by other institutions, that described several barriers towards an implementation of recently published recommendations and guidelines. Similarly to other studies that mentioned a significant rate of missed and misdiagnosed torus fractures, this study found diagnostic difficulties. To summarise, recent guidelines for the treatment of torus fractures of the distal radius are not followed. These findings may stimulate intra-hospital multidisciplinary discussion to improve diagnostic accuracy and patient management. They may also guide further research, in which focus may be switched from torus fractures towards all stable forearm when assessing diagnostic and therapeutic possibilities, which may be more feasible given the diagnostic difficulties.

Klaas VANDERBIEST (Ghent, BELGIUM), Patrick VAN DE VOORDE
15:00 - 15:10 #18222 - OP011 Can we combine clinical decision rules to reduce imaging of the cervical spine in trauma? A prospective pilot study.
OP011 Can we combine clinical decision rules to reduce imaging of the cervical spine in trauma? A prospective pilot study.

Can we combine clinical decision rules to reduce imaging of the cervical spine in trauma?
A prospective pilot study.

E.J. van Leest, MD, Resident Emergency Physician, D.S.E Varin, MD Emergency Physician, A.V. Brown, MD, Emergency Physician, E.Birnie, PhD, Statistician. Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands.  Designated speaker: E.J. van Leest.

Abstract
Introduction The National Emergency X-Radiography Utilization Study low risk (NEXUS) criteria and the Canadian C-spine (CCS) rule are validated  rules with high specificity and negative predictive values to evaluate the need for radiography. Dr. Scott Weingart proposed/suggested a combined NEXUS-CCS rule as optimal. Aim of our study is to investigate whether the diagnostic characteristics of the combined NEXUS-CCS rule  is comparable or better  than the separate/single NEXUS and CCS rules.
Methods This is a prospective pilot study (n=99) of adult patients with suspicion of cervical spine injury by using NEXUS criteria, presenting at the Emergency Department (ED). The NEXUS, CCS and NEXUS-CCS rule were scored before Computed Tomography (CT). CT outcome and treatment were noted. The CT amounts, negative predictive values and NRI were estimated.
Results  The incidence of cervical fracture was 3.0%. Two of the three patients had multiple fractures with a sum of 6 fractures. Dens fracture (n=1), anterior/posterior arch of C1 (n=2), fracture of calcificated anterior corpus ligament (n=2), fracture of anterior syndesmophyte (n=1). The amount of C spine CT’s was 64.6% [95% CI: 54.4-74.0] compared with 88.9% [95% CI: 81.0-94.3] with NEXUS and 62.6% [95% CI: 52.3-72.2] with CCS. Negative predictive value was 11.5% [95% CI: 5.9-19.6] for NEXUS, 37.5% [95% CI: 27.8-48.0] for CCS and 35.4% [95% CI 25.9-45.8] for NEXUS-CCS. An instable fracture was missed by NEXUS-CCS and the CCS rule alone due to a young frail M. Bechterew patient.
Conclusion Our small size pilot study suggests that the test characteristics of the combined NEXUS-CCS rule are comparable to the CCS rule alone and suboptimal compared to the NEXUS rule. The combined NEXUS-CCS rule cannot accurately diagnose, nor rule out, cervical spine injury. A refinement by adding an extra criteria to select patients with bone or muscle disease as high risk patients needs further investigation.

Keywords
Clinical decision rule, cervical spine injury, cervical spine fracture, trauma patients, imaging, cervical spine Computed Tomography (CT), NEXUS, Canadian C Spine rule.

 

 

 

 

Els VAN LEEST (Rotterdam, THE NETHERLANDS), Dorien VARIN, Vanessa BROWN, Erwin BIRNIE
15:10 - 15:20 #18410 - OP012 The risk of significant traumatic brain injury in adults with minor head injury taking direct oral anticoagulants: an observational cohort study.
OP012 The risk of significant traumatic brain injury in adults with minor head injury taking direct oral anticoagulants: an observational cohort study.

Background

Patients taking direct oral anticoagulants (DOACs) commonly undergo computed tomography (CT) head imaging after minor head injury, regardless of symptoms or signs. However, the risk of intracranial haemorrhage (ICH) in such patients is unclear, and further research has been recommended by the UK NICE head injury guideline group.

Methods

An observational cohort study was performed in 2 UK major trauma centres (Sheffield, Hull) between 26th June and 3rd September 2018. Adult patients taking DOACs with minor head injury were prospectively identified, with case ascertainment supplemented by screening of radiology and emergency department information technology systems. Clinical and outcome data were subsequently collated from patient records. The primary endpoint was adverse outcome within 30 days, comprising: neurosurgery; ICH; or death due to head injury. Adverse outcome risk was calculated overall; and for GCS 15 patients who did not meet NICE criteria for CT head imaging.

Results

169 patients with minor head injury were included (69% GCS 15, 31% GCS 14). Patients were elderly (median 82 years) and most frequently injured from ground level falls (96%). Overall risk of adverse outcome was 4% (7/169, 95%CI 2-8%). 7 patients had ICH, of whom 3 died. No patient received critical care management or underwent neurosurgical intervention. Risk of adverse outcome in patients who did not meet NICE imaging criteria was 2% (2/96, 95%CI 0-8%). Of these NICE false negative cases, one patient presented with GCS 15 and a headache; the other was GCS 15, asymptomatic, but fell >2m.

Conclusions

The risk of adverse outcome was low, particularly in patients not meeting NICE CT criteria. No patient with ICH underwent neurosurgery or received critical care, suggesting that imaging did not influence management. These findings would support shared patient-clinician decision making, rather than routine imaging, following minor head injury whilst taking DOACs.

Gordon FULLER, Rachel EVANS, Lisa SABIR, Luczawski MAXONE, Pr Suzanne MASON (Sheffield, UK)
15:20 - 15:30 #18435 - OP013 Ultrasound directed reduction of distal radial fractures.
OP013 Ultrasound directed reduction of distal radial fractures.

Introduction: Colles’ type distal radial (wrist) fractures are one of the commonest fractures seen in the Emergency Department (ED). Fracture displacement is usually associated with a fall onto an outstretched hand, especially in the elderly. These displaced fractures typically undergo manipulation under anaesthesia (MUA) in ED, undertaken ‘blindly’ without real time imaging. Inadequate fracture reduction or subsequent re-displacement of these injuries frequently results in surgical fracture fixation (closed MUA failure) and occurred in up to 30% of cases in small local audit. 

Use of ultrasound to guide distal radial fracture reduction as precisely as possible might reduce instability and subsequent need for surgery. We have therefore commenced a Royal College of Emergency Medicine (RCEM) funded project ('Ultrasound Directed Reduction of Colles' Type distal radial fractures - UDiReCT') to determine whether a large trial to assess the benefit and cost effectiveness of ultrasound guided fracture reduction is both justified and feasible. 

Methods: Firstly we have conducted a trainee led service evaluation of Colles’ type fracture ED management to estimate the ED MUA failure rate (surgery with 6 weeks of ED MUA) rate and current use of ultrasound, across 16 UK EDs over a two month period from February 2019. Only anonymous data was used and this evaluation was exempted from formal ethical approval after review by the sponsoring institution. All adult distal radial fractures were identified from radiology and ED databases over a two week case identification period and screened against defined eligibility criteria. We excluded those under 18yrs, patients with volar displaced (Smith's) fractures and those followed up elsewhere. All fractures undergoing ED MUA were followed up for 6 weeks to determine the subsequent need for surgery. This service evaluation is being followed by a single blind feasibility RCT, comparing ultrasound guided fracture reductions with standard care, in two models of care. Together with the service evaluation, this trial will determine the potential participant recruitment rate, test a definitive trial protocol and check data collection for a future full multicentre trial.

Results: 328 distal radial fractures were identified over the two week case identification period. Of these 89 patients underwent ED MUA with a subsequent need for surgery identified in 34 (39.5%) of 86 with follow up data. No sites routinely used ultrasound to guide reductions. Our conference presentation will outline findings from the service evaluation, speculate on why ultrasound might be beneficial and discuss the controversies and challenges in this field of research. We will then describe in detail the forthcoming UDiReCT RCT protocol and discuss opportunity for European collaboration.

Hamza MALIK, Pr Andrew APPELBOAM (Exeter, UK), Darryl WOOD, Gordon TAYLOR
15:30 - 15:40 #18659 - OP014 Methoxyflurane, an efficient and well tolerated analgesic for elderly patients, compared with standard analgesic treatment: subgroup analysis of a phase IIIb randomised, controlled trial (InMEDIATE).
OP014 Methoxyflurane, an efficient and well tolerated analgesic for elderly patients, compared with standard analgesic treatment: subgroup analysis of a phase IIIb randomised, controlled trial (InMEDIATE).

Background

Undertreatment of acute pain in the emergency setting remains a widespread problem, and elderly patients receive even worse pain treatments than others. The probability that these patients receive analgesic treatment is up to 20% lower than that of younger patients.

Low-dose methoxyflurane is an inhaled, rapid-acting, non-narcotic analgesic now approved in Europe that may overcome some barriers to effective pain management. There is, however, a lack of data from large, randomised, active-controlled trials.

Methods

InMEDIATE (EudraCT: 2017-000338-70; NCT03256903) was a Phase IIIb, open-label, randomised controlled trial conducted by the Pain Group of the Spanish Society of Emergency Medicine/Spanish Clinical Research Network in 14 Spanish emergency units from July 2017 to April 2018. We present a post hoc analysis in the subgroup of patients aged ≥65 years. At triage, adults with acute moderate-to-severe trauma pain (score ≥4 on the 11-point Numeric Rating Scale [NRS]) secondary to trauma were randomised 1:1 to receive inhaled methoxyflurane (up to 2´3mL vials) or SAT (standard analgesic treatment per each site’s own analgesic protocol) while in the unit. Exclusion criteria included use of analgesic for the acute traumatic pain before randomisation, and contraindications to analgesics to be used in the trial. Efficacy endpoints included change in NRS pain intensity (primary endpoint), and time to onset of pain relief (co-primary endpoint) for 20 min after start of treatment, and patient/clinician-reported outcomes, which were analysed in an exploratory manner for the elderly subgroup using 2-tailed t-tests.

 

Results

The elderly subgroup included 33 methoxyflurane-treated patients and 26 SAT-treated patients, (19.34% of the patients included in the whole trial) 30.5% males, mean±SD age 73.6±6,0 years with mostly fractures and/or contusions. 22 of 26 (85%) patients in the SAT group received non-steroidal anti-inflammatory drugs (mainly intravenously) and 4 received opioid analgesics. Mean (±SD) baseline NRS pain intensity was 8.10±1.62 in the methoxyflurane group and 7.28±1.97 in the SAT group. Mean decreases from baseline in NRS pain intensity at 3, 5, 10, 15 and 20 were 1.61, 2.37, 3.43, 4.04 and 4.78 for methoxyflurane and 0.60, 1.00, 1.81, 2.53 and 3.19 for SAT. The treatment difference was statistically significant in favour of methoxyflurane at all time points. Time to first pain relief was significantly shorter for methoxyflurane than SAT (5.55 vs. 12.38 min; difference: -6.43min; 95%CI: -10.27, -2.58, p<0.001), as was time to first meaningful pain relief (12.57 vs. 25.07 min; difference: -12.10min; 95%CI: -18.06, -6.14; p<0.001). Both treatments scored highly for patient and clinician satisfaction with the efficacy, comfort and safety of treatment (from 7.64±2.35 to 8,71±1.87). Clinicians rated methoxyflurane significantly better for comfort; difference 1,17 95%CI 0.52, 1.83; p<0,001. Methoxyflurane exceeded patient/clinician expectations of treatment in 70%/64% of cases versus 50%/31% for SAT. Adverse events were reported for 8 methoxyflurane-treated patients (dizziness -2-, drowsiness -2-, euphoria, oral itching, pain and sickness) and 3 SAT-treated patients (hospitalisation, nauseas and pain)

 

Conclusions

These results support consideration of methoxyflurane as a non-narcotic, easy-to-use, rapid-acting, first-line alternative to currently available analgesic treatments for elderly patients with trauma pain.

 

Rosa CAPILLA PUEYO, Cesareo FERNÁNDEZ ALONSO, Dr Sergio GARCÍA COLLADO (Valladolid, SPAIN), César CARBALLO CARDONA, Ignacio PÉREZ TORRES , Pere LLORENS SORIANO , José Ramón CASAL CODESIDO , María ARRANZ BETEGÓN , Luis AMADOR BARCIELA , Aitor ODIAGA , Anselma FERNÁNDEZ TESTA , Jorge TRIGO COLINA , Antonio CID DORRIBO , Isabel LÓPEZ ISIDRO , Susana TRASEIRA LUGILDE , Alberto M. BOROBIA PÉREZ
15:40 - 15:50 #18661 - OP015 Low dose of inhaled methoxyflurane is more effective with higher patient and clinician satisfaction than first-step intravenous analgesic treatment for acute trauma-related pain: subgroup analysis of a phase IIIb randomised controlled trial (InMEDIATE).
OP015 Low dose of inhaled methoxyflurane is more effective with higher patient and clinician satisfaction than first-step intravenous analgesic treatment for acute trauma-related pain: subgroup analysis of a phase IIIb randomised controlled trial (InMEDIATE).

Background

The use of opioids for treating pain in the emergency settings is a pillar of current options, however some health professionals are reluctant to prescribe opioids, which contributes to the problem of poor pain management. Therefore, there is an unmet need for a non-narcotic, rapid-acting, safe and effective analgesic. Inhaled methoxyflurane has recently been approved in Europe for the emergency relief of moderate-to-severe pain in conscious adults with trauma and associated pain. The InMEDIATE trial compared the pain relief achieved with methoxyflurane versus standard analgesic treatment (SAT), comprising any opioid or non-opioid analgesia by any route as defined per the pre-registered local analgesic protocol used in each site. The results of the trial shown that although patients included suffered a severe mean baseline pain, more than three quarters of the group (77.85%) were treated with intravenous non-opioids. Results of a post hoc subgroup analysis of methoxyflurane vs. intravenous non-opioid analgesia (IV-NOP) are reported here.

 

Methods

 

InMEDIATE (EudraCT: 2017-000338-70; NCT03256903) was a phase IIIb, open-label, randomised controlled trial conducted in 14 Spanish emergency units from July/2017 to April/2018. At triage, adults with acute trauma pain, NRS0-10 score ≥4, secondary to trauma were randomized 1:1 to receive inhaled methoxyflurane or SAT. Exclusion criteria included use of analgesic for the acute traumatic pain before randomisation, and contraindications to analgesics to be used in the trial. Efficacy endpoints included change in pain intensity (primary endpoint), and time to onset of pain relief (co-primary endpoint) for 20 min after start of treatment, and patient/clinician-reported outcomes. The treatments were compared in an exploratory manner using 2-tailed t-tests.

 

Results

156 patients received methoxyflurane and 104 IV-NOP, mean age 45.3±18.7 vs 45.5±18.2 years; 51% vs 43% male, and mean baseline pain scores 7.63±1.39 vs 7.48±1.55, respectively. In the IV-NOP group almost all patients (92,3%) received non-steroidal anti-inflammatory drugs [NSAIDs], ± other non-opioids ± diazepam). Other drugs were metamizole and paracetamol. Mean pain relief was significantly greater (p<0.001) for methoxyflurane than IV-NOP at all-time points, with the largest treatment difference at 10min (1.81; 95% CI: 1.31, 2.31). Mean changes from baseline to 3, 5, 10, 15 and 20min were 1.80, 2.73, 3.66, 4.20 and 4.73 for methoxyflurane and 0.56, 1.11, 1.84, 2.58 and 3.30 for IV-NOP. Time to onset of pain relief was significantly shorter for methoxyflurane than IV-NOP (mean 5.52 vs. 12.19min; difference: -6.26min; 95% CI: -8.28, -4.25min; p<0.001) as was time to first meaningful pain relief (mean 12.39 vs. 24.37min; difference: -11.58min; 95% CI: -15.22, -8.33min; p<0.001). Investigators and clinicians scored significantly better effectiveness and comfort with methoxyflurane vs IV-NOP (p<0,001) using a NRS0-10 scale. Methoxyflurane exceeded patient/clinician expectations of treatment in 75%/71% of cases vs. 40%/21% for IV-NOP. 24% methoxyflurane-treated patients and 4% of IV-NOP patients experienced adverse events. The most frequent event was dizziness (13,4%), mainly mild and transient.

 

Conclusions

Methoxyflurane provided superior pain relief to IV non-opioid analgesics in patients with acute trauma pain, with higher patient and clinician satisfaction with methoxyflurane treatment.

César CARBALLO CARDONA, Rosa CAPILLA PUEYO, Cesareo FERNÁNDEZ ALONSO, Dr Sergio GARCÍA COLLADO (Valladolid, SPAIN), Ignacio PÉREZ TORRES , Pere LLORENS SORIANO , José Ramón CASAL CODESIDO , María ARRANZ BETEGÓN , Luis AMADOR BARCIELA , Aitor ODIAGA , Anselma FERNÁNDEZ TESTA , Jorge TRIGO COLINA , Antonio CID DORRIBO , Isabel LÓPEZ ISIDRO , Susana TRASEIRA LUGILDE , Alberto M. BOROBIA PÉREZ
15:50 - 16:00 #18777 - OP016 Direct Oral Anticoagulants treatment and minor head injury: risk of early, delayed bleeding and severity of injuries compared to Vitamin K Antagonists.
OP016 Direct Oral Anticoagulants treatment and minor head injury: risk of early, delayed bleeding and severity of injuries compared to Vitamin K Antagonists.

Background: Direct Oral Anticoagulants (DOACs) are one of the novel treatments in clinical practice in decades. These drugs been proved to have analogue efficacy in thromboembolic prevention compared to Vitamin K Antagonist (VKAs) and have set doses with no requirement of require regular international normalisation ratio blood test monitoring. Those characteristics contributed to a rapid spread of DOACs in clinical practice. considering them a valid alternative to VKAs in patients requiring anticoagulation

Objective: to evaluate the differences in the risk of developing early, delayed as well global bleeding after a minor head injury among patients treated with DOACs compared to those treated with VKAs.

Methods: We performed a retrospective observational study on patient admitted to our Emergency Department from Jun 1st, 2017 to Aug 31st, 2018 due to a MTBI. All patients with a GCS score of 13-15, regardless of the presence of loss of consciousness (LOC) or amnesia immediately after the injury, were included in the study. All patients in AOT accessing to the ED receive an immediate CT brain scan (T0) and a second CT scan after 24 hours (T1) with a clinical observation period between the two exams before discharge from the ED. All the patients were then followed for the next 30 days for late ICH (T2) after discharge.

Results: during study period we enrolled 451 patients, 268 VKAs versus 183 DOACs. We did not observe significant differences in basal characteristics between the two groups of patients (DOACs vs. VKAs). 7.7% (14/183) of patients in DOACs presented an overall intracranial bleeding against 14.9 (40/268) of those receiving VKAs (p=0.026), while immediate bleeding was present in 5.5% (10/183) of patients in DOACs against 11.6% (31/268) of AVK patients (p=0.030). No difference was found in delayed bleeding (3.8 versus 2.3, p=0.570). No difference was showed between DOACs and AVK groups in neurosurgical treatment. Finally, none of the patients discharged at home after with negative CT scan after 24 hours ED observation presented ICH during the following 30 days.

The univariate analysis showed to be factors associated with a risk of global intracranial bleeding: AVK treatment, a high impact trauma, post-traumatic amnesi, loss of consciousness, a GCS lower than 15, presence of cranial fracture and a trauma beyond the clavicles. When subsequent multivariate analysis was performed, the risk factors confirmed as independent predictors of risk for a global intracranial haemorrhage in patients with an anticoagulant therapy were: AVK therapy (OR 2.327, p=0.024), high energy trauma (OR 11.229, p<0.001), amnesia (OR 2.814, p=0.017), loss of consciousness (OR 5.286, p=0.037), a GCS lower than 15 (OR 4.719, p=0.001) and the presence of an objectively lesion above the clavicles (OR 2.742, p=0.008).

Conclusion: patients treated with DOACs seem to present a lower risk of post-traumatic bleeding compared to patients treated with AVKs. Delayed bleeding, although not negligible, does not appear to aggravate the outcome of patients.

Gianni TURCATO, Massimo ZANNONI (VERONA, ITALY), Arian ZABOLI, Andrea TENCI, Norbert PFEIFER, Antonio MACCAGNANI, Dr Antonio BONORA, Giorgio RICCI
16:00 - 16:10 #19099 - OP017 Opioid-Related Suicide Attempts in the United States.
OP017 Opioid-Related Suicide Attempts in the United States.

Objectives: Suicides are a global phenomenon, with the World Health Organization estimating the annual mortality rate due to suicides to be 10.7 per 100,000 individuals. In Europe, self-harm attempts in 2015 exceeded 50,000. According to the Centers for Disease Control and Prevention, the rates of opioid-related suicides and unintentional overdoses doubled between 2000 and 2017 in the United States (U.S.). This study aims to characterize the opioid-related suspected suicide attempts (SSAs) that are reported to the U.S. National Poison Data System (NPDS).

Methods: The NPDS was queried for opioid-related SSAs that were reported to the U.S. poison centers (PCs) from 2011 to 2017. We identified and descriptively assessed the relevant characteristics of SSAs. Calls from acute care hospitals and emergency departments (collectively, hospitals) were studied. Poisson regression models were used to evaluate the trends in the number and rates (per 100,000 human exposures) of SSAs. Percent changes from the first year of the study (2011) were reported with the corresponding 95% confidence intervals (95% CI).

Results: Overall there were 184,645 opioid-related SSA cases reported to the U.S. PCs during the study period. Among these, 84% were directly reported by hospitals. Cases between 20 and 39 years (39.3%) constituted the most common age group. The proportion of older adults above 60 years of age almost doubled during the study period (7.4% to 14.2%). Females accounted for 63.8% of cases. Most exposures occurred in a residence (94.2%). More than one substance was reported for most cases (78.2%). Major clinical effects were demonstrated in 9.4% of exposures and the case fatality rate was 0.8%. Major effects were less common in teenagers (4.3%) and there were 92 deaths in this age group during the study period. Among cases, 33.2% were admitted to a critical care unit while 22.6% were admitted to a psychiatric facility directly from the emergency department. The proportion of cases from hospitals increased during the study period (80.4% to 86.4%). Hydrocodone (36.7%) was the most common opioid reported in SSA cases followed by tramadol (20.8%). Benzodiazepines were the most common non-opioid co-occurring substance reported for SSAs (28.9%). The most frequent clinical effect demonstrated was drowsiness (51.8%), while tachycardia (22.5%) and respiratory depression (10.3%) were commonly seen. Naloxone was used in 28.3% cases. In approximately one-fourth of the cases, naloxone was used after consultation and recommendation from the PCs. SSAs decreased by 24.4% (95% CI: -25.7, -23.1%, p<0.001) while the SSA rate also decreased by 16.5% (95% CI: -23.4%, -9.3%, p<0.001).

Conclusions: SSA cases handled by the PCs decreased significantly, however there was a rise in the older population. There was a low fatality rate.  The majority of calls originated from the hospitals or emergency department.  Hydrocodone and tramadol were the most common opioids reported for the sample. Personalized evidence-based strategies, population-level interventions, creation of protective environments, and better screening of patients at risk of suicide are some key measures to limit suicide attempts. PCs play a significant role in the care of this patient population and partner closely with emergency personnel.  

Saumitra REGE (Charlottesville, VA, USA), Heather A. BOREK, Marissa KOPATIC, Dr Christopher HOLSTEGE
16:10 - 16:20 #19229 - OP018 Head-to-head comparation of the Shock Index, Modified Shock Index, and Age Shock Index for predicting early mortality in major injury in prehospital scope.
OP018 Head-to-head comparation of the Shock Index, Modified Shock Index, and Age Shock Index for predicting early mortality in major injury in prehospital scope.

Introduction: Major injury is a time-dependent pathology in which the quantification of vital prognosis is fundamental for professionals. The objective of this study is to evaluate the ability of the Shock Index (SI), Modified Shock Index (MSI) and Age Shock Index (aSI) to predict early mortality (2 days) from the index event.

Material and methods: Prospective longitudinal longitudinal study, between April 1, 2018 and April 30, 2019. The study was developed on a reference population of 1,021,086 inhabitants, distributed in four provinces of Spain (Burgos, Salamanca, Segovia and Valladolid). All the hospitals included in the study have ICU and ample surgical capacity. It was considered that a patient fulfilled criteria to be included in the study if he had been attended by Advanced Life Support Units and transferred to the emergency services with major injury diagnosis, and did not meet any exclusion criteria: minors, cardiorespiratory arrest, death and pregnant women.

Demographic data (age and gender) and clinical parameters (systolic, diastolic, mean and heart rate) for the calculation of SI, MSI and aSI were collected during the first contact with the patient in prehospital care with the LifePAK® 15 monitor (Physio-Control, Inc., Redmond, USA).

The need for admission, the Intensive Care Unit and the mortality data were obtained by reviewing the patient's electronic history after 3 days.

The main dependent variable was mortality from any cause in the hospital before the first two days from the index event.

The area under the curve (AUC) of the receiver operating characteristic (ROC) was calculated for each scale in terms of 2-day mortality, as well as the best score that offered greater sensitivity and joint specificity.

Results: a total of 220 patients were included in our study. The median age was 62 years (IQR: 38-68 years), 35.9% of them were women. The 2-day mortality was 5.1% (11 cases). 18.6% (41 cases) of patients required ICU.

The AUROC obtained were SI (0.569, 95% CI: 0.38-0.75, p = 0.452), MSI (0.625, 95% CI: 0.44-080, p = 0.174) and aSI (0.775, 95% CI: 0.61-0.94; p = 0.019). The value with the best overall sensitivity and specificity for the aSI was 37.05, sensitivity of 90.9% (62.3-98.4), specificity of 67.0% (60.4-73.0), positive predictive value 12.7 (7.0-21.8), negative predictive value 99.3 (96.1-99.9), Likelihood ratio (+) 2.75 (2.10-3.60), Likelihood ratio (-) 0.14 (0.02-0.89) and odds ratio 20.29 (2.55-161.73).

Conclusions: The prehospital aSI has an excellent capacity to predict the early mortality of patients with major injury, and is a diagnostic tool, cheap, easy to obtain and reliable that can help in the clinical decision making, as well as in the selection of the center Hospital more suitable, with intensive care unit and surgical capacity.

Dr Francisco MARTÍN-RODRÍGUEZ (Valladolid, SPAIN), Raúl LÓPEZ-IZQUIERDO, Rodrigues LEONARDO, Maria Antonia UDAONDO CASCANTE, Virginia CARBAJOSA RODRÍGUEZ, Juan F. DELGADO BENITO, Miguel A. CASTRO VILLAMOR, José Ángel GUTIÉRREZ SEVILLA, Santiago OTERO DE LA TORRE, David GUILLÉN GIL, María Nieves DIEGO RASILLA, Pedro ARNILLAS GÓMEZ, Cristina VÁZQUEZ DONIS, Carmen DEL POZO PÉREZ, Ana Mercedes HUIDOBRO DEL ARCO, Carlos DEL POZO VEGAS
TERRACE 2B
16:40

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Infectious Disease & Sepsis
Common questions in the Emergency Department
Antibiotics, Sepsis

Moderators: Pr Christian BACKER-MOGENSEN (Professor) (Aabenraa, DENMARK), Maaret CASTREN (Professor) (HELSINKI, FINLAND)
16:40 - 18:10 Tropical diseases in travellers. Pr Christian BACKER-MOGENSEN (Professor) (Aabenraa, DENMARK)
16:40 - 18:10 Antibiotics are not automatic: how can we target antibiotic treatment? Pr Jim DUCHARME (President) (Mississauga, CANADA)
16:40 - 18:10 My Career in Pictures. Dr David CARR (Associate Professor of Emergency Medicine) (Toronto Canada, CANADA)
16:40 - 18:10 Rapid diagnosis in sepsis: is molecular pathogen identification the future? Dr Frank BLOOS (Consultant) (Jena, GERMANY)
CONGRESS HALL

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16:40 - 18:10

Medicolegal Emergency Medicine
Crime and dime: when the law meets Emergency Medicine
Medicolegal, Toxicology

Moderators: Kurt ANSEEUW (Medical doctor) (Antwerp, BELGIUM), Dr John HEYWORTH (Consultant) (Southampton, UK)
16:40 - 18:10 Perfect techniques of criminal poisoning. Andy NEILL (Doctor) (Dublin, IRELAND)
16:40 - 18:10 Drug facilitated rape. Pr Bruno MEGARBANE (Professor, head of the department) (Paris, FRANCE)
16:40 - 18:10 Welcome to the Coroner's Court. Dr Susie HEWITT (Consultant) (Derby, UK)
FORUM HALL

Sunday 13 October

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C13
16:40 - 18:10

NON-VITAL TRAUMA
Expert insights into the management of minor injuries in the Emergency Department
Innovation, Research, Trauma

Moderators: Dr Jean-Jacques BANIHACHEMI (MD PhD) (Grenoble, FRANCE), Alberto GREGORI (Consultant Trauma & Orthopaedic Surgeon) (Glasgow, UK)
16:40 - 18:10 Evaluation of the severity of ankle sprains, what to do? Dr Jean-Jacques BANIHACHEMI (MD PhD) (Grenoble, FRANCE)
16:40 - 18:10 Shoulder Examination, tips and tricks from an Emergency Medicine Perspective. Patricia O'CONNOR (UK)
16:40 - 18:10 Hypnosis as a way to decrease pain in non-vital traumatology. Franck VERSCHUREN (MD, PhD) (Brussels, BELGIUM), Nazmine GULER (Doctor) (Metz, FRANCE)
16:40 - 18:10 Quality and Safety approach to decrease medical errors in the management of non-vital trauma patients in the emergency department? Pr Abdelouahab BELLOU (Research) (Boston, USA)
SOUTH HALL 3AB

Sunday 13 October

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D13
16:40 - 18:10

YEMD - Revolutionaries! Go change EM!
We can shake things up - what do we need to know and do?
Management, Mythbusters, Young Emergency Medecine

Moderators: Martin FANDLER (Consultant) (Bamberg, Germany, GERMANY), Eeva TUUNAINEN (Emergency Medicine Registrar) (Kajaani, FINLAND)
16:40 - 18:10 Saving ourselves after traumatising situations: The EMPTY project. Isabel LUECK (Resident) (Hamburg, GERMANY)
16:40 - 18:10 This is how it always has been done! Eeva TUUNAINEN (Emergency Medicine Registrar) (Kajaani, FINLAND)
16:40 - 18:10 Mythbusters. Justus WOLFF (Medical Student) (Berlin, GERMANY)
SOUTH HALL 3C

Sunday 13 October

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F13
16:40 - 18:10

ABSTRACTS SESSION

Moderators: Roberta PETRINO (Head of department) (Italie, ITALY), Basak YILMAZ (Faculty) (Burdur, TURKEY)
16:40 - 16:50 #19114 - OP019 Tramadol Exposures Reported to the U.S. Poison Centers.
OP019 Tramadol Exposures Reported to the U.S. Poison Centers.

Background: There were more than 72,000 overdose-related deaths in the United States in 2017, with 68% of these fatalities involved opioids. Tramadol prescriptions increased by 88% between 2008 and 2013. Tramadol-related emergency department visits involving misuse or abuse of tramadol increasing by 250% between 2005 and 2011. This study aims to examine the national trends in tramadol exposures reported to U.S. poison centers (PCs).

Methods: The National Poison Data System (NPDS) was queried for all closed, human exposures to tramadol from 2012 to 2018 using the American Association of Poison Control Center (AAPCC) generic code identifiers. We identified and descriptively assessed the relevant demographic and clinical characteristics. Tramadol reports from acute care hospitals and EDs were analyzed as a sub-group. Trends in tramadol frequencies and rates (per 100,000 human exposures) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2012) were reported with the corresponding 95% confidence intervals (95% CI).

Results: There were 84,800 tramadol exposures reported to the PCs from 2012 to 2018, with the calls decreasing from 13,113 to 9,599 during the study period. Among the overall tramadol calls, the proportion of calls from acute care hospitals and EDs increased from 53.5% to 60.9% from 2012 to 2018. Multiple substance exposures accounted for 52.1% of the overall tramadol calls and 62.4% of the calls from acute care hospitals and EDs. The most frequent co-occurring substances reported were benzodiazepines (13.9%) and alcohol (8.9%). The residence was the most common site of exposure (95.7%) and 64.4% cases were enroute to the hospital when the PC was notified. Tachycardia and hypertension were the most frequently demonstrated clinical effects. Naloxone was a reported therapy for 7.9% cases, with this therapy being performed prior to PC contact in most cases. Demographically, 61.2% of cases were females, and the most frequent age groups were 20-39 years (33.1%) and 40-59 years (25.8%). Suspected suicides (45.3%) and intentional misuse (7.8%) were commonly observed reasons for exposure, with the proportion of suicides being higher in cases reported by acute care hospitals and EDs (66.2%). Approximately 18% of the patients reporting tramadol exposures were admitted to the critical care unit (CCU), with 11% of patients being admitted to non-CCU. Major effects were seen in 5.1% cases and the case fatality rate for tramadol was 0.5%, with 416 deaths reported. There were 208 deaths reported within acute care hospitals and EDs during the study period. The frequency of tramadol exposures decreased by 26.8% (95% CI: -28.8%, -24.8%; p<0.001), and the rate of tramadol exposures decreased by 20.7% (95% CI: -29.9%, -1.4%; p=0.002).

Conclusions: PC data demonstrated a decreasing trend of tramadol exposures, which may in part be attributed to the rescheduling of this medication by the Drug Enforcement Administration to Schedule IV in 2014. Our study demonstrated a significant proportion of tramadol exposures associated with suicide. Despite an overall decreasing trend in tramadol exposures, there was an increase in tramadol exposure reports from acute care hospitals and EDs during the same time period.

Saumitra REGE (Charlottesville, VA, USA), Jennifer ROSS, Dr Christopher HOLSTEGE
16:50 - 17:00 #18434 - OP020 Peripheral regional anesthesia in isolated environment : a French military medicine survey.
OP020 Peripheral regional anesthesia in isolated environment : a French military medicine survey.

Aim: The medicalization policy of the French armed forces places military general practitioners (MGP) near the front line, allowing soldiers to carry out their actions away from their base camp, while maintaining operational capacities. Thus, the activity is split between primary care and combat casualty care. Regional anaesthesia (RA) techniques could be useful in both cases. The aim was to assess the state of art of RA use among MGP and to track the limiting factors.

 

Procedure: we conducted a multicentric observational study, with MGP from metropolitan France that realized at least one mission during the last 3 years. Each one completed a questionnaire about experience, education and RA practice during the last mission. We used chi-square tests or Fisher exact test in case of insufficient number, to cross RA practice with demographic features, experience markers and mission’s characteristics. The threshold for significance was a p-value < 0.05.

 

Results: From October 2015 to December 2016, we collected 138 answers, of which 114 (83%) were included and analysed. Mean age was 33 ± 5, consistent with deployed MGP profile. RA scholar education concerned 42/114 (37%) MGP, whereas RA practice based on companionship concerned 94/114 (82%) of them. During their last mission, 26/114 (23%) MGP had performed at least one RA technique. The guidance technique was anatomical for 68/70 (97%) of procedures. Among all responders, 25/114 (22%) didn’t perform a RA technique even though they thought it was indicated. Their main reasons were lack of techniques’ mastery (38%), missing equipment (20%), time shortness (15%), and hygiene issues (12%). None of the tested factors were statistically associated with RA practice. Although senior MGPs tend to practice (p = 0.06) RA more, which seems to be consistent with previous data.

 

Conclusion: Environmental factors, patients recruitment and lack of techniques’ mastery seemed to be the main explanations of such a low practice rate. Development of RA techniques in a military environment should be associated with an adapted training that takes tactical background into consideration. It has to focus on what is feasible for primary care on one hand and combat casualty care on the other hand. Since it has been largely widespread on operations fields, and validated for RA techniques guidance in civilian practice, ultrasonography should be considered as a valuable aid in some cases. Even though RA education program has well been written for anaesthesiologists, a training program for MGPs for RA should be different and perhaps mainly based on clinical practice.

Thomas CHINIARD, Elise DIB, François GUÉNOT, Hugues LEFORT, Dr Abdo KHOURY (Besançon), Gaël CINQUETTI, Luc AIGLE, Christian LANDY
17:00 - 17:10 #18153 - OP021 Utility of a pre-hospital National Early Warning Score 2 as a prognostic tool in time-dependent diseases: a multi-center observational prospective cohort study.
OP021 Utility of a pre-hospital National Early Warning Score 2 as a prognostic tool in time-dependent diseases: a multi-center observational prospective cohort study.

Introduction: The time-dependent diseases represent one of the most frequent causes of attention by the Prehospital Emergency Medical Services (PhEMS), one of the most frequent reasons for hospital admission and one of the main potential causes of early mortality.The main objective was to evaluate the ability of the prehospital National Early Warning Score 2 (pNEWS2) to predict early mortality (before 48 hours) from the index event.

Material and methods: Multicentric prospective observational longitudinal study of cohorts, between April 1, 2018 and March 30, 2019. The study was developed on a reference population of 1,113,073 inhabitants, distributed in four provinces of Spain (Burgos, Salamanca, Segovia and Valladolid), in a geographical area of 41,403 km2. It was considered that a patient fulfilled criteria to be included in the study if he had been attended by Advanced Life Support and transferred to the Emergency Department, and did not meet any exclusion criteria: under 18 years old, cardiorespiratory arrest, exitus, pregnant women, patients with psychiatric pathology or terminal pathology or discharged in situ. Demographic data (age and gender), vital parameters (respiratory rate, oxygen saturation, heart rate, systolic blood pressure and body temperature), clinical observations (consciousness level and use of supplemental oxygen) were collected during the first contact with the patient in prehospital care.

The temperature was measured using the ThermoScan® PRO 6000 tympanic thermometer (Welch Allyn, Inc., Skaneateles Falls, USA), and the rest of the vital parameters with the LifePAK® 15 monitor (Physio-Control, Inc., Redmond, USA) .

Diagnosis and mortality data were obtained by reviewing the patient's electronic history at 3 days from the index event.

The main dependent variable was mortality from any cause in the hospital before the first 48 hours from the index event.

The area under the curve (AUC) of the receiver operating characteristic (ROC) of the pNEWS2 scale was calculated in terms of 2-day mortality as well as the best score that offered greater sensitivity and joint specificity.

Results: a total of 1466 patients were included in our study. The median age was 69 years (IQR: 54-81 years), 40.9% of them were women. The 2-day mortality was 5.6% (82 cases).

The AUCROC of pNEWS2 was 0.873 (0.82-0.92, p <0.001). The value with the best sensitivity and specificity overall was 9 points, sensitivity of 74.4% (64.0-82.6), specificity of 84.5% (82.5-86.3), positive predictive value 22.2 (17.7-27.5), negative predictive value 98.2 ( 97.3-98.8), Likelihood ratio (+) 4.81 (4.03-5.74), Likelihood ratio (-) 0.30 (0.21-0.44), odds ratio 15.88 (9.47-26.63) and diagnostic accuracy of 84.0% (82.0-85.8).

Conclusions: Being aware of the patient's physio-pathological situation is basic to managing the situation, where early diagnosis is essential.

The PhEMS should evaluate the implementation of pNEWS2 as a routine evaluation among its procedures, since it effectively serves to predict mortality from any cause and the detection of high risk patients at an early stage.

Dr Francisco MARTÍN-RODRÍGUEZ (Valladolid, SPAIN), Raúl LÓPEZ-IZQUIERDO, Carlos DEL POZO VEGAS, Jesús C. MINGUEZ BRAVO, María D. JÍMENEZ MARTÍNEZ, María J. SANTOS LARREGOLA, Cristina BOLON RODRÍGUEZ, José M. ACEBES REY, Gemma DE GRADO RODRÍGUEZ, Virginia CARBAJOSA RODRÍGUEZ, Germán FERNÁNDEZ BAYÓN, Juan F. DELGADO BENITO, Violante MÉNDEZ MARTÍN, Maria Antonia UDAONDO CASCANTE, Mario HERNÁNDEZ GAJATE, Rodrigues LEONARDO, Miguel A. CASTRO VILLAMOR
17:10 - 17:20 #18210 - OP022 Epidemiological profile of emergency medical services performance and regional variations in Japan: a nationwide population-based study.
OP022 Epidemiological profile of emergency medical services performance and regional variations in Japan: a nationwide population-based study.

Background: Emergency medical services (EMS) are key component of prehospital care. Evidence on EMS performance and its regional variation is limited. We sought to describe epidemiologic characteristics of ambulance transport to the emergency department (ED) and possible regional variations in Japan.

Methods: We conducted a nationwide, population-based, descriptive review of anonymized ambulance transport records in Japan. The EMS system in Japan is operated by local fire departments and is activated by phoning 119. The data were obtained from the Fire and Disaster Management Agency in Japan. All emergency patients transported to the emergency medical institution by EMS from January 1 to December 31 in 2016 were enrolled in this study. We excluded patients who were not transported. We described regional variations with eight divisions; Hokkaido, Tohoku, Kanto, Chubu, Kansai, Chugoku, Shikoku, and Kyushu/Okinawa regions.

Results: Over the study period, there were 5,707,177 transported to a hospital. The median age of the patients was 69 [interquartile range (IQR) 44-82] years and 50.6% of them were male. Patients aged over 65 years were 56.4%, and those aged 75 to 84 years were the largest group (22.3%). The median time duration from EMS call to EMS arrival on scene was 8 (IQR 6-10) minutes and that from EMS arrival to medical facility was 34 (IQR 27-43) minutes. The median time durations from EMS call to EMS arrival at the scene were similar among regions, which were ranged from 7 to 9 minutes. The longest median time duration from EMS call to hospital arrival was 38 minutes (Kanto region), whereas the shortest median time duration was 31 minutes (Chubu and Kyushu/Okinawa regions).

Conclusions: We demonstrated epidemiological profile of EMS performance and regional variations in Japan. In this nation-wide, population-based study, we found a wide regional variation in time to transport patients to medical facility.

Dr Shunichiro NAKAO (Osaka, JAPAN), Yusuke KATAYAMA, Tetsuhisa KITAMURA, Jotaro TACHINO, Takeshi SHIMAZU
17:20 - 17:30 #18412 - OP023 Developing and testing a set of prehospital outcome, quality and performance measures.
OP023 Developing and testing a set of prehospital outcome, quality and performance measures.

Background

Developing new prehospital quality and performance measures is important as previous outcome measures have mainly focussed on response times or on specific emergency conditions. There has been little work to identify what is important to patients and the public, or to identify measures that reflect the wide range of calls and conditions faced by the ambulance service.  The Prehospital Outcomes for Evidence Based Evaluation (PhOEBE) research programme was commissioned with the dual aims of developing methods for linking patient level ambulance data to other health information and to develop better ways of measuring ambulance service quality and performance.  In this abstract we aim to assess the outcome and performance measures developed for the PhOEBE study against criteria for good outcome measures.  

Method

Following a substantial programme of consensus work (interviews, consensus conference, Delphi study) to select and refine a set of outcome and performance measures, we constructed six candidate measures using the PhOEBE linked dataset. We then undertook a review of published literature to identify key criteria for good indicators, and used this to assess whether the measures developed for the PhOEBE study are good indicators of the quality and performance of the emergency ambulance system. The review identified six criteria for good indicators (important to users; valid and evidenced based; use reliable data; be statistically robust; simple to understand; remediable). The assessment was undertaken by a multi-disciplinary expert group, who assessed the indicators from different perspectives, including health-care commissioners, ambulance providers and statisticians. Each of the good indicator criterion was made up of several subcomponents and each indicator was assessed against all of the subcomponents, resulting in 510 ratings by the five experts.

Results

The measures identified and developed by the PhOEBE study relate to pain; accuracy of call ID; response time (mean/median); recontacts after non-transport decisions; unnecessary ED attendances and survival from emergency conditions. The measures mostly or partly met the six criteria for good indicators. The expert panel all agreed the PhOEBE measures are important to users, and this is reflective of the involvement of patients and the public in the research process (interviews and consensus work). One of the panel felt they required more information to assess some of the measures. There were 5/510 ratings which were rated as does not meet the criteria and four of these were for the remediable component of the survival from emergency conditions measure. In addition, there is some uncertainty around the pain measure, due to the subjectivity of pain assessments.

Conclusion

Our overall findings were that the set of indicators developed for the PhOEBE study met or partly met the criteria for good indicators, and could be used to reliably measure the quality and performance of emergency ambulance service care. As a group of measures, they have relevance to different patient groups and are relevant to multiple domains of quality. The measures include both process measures and outcome measures and have been shown to be important to a wide range of stakeholders, including patients and the public.

 

Joanne COSTER (Sheffield, UK), Janette TURNER, A. Niroshan SIRIWARDENA, Jon NICHOLL
17:30 - 17:40 #18471 - OP024 Effectiveness of a community based Out-of-hospital cardiac arrest interventional bundle: results of a pilot study.
OP024 Effectiveness of a community based Out-of-hospital cardiac arrest interventional bundle: results of a pilot study.

AIM: This study aims to assess the effectiveness of a community based Out-of-hospital cardiac arrest (OHCA) interventional bundle in improving OHCA survival.

BACKGROUND: Out-of-hospital cardiac arrests (OHCAs) are a leading cause of death globally, and a major public health issue. Yearly, an estimated 700,000 people across Europe and North America suffer from OHCAs, of whom only approximately 10% survive. Recent data shows an increase in OHCA cases in Singapore from 800 per year (2001 – 2004) to 1500 per year (2010 – 2012). Furthermore, 70% of OHCA cases in Singapore have been found to occur in residential areas, and are associated with poorer outcomes. A core component to the interventional bundle is the Save-a-life (SAL) initiative. This initiative involves training residents of a selected geographical region in cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, along with concurrent AED installation at public-access areas of public housing blocks in these same regions. This is further supplemented by a Dispatcher-Assisted CPR (DA-CPR) program and MyResponder (mobile phone application). We hypothesized that the interventional bundle will significantly increase OHCA survival.

METHODS: This is pilot data from initial implementation of a stepped-wedge, before-after, real-world interventional bundle in six selected regions. Data was obtained from Singapore’s national OHCA Registry. We included all adult patients who experienced OHCA in Singapore from 2011 to 2016 within study regions, excluding EMS-witnessed cases and cases due to trauma/drowning/electrocution. Cases occurring before and after intervention were allocated as Control and Intervention groups respectively. Survival (survival to discharge/ 30-day survival post-cardiac arrest) was assessed via multivariable logistic regression.

RESULTS: 1241 patients were included for analysis (Intervention: 361; Control: 880). Intervention group had a higher mean age (70 vs 67 years), survival (3.3 % [12/361] vs. 2.2% [19/880]), pre-hospital return of spontaneous circulation (ROSC) (9.1% [33/361] vs 5.1% [45/880]), bystander CPR (63.7% [230/361] vs 44.8% [394/880]) and bystander AED application (2.8% [10/361] vs 1.1% [10/880]). After adjusting for age, gender, race and significant covariates, intervention was associated with increased odds ratio (OR) for survival (OR 2.39; 95% CI: 1.02-5.62), pre-hospital ROSC (OR 1.94, 95% CI: 1.15-3.25) and bystander CPR (OR 2.29 95% CI: 1.77-2.96) compared to control group. Subgroup analysis showed that the intervention was associated with a significant increase in bystander CPR for OHCAs occurring in residential areas (OR 2.40, 95% CI 1.83 – 3.14), but not for OHCAs occurring in non-residential areas (OR 1.46, 95% CI 0.62 – 3.43).

DISCUSSION & CONCLUSION: Previous studies on improving OHCA survival have often focused solely on community CPR training programs and showed variable results. We demonstrate the effectiveness of this community based interventional bundle in improving OHCA survival. These findings support the feasibility and effectiveness of the interventional bundle, which is being scaled up as a national program, with further evaluation planned.

Dr Pamela Jia Min TAY (Singapore, SINGAPORE), Pin Pin PEK, Qiao FAN, Yih Yng NG , Benjamin Sieu-Hon LEONG, Han Nee GAN, Desmond Renhao MAO, Michael Yih Chong CHIA, Si Oon CHIA, Nausheen DOCTOR, Lai Peng THAM, Marcus Eng Hock ONG
17:40 - 17:50 #18592 - OP025 Effects of methoxyflurane as an analgesic agent for trauma management in the pre-hospital settings in Slovakia.
OP025 Effects of methoxyflurane as an analgesic agent for trauma management in the pre-hospital settings in Slovakia.

Background: Methoxyflurane (Penthrox) has been extensively used as an analgesic agent by Emergency Medical Service (EMS) providers in Australia since 1974. However, only in 2017 the Penthrox methoxyflurane inhaler was introduced in some European countries including Slovakia for the treatment of moderate to severe pain in adult trauma patients. Falck Zachranna, the leading EMS provider in Slovakia, included the medicine into its paramedic stuffed ambulances drug portfolio in 2018. The implementation project process consisted of some steps such as development of a checklist and a protocol for the drug administration and subsequent education and training sessions for the paramedic personnel. The aim of our study was to evaluate the efficacy and safety of methoxyflurane administered by our paramedics for one year time since the project beginning.

 

Methods: Authors used case series research design and retrospectively analyzed 127 protocols of cases where trauma patients with moderate to severe pain were treated with Penthrox. The analyzed protocols were filled by the Falck Zachranna paramedics from May 2018 till April 2019. Authors mainly focused on such parameters as subjective pain relief scores and significant side effects after the Penthrox usage, and also paramedics and patients satisfaction with the drug administration. Subjective pain relief was evaluated by the visual analogue scale (VAS), patients gave their scores before and after 10 and 20 minutes of the drug application. Side effects were considered to be significant when they severely compromised cardiovascular, respiratory or central nervous systems on the scene and required additional actions from paramedics. Paramedics and patients satisfaction levels with the drug administration (technical aspects) were measured with the 5-points Likert scale.

 

Results: During one year time our paramedics administered Penthrox to 127 patients from 18 to 92 years old (mean age approximately 52 years), predominant diagnoses were femur fractures (63% of all the cases). The mean figures for the pain scores were the following: before administration 8.07±1.133, 10 min after administration 5.94±2.10, and 20 min after administration 3.41±2.12. The median figures were 8, 5 and 3 respectively. The significance levels of both score changes (p) reached 0.01. Regarding significant side effects, only 1 case of severe bradycardia was reported (0.79% of all the cases). Totally, 91% of patients and 92% of paramedics were satisfied (or very satisfied) with the drug administration.

 

Conclusion: Authors believe that the reported figures of subjective pain relief and minimal significant side effects after the Penthrox methoxyflurane inhaler usage confirm the drug efficacy and safety when administered to adult trauma patients in the pre-hospital settings. Yet, the study needs to be extended to make the acquired statistical data more meaningful and persuasive.

Adriana KILIANOVA, Volodymyr KIZYMA (Kosice, SLOVAKIA), Eva HAVLIKOVA
17:50 - 18:00 #19025 - OP026 Location Selecting of Automated External Defibrillator Deployment in Terms of Disability Adjusted Life Years Comparison.
OP026 Location Selecting of Automated External Defibrillator Deployment in Terms of Disability Adjusted Life Years Comparison.

Objective:

Receiving early defibrillation is one of the major factors determining outcomes of out-of-hospital cardiac arrest patients. Widely siting public access automated external defibrillators (AED) is too costly to be executable.Therefore, we need to compare and chose a more cost-effectiveness location for AED deployment. Analysis with disability adjusted life years (DALY) is a common used methods for cost-effectiveness  comparison. Objective of our study is to calculate and to compare the DALYs for out-of-hospital cardiac arrest (OHCA) patients, and the find the effectiveness of defibrillation between different types of locations.

Method:

The is a retrospective cohort study, from January 2015 to December 2016, under the help of OHCA registry of Fire Bureau of Kaohsiung City Government, using the template of Utstein resuscitation registry. DALYs is the sum of years of life lost (YLL) and years lived with disability (YLD). The YLL was calculated from the remaining standard life expectancy at the age of death. The YLD was calculated by multiplying the anticipated life duration and disability weight (DW). The DWs were assigned according to cerebral performance category (CPC) scores on the days of hospital discharge. Model of multivariate liner regression, adjusting age, sex, bystander resuscitation and defibrillation, in overall and different location types  were performed. And the effect of defibrillation on DALYs were reported and compared.

Result: 

After excluding 507 trauma-related events and 28 pediatric events (age < 18 years-old), there were 4600 non-trauma adult OHCA events in the study years. Among them, male 84.8%, mean age 69.3 +/-16.3, defibrillation rate 17.7%. The  arrest occurrence numbers and defibrillation rate, mean age and good CPC result percentage (CPC score 1 and 2) of different locations were home/residence 2480 (14.19%), 70.76 y/o (0.89%); industrial/workplace 77 (45.45%), 52.39 y/o (9.76%); sports/ recreation 39 (58.97%), 59.40 y/o (14.29%); street/highway 146 (36.99%), 60.22 y/o (5.56%); public building 31 (32.6%), 56.46 y/o (0%); assisted living/nursing home 145 (10.34%), 77.77 y/o (0%); educational institution 9 (66.67%), 52.20 y/o (42.86%); other 150 (32.67%), 61.22 y/o (1.65%), unknown/not recorded 894.

The effect of defibrillation on DALYs  in different location were: home/residence 1.06*; industrial/workplace 2.40; sports/ recreation 7.52*; street/highway 2.09*; public building 1.57; assisted living/ nursing home 0.03; educational institution 20.85*; other 1.95* (*, reaching statistical significance). Taking the occurrence numbers into considering, the avoiding DALYs attributed by defibrillation were home/residence 3388.91; sports/ recreation 315.66; street/highway; 376.38 educational institution 244.89.

Conclusion:

The effect of defibrillation on DALYs is most obviously in location of education institution. But taking into account the high occurrence numbers in home/residence, the more appropriate place to deploy AED is mass gathering high-rise apartment complex.

Reference:

  • Ryan A. Coute, Brian H. Nathanson,  Ashish R. Panchal, etc . Disability-Adjusted Life Years Following Adult Out-of-Hospital Cardiac Arrest in the United States. Circ Cardiovasc Qual Outcomes. 2019;12:e004677. DOI: 10.1161/CIRCOUTCOMES.118.004677 
Shih-Chiang HUNG (Kaohsiung City, TAIWAN), Hung-Yi CHUANG, Wen-Huei LEE, Kuan-Han WU
18:00 - 18:10 #19056 - OP027 Symptoms related to spontaneous subarachnoid haemorrhage in an emergency system telephone triage – a retrospective cohort study.
OP027 Symptoms related to spontaneous subarachnoid haemorrhage in an emergency system telephone triage – a retrospective cohort study.

Background:

Spontaneous subarachnoid haemorrhage (sSAH) is a neurosurgical emergency. Clinical characteristics may vary from sudden onset of thunderclap headache or loss of consciousness to diffuse and mild symptoms. The European emergency telephone number 1-1-2 is supposed to be used for potential life-threatening injuries and illness. To assist in the triage, electronic decision support systems such as Criteria Based Dispatch (CBD) is often used.  

We aimed to determine which dispatch criteria were used in patients with sSAH. Secondly, we sought to determine the positive predictive value (PPV), negative predictive value (NPV), sensitivity (SE) and specificity (SP) of these criteria.

Methods:

This was a retrospective cohort study conducted in March 2019. Data were extracted from the Danish National Patient Register on all patients aged 18 years or older, admitted to any hospital in the Capital Region of Denmark between May 1, 2011 and December 31, 2013 and discharged with a primary diagnosis of sSAH. Diagnoses were verified by medical record review. We merged these with CBD data from the Emergency Medical Service Copenhagen (EMS). Proportions, PPV, NPV, SE and SP were reported with 95% confidence intervals (CI).

Results: A total of 200 patients with sSAH were admitted within the study period. Sixty-two had not contacted the EMS. Of the remaining 138 patients, 36 had called a non-urgent medical helpline or ambulances had been requested by general practitioners. Thus, 102 patients had called the emergency number 1-1-2 but complete data were only available in 98 patients. The EMS received a total of 282,898 emergency calls during the relevant time period. The dispatch criterion “thunderclap headache” was recorded in 17 patients with sSAH (17.4%, 95% confidence interval (CI): 10.4-26.3) and 224 patients without sSAH (PPV 7.6% (CI: 4.5-11.9), NPV 100%, SE 17.4% (CI: 10.4-26.3), SP 99.9% (CI: 99.9-99.9)). Any form of severe headache was recorded in 22 sSAH cases (22.5%, CI: 14.6-32.0), (PPV 4.5% (CI: 2.9-7.0), NPV 100%, SE 22.4% (CI: 14.6-32.0), SP 99.8% (CI: 99.8-99.9)). The third most common criterion was unconsciousness, 14 cases. Other stroke symptoms (paralysis, impaired speech or visual disturbances) were found in 13 cases. In addition, a total of 36 other dispatch criteria were recorded including chest pain, seizures, traffic accident, diabetes, intoxication, gastrointestinal conditions, breathing difficulties, and unclear symptoms.

Discussion and conclusion: We found that numerous different dispatch criteria were recorded in patients with sSAH assessed via telephone. Typical symptoms like classic thunderclap headache are not commonly reported and the positive predictive value is low. sSAH should be considered as a possible diagnosis in a variety of patient groups during telephone triage.

Asger SONNE (Copenhagen, DENMARK), Jesper B ANDERSEN, Vagn ESKESEN, Frans B WALDORFF, Freddy LIPPERT, Nicolai LOHSE, Lars S RASMUSSEN
TERRACE 2B
Monday 14 October
08:30

Monday 14 October

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A20
08:30 - 09:00

KEYNOTE LECTURE 1

Moderator: Dr Jana SEBLOVA (Emergency Physician) (PRAGUE, CZECH REPUBLIC)
08:30 - 09:00 Resus for the 2020s: how can we reduce the heartache of sudden death? Maaret CASTREN (Professor) (HELSINKI, FINLAND)
CONGRESS HALL
09:10

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A21
09:10 - 10:40

The Tantalising Travelling Troponin Tour: A Masterclass
Insights from the International Federation for Clinical Chemistry Committee for Cardiac Biomarkers
Cardiovascular

Moderator: Pr Rick BODY (Professor of Emergency Medicine) (Manchester, UK)
09:10 - 10:40 IFCC practice recommenations for hs-troponin. Pr Rick BODY (Professor of Emergency Medicine) (Manchester, UK), Paul COLLINSON (Consultant Chemical Pathologist) (London, UK), Allan JAFFE (Professor of Cardiology) (USA)
10:10 - 10:40 Panel discussion. Barbra BACKUS (Emergency Physician) (Leiden, THE NETHERLANDS), Pr Edd CARLTON (Emergency Medicine Consultant) (Bristol, UK)
CONGRESS HALL

Monday 14 October

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B21
09:10 - 10:40

The Mood Zone
Workshop on resilience in the emergency department
Resilience, Wellbeing

Moderator: Senad TABAKOVIC (Zürich, SWITZERLAND)
09:10 - 10:40 "In a mad world only the mad are sane"- tips for how to stop doing Harakiri at work. Ahmed KAZMI (eusem) (London, UK)
09:10 - 10:40 How to set up a wellbeing program for your ED. Shweta GIDWANI (UK)
09:10 - 10:40 Staying Well Or At Least Drop Dead With Some Grace. Greg HENRY (USA)
FORUM HALL

Monday 14 October

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C21
09:10 - 10:40

Traumatic Cardiac Arrest
So much more than Advanced Life Support
ARRHYTHMIAS, Stroke, Trauma

Moderators: Christian HOHENSTEIN (PHYSICIAN) (Madgeburg, GERMANY), Bernd A. LEIDEL (Vice Head) (Berlin, GERMANY)
09:10 - 10:40 Cardiac arrest following blunt trauma – no dead end. Bernd A. LEIDEL (Vice Head) (Berlin, GERMANY)
09:10 - 10:40 Thoracotomy in the prehospital field. Dr Gareth DAVIES (Speaker) (London, UK)
09:10 - 10:40 REBOA - Who and When? Dr Zaffer QASIM (Speaker) (Philadelphia, USA)
SOUTH HALL 3AB

Monday 14 October

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D21
09:10 - 10:40

YEMD - Surviving daily life in EM
Sometimes just survinig the daily struggle is a challenge
Stereotypes, Wellbeing, Young Emergency Medecine

Moderators: Dr Ross EVANS (Junior doctor) (Wolverhampton, UK), Tereza RADL (Doctor) (Prague, CZECH REPUBLIC)
09:10 - 10:40 Family compatibility & EM? What? Tereza RADL (Doctor) (Prague, CZECH REPUBLIC)
09:10 - 10:40 Everybody is a stereotype. Aleks SUSTAR (EM Resident) (Maribor, SLOVENIA)
09:10 - 10:40 Surviving mental and physical harm. Jenny GAIAWYN (Emerngency Medicine Clinical Fellow) (Truro, UK)
SOUTH HALL 3C

Monday 14 October

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E21
09:10 - 10:40

PAEDIATRICS
Paediatric Emergencies#1
HOT TOPIC SPEAKER!, Pediatric, Pulmonary, Sepsis

Moderators: Niccolò PARRI (Attending Physician) (Florence, ITALY), Pr Luigi TITOMANLIO (Head of Department) (Paris, FRANCE)
09:10 - 10:40 Fever without source in infants 0-90 days in the emergency department. Dr Roberto VELASCO (Pediatrician) (Laguna de Duero, SPAIN)
09:10 - 10:40 HOT TOPIC SPEAK! Bronchiolitis: State of the evidence based on the latest trials. Pr Franz BABL (Professor) (Melbourne, AUSTRALIA)
09:10 - 10:40 e-Health. How technologies applied to emergency medicine may help physicians? Cécile MONTEIL (FRANCE)
CHAMBER HALL

Monday 14 October

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F21
09:10 - 10:40

ABSTRACTS SESSION

Moderators: Felix LORANG (Consultant) (Jena, GERMANY), Nisanth MENON NEDUNGALAPARAMBIL (Moderator/ Faculty) (India, INDIA)
09:10 - 09:20 #18096 - OP028 Overlooked emergency – burnout syndrome among the emergency department staff.
OP028 Overlooked emergency – burnout syndrome among the emergency department staff.

Introduction: Examination of the burnout syndrome in various healthcare fields is of paramount importance for better understanding of the disorder as well as for the establishment of a suitable preventive and intervention program. The emergency departments’ employees are a risk group among healthcare workers, so it is our objective to further expand the knowledge on the characteristics of the burnout syndrome among the Hungarian emergency department staff. Aim of this study is to examine the burnout syndrome and its associations with different variables among the workers of the Department of Emergency Medicine at the University of Szeged moreover to develop and finetune a prevention and intervention training for the medical staff to help coping with everyday stress as well as rise awareness to burnout symptoms.

Method: Cross-sectioned design utilizing a self-administrated questionnaire was used to collect data from the staff (n=72). Burnout was measured using the Maslach Burnout Inventory, while psychological immune competence was measured using the Psychological Immune Competence Questionnaire. Upon data collection a three-round training was developed and implemented after which the measurement of burnout was repeated using the same test battery. We tested the interaction between different variables (age, number of children, years spent in healthcare, weekly number of working hours, number of somatic symptoms, social support and psychological immune competence) and burnout subscales (emotional exhaustion, depersonalization and personal accomplishment) using Pearson correlation. Independent samples t-test was used to compare burnout subscale means in different marital status groups, while Mann-Whitney U-test to compare burnout values between genders. Lastly, the data of the retest was compared using paired sample t-test.  

Results: We found burnout syndrome to be considerably prevalent among the workers especially nurses and physicians (compared to other staff: medical orderlies, medical clerks). Moderate emotional exhaustion was reported both among doctors and the nursing staff. While physicians reported moderate depersonalization, lower personal accomplishment was measured among the nurses. In both, original and post-training study we found a significant correlation between burnout and age, number of children, number of years in healthcare system, number of physical symptoms, social support and psychological immune system. There was no difference between genders, while the workers who were in a relationship reported significantly lower depersonalization. Due to personnel fluctuation we were able to retest only 54% of the original sample, with no change in burnout results. Nonetheless, the data shows the need for individual burnout intervention which presents in significantly stronger relationship with the psychologist as well as in frequency of contact with the psychologist.

Conclusions: The results obtained show correlations and reveal protective and risk factors in burnout which can be key to establishing a preventive and intervention strategies. The training on burnout syndrome rose awareness among the departments’ staff, while personal one to one interventions helped the workers develop individual coping strategies. This data allows us to further develop new institutional intervention techniques. Ethical approval was given by the Ethics Committee of the University of Szeged, with the license number: 122/2017-SZTE (4035).

Mona STANKOVIC (Szeged, HUNGARY), Annamária TÖREKI , Zoltán PETŐ
09:20 - 09:30 #18857 - OP029 Assessed and discharged – short-term emergency department visits.
OP029 Assessed and discharged – short-term emergency department visits.

Background

Emergency departments (EDs) play a vital role in the healthcare system either as the freely accessible primary entry point for healthcare or as secondary healthcare referred to by primary healthcare services. Recently, EDs have experienced an increased number of patients including to a greater extent elderly patients with more comorbidity. In addition, some EDs also face decreased available resources (e.g. fewer beds) and crowding in the EDs is now a reality in many countries. It is unclear how these changes affect the ED patient population. We chose to focus on the contribution of short-term ED visits to the ED population and outcome following these contacts.

Aim

Thus, our aim was to investigate 1) the proportion of short-term ED visits (5 hours or less) & 2) the characteristics, diagnoses, patterns of renewed contacts and mortality of patients with short-term ED visits.

Method

Observational cohort study of patients in the emergency departments at three sites in the North Denmark Region 2014-2016. Patients with a valid personal identification number were included. Short-term ED visits defined as 5 hours or less. Primary outcomes were ICD-10 diagnosis chapter, 1- and 30-day mortality and readmissions on days 1 and 2. Data was retrieved from the Patient Administrative System and the Danish Civil Registration System. Descriptive statistical analyses and Kaplan-Meier mortality estimates were performed.   

Results

During 2014-2016, there were 280 365 contacts to the EDs in the North Denmark Region. Of these, we included 134 362 ED visits with duration of 5 hours or less (47.9%). Mean age was 32 (IQR: 16-57), 48.6% were female.

Top five ICD-10 chapters were injury and poisoning N=80 862 (60.2%), other factors N=19 725 (14.5%), symptoms and signs N=15 568 (11.6%), musculoskeletal disease N=3 643 (2.7%) and respiratory disease N=2 413 (1.8%). Overall mortality was 1-day: 0.30% (0.27-0.33), 30-day: 0.74% (0.70-0.79), with the highest mortality among circulatory diseases: 1-day: 10.67% (9.38-12.12) 30-day: 11.94% (10.59-13.46).

Number of renewed contacts on days 1 and 2 after discharge were N=4 696 (3.5%) and N=1 652 (1.2%). ICD-10 chapter from the initial contact for patients with renewed contact on day 1: other factors N=2 522 (53.7%), injury and poisoning N=1 587 (33.8%) and symptoms and signs N=223 (4.8%) and on day 2: injury and poisoning N=951 (57.8%), other factors N=258 (15.6%) and symptoms and signs N=172 (10.4%). Overall mortality for patients with renewed contacts on day 1 or 2 was: 1-day 0.02% (0.00-0.11) and 30-day: 0.43% (0.29-0.62).

 

Discussion and conclusion

Almost half of all ED contacts were short-term visits and predominately due to injuries, which explains the young mean age and low overall mortality. Non-specific diagnoses was the second largest group of patients. Overall, only few patients had a renewed contact within 1 or 2 days. Nevertheless, patients who received non-specific diagnoses during the first admission comprised the largest group of readmitted patients on day 1.

Further research on the non-injury group of patients is needed, in particular the non-specific diagnoses.

 

 

Hassan AL-MASHAT, Tim Alex LINDSKOU, Jørgen Munkhoff MØLLER, Marc LUDWIG, Erika FRISCHKNECHT CHRISTENSEN, Dr Morten BREINHOLT SØVSØ (Aalborg, DENMARK)
09:30 - 09:40 #18354 - OP030 Applying lean methodology in the emergency department: reducing inappropriate high-sensitivity cardiac troponin I testing in patients complaining of chest pain.
OP030 Applying lean methodology in the emergency department: reducing inappropriate high-sensitivity cardiac troponin I testing in patients complaining of chest pain.

Background: chest pain is the reason for emergency department (ED) admission in 5-9% of cases. Cardiac origin has been reported in up to 45% of ED admission for chest pain. In our ED there are several predefined panels of laboratory tests that allow to improve and speed up the diagnostic process based on the prevalent symptomatology shown by the patient (for example: chest pain, abdominal pain, sepsis). In our ED we observed an increasing number of high-sensitivity cardiac troponin I (hsTnI) tests in patients complaining of chest pain. We thought that the main reason for this increase was the presence of hsTnI in the predefined chest pain test panel; furthermore, said panel didn’t differentiate between typical and atypical chest pain. The ideal management of patients experiencing chest pain includes not only avoiding misdiagnosis, but also avoiding unnecessary lab tests and therefore inappropriate hospitalizations. Based on lean methodology applied to emergency medicine, in order to further increase the quality and safety of patient care by reducing inappropriate testing, from June 2017 we decided to remove hsTnI from the predefined chest pain test panel.

Methods: we decided to conduct a retrospective, observational, monocentric study with the primary outcome of verifying whether removing hsTnI from the chest pain test panel had led to a reduction in its dosage requests over a six-month period (June-December 2018), compared to June-December 2016 in which hsTnI still appeared in the chest pain test panel. In these two periods of time we first considered the total number of patients admitted to our ED and then those who had admission and discharge diagnoses, according to the International Classification of Diseases, Tenth Edition (ICD-10), compatible with presentation of chest pain; we also considered patients with ICD-10 diagnoses not related to chest pain presentation in which hsTnI testing was requested.

Results: from June to December 2016 ED admissions were 29441 and hsTnI dosage was requested 7021 times (mean value 0.24), in the same six-months period of 2018 admissions were 30182 with 5160 hsTnI dosage requests (mean value 0.17). In 2016 and in the same six-month period cited above, patients with ICD-10 diagnosis compatible with presentation of chest pain were 1728 with 2089 hsTnI dosage requests (mean value 2.21, considering multiple tests in the same patient); in 2018 out of 1697 patients only 1752 HsTnI were requested (mean value 1.03). The same can be seen in patients with ICD-10 diagnosis not related to chest pain presentation: in 2016 out of 26307 admission hsTnI dosage was requested 4932 times (mean value 0.19), in 2018 out of 27034 admissions, hsTnI dosage was requested 3408 times (mean value 0.13).

Discussion and conclusion: the removal of hsTnI from the predefined chest pain test panel led to a decrease of inappropriate hsTnI dosage requests without causing missed diagnoses of acute coronary syndrome (ACS). Applying this kind of methodology probably forced ED physicians to better evaluate chest pain characteristics, EKG findings and patient medical history.

Roberto TARENZI, Dr Silvia PAIARDI (rozzano, ITALY), Marta PELLEGRINO, Elena CORRADA, Antonio VOZA
09:40 - 09:50 #18628 - OP031 A validation of the National Emergency Department Overcrowding Score (NEDOCS) in a UK non-specialist emergency department: a prospective observational study.
OP031 A validation of the National Emergency Department Overcrowding Score (NEDOCS) in a UK non-specialist emergency department: a prospective observational study.

Introduction 

Crowding in the Emergency Department (ED) is recognised as a significant problem linked with various adverse health outcomes.  However, there is no widely accepted measurement tool to enable clinicians to better understand and manage ED crowding, though several have been proposed including from the US the NEDOCS score.

 

Objectives

This study aimed to externally validate NEDOCS in a UK ED setting against expert clinician opinion, and to assess inter-rater reliability between nurse and consultant physician opinions.

 

Methods

This prospective single-centre study sampled data in real-time over four time periods during 2018 in a non-specialist hospital ED in the south of England to calculate NEDOCS values.  The outcome variable was clinician opinion of crowding using a six point Likert-scale for both consultant-in-charge and nurse-in-charge. Paired results were averaged to give a combined score, and dichotomised to construct AUROCs and diagnostic testing for a range of NEDOCS cut-offs.  The same method was also used to assess the association of scores with clinician opinion of risk of patient harm, safety, and adequacy of staffing levels. To adjust for the effect of temporal correlation (7), further analysis was conducted on observations sampled every six hours, offset by 2 hours for each sequential day to allow analysis of variability between and within days.

 

Results

From 905 sampled hour intervals, 448 complete data points (both clinician opinions of crowding) were obtained.  The ED was crowded 18.53% according to the composite opinion. Median NEDOCS score was 63 (IQR 43 to 85). Weighted kappa score evaluating inter-rater agreement of nurse and consultant opinion was moderate at 0.57 (95% CI: 0.56 to 0.60). AUROC for NEDOCS to predict clinical opinion of crowding was 0.81 (95% CI 0.77 to 0.86)  

For 6-hour sampling there were 157 complete observations. Adjusted for temporal correlation in this manner, AUROC was 0.80 (95% CI 0.73 to 0.88).  

For predicting clinician opinion of risk of harm and safety, AUROCs were 0.71 (95% CI 0.61 to 0.82) and 0.71 (95% CI 0.63 to 0.80) respectively. Higher scores of NEDOCS also correlated with a clinician opinion of insufficient staffing; AUROC was 0.70 (95% CI 0.64 to 0.76).

Optimal performance in our ED was a NEDOCS of >85 with a sensitivity of 59.0% (95% CI 47.7 to 69.7) and a specificity of 82.7% (95% CI 78.5 to 86.5).

Conclusions 

NEDOCS demonstrated good discriminatory power for crowding in our ED.  It also correlated with perception of safety, adequacy of staffing and risk of patient harm.  However further refinement of the score is needed, including the impact of triaged patient acuity-level, which was not incorporated in the original score.  Determining ED specific cut-off point(s) for the score is important, as the previously published thresholds for crowding may not be suitable for all EDs.  This study has demonstrated the feasibility of electronic capture in real time in a UK ED.  

Sophie SNEL (Brighton, UK), Dr Duncan HARGREAVES, Colin DEWAR, Luke HODGSON, Piervirgilio PARRELLA, Theophilus SAMUELS, Paul RODERICK
09:50 - 10:00 #18629 - OP032 An external validation of the full International Crowding Measure for the Emergency Department (ICMED) in a UK non-specialist emergency department: a prospective observational study.
OP032 An external validation of the full International Crowding Measure for the Emergency Department (ICMED) in a UK non-specialist emergency department: a prospective observational study.

Introduction 

Crowding in the Emergency Department (ED) is recognised as a significant problem linked with various adverse health outcomes.  However, there is no widely accepted measurement tool to enable clinicians to better understand and manage ED crowding, though several have been proposed including the recently derived ICMED. 

 

Objectives

This study aimed to externally validate ICMED in a different UK ED setting to the derivation studies.  Additionally the study aimed to evaluate whether using the full form of ICMED improved the score’s diagnostic ability. 

 

Methods

This prospective single-centre study sampled data in real-time over four time periods during 2018 in a UK non-specialist hospital ED to calculate ICMED values, including calculation of proportion of patients leaving the ED without being seen, the measure omitted from other studies. The outcome variable was clinician opinion of crowding using a six point Likert-scale for both consultant-in-charge and nurse-in-charge. Paired results were averaged to give a combined score, and dichotomised to construct AUROCs and diagnostic testing for a range of ICMED cut-offs.  Association of scores with clinician opinion of risk of patient harm, safety, and adequacy of staffing levels was also assessed.  To adjust for the effect of temporal correlation, further analysis was conducted on observations sampled every six hours, offset by 2 hours for each sequential day to allow analysis of variability between and within days.

 

Results

From 905 sampled hour intervals, 448 complete data points (both clinician opinions of crowding) were obtained.  The ED was crowded for 18.5% according to the composite opinion. Median ICMED score was 2 (IQR 2 to 3).  AUROC for ICMED to predict clinical opinion of crowding was 0.64 (95% CI 0.58 to 0.70). For predicting clinician opinion of risk of harm and safety, AUROCs were0.60 (95% CI 0.50 to0.70) and 0.59 (95% CI 0.49 to 0.69) respectively. Higher scores of ICMED also correlated moderately with a clinician opinion of insufficient staffing; AUROC was 0.58 (95% CI 0.52 to 0.65)

Optimal performance in our ED was an ICMED of >3 with a sensitivity of 49.4% (38.2 to 60.6) and a specificity of 74.3% (69.4 to 78.7).

For 6-hour sampling there were 157 complete observations. Adjusted for temporal correlation in this manner, AUROC was 0.69 (95% CI 0.59 to 0.79).  However, for ICMED adjustment for temporal correlation required a total of 208 complete observations and 30 crowded observation intervals for adequate power.

  

Conclusions 

This is the first study to validate the full form of the ICMED score.  ICMED demonstrated moderate discriminatory power for crowding (in line with previously published values) as well moderate discrimination for perception of safety, adequacy of staffing and risk of patient harm in our ED.  When adjusted for temporal correlation the AUROC showed a trend towards improvement.  However, the sample size was inadequate to fully account for the effect of temporal correlation.   Further data capture is currently underway to address this.  This study has demonstrated the feasibility of electronic capture of all the parameters of the ICMED score in real time in a UK ED.  

Dr Duncan HARGREAVES (Worthing, UK), Sophie SNEL, Colin DEWAR, Luke HODGSON, Piervirgilio PARRELLA, Theophilus SAMUELS, Paul RODERICK
10:00 - 10:10 #18756 - OP033 Retrospective analysis of complaints in emergency department: a quality indicator?
OP033 Retrospective analysis of complaints in emergency department: a quality indicator?

Background:

Emergency department patient complaints are often justified and may lead to apology, remedial action or compensation. The aim of the present study was to analyze emergency department patient complaints in order to identify procedures or practices that require change and to make recommendations for intervention strategies aimed at decreasing complaint rates.

Methods:

We undertook a retrospective analysis of patient complaints from a tertiary hospital emergency department from 2010 to 2018. Data were obtained from letters of response to patient’s complaints. Ethics committee of the Erasme hospital approved the study and waived informed consent.

Results:

349,714 patients were seen in the emergency room from 2010 to 2018, of whom 74,944 (21.4%) were hospitalized. In addition to this number, there are 18,206 patients (5.2%) who leave the emergency department without being seen due to department overcrowding. 279 written complaints (0.08%) were sent to the medical management of the hospital, the mediation service or directly to the emergency department. The median age of patients associated with a complaint was 33 (18-53, IQR; 0 to 80, range) years, with M:F ratio = 0.47. Among the complaints 23.5 % concerned the diagnosis, 22 % invoices for hospital care, 18 % communication with the medical doctor, 16 % the length of the waiting time, 10.5 % the treatment itself, and 10 % the nurse’s communication.

Discussion & conclusions:

Over the observation period, the yearly number of written complaints remained stable at less than 0.1 % of total number of the ED’s patients. More than 50 % of the complaints concerned a wrong or inadequate diagnosis, invoice for hospital care, and communication with the medical doctor. As a remedial measure, meticulous patient care and communication skills workshops for emergency department doctors and nurses will improve patient’s satisfaction and quality of care in the ED.

Ludovic LEFRANCQ (Mons, BELGIUM), Marc VAN NUFFELEN, Siham HBAT, Stéphane DEBAIZE, Fouzya CHIHI, Laurent LIGY, Christian MELOT
10:10 - 10:20 #18903 - OP034 Performing blood samples during Triage evaluation can improve overcrowding in ED: a Propensity-Score-Weighted Population-Based Study.
OP034 Performing blood samples during Triage evaluation can improve overcrowding in ED: a Propensity-Score-Weighted Population-Based Study.

BACKGROUND: the length of stay (LOS) in the Emergency Department (ED) is one of the causes of the overcrowding condition that currently affects most European EDs. As demonstrated in the literature, the LOS of ED patients is increasing and will increase in the coming years. A longer LOS leads to more significant crowding, poorer functioning of emergency services, increased risk of mortality and exponential cost increases. The heterogeneous morbid conditions combined with the increasing comorbidities presented by patients, force an in-depth diagnostic in many cases. It has been proved that 2/3 of patients accessing ED need an instrumental assessment and 1/3 need blood analysis. The patient's diagnostic path strongly influences the LOS.

OBJECTIVES: to verify whether sending blood samples during the triage process can decrease the LOS and the duration of the medical examination in patients with green and yellow code according to the Manchester Triage System (MTS).

METHODS: a retrospective observational study was performed from January 2018 to January 2019. All patients with a minor code (green and yellow) who needed blood sample for further diagnosis were considered. Patients who performed blood sampling during the TRIAGE evaluation were compared with those who performed blood sampling during the medical visit. Moreover, we calculated and compared the LOS and the time between the start of the medical evaluation and discharge of the two groups of patients. The anamnesis, clinical and severity characteristics documented at the time of triage were recorded.

RESULT: during the study period, 15.596 patients were enrolled. LOS was lower in the group of patients with triage blood sampling with a median of 154 minutes (100 - 231) compared to 172 (119 - 246) in the control group (p< 0.001). Overall, the triage blood sampling group was older, with greater comorbidity and with a more severe clinical condition. A propensity score matching was performed to obtain two homogeneous groups. After statistical matching, LOS remained lower in the triage-sampling group of patients (151 versus 175 minutes, p<0.001). In the adjusted multivariate model, the triage blood sample was found to be an independent factor of decrease of the LOS with standardized coefficients β = 0.857 (0.822 – 0.894, p<0.001). After propensity score matching, we also evaluated the duration of the triage, obtaining an equality of triage times both if the blood sample was taken in triage or during the medical examination, the total duration of the triage lasted 4 minutes.

CONCLUSION the execution of blood samples by the triage nurse reduces the LOS of non-urgent patients in ED and significantly reduces the duration of the medical examination.

Tania MARSONER (Merano, ITALY), Arian ZABOLI, Gianni TURCATO, Gabriele MAGNARELLI, Pasquale SOLAZZO, Eliana DUCATI, Giulia SCOLA, Annalisa FIORETTI, Norbert PFEIFER
10:20 - 10:30 #19039 - OP035 Economic value of a clinical pharmacist at the Emergency Department: a retrospective observational study.
OP035 Economic value of a clinical pharmacist at the Emergency Department: a retrospective observational study.

Background. Medication errors (MEs) and other drug related problems (DRPs) are common issues on hospital admission. These MEs and DRPs can cause preventable adverse drug events (pADEs) resulting in patient harm with a significant additional cost. A clinical pharmacist (CP) dedicated to the Emergency Department (ED) can improve medication safety by performing medication reconciliation and review, and hence avoid additional costs.

Objective. The aim of this study was to determine the economic value and the cost-benefit of a CP in the ED by applying a theoretical model (University of Sheffield School of Health and Related Research – SCHARR1).

Setting and Methods. This retrospective, single-centre, observational study was carried out in the ED of a tertiary care university hospital. Since October 2016, 1 FTE CP is dedicated to the ED. Patient-specific recommendations recorded by the CP during a 1 month period were observed. On admission to the ED, the CP had carried out a standardized medication reconciliation and medication review in order to determine pADEs. The most important pADE for each patient was selected and classified for its potential to cause harm using severity rating methods. An expert panel of senior ED physicians evaluated the pADEs for clinical significance. The net cost avoidance was calculated according to the SCHARR model1. We took into account the lower cost limit of the SCHARR model and current inflation. Statistical analysis was done using Graphpad Prism® and Microsoft Excel®.

Results. During 1 month (18 weekdays), the CP recorded recommendations for 136 patients (>18 years) admitted to the ED. On ED admission, medication reconciliation was performed for 98 patients with a median of 4 (IQR 2-7) discrepancies/patient. A medication review for both chronic medication and medication prescribed at hospital admission was performed (n=109 and n=98 respectively). Only the CP’ interventions leading to the most important pADE for each patient were taken into account for the calculation of the cost avoidance. We classified 18 (14.8%) DRPs, 66 (54.1%) DRPs, 37 (30.3%) DRPs and 1 (0.8%) DRP as a pADE with minor or no harm, significant pADE, serious pADE and at least as a severe, life-threatening or fatal pADE, respectively. According to the SCHARR model, this contributed to a net cost avoidance of €40 940. We documented 5 (4.1%) discrepancies without DRP, 53 (43.4%) discrepancies linked to a DRP and 64 (52.5%) DRPs without discrepancy with a cost avoidance of respectively €303, €17 734 and €31 003. The benefit:cost ratio was 5.05:1. Furthermore, the pharmacist carried out a total of 722 interventions.

Conclusion. A CP, integrated in a multidisciplinary ED team, has an important economic value. Furthermore, the CP enhances medication quality and safety by preventing discrepancies in the chronic medication and by the identification of DRPs on admission at the ED.

1 Campbell F, Karnon J, Czoski-Murray C, et al. A systematic review of the effectiveness and cost-effectiveness of interventions aimed at preventing medication error (medicines reconciliation) at hospital. Report for the National Institute for Health and Clinical Excellence as part of the Patient Safety Pilot. 2007


Saskia VAN KEMSEKE, Ellen OUDAERT (brussels, BELGIUM), Hilde COLLIER, Stephane STEURBAUT, Koen PUTMAN, Door LAUWAERT, Ives HUBLOUE
10:30 - 10:40 #19246 - OP036 Utility of a Regional Poison Center in Care of Patients Seen at Emergency Departments.
OP036 Utility of a Regional Poison Center in Care of Patients Seen at Emergency Departments.

Background:  Poison control centers (PCs) are an essential component of the healthcare system and providing clinical management and improving patient outcomes in cases of toxic exposures. PCs have also demonstrated utility in decreasing the healthcare costs by reducing the use of emergency medical services and length of stay in hospitals. Apart from the clinical expertise, PCs also provide valuable information regarding drugs including medication identification, dosage, interactions, storage, and disposal. This study analyzed the trends in exposure calls received by the PCs from emergency departments (EDs).  

Methods: The case management software, Toxicall, was queried for human exposure calls from EDs between 2016 and 2018. We descriptively assessed the relevant demographic characteristics. Trends in call frequencies and rates (per 100,000) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2016) were reported with the corresponding 95% confidence intervals (95% CI).

Results: The regional poison center serves over 2.4 million people and 45 hospitals within Southwest Virginia, with the specialists handling an average of 58,000 calls every year. Between 2016 and 2018, there were 9,767 calls that were received from the EDs, with 74% of these reporting an acute exposure to a toxic substance. Most exposures occurred at the patients’ residence (87.2%). Females (54%) were predominant in this sample. Among the cases, 23.1% were children under 6 years of age while 8.2% were individuals above 60 years of age. Unintentional reasons accounted for 47.9% cases, while suspected suicides were responsible for 36.2% calls. Ingestion (77.6%) was the most common route of exposure followed by inhalation (7.2%). Unintentional reasons accounted for majority of cases under 6 years of age, while intentional reasons caused 83% of teenage exposures. Intentional exposures were more common among the adult age groups. Serious adverse events were uncommon in our sample, with 10% cases exhibiting major clinical outcomes and only 10 fealties reported in the 3 year study period. Neurological (28.9%) and cardiovascular (19.4%) effects were most pronounced. Approximately one-fourth of the patients were admitted to the psychiatric facility. Exposures to pharmaceuticals like acetaminophen (7.6%) were frequent. Exposures to alcoholic beverages (8%) were also common. Fluids and IV were used as a therapy in 40% cases. While the frequency of calls received by the PC from EDs decreased from 3,461 in 2016 to 3,302 in 2018, the rate of such calls per 1,000 calls received by the PC increased significantly by 5.7% (95% CI: 2.3%, 8.7%, p<0.011) from 169.9 to 179.6 during the study period.     

Conclusions:  Rate of calls received by the PC from EDs during the study period increased. The PCs, a reliable source of information, are being increasingly utilized for the management of complex poisoning cases. PCs provide the EDs with immediate access to the experts who can help in the diagnosis, management, and treatment of toxic exposures and drug overdoses. This triage of cases ensures an optimal level of care leading to reductions in hospitalizations and improving the quality of healthcare.

Saumitra REGE (Charlottesville, VA, USA), Dr Christopher HOLSTEGE
TERRACE 2B
10:40 COFFEE BREAK AND EXHIBITION - E-POSTER SESSION
11:10

Monday 14 October

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A22
11:10 - 12:40

Prehospital
Changing Views Outside the ED
Pre Hospital

Moderators: Erika FRISCHKNECHT CHRISTENSEN (Professor) (DENMARK, DENMARK), Dr Jana SEBLOVA (Emergency Physician) (PRAGUE, CZECH REPUBLIC)
11:10 - 12:40 From The Fab Four to the Rolling Stones – changes in EMS-patient pattern. Erika FRISCHKNECHT CHRISTENSEN (Professor) (DENMARK, DENMARK)
11:10 - 12:40 New ethical (and other) challenges in prehospital emergency care. Dr Jana SEBLOVA (Emergency Physician) (PRAGUE, CZECH REPUBLIC)
11:10 - 12:40 New technologies in prehospital conditions. Eric REVUE (Praticien Hospitalier Adjoint Chef de Service) (Paris, FRANCE)
CONGRESS HALL

Monday 14 October

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B22
11:10 - 12:40

True stories from the E.R.
Sharing wisdom through stories
General EM

Moderators: Katrin HRUSKA (Emergency Physician) (Stockholm, SWEDEN), Senad TABAKOVIC (Zürich, SWITZERLAND)
11:10 - 11:30 Do you want me to kill him, Doc? Greg HENRY (USA)
11:30 - 11:50 A Tale of Two Stabbings. Colin GRAHAM (Director and Professor of Emergency Medicine) (Hong Kong, HONG KONG)
11:50 - 12:10 The patients I’ve forgotten. Katrin HRUSKA (Emergency Physician) (Stockholm, SWEDEN)
12:10 - 12:30 The Wild Wild Life. Judith TINTINALLI (Professor) (Chapel Hill NC, USA)
11:30 - 12:40 Panel Discussion.
FORUM HALL

Monday 14 October

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C22
11:10 - 12:40

Cardiovascular Pros and Cons
The hottest issues in cardiovascular emergency medicine
Cardiovascular, Decision making

Moderators: Barbra BACKUS (Emergency Physician) (Leiden, THE NETHERLANDS), Pr Rick BODY (Professor of Emergency Medicine) (Manchester, UK)
11:10 - 11:25 How do we use decision aids AND our brains? Barbra BACKUS (Emergency Physician) (Leiden, THE NETHERLANDS)
11:25 - 11:40 Panel duscussion 1. Barbra BACKUS (Emergency Physician) (Leiden, THE NETHERLANDS), Dr Steve SMITH (Speaker) (Minneapolis, MN, USA), Tomas VILLEN (Attending Physician) (Madrid, SPAIN)
11:40 - 11:55 Do we still need the ECG in the high-sensitivity troponin era? Dr Steve SMITH (Speaker) (Minneapolis, MN, USA)
11:55 - 12:10 Panel discussion 2. Barbra BACKUS (Emergency Physician) (Leiden, THE NETHERLANDS), Dr Steve SMITH (Speaker) (Minneapolis, MN, USA), Tomas VILLEN (Attending Physician) (Madrid, SPAIN)
12:10 - 12:25 How can we best use point-of-care ultrasound (POCUS) to diagnose acute heart failure? Tomas VILLEN (Attending Physician) (Madrid, SPAIN)
12:25 - 12:40 Panel discussion 3. Tomas VILLEN (Attending Physician) (Madrid, SPAIN), Dr Steve SMITH (Speaker) (Minneapolis, MN, USA), Barbra BACKUS (Emergency Physician) (Leiden, THE NETHERLANDS)
SOUTH HALL 3AB

Monday 14 October

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D22
11:10 - 12:40

YEMD - Surviving a terror attack - a practical guide for YOU
A spectacular, interactive experience prepared by special forces professionals
Disaster medicine, Mass casualty, Sonography, Ultrasound, Young Emergency Medecine

Moderator: Dr Kasia HAMPTON (Emergency Department Medical Director) (USA/Poland, USA)
11:10 - 12:40 Interactive - what if YOU are under attack? Jan VINS (Prague, CZECH REPUBLIC)
11:10 - 12:40 Interactive - what if YOU are under attack? Marcus CALISSENDORFF (.....) (Sweden, SWEDEN)
11:10 - 12:40 Ultrasound for triage in mass casualty. Dr Kasia HAMPTON (Emergency Department Medical Director) (USA/Poland, USA)
SOUTH HALL 3C

Monday 14 October

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E22
11:10 - 12:40

PAEDIATRICS
Paediatric Emergencies#2
Pediatric, Resuscitation

Moderator: Pr Said HACHIMI IDRISSI (head clinic) (Ghent, BELGIUM)
11:10 - 12:40 Paediatric resuscitation: what to expect from the 2020 ERC guidelines. Patrick VAN DE VOORDE (Prof) (Ghent, BELGIUM)
11:10 - 12:40 Vital signs in the Paediatric ED: what's the score? Dr Damian ROLAND (Paediatric EM) (@damian_roland, UK)
11:10 - 12:40 Jack and Jill went up a hill. What happened after and how were they looked after. Epidemiology, nature and outcomes for children suffering major trauma. Ross FISHER (Consultant Paediatric Surgeon) (Sheffield, UK)
CHAMBER HALL

Monday 14 October

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F22
11:10 - 12:40

ABSTRACTS SESSION

Moderators: Door LAUWAERT (Manager) (BRUSSELS, BELGIUM), Gregor PROSEN (EM Consultant) (MARIBOR, SLOVENIA)
11:10 - 11:20 #18155 - OP037 Pre-hospital lactate and hospital troponin: short-term prognostic implications in the patient with a heart attack code, a observational prospective study.
OP037 Pre-hospital lactate and hospital troponin: short-term prognostic implications in the patient with a heart attack code, a observational prospective study.

Introduction: chest pain (ischemic heart disease) represents one of the leading causes of mortality, one of the most frequent causes of hospital admission, and one of the most common causes of consultation and care of Prehospital Emergency Medical Services (PhEMS).

The main objective was to evaluate the capacity of prehospital lactic acid (PLA) vs hospital troponin (HT), to predict early mortality at two days from the index event in patients with chest pain (ischemic heart disease).

Material and methods: Longitudinal prospective observational study, between April 1 and December 31, 2018. The study was developed on a reference population of 1,021,086 inhabitants, distributed in three provinces of Spain (Burgos, Salamanca and Valladolid) . All the hospitals included in the study have Intensive Care Unit (ICU) and hemodynamic service. It was considered that a patient fulfilled criteria to be included in the study if he had been attended by Advanced Life Support Units and transferred to the emergency services with a main diagnosis of chest pain (ischemic heart disease), and did not meet any exclusion criteria: under 18 years old, cardiorespiratory arrest, exitus and pregnant women.

Demographic data (age and gender) and PLA were collected during the first contact with the patient in prehospital care. To obtain the PLA values, the Accutrend Plus measuring device (Roche Diagnostics, Mannheim, Germany) was used. HT was collected in the Emergency Department at the hospital level with the cobas b 123 POC system (Roche Diagnostics, Mannheim, Germany).

The days of admission, need for ICU and / or hemodynamics and mortality data were obtained by reviewing the patient's electronic history at 30 days.

The main dependent variable was mortality from any cause in the hospital before the first two days from the index event.

The area under the curve (AUC) of the receiver operating characteristic (ROC) was calculated for each biomarker in terms of 2-day mortality, as well as the best score that offered greater sensitivity and joint specificity.

Results: a total of 258 patients were included in our study. The median age was 68 years (IQR: 58-81 years), 30.2% of them were women. The 2-day mortality was 7.4% (19 cases). 49.2% (127 cases) of patients required ICU.

The PLA obtained an AUROC for the two-day mortality of 0.918 (0.83-1, p <0.001), and the HT of 0.727 (0.59-0.85, p = 0.001). When comparing both curves, significant differences were observed (p = 0.001).

The value with the best sensitivity and specificity overall for the PLA was 4.1 mmol/L, sensitivity of 94.7% (75.4-99.1), specificity of 79.9% (74.4-84.5), positive predictive value 27.3 (18.0-39.0), negative predictive value 99.5 (97.1-99.9), Likelihood ratio (+) 4.72 (3.59-6.21), Likelihood ratio (-) 0.07 (0.01-0.45) and odds ratio 71.63 (9.33-549-97).

Conclusions: The use of PLA presents a very high AUROC in patients with chest pain (ischemic heart disease). The PLA can help PhEMS in the selection of the most appropriate hospital center, with acute cardiac care unit and hemodynamic unit, in order to reduce morbidity and mortality due to this prevalent pathology.

Dr Francisco MARTÍN-RODRÍGUEZ (Valladolid, SPAIN), Raúl LÓPEZ-IZQUIERDO, Carlos DEL POZO VEGAS, Julio C. SANTOS PASTOR, Ana B. LÓPEZ TARAZAGA, Juan F. DELGADO BENITO, María T. HERRERO DE FRUTOS, Mónica ESCRIBANO BARBERO, Ana VALDERREY MIELGO, María GERVÁS DE LA PISA, Francisco T. MARTÍNEZ FERNÁNDEZ, Arancha MORATE BENITO, María P. DELGADO BENITO, Isabel MANJÓN HERRERA, Maria Antonia UDAONDO CASCANTE, Germán FERNÁNDEZ BAYÓN, Rodrigues LEONARDO, Miguel A. CASTRO VILLAMOR
11:20 - 11:30 #18519 - OP038 Effectiveness of hypnosis for the prevention of anxiety during coronary angiography: The HypCor Study.
OP038 Effectiveness of hypnosis for the prevention of anxiety during coronary angiography: The HypCor Study.

Abstract

 

Background – Coronary angiography is the gold standard for the diagnosis of coronary artery disease. This procedure is nevertheless a source of anxiety given the inconvenience caused by its invasiveness but also due to the consequences linked to the discovery of potential diseases.

Aim - The aim of this study was to determine the effectiveness of hypnosis on reducing patient anxiety prior to coronary angiography.

Methods – A total of 169 patients with non-urgent indications of coronary angiography and no history of prior coronary angiography were randomized to a Hypnosis or Control group. Patients in the Hypnosis group underwent a hypnosis session with posthypnotic suggestions in self hypnosis, while those in the control group had a conversational interview with the hypnotherapist. The primary endpoint was the level of anxiety prior to the exam assessed by the Spielberger State-Trait Anxiety Inventory (STAI-Y A).

Results - Performing a hypnosis session did not translate into a significant decrease in anxiety prior to the procedure. The use of midazolam was lower (5% in the Hypnosis group versus 12%, p=0.05). Systolic blood pressure (SBP) was significantly lower before the examination (p = 0.01). There was no adverse effect secondary to hypnosis. There was no statistically significant difference between the 2 groups for the occurrence of complications due to the procedure.

Conclusion - In the present study, performing a hypnosis session upstream of a coronary angiography, with suggestions in self-hypnosis to be performed during the procedure, did not reduce the state anxiety measured immediately before the intervention. In contrast, a significant reduction in SBP was observed in the Hypnosis group. There appears to be a possible reduction in the prescription of anxiolytics through hypnosis, although the latter necessitates confirmation in a larger-scale study.

Nazmine GULER (Metz), François BRAUN, Sandrine WEBER, Christophe GOETZ, Khalife KHALIFE , Charles GENTILHOMME
11:30 - 11:40 #18548 - OP039 Could the YEARS algorithm be used to exclude PE during pregnancy? Data from the CT-PE-pregnancy study.
OP039 Could the YEARS algorithm be used to exclude PE during pregnancy? Data from the CT-PE-pregnancy study.

Introduction

In the recently published ARTEMIS study, the YEARS algorithm was shown to safely exclude pulmonary embolism (PE) and reduce usage of computed-tomography pulmonary angiogram (CTPA) among pregnant women with suspected PE. However, further validation is desirable prior to its implementation in clinical practice. Our aim was to externally validate the YEARS algorithm in pregnant women with suspected pulmonary embolism.

Methods

We performed a post-hoc analysis of a prospective management outcome study for PE diagnosis in pregnant women. PE was diagnosed using an algorithm that combined the revised Geneva Score, D-dimer test, bilateral lower limb compression ultrasonography and CTPA. All the items necessary to follow the YEARS algorithm were prospectively collected at the time of the study by the attending physician. The primary outcome was the rate of adjudicated symptomatic venous thromboembolic events at the 3-month follow up.

Results

Of the 395 women included in the original study, 371 were available for the present analysis. PE prevalence was 6.5%. Among the 371 women, 91 (25%) had no YEARS item, while 280 (75%) had one item or more: 14 had hemoptysis (3.8%), 55 had signs or symptoms of DVT (14.8%, of them 5 had a confirmed DVT on ultrasound) and pulmonary embolism was the most likely diagnosis for 262 patients (70.6%). When combined with D-dimer levels (<1000 ng/mL in women with zero item, and <500 ng/mL in women with ≥1 item), 77 women (21%) met the criteria for PE exclusion and would not have undergone a CTPA as per the YEARS algorithm. None of these 77 women had PE diagnosed during the initial work up or 3-month follow up. Therefore, the failure rate of the YEARS algorithm in our pregnant women population was 0/77 (95% confidence interval 0.0-3.9).

Discussions

These results confirm those from the recently published ARTEMIS prospective management study and provide additional evidence that the YEARS algorithm appears safe for pregnant women. Almost twice as many women could be spared from radiating imaging tests compared to the traditional algorithm. Given that D-dimer physiologically rises though pregnancy, the use of a higher D-dimer threshold (< 1000ng/ml) among patients with zero YEARS item could account for the higher diagnostic yield of the YEARS algorithm.

Limitations

The total number of women with a negative YEARS algorithm was small and the confidence interval around the estimation of PE prevalence in this group was wide, above the usual recommended limit for safe exclusion, precluding any definite conclusion to be drawn from the study. Also, in the CT-PE-pregnancy study, the likelihood of an alternative diagnosis (which is part of the Wells score but not of the Geneva score) had no consequence on patients’ management, which could have impacted the way physicians assessed this variable.

Conclusion

In our study, application of the YEARS algorithm would have resulted in safe exclusion of PE in 1 out of 5 pregnant women without the need for radiating tests, further supporting the use of the algorithm in this population.

Camille CUSSON-DUFOUR, Emilie LANGLOIS, Dr Thomas MOUMNEH (Angers), Antoine ELIAS, Guy MEYER, Karine LACUT, Jeannot SCHMIDT, Catherine LE GALL, Céline CHAULEUR, Frédéric GLAUSER, Helia ROBERT-EBADI, Marc RIGHINI, Grégoire LE GAL
11:40 - 11:50 #19063 - OP040 Pleuritic chest pain. Diagnosis of pulmonary embolism with lung ultrasound. US Wells Project.
OP040 Pleuritic chest pain. Diagnosis of pulmonary embolism with lung ultrasound. US Wells Project.

Background
Pleuritic chest pain is a common presentation in ED and it could sometimes be related to pleural irritation due to pulmonary infarct in pulmonary embolism (PE). Lung ultrasound (LUS) can detect pulmonary infarct, however its diagnostic accuracy for PE in a selected population presenting with pleuritic chest pain is unknown. The aim of the study is to analyze the performance of LUS in the diagnosis of PE in patients complaining of pleuritic chest pain. 

Methods

We combined individual patient data from three prospective cohort studies (one monocentric and two multicentric) involving patients evaluated for suspected PE in which LUS was performed at presentation. We extrapolated data regarding patients with and without pleuritic pain, and re-assessed the performance of LUS in the two populations for comparison.

Results

Among the 872 patients suspected of PE considered in the three studies, 217 (24.9%) presented with pleuritic chest pain and 655 (75.1%) without. Overall, 279 patients (32%) were diagnosed with PE. Pooled sensitivity of LUS in patients with and without pleuritic pain was respectively 81.5% (95%CI 70-90.1%) and 59.3% (95%CI 38.8-77.6%) (p <0.01). Specificity of LUS was similar in the two groups, respectively 95.4% (95%CI 90.7-98.1%) and 94.8% (95%CI 92.3-97.7%) (p>0.05). In patients with pleuritic pain, a diagnostic strategy combining Wells score with LUS performed better in terms of sensitivity (93%, 95%CI 80.9-98.5% vs 90.7%, 95%CI 77.9-97.4%), negative predictive value (96.2%, 95%CI 89.6-98.7% vs 93.3%, 95%CI 84.4-97.3%) and efficiency (56.7%, 95%CI 48.5-64.9% vs 42.5%, 95%CI 34.3-50.7%), than the conventional strategy based on Wells score and d-dimer.

Conclusion
In a population of patients suspected for PE, LUS for PE showed better sensitivity when applied to the subgroup complaining of pleuritic chest pain. In these patients, a diagnostic strategy based on Wells score and LUS performs better to exclude PE than the conventional rule based on clinical scoring and d-dimer.

Dr Cosimo CAVIGLIOLI (Florence, ITALY), Francesca Romana ERMINI, Chiara GIGLI, Angelika REISSIG, Alessandro BECUCCI, Peiman NAZERIAN, Giuliano DE STEFANO, Giovanni VOLPICELLI, Stefano GRIFONI
11:50 - 12:00 #19067 - OP041 Diagnostic accuracy of conventional chest radiography for acute aortic syndromes: results from ADVISED prospective multicenter study.
OP041 Diagnostic accuracy of conventional chest radiography for acute aortic syndromes: results from ADVISED prospective multicenter study.

ABSTRACT

Purpose. Guidelines recommend chest radiography (CR) in the workup of suspected acute aortic syndromes (AAS), if the pre-test clinical probability is low. However, the diagnostic impact of CR integration for rule-in and rule-out of AAS is unknown.

Methods. We performed a secondary analysis of the ADvISED multicenter study. Emergency Department (ED) outpatients were eligible if AAS was clinically suspected. Clinical probability was defined with the aortic dissection detection risk score (ADD-RS). CR was evaluated blindly by a radiologist, who judged on mediastinum enlargement (EM) and other signs.

Results. 1030 patients were analyzed, including 48 (4.7%) with AAS. The sensitivity and specificity of CR (any sign) were 54.2% (95%CI 39.2-68.6%) and 92.4% (95%CI 90.5-93.9%), with moderate inter-observer agreement between attending physician and radiologist for EM (k=0.44). CR integration increased the diagnostic accuracy over ADD-RS (AUC 0.87 vs 0.66; P<0.001). The sensitivity and specificity of a CR-integrated strategy were 68.8% (95%CI 53.6-80.9) and 76.5% (95%CI 73.7-79.1). CR-integrated rule-in (ADD-RS>1 or CR-positive) applied to 264 vs 130 patients with ADD-RS>1 alone, including 15 with AAS and 119 false positives. CR-integrated rule-out (ADD-RS≤1 and CR-negative) applied to 766 (74.4%) patients, including 15 with AAS (31.3% of cases).

Conclusions. In this observational study, CR integration with clinical probability assessment showed modest rule-in efficiency and insufficient sensitivity for conclusive rule-out. The pragmatic impact of CR on the workup of AAS appears questionable.

 

Alessandro BECUCCI (firenze, ITALY), Peiman NAZERIAN, Simona VEGLIA , Edoardo CAVIGLI, Soeiro ALEXANDRE DE MATOS , Christian MUELLER , Leidel BERND A. , Cosimo CAVIGLIOLI, Emanuele PIVETTA, Giovanni ALBANO, Stefano GRIFONI
12:00 - 12:10 #19175 - OP042 Myocardial strain as a marker of disease severity in infants with bronchiolitis, a pilot study.
OP042 Myocardial strain as a marker of disease severity in infants with bronchiolitis, a pilot study.

Introduction: Bronchiolitis is a respiratory viral infection, in most severe cases this may lead to acute respiratory failure and pulmonary hypertension (PH), although echocardiographic evidences of PH have been reported in mild cases too. PH may potentially affect cardiac function, though this has never been investigated so far.

Aim: To evaluate cardiac function in infants with bronchiolitis.

Methods: Infants with evidence of bronchiolitis were included. All cases underwent viral antigen testing on nasopharyngeal aspirates, arterial blood gas test and functional echocardiography within 24 hours from admission. Systolic and diastolic function for the left ventricle (LV) and right ventricle (RV) were assessed with longitudinal strain, as a measure of percentage of myocardial deformation. Based on existing normative data cut-off for RV and LV function were assessed. PH was defined by the presence of tricuspid regurgitation jet (TR) and septal position quantified by end-systolic eccentricity index (EI ES). Main outcomes (duration of respiratory support, DRS, and length of stay, LOS), were collected.

Results:  28 infants, of which 15 males and 13 females, age 31 ±19 days, weight 3.160 (1.960–4.010) kg. 17 and 11 patients had syncytial respiratory virus and rhinovirus infection respectively. Cases with bronchiolitis showed significantly lower values of LS for both ventricles (LV: p0.02 and RV: p0.03) compared to normative values. Among these, 12 (43%) had normal biventricular function, 10 (36%) showed LV dysfunction and 6 (21%) a biventricular dysfunction. No significant data were found for TR and EI ES. Infants with biventricular dysfunction showed a significant increase in LOS (p0.03) and DRS (p0.03) compared to those with normal function.

Conclusions: Infants with bronchiolitis may present myocardial impairment. Cardiac function may be related to disease severity and should be routinely assessed. Future studies with larger samples are needed to confirm these data. 

Anna Maria Caterina MUSOLINO, Dr Giulia Vanina CANTONE (Rome, ITALY), Braguglia ANNABELLA, Melania EVANGELISTI, Maria CLEMENTE, Elena BOCCUZZI, Maria Chiara SUPINO, Maria Pia VILLA, Anna Claudia MASSOLO
12:10 - 12:20 #19224 - OP043 A comparison among three clinical scores to identify low risk patients with non traumatic chest pain: a retrospective study.
OP043 A comparison among three clinical scores to identify low risk patients with non traumatic chest pain: a retrospective study.

Background:

In Italy, non-traumatic chest pain represents about 6% of admission to the Emergency Department (ED), but only 15-20% of these is due to acute coronary syndrome (ACS). There are many scoring systems developed to stratify patients depending on the risk of major adverse cardiac events (MACE), particularly the HEART score, the North American Chest Pain Rule (NACPR), the Not Objective Testing Rule (NOT).

The aim of this study is the comparison of these scores in order to identify patients who can be safely discharged from the ED.

Methods:

We analysed data obtained from a previous monocentric, retrospective, observational study performed in order to analyse modified Heart Score in patients admitted to ED of Policlinico Sant’Orsola in Bologna for chest pain, between January 1 and June 30, 2014.

We enrolled 1597 consecutive 18 or older aged patients for acute non-traumatic chest pain, irrespective of comorbidities, medical treatments and the onset of symptoms. Of them, 262 were excluded because of anginal equivalent without chest pain, significant ST-segment elevation, impossibility to complete the physician’s evaluation or the follow up. 191 patients were excluded because of the lack of the second troponin, necessary for NOT and NACPR. The final population is then composed by 1144 patients.

Patients were recalled within 180 days in order to register MACE.

We used Heart Score modified for the EKG criteria: two points were assigned in case of typical acute ischemia (significant ST-segment depression and T wave changes), 0 points in the case of a normal EKG or a single known anomaly without ST-T abnormalities, one point was assigned in the other cases. Instead, we used unchanged version of the NACPR and NOT.

The performance of these scores was evaluated with the estimates of sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV). We also compared the proportion of MACE in each low risk category of Heart Score, NACPR and NOT.

Results:

According to data analysis, the average age of the population is 60 ± 19. The Heart Score identified 26% (n=297) of patients in the low risk category, NACPR 9.3% (n=107) and NOT 11% (n=123). In this class of patients, all the scores showed a sensibility and an NPV of 100% for MACE, as nobody of these presented major adverse cardiac events.

Discussion & conclusion:

According to the literature, all these scores have high NPV, which reflects their capability to identify low risk patients for ACS. Instead Heart Score identified a significantly greater number of patients than the other two scores ( p<0.0001).

This likely depends on the inclusion criteria, in particular the exclusion of patients aged greater than 50 years old, who represent the majority of the ones admitted to the ED.

If these data were confirmed in new prospective studies, Heart Score would be used in clinical practice to safely discharge patients to the ED. In this way we could improve health costs and the hospital’s overcrowding.

Gabriele FARINA, Dr Eleonora TUBERTINI (Bologna, ITALY), Luca SANTI, Elena CASADEI, Giulia CESTER, Mario CAVAZZA
12:20 - 12:30 #19241 - OP044 Blood pressure in the emergency department and incident cardiovascular disease: a retrospective cohort study.
OP044 Blood pressure in the emergency department and incident cardiovascular disease: a retrospective cohort study.

Background: High blood pressure (BP) is an established risk factor for cardiovascular disease (CVD), but hypertension remains a global challenge. Prevention, diagnosis, treatment and control of hypertension needs improvement. In the emergency department (ED), BP is measured on almost every patient in order to assess patients’ condition in the short-term, and many patients have BP levels above the threshold for hypertension. It is still unknown if BP in the ED is associated with long-term prognosis or how this BPs should be handled. The purpose of this study was to explore if BP obtained in the ED is associated with incident atherosclerotic cardiovascular disease (ASCVD), myocardial infarction (MI), or stroke.

Methods: All patients who visited two university hospital EDs between 2010 to 2016 with an obtained BP in the ED were included and studied regarding incident ASCVD, MI, and stroke. Systolic BP (SBP) and diastolic BP (DBP) were obtained through EDs databases and the endpoint diagnosis from the Swedish National Patient Register and Cause of Death Register. BP was categorized based on the definition of BP and hypertension grades. Cox proportional hazard regression was used in crude and adjusted models to estimate hazard ratios (HR), confidence interval (CI) and cumulative incidence for ASCVD, MI, and stroke. Age, sex, history of hypertension, CVD and diabetes mellitus were adjusted for, in adjusted models.

Results: A total of 300,272 patients were followed for a median of 42 months (range 0-84 months). Incident ASCVD occurred in 8,914 cases (MI 4,709 events and stroke 6,700 events). BP levels above normal (SBP: >120-129 mmHg, DBP: >80-84 mmHg) had a progressively increased association with ASCVD, MI, and stroke. In the adjusted model, SBP that corresponded to hypertension grade 1, 2, and 3 had a statistically significant association with ASCVD (SBP 140-159 mmHg: HR 1.15, 95% CI 1.06-1.24, 160-179 mmHg: HR 1.35, 95% CI 1.24-1.46, ≥180 mmHg: HR 1.59, 95% CI 1.46-1.73). Similar results were observed for DBP. DBP in the high normal category (85-89 mmHg), had a statistically significant association with ASCVD (HR 1.15, 95% CI 1.06-1.25) and stroke (HR 1.17, 95% CI 1.07-1.29). In the crude model, SBP ≥180 mmHg had the strongest association with ASCVD (HR 5.50, 95% CI 5.06-5.99). Patients with no history of hypertension had a stronger association with ASCVD (SBP ≥180 mmHg: HR 2.01, 95% CI 1.75-2.32), compared to patients with a history of hypertension (SBP ≥180 mmHg: HR 1.34, 95% CI 1.20-1.49). There was a similar association with ASCVD between directly discharged (SBP ≥180 mmHg: HR 1.55, 95% CI 1.36-1.76) and admitted patients (SBP ≥180 mmHg: HR 1.74, 95% CI 1.55-1.96). The six-year cumulative incidence of ASCVD was approximately 12% for SBP ≥180 mmHg compared to 2% for normal SBP (120-129 mmHg).

Conclusions: BP in the ED is associated with incident ASCVD, MI, and stroke with a stronger association for higher BP levels. High BP recordings in EDs should not be disregarded as isolated events, but treatment should be initiated, and patients should be referred to primary care for hypertension investigation.

Pontus ORAS (Stockholm, SWEDEN), Henrike HÄBEL, Per SKOGLUND, Per SVENSSON
12:20 - 12:40 #19268 - OP045 The CARE Rule and the CARE-HEART strategy to safely reduce troponin measurement in patients presenting with chest pain.
OP045 The CARE Rule and the CARE-HEART strategy to safely reduce troponin measurement in patients presenting with chest pain.

Objectives:

Current guidelines for patients presenting to the Emergency Department (ED) with chest pain but with no ST segment Elevation Myocardial Infarction (STEMI) on ECG are mainly based on serial troponin measurements. These strategies are safe but costly and time consuming, contributing to emergency departments’ overcrowding. Our main objective was to prospectively assess the reliability of the CARE rule, corresponding to the first 4 items on the HEART score and its association with the HEART score to safely rule-out Non-STEMI without troponin measurement (CARE) or with a single baseline troponin measurement (HEART).

Methods:

Prospective observational study in six EDs. Consecutive patients with non-traumatic chest pain and no formal diagnosis after examination and ECG were included and followed for 45-days. Items allowing computation of the CARE rule and HEART score were prospectively collected by the attending physician. The main study endpoint was the 45-day rate of MACE (myocardial infarction, percutaneous coronary intervention, coronary bypass and cardiac death). Secondary endpoint was the theoretical reduction of the number of required troponin tests, computed by the difference between the actual number of troponin tests with the theoretical number of troponin test needed if the CARE-HEART strategy would have been applied. The procedure would be deemed reliable if, when negative, the rate of MACE is <1% with an upper limit of the 95% confidence interval (95% CI) <3%.

Results:

From 1452 patients included, 1402 were analysed, 1285 had at least one troponin measurement and 97 (7%) had MACE during the follow-up. The CARE rule was negative for 279 (20%) patients and one presented a MACE: 0.4% (1/279, 95% CI: 0-2.0%). The CARE-HEART strategy was negative for an additional 476 patients (34%) and one of them had a MACE: 0.3% (2/755, 95% CI: 0-0.9%). The CARE-HEART strategy could theoretically have spared 360 troponin measurements (19%).

Discussions:

The CARE rule safely classified 20% of patients in a very-low risk category, for whom the hypothesis of a NSTEMI would have been ruled-out without the need for a troponin test. An additional 34% patients were safely classified in the low risk group according to the HEART score, on the basis of a single troponin test.

Limitations:

This was an observational study. Physicians were not aware of the strategy interpretation and they may have a different and more prudent assessment of CARE items if they were asked to apply the rule. The reduction in terms of troponin tests is theoretical and likely overestimated. Nevertheless, this testifies to the potential medico-economic benefit of the procedure.

Conclusions:

With a very low risk of MACE during follow-up, the CARE Rule and the CARE-HEART strategy may safely allow reduction of troponin measurements in patients presenting to the Emergency Department with chest pain.

Dr Thomas MOUMNEH (Angers), Andréa PENALOZA, Anda CISMAS, Sandrine CHARPENTIER, Thibault SCHOTTÉ, Sabrina PERNET, Stephanie MALATEST, Fabrice PRUNIER, Alexandra WARNANT, Tin-Hinan MEZDAD, Cédric GANGLOFF, Louis SOULAT, Delphine DOUILLET, Jérémie RIOU, Pierre-Marie ROY
TERRACE 2B
12:40 LUNCH BREAK AND EXHIBITION
14:10

Monday 14 October

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A23
14:10 - 15:40

Resuscitation
Evidence-based cardiac arrest management, guided by a simulated case
Resuscitation

Moderators: Wilhelm BEHRINGER (Director) (Jena, GERMANY), Maaret CASTREN (Professor) (HELSINKI, FINLAND)
Animators: Tomas JEZEK (head of education and training center) (Hradec Králové, CZECH REPUBLIC), Dr Jiri NOVY (consultant) (Jičín, CZECH REPUBLIC), Dr Anatolij TRUHLAR (Medical Director EMS) (Hradec Kralove, CZECH REPUBLIC)
14:20 - 14:35 Intubation - Airway (AIRWAY II). Dr Lars ANDERSEN (Associate Professor) (Aarhus, DENMARK)
14:40 - 14:55 Epinephrine (PARAMEDIC II). Mathias HOLMBERG (Medical Doctor) (Aarhus, DENMARK)
15:00 - 15:15 Postresuscitation Care. Wilhelm BEHRINGER (Director) (Jena, GERMANY)
CONGRESS HALL

Monday 14 October

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B23
14:10 - 15:40

Court Room
You don't want to be part of this in real life
Human factors, Management, Medicolegal

14:10 - 15:40 4 Cases. Greg HENRY (USA), Dr John HEYWORTH (Consultant) (Southampton, UK), Dr Susie HEWITT (Consultant) (Derby, UK), Bernard FOEX (Consultant in Emergency Medicine and Critical Care) (Manchester, UK)
FORUM HALL

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C23
14:10 - 15:40

The Heart of the Matter
The one man show!
ARRHYTHMIAS, Stroke, Cardiovascular, HOT TOPIC SPEAKER!

Moderator: Pr Rick BODY (Professor of Emergency Medicine) (Manchester, UK)
14:10 - 15:10 HOT TOPIC SPEAK! Subtle ECG Findings of LAD Occlusion Myocardial Infarction. Dr Steve SMITH (Speaker) (Minneapolis, MN, USA)
15:10 - 15:40 Challenge Steve Smith! Dr Steve SMITH (Speaker) (Minneapolis, MN, USA)
SOUTH HALL 3AB

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D23
14:10 - 15:40

YEMD - Unique circumstances, challenge accepted
Listen to unique stories from unique people
Conflict, Disaster medicine, International EM, MSF, Young Emergency Medecine

Moderators: Wilma BERGSTRÖM (Nurse, medical student) (Berlin, GERMANY), Youri YORDANOV (Médecin) (Paris, FRANCE)
14:10 - 15:40 From Peking to Paris. Tom ROBERTS (Doctor) (Bristol, UK)
14:10 - 15:40 In the midst of Paris during the attacks. Youri YORDANOV (Médecin) (Paris, FRANCE)
14:10 - 15:40 EM in a conflict zone (Congo). Dr Steven VAN DEN BROUCKE (Internal Medicine) (Kortrijk-Dutsel, BELGIUM)
SOUTH HALL 3C

Monday 14 October

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E23
14:10 - 15:40

PAEDIATRICS
Research in PEM - Best PEM abstract AWARD
INTERACTIVE SESSION, Pediatric, Research

Moderators: Silvia BRESSAN (Moderator) (Padova, ITALY), Rianne OOSTENBRINK (pediatrician) (Rotterdam, THE NETHERLANDS)

14:10 - 14:40 Fast track in PEM. Rianne OOSTENBRINK (pediatrician) (Rotterdam, THE NETHERLANDS), Dr Ruud NIJMAN (academic clinical lecturer) (London, UK)
14:40 - 15:10 PSA in the ED. Cyril SAHYOUN (Attending Physician / Médecin adjoint du chef de service) (Geneva, SWITZERLAND), Silvia BRESSAN (Moderator) (Padova, ITALY)
15:10 - 15:20 #18296 - OP118 A NICE combination predicting hospitalisation at triage: a European multicentre prospective observational study of febrile children presenting to the Emergency Department.
OP118 A NICE combination predicting hospitalisation at triage: a European multicentre prospective observational study of febrile children presenting to the Emergency Department.

Background and aims:

A large proportion of paediatric Emergency Department (ED) visits consists of febrile children. A prolonged process between arrival at the ED and hospital admission can negatively influence ED crowding and subsequent quality of care for the individual patient. 

While several studies have focused on predicting hospital admission, many of those either focused on adults, on specific diseases (e.g. asthma only) or were performed in a single setting, thus limiting the generalizability of the result to other settings with a different case mix and different admission rates. Furthermore, many models included variables that were not available at triage, such as laboratory results.

We aimed to investigate early risk factors for hospital admission in febrile children attending different EDs in Europe, and to develop and validate a prediction model identifying those children needing hospitalisation, thereby improving patient flow and quality of care.

 

Methods:

In the MOFICHE study (Management and Outcome of Fever in children in Europe, January 2017-April 2018) data were collected on febrile children aged 0–18 years presenting to 12 European. MOFICHE is part of the PERFORM study (http://www.perform2020.eu). Routine data were prospectively collected and included general patient characteristics, markers of disease severity (abnormal vital signs according to the APLS reference ranges, Paediatric Early Warning Score (PEWS) and NICE fever guideline red alarming signs) and disposition (discharge, admission, ICU admission). 
A prediction model for hospitalisation was constructed using multivariable logistic regression analysis. We used a stepwise approach in which models with general patient characteristics, vital signs, PEWS and NICE alarming signs were tested separately, and were subsequently combined in the final model. The prediction model was derived in a random sample of half of the cases and validated in the remaining set. We determined the discriminative value of the model by calculating the receiver operating curves (ROCs) and assessed the predictive performance (sensitivity, specificity) at a high specificity level as our aim was to identify children at high risk for admission. 

 

Results:

38,496 children were included. Of those, 13.397 (34,9%) children were admitted to a general ward and 156 to the ICU. 
When testing patient characteristics and markers of disease severity separately, only the NICE alarming signs performed well with an AUC of 0.77 (95% CI 0.77-0.77), while patient characteristics, vital signs and PEWS performed poorly (AUC’s all below <0.70). 

However, combining patient characteristics, vital signs and NICE alarming signs yielded an AUC of 0.82 (95% CI 0.82-0.82). The model performed equally well in the validation set.
A “rule-in model” was created, which was highly specific (95%) with low sensitivity (37%), a positive likelihood ratio of 7.5 and a positive predictive value of 72%.

A digital calculator was constructed to facilitate clinical use.

 

Conclusion:

The combination of patient characteristics and markers of disease severity available at triage can be used to identify children at high risk for hospitalisation at an early stage and improve ED patient flow.

Dorine BORENSZTAJN (Rotterdam, THE NETHERLANDS), Nienke HAGEDOORN, Ulrich VON BOTH, Enitan D. CARROL, Manuel DEWEZ, Marieke EMONTS, Michiel VAN DER FLIER, Ronald DE GROOT, Jethro HERBERG, Benno KOHLMAIER, Emma LIM, Ian MACONOCHIE, , Federico MARTINON-TORRES, Ruud NIJMAN, Marko POKORN, Franc STRLE, Maria TSOLIA, Clementien VERMONT , Shunmay YEUNG, Dace ZAVADSKA, Werner ZENZ, Michael LEVIN, Henriëtte A MOLL
15:20 - 15:30 #18493 - OP119 A randomised, double-blind, placebo controlled trial of ondansetron to reduce vomiting in children receiving intranasal fentanyl and nitrous oxide for procedural sedation and analgesia.
OP119 A randomised, double-blind, placebo controlled trial of ondansetron to reduce vomiting in children receiving intranasal fentanyl and nitrous oxide for procedural sedation and analgesia.

Background:

Intranasal fentanyl and nitrous oxide are frequently combined for procedural sedation and analgesia in children. This approach is advantageous for its non-parenteral administration, but is associated with a higher incidence of vomiting than nitrous nitrous used as a sole agent. We sought to assess whether the preprocedural use of ondansetron reduces the incidence of vomiting associated with the combination of intranasal fentanyl and nitrous oxide for procedural sedation compared with placebo.

 Methods:

This was a double-blind, randomised, placebo controlled superiority trial conducted between October 2016 and January 2019 at a single tertiary care paediatric emergency department. Eligible patients were children aged 3-18 years with planned sedation with intranasal fentanyl and nitrous oxide. Participants were randomised to receive ondansetron or placebo 30-60 minutes prior to nitrous oxide administration. The primary outcome was early vomiting associated with procedural sedation defined as occuring during or up to 1 hour after nitrous oxide administration. Secondary outcomes were: number of vomits and retching during procedural sedation, vomiting 1 to 24 hours post procedural sedation, procedural sedation duration, adverse events and quality of sedation across the two groups.

 

Results:

442 participants were randomised and outcome data were available for analysis in 436 participants. There was little evidence of a difference in the primary outcome, early vomiting associated with procedural sedation, between the groups: ondansetron 12% vs. placebo 16%, difference in proportions -4.6% (95% confidence interval [CI] -11 to 2.0; P=.18). However, the overall vomiting incidence up to 24 hours after the procedure was lower in ondansetron treated patients 21% vs. placebo 31% (-10%, 95%CI -19 to -1.4; P=.02), number needed to treat of 10. All other secondary outcomes were similar between the groups. Most sedations were reported as optimal by the treating clinician (91%). There were only two minor adverse events, both in the placebo group. There were no serious adverse events.

 

Discussion & Conclusions:

This is the first study reporting on premedication to prevent vomiting associated with the combination of intranasal fentanyl and nitrous oxide for procedural sedation in children. In this trial, the incidence of early vomiting was lower than previously reported in the literature, which may explain our null findings. We found little evidence that ondansetron reduces the incidence of early vomiting related to procedural sedation with the combination of intranasal fentanyl and nitrous oxide. This trial adds further evidence regarding safety of this sedation strategy.

Emmanuelle FAUTEUX-LAMARRE, Pr Franz E BABL (Melbourne, AUSTRALIA), Michelle MCCARTHY, Nuala QUINN, Andrew DAVIDSON, Donna LEGGE, Katherine J LEE, Greta M PALMER, Sandy M HOPPER
15:30 - 15:40 #18769 - OP120 Clinical prediction to target new biomarkers in febrile children at the ED, a European observational study.
OP120 Clinical prediction to target new biomarkers in febrile children at the ED, a European observational study.

Background: Early detection and treatment of invasive bacterial infections reduces morbidity and mortality. Distinguishing between invasive bacterial and self-limiting viral infections solely based on clinical signs and symptoms is unreliable. Therefore, overtreatment with antibiotics in febrile illnesses is common. In Europe, antibiotic prescription rates for febrile illness vary from 19% to 64%.

Aim: To externally validate and update a clinical prediction model to identify invasive bacterial infections and define risk thresholds where new biomarkers could improve accurate diagnosis.

Methods: Data of febrile children <18 years attending 12 European EDs were collected between January 2017-April 2018. The main outcome measure was invasive bacterial infection (IBI) defined as bacteremia, sepsis or bacterial meningitis. For this analysis, we excluded children without C-reactive protein (CRP) measurement and children with urinary tract infection. We externally validated and updated an existing clinical prediction model (Feverkidstool which includes vital signs, clinical symptoms and CRP) and extended the model by including level of consciousness. We determined the discriminative value by the C-statistic and assessed the predictive performance (sensitivity, specificity, negative and positive likelihood ratios) at different thresholds.

Results: 16,225 patients were included (median age 2.8 years (IQR 1.4-6.0), 29% ill appearing) of whom 155 had an IBI. The discriminative ability of IBI versus no IBI was moderate for the original model (0.73 (95% CI 0.69-0.77) and improved in the updated model with consciousness (0.79 (95% CI 0.75-0.83). The updated model for IBI performed well for the low-risk threshold of 2.5% (sensitivity 0.93 (95% CI 0.86-0.97), negative likelihood ratio 0.39 (95% CI 0.2-0.8)) and was moderate for the high-risk threshold of 30% (specificity 0.88 (95 % CI 0.87-0.89), positive likelihood ratio 3.5 (95% CI 2.7-4.6). The intermediate thresholds of 5-30% performed poorly (ranges: sensitivity 0.58-0.85, negative likelihood ratio 0.46-0.59, specificity 0.33-0.71, positive likelihood ratio 1.26-1.99).

Conclusion: The low-risk threshold of the updated clinical prediction model is useful to rule- out patients with IBI at the ED. The intermediate and high-risk thresholds are lacking excellent rule-in value for IBI to target treatment. The number of unnecessary treated patients could potentially be reduced by addition of other new sensitive biomarkers.

Nienke HAGEDOORN (Rotterdam, THE NETHERLANDS), Dorine BORENSZTAJN, Ian MACONOCHIE, Ruud NIJMAN, Federico MARTINON-TORRES, Jethro HERBERG, Enitan CARROL, Emma LIM, Maria TSOLIA, Marieke EMONTS, Ronald DE GROOT, Michiel VAN DER FLIER, Werner ZENZ, Benno KOHLMAIER, Franc STRLE, Marko POKORN, Dace ZAVADSKA, Ulrich VON BOTH, Clementien VERMONT, Shunmay YEUNG, Michael LEVIN, Henriëtte MOLL
15:10 - 15:40 Best PEM abstract AWARD.
CHAMBER HALL

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F23
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ABSTRACTS SESSION

Moderators: Marco BONSANO (YEMD Secretary) (London, UK), Christoph DODT (ead of the Department) (München, GERMANY)
14:10 - 14:20 #19093 - OP046 The impact of dispatcher assistance in the rates and efficacy of bystander cardiopulmonary resuscitation: A meta-analysis.
OP046 The impact of dispatcher assistance in the rates and efficacy of bystander cardiopulmonary resuscitation: A meta-analysis.

Objectives The introduction and development of the concept of emergency medical services (EMS) has played a crucial role in decreasing mortality rates and returning to independent survival in out-of-hospital cardiac arrests(OHCA). The role of Dispatcher Assisted Cardiopulmonary Resuscitation (DACPR) has not been widely reported. The objectives of the study were to perform a meta-analysis of observational studies addressing whether DACPR, compared with independent Bystander Cardiopulmonary Resuscitation (BCPR),increased the rates of BCPR, and whether they altered survival outcomes compared with no BCPR in OHCA.

Methods We searched the relevant literature from PubMed and Cochrane databases. The basic information and outcome data (BCPR rates, survival to hospital discharge, 1-month survival) were extracted from the included studies. Meta-analyses were performed by using STATA 11.0 software.

Results Eight studies involving 65,148 patients were eligible. Overall meta-analysis showed that DACPR was associated with statistically improved rates of BCPR (Odds Ratio [OR] =3.48, 95% confidence interval[CI]: 2.08-5.83, I2= 96.7%), and survival to discharge/ 1-month survival (OR=1.51, 95%CI: 1.40-1.63, I2= 24.9%) when compared with no BCPR.However, no significant effect of DACPR in survival rate was found, when compared with independent BCPR (OR=0.84, 95% CI: 0.62-1.14, I2= 88.6%).

Conclusion This study found that DACPR resulted in significantly higher rates of BCPR as compared withindependentBCPRin OHCAs.Considering that DACPR also resulted in greater survival rate compared withno BCPR,DACPR should be a standard protocol for EMS systems worldwide.

Yu WANG, Yu WANG (Hefei,China, CHINA), Hong ZHANG
14:20 - 14:30 #18119 - OP047 Degeneration of Shockable Rhythm According to the No-flow Time for Out-of-Hospital Cardiac Arrest Patients.
OP047 Degeneration of Shockable Rhythm According to the No-flow Time for Out-of-Hospital Cardiac Arrest Patients.

Background

Patients for whom the out-of-hospital cardiac arrest (OHCA) is not witnessed are generally not considered eligible for extracorporeal resuscitation (E-CPR) because the duration before the initiation of their resuscitation (no-flow) is uncertain. It has previously been proposed that an initial shockable rhythm (SR) strongly suggested a short period of no-flow. The objective of this study was to describe the association between the duration between the initiation of the prehospital resuscitation and the presence of a SR for patients suffering from an OHCA.

Methods

The present cohort study used a registry of adult OHCA between 2010 and 2015 in Montreal, Canada. Adult patients suffering from a non-traumatic OHCA for whom the OHCA was witnessed, who did not have by-stander cardiopulmonary resuscitation were included. Patients who had a paramedic-witnessed OHCA were also included as a control group (no-flow time = 0 minutes). Patients who experienced a return of spontaneous circulation (ROSC) before the paramedics’ arrival or for whom the initial rhythm was not known were excluded. The evolution of the proportion of SR was initially described and a multivariable logistic regression controlling for pertinent demographic and clinical variables (e.g. age, gender, time of the day).

Results

A total of 1751 patients (male = 67%, mean age = 69 years [standard deviation = 16]) were included in the main analysis, of whom 603 (34%) had an initial shockable rhythm. A total of 663 other patients had their OHCA witnessed by paramedics. A shorter no-flow duration was associated with the presence of an initial SR (adjusted odds ratio = 0.97 [95% confidence interval = 0.94-0.99], p=0.016). However, this relation was not linear and the proportion of SR does not seem to lower until 15 minutes of no-flow duration (0 min = 35%, 1-5 min = 37%, 5-10 min = 35%, 10-15 min = 34%, more than 15 min = 16%).

Conclusion

Although the proportion of patients with a SR decreases as the no-flow duration increase, this relationship does not appear to be linear. The main decline in the proportion of patients with SR seems to occur after the fifteenth minute of no-flow time.

Dr Alexis COURNOYER (Montréal, CANADA), Sylvie COSSETTE, Raoul DAOUST, Judy MORRIS, Jean-Marc CHAUNY, Brian POTTER, Luc DE MONTIGNY, Dave ROSS, Luc LONDEI-LEDUC, Yoan LAMARCHE, Jean PAQUET, Martin MARQUIS, Éric NOTEBAERT, Francis BERNARD, Martin ALBERT, Éric PIETTE, Yiorgos Alexandros CAVAYAS, André DENAULT
14:30 - 14:40 #18370 - OP048 Urban-Rural gap in Effectiveness of Dispatcher-Assisted Cardiopulmonary Resuscitation.
OP048 Urban-Rural gap in Effectiveness of Dispatcher-Assisted Cardiopulmonary Resuscitation.

Background:

  Out-of-hospital cardiac arrest (OHCA) is the leading cause of death worldwide. Dispatcher-assisted cardiopulmonary resuscitation (DACPR) is an effective intervention to promote early bystander CPR and improve survival outcome in patients with OHCA. The different effectiveness of implementing DACPR in urban and rural areas has not been explored.

Methods:

  This is a prospective observational study. It was carried out in Taichung County, which is consisted with urban, suburban and rural areas. In 2018, Taichung had more than 2.8 million residents and more than 2500 patients with OHCA. We have been promoting DACPR since 2015. All dispatchers have received at least 8-hour training on providing DACPR instructions. After two years of running-in, DACPR was implemented steadily in Taichung.

  All OHCA cases occurred in Taichung County from July 1, 2017 to November 30, 2018 were included in the study. Those appeared apparent death, refused hospital referral, aged younger than 20 years and those who with cardiac arrest consecutive to trauma were excluded. Those who lacked audio file records were also excluded. Prehospital data were collected according to the Utstein-style template. The primary outcome of this study was to determine the urban-rural gap in the proportion of bystander performed CPR after dispatchers identified cardiac arrest status. Patient’s outcome, such as return of spontaneous circulation (ROSC) before hospital arrival, 2-hour survival rate, and neurological outcomes were also recorded.

 

Results

  A total of 2716 patients were enrolled in this study after excluded those who met the aforementioned exclusion criteria. Patients with OHCA in the rural areas were older than urban areas (71.0±16.4 in urban areas, 69.68±15.8 in suburban areas, and 73.03±14.9 in rural areas respectively, p = 0.006). When compared with urban areas, emergency medical services response time was increased in rural areas. There was no difference in gender, types of location where cardiac arrest occurred, witness of arrests and initial shockable arrests.

  There was no difference in the recognition of cardiac arrest between urban and rural areas. However, after the dispatchers identified cardiac arrests, the proportion of bystanders who performed CPR in urban areas is higher than in rural areas (75.87% in urban areas, 73.46% in suburban areas and 67.73% in rural areas). The urban area has a relatively higher chance to achieve ROSC, and has a relatively higher proportion patients survived with favorable neurological function, but those had not reached statistical significance.

 

Conclusion

The study found that in the same dispatch center, bystanders in urban areas had a higher rate of acceptance and perform of cardiopulmonary resuscitation. Although no statistically significance, it was found that patients with OHCA in urban areas had a better prognosis. In the future, public health and public education are need to make people more likely to perform cardiopulmonary resuscitation and achieve more bystander cardiopulmonary resuscitation.

Hong-Mo SHIH, Shao-Hua YU (Taichung, TAIWAN)
14:40 - 14:50 #18530 - OP049 Thrombolysis during resuscitation for out-of-hospital cardiac arrest caused by pulmonary embolism increases 30-day survival: findings from the French National Cardiac Arrest Registry.
OP049 Thrombolysis during resuscitation for out-of-hospital cardiac arrest caused by pulmonary embolism increases 30-day survival: findings from the French National Cardiac Arrest Registry.

Background: Pulmonary embolism (PE) represents 2% to 13% of all causes of out-of-hospital cardiac arrest (OHCA) and is associated with extremely unfavorable prognosis. In PE-related OHCA, inconsistent data showed that thrombolysis during cardiopulmonary resuscitation (CPR) may favor survival.

Methods: It was a retrospective, observational, multicenter study from the French National OHCA. All adult OHCA, managed by a mobile intensive care unit, and with a diagnosis of pulmonary embolism confirmed on hospital admission were included. PE was diagnosed on hospital admission by computed tomography pulmonary angiography (CTPA) (definite PE) or echocardiogram (probable PE). We excluded all other causes of OHCA and patients who had ROSC prior to mobile intensive care unit management. Patients were classified in two groups: those who received thrombolytic therapy during cardiopulmonary resuscitation and those who did not. The primary end point was day-30 survival in a weighted population. In order to obtain unbiased estimations of the average treatment effects, we used inverse probability of treatment weighting (IPTW). This method was performed in two steps: first, an estimation of the propensity score of treatment (thrombolysis during cardiopulmonary resuscitation) with a logistic model, and then an estimation of the effect of treatment on 30-day survival, weighted on the propensity score. The present study was approved by the French Advisory Committee on Information Processing in Health Research (CCTIRS) and the French National Data Protection Commission. It was approved as a medical assessment registry without requirement for patient consent.

Results: From July 2011 to March 2018, of the 14,253 patients admitted to the hospitals, 328 had a final diagnosis of PE and 246 were included in the analysis. In the group that received thrombolysis during resuscitation (n=58), 14 received alteplase (24%), 43 tenecteplase (74%) and 1 streptokinase (2%). Thirty-day survival was higher in the thrombolysis group than in the control group (16% vs 6%, P=0.005; adjusted log-rank test) but the good neurological outcome was no significantly different (10% vs 5%; adjusted relative risk = 1.97 CI95[0.70–5.56]). Median duration of stay in the intensive care unit (ICU) was 1 (0-5) day in the thrombolysis group and 1 (0-3) day in the control group (P=0.23). Mortality on day 0 (i.e., day of the OHCA) was 34% in the thrombolysis group and 37% in the control group (P = 0.76). Among all survivors at day 30, the median time until ICU discharge was 10 (4-21) days. Subjects in the thrombolysis group would not die of hemorrhage any more than those in the control group (6% vs 5%; P = 0.73). On the other hand, irreversible coma appeared slightly less frequent as a cause of death in the thrombolysis group (2% vs 11%; P = 0.05).

Conclusions: In OHCA patients with confirmed PE and admitted with recuperation of spontaneous circulation in the hospital, there was significantly higher 30-day survival in those who received thrombolysis during CPR compared with patients who did not receive thrombolysis. Randomized controlled trials are needed to define the role of thrombolysis in the management of suspected PE-related OHCA.

François JAVAUDIN (Nantes), Jean-Baptiste LASCARROU, Quentin LE BASTARD, Quentin BOURRY, Hugo DE CARVALHO, Philippe LE CONTE, Joséphine ESCUTNAIRE, Hervé HUBERT, Emmanuel MONTASSIER, Brice LECLERE
14:50 - 15:00 #18988 - OP050 Effect of the floor level on a neurologically favorable discharge after cardiac arrest according to the event location.
OP050 Effect of the floor level on a neurologically favorable discharge after cardiac arrest according to the event location.

Background:

Increases in the population concentrations in urban areas have led to increases in the numbers of people who live in high-rise buildings. Several studies reported the negative outcomes of patients who experience OHCA in high-rise buildings. Despite the above findings, we assumed that an increased vertical distance would always lead to a delayed EMS response time, as high-rise buildings tend to be densely populated and located in traffic center. This study aimed to compare the emergency medical service (EMS) response times and probability of a neurologically favorable discharge among patients who suffered an out-of-hospital cardiac arrest (OHCA) while on a high or low floor at home or in a public place.

Methods:

This retrospective analysis was based on Smart Advanced Life Support registry data from January 2016 to December 2017. Patients older than 18 years who suffered an OHCA due to medical causes were included in this study. Patients who were not resuscitated because of obvious signs of death, a refusal of CPR, do-not-resuscitation (DNR) state, or medically directed cessation of CPR; whose CA was witnessed by 911-initiated first responders; or who had incomplete data were excluded. A high floor was defined as the ≥3rd floor above ground. We compared the probability of a neurologically favorable discharge according to the floor level and location (home vs. public place) of the OHCA event. Additionally, we calculated the call-to-scene and call-to-patient times after OHCA for patients classified into the high and low (<3rd) floor groups according to the CA event location.

Results:

Of the 6,335 included OHCA cases, 4,154 (65.6%) events occurred in homes. Rapid call-to-scene times for high floor events were reported in both homes and public places. A longer call-to-patient time was observed for home events. Among OHCA events that occurred on high floors, the likelihood of a neurologically favorable discharge was significantly lower if the event occurred in a public place (adjusted odds ratio [aOR]=0.58) but higher if the event occurred at home (aOR=1.49).

Discussion & Conclusions:

Both the EMS response times to OHCA events in high-rise buildings and the probability of a neurologically favorable discharge differed between homes and public places. The results suggest that the prognosis of an OHCA patient is more likely to be affected by the building structure and use rather than the floor height.

Choung Ah LEE (Hwaseong, KOREA), Han Joo CHOI, Hyung Jun MOON, Won Jung JEONG, Gi Woon KIM
15:00 - 15:10 #19052 - OP051 Implementation of Dispatcher-assisted CPR was associated not only with better survival rates but also with increased number of cardiac arrest patients found by EMS with ventricular fibrillation.
OP051 Implementation of Dispatcher-assisted CPR was associated not only with better survival rates but also with increased number of cardiac arrest patients found by EMS with ventricular fibrillation.

Background

Many studies confirmed that dispatcher-assisted CPR (D-CPR) could improve survival from out-of-hospital cardiac arrest (OHCA) by significant improvement of bystander-CPR (B-CPR) rates. The aim of this study was to confirm relation between D-CPR implementation, incidence of cardiac arrest patients found by EMS with ventricular fibrillation (VF OHCA) and survival from VF OHCA from long-term (15 years) perspective.

Method

This is a retrospective analysis of Prague Utstein-style OHCA registry from the beginning of D-CPR implementation (2003) until the end of 2018. Survival from cardiac arrest was defined as survival with cerebral performance category 1 or 2 during 30 days follow-up after OHCA.

Results

During first ten years of D-CPR implementation, B-CPR rates increased from 13,6%  to 81,0% (p<0,0001) and then remained more or less stable for following 6 years. This process was in strong correlation with VF OHCA incidence (Pearson R score = 0,684; P-Value = 0,003) as well as with VF OHCA survival rate (Pearson R score = 0,782; P-value = 0,00011). 

Conclusion

VF OHCA incidence as well as VF OHCA survival rates were in a strong correlation with D-CPR implementation as measured by B-CPR ratios. This supports the hypothesis that D-CPR increases survival from OHCA not only by improving survival rates, but also by keeping more patients with ventricular fibrillation running until EMS arrival.

Ondrej FRANEK (PRAHA, CZECH REPUBLIC), Jaroslav PEKARA
15:10 - 15:20 #19153 - OP052 Comparison between emergency physicians’ decision to hospitalize or discharge home and clinical risk categories of the MEESSI scale among patients with acute heart failure.
OP052 Comparison between emergency physicians’ decision to hospitalize or discharge home and clinical risk categories of the MEESSI scale among patients with acute heart failure.

Objective: The MEESSI is a validated clinical decision tool that characterizes risk of mortality in emergency department (ED) acute heart failure (AHF) patients. The objective of this study was to compare the distribution of risk categories between hospitalized and discharged ED patients with AHF.

Methods: We included consecutive AHF patients from 34 Spanish EDs. Patients were retrospectively classified according to MEESSI risk categories. We calculated the odds of hospitalization (vs. direct discharge from the ED) across MEESSI risk categories. Next we assessed the following 30-day post-discharge outcomes: ED revisit, hospitalization, death, and their combination. We used Cox hazards models to determine the adjusted association between ED disposition decision and the outcomes among patients who were stratified into low and increased risk categories.

Results: We included 7,930 patients [age=80.5 (SD=10.1) years; women=54.7%; hospitalized=75.3%]. Compared to low-risk MEESSI patients, OR for hospitalization of patients in intermediate, high and very-high risk categories were 1.83 (1.64-2.05), 3.05 (2.48-3.76) and 3.98 (3.13-5.05), respectively. However, almost half (47.6%) of all discharged patients were categorized as increased risk by MEESSI, and 19.0% of all the increased risk patients were discharged from the ED. Among the low-risk MEESSI patients, the 30-day post-discharge mortality did not differ by ED disposition (HR for discharged patients respect to hospitalized 0.65, 0.70-1.11), nor did it differ in the increased risk group (0.88, CI 0.63-1.23). The low risk MEESSI patients had higher risks of 30-day ED revisit and hospitalization (1.86, 1.57-2.20; and 1.92, 1.54-2.40; respectively) as did the increased risk group (1.62, 1.39-1.89; and 1.40, 1.16-1.68), with similar results for the combined endpoint[MO(1] .

Conclusions: The disposition decisions made in current clinical practice for ED AHF patients calibrate with MEESSI risk categories, but nearly half of the patients currently discharged from the ED fall into increased risk MEESSI categories.

Acknowledge of funding: This study was partially supported by grants from the Instituto de Salud Carlos III supported with funds from the Spanish Ministry of Health and FEDER (PI15/01019, PI15/00773, PI18/00393, PI18/00456) and Fundació La Marató de TV3 (2015/2510).

Oscar MIRO (Barcelone, SPAIN), Víctor GIL, Pablo HERRERO-PUENTE, Jacob JAVIER, Pere LLORENS, F. Javier MARTÍN-SÁNCHEZ, Xavier ROSSELLÓ
15:20 - 15:30 #19168 - OP053 Evolution of bystander intention to perform cardiopulmonary resuscitation after training : an online survey.
OP053 Evolution of bystander intention to perform cardiopulmonary resuscitation after training : an online survey.

Background:

Early cardiopulmonary resuscitation (CPR) dramatically increases the chances of neurologically intact survival after cardiac arrest. CPR is however initiated by bystanders in less than half of all out-of-hospital cardiac arrests. The probability of starting CPR depends on the intention to perform resuscitation, which can be divided into three components: attitude, perceived norms, and self-efficacy. The aim of our study was to evaluate how these components change according to the time elapsed since the last CPR training.

Method:

After consultation of our local ethics committee, a web-based survey was created. Intention to perform CPR was assessed by 17 questions based on a 4-point Likert scale.

A link to the survey was sent via e-mail by a Red Cross National Society affiliated CPR training centre based in Geneva, Switzerland, to all previous participants for whom an electronic address was available. No personal data other than that required for the demographic analysis was ever recorded or asked for.

After connection to the web site, a consent form and confidentiality statement were immediately displayed.

Surveys were excluded if they were completed by healthcare professionals, healthcare students, or if the last CPR training took place more than five years prior to our study.

Data was stored in an encrypted MySQL database, extracted to a comma-separated value file, and analysed using Stata 15. Participants were sorted in two groups according to their last CPR training (< 1 year and ≥ 1 year). Fisher’s exact test or chi-square test were used according to normality and sample size. A p value < 0.05 was considered significant.

Results:

3360 e-mails were sent at the end of January 2019. 162 surveys were included in our analysis (59 were excluded according to our criteria). There was no significant difference in demographics between the two groups.

Attitude: 5 out of 6 elements did not differ significantly. The ≥ 1 year group was more worried about the risk of contracting a transmissible illness in (p=0.010).

Perceived norms: 5 out of 6 elements did not differ significantly. Participants in the ≥ 1 year group were more prone to the risk of diffusion of responsibility (p=0.011).

Self-efficacy: 2 out of 5 elements did not differ significantly.  Participants in the ≥ 1 year group felt less confident about their ability to recognize a cardiac arrest (p < 0.001) and to perform CPR (p=0.029). They also felt they wouldn’t be helpful if they had to deal with a cardiac arrest (p=0.004).

Conclusion:

After CPR training, elements related to all three components determining the intention to perform CPR decreased significantly over time. This might prevent some bystanders from providing early CPR, and further research should therefore focus on means to prevent, avoid, or compensate this decrease, far beyond technical considerations.

Django ROSA (Geneva, SWITZERLAND), Mélanie SUPPAN, Robert LARRIBAU, Marc NIQUILLE, François SARASIN, Simon REGARD, Laurent SUPPAN
15:30 - 15:40 #19329 - OP054 Peer teaching model for basic life support in high school student.
OP054 Peer teaching model for basic life support in high school student.

Objective: It has been shown that initiation of early cardiopulmonary resuscitation (CPR) decreases morbidity and mortality of out-of-hospital cardiac arrest patients.Despite this information, the rate of early CPR application is low in most countries. Basic life support (BLS) training for the public is important to increase the rate of CPR application in out-of-hospital cardiac arrests. In this study we aimed to test the effectiveness of peer education method on the learning and application of BLS in high school students.

Method: The study was conducted in high school and grade one students were included in the study. Students are divided in two groups (Group A and Group B). Pre-test and post-test tests were applied before and after training to measure the awareness and knowledge of all students.At the beginning of the study pediatric emergency and pediatric intensive care physicians trained eight students in group A.  These eight students were given BLS instructor training.   Afterwards these students trained eight students in group B with same method and those eight students in group B became instructor.  Instructor students from both groups trained their friends in their own group.A medical doctor supervised every training session. Training session was not intervened unless there is wrong information transfer or unanswered question by instructor student.

Results:153 students were included in the study. 5 students were excluded from the study because they did not participate in the tests. There were 76 students in group A and 72 students in group B.There was a statistically significant improvement in 8 questions from 13 questions in the pre- and post-training knowledge tests (p <0.05). Students were able to give true answers regarding environmental safety, consciousness assessment, control of the airway and respiration, 30: 2 chest compression, 100 times chest compression, the hands placed in the middle of the chest. This situation was similar in two groups and there was no difference between two groups in terms of improvement in post-test performance.Students were evaluated in terms of BLS application competence. In the 16-step evaluation, the students in group A applied BLS with a success rate of 90.2% and B group with a success rate of 93.4%. In group A, it was found that the most successful steps were respiration control and performing 30: 2 chest compressions.Calling emergency call center step was the most forgotten step in group A.In Group B, most successful step was to provide environmental safety, the most forgotten step was to call emergency call center.In post-training awareness questionnaire, significant improvement was determined in terms of basic life support (BLS) hearing, understanding of BLS need, feeling sufficient to apply BLS, giving BLS training in schools and watching videos about BLS.

Conclusion:This is the first study testing the effectiveness of peer education method in BLS training of high school students. It was shown that with peer education model students could train other students as basic life support instructors. With the implementation and dissemination of this training model, BLS training can be given to the public much faster.

Ahmet Ziya BIRBILEN (Ankara, TURKEY), Selman KESICI, Damla HANALIOGLU, Zeynel OZTURK, Ozlem TEKSAM, Benan BAYRAKCI, Zeynep BAYRAKCI
TERRACE 2B
15:40 COFFEE BREAK AND EXHIBITION - E-POSTER SESSION
16:10

Monday 14 October

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A24
16:10 - 17:40

Major trauma
Changing the alphabet of trauma care
Trauma

Moderators: James CONNOLLY (Consultant) (Newcastle-Upon-Tyne, UK), Gareth ROBERTS (Doctor) (Manchester, UK)
16:10 - 17:40 A Primary Survey fit for the 21st Century. James CONNOLLY (Consultant) (Newcastle-Upon-Tyne, UK)
16:10 - 17:40 A is for archaic? Did the ATLS 10 go far enough? Dr Zaffer QASIM (Speaker) (Philadelphia, USA)
16:10 - 17:40 The one before A-Managing catastrophic hemmorrhage. Dr Clare BOSANKO (EM/PHEM) (Plymouth, UK, UK)
CONGRESS HALL

Monday 14 October

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B24
16:10 - 17:40

What characteristics does a good emergency physician have?
What does it take to be excellent in Emergency Medicine? Tips from the experts
General EM, Human factors, Soft skills

Moderators: Christian HOHENSTEIN (PHYSICIAN) (Madgeburg, GERMANY), Senad TABAKOVIC (Zürich, SWITZERLAND)
16:10 - 16:20 The 7 habits of a highly effective emergency physician (15 minute introduction talk). Dr Thomas FLEISCHMANN M.D. (Medical Director) (Rendsburg, GERMANY)
16:20 - 16:40 Panel Discussion 1. Greg HENRY (USA), Dr Thomas FLEISCHMANN M.D. (Medical Director) (Rendsburg, GERMANY)
16:40 - 16:50 Carry on erring: Would routinely cross-checking cases improve safety? Pr Yonathan FREUND (Emergency Physician) (Paris, FRANCE)
16:50 - 17:10 Panel Discussion 2. Greg HENRY (USA), Pr Yonathan FREUND (Emergency Physician) (Paris, FRANCE), Dr Thomas FLEISCHMANN M.D. (Medical Director) (Rendsburg, GERMANY)
17:10 - 17:20 Lecture 3. Greg HENRY (USA)
17:20 - 17:40 Panel Discussion 3. Greg HENRY (USA), Judith TINTINALLI (Professor) (Chapel Hill NC, USA), Dr Thomas FLEISCHMANN M.D. (Medical Director) (Rendsburg, GERMANY), Pr Yonathan FREUND (Emergency Physician) (Paris, FRANCE)
FORUM HALL

Monday 14 October

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C24
16:10 - 17:40

Resuscitation in different colors
Soft skills and philosophy of resuscitation
ARRHYTHMIAS, Stroke, Human factors, Wellbeing

Moderators: Wilhelm BEHRINGER (Director) (Jena, GERMANY), Marie-Laure BOUCHY JACOBSSON (Consultant) (Hellerup, DENMARK)
16:10 - 17:40 What is a good resuscitation? Maaret CASTREN (Professor) (HELSINKI, FINLAND)
16:10 - 17:40 Debriefing after a disaster in the resus room. Simon CARLEY (Consultant in Emergency Medicine) (Manchester, UK)
16:10 - 17:40 Are we still performing inappropriate CPR attempts at the end of life? Pr Suzanne MASON (Professor of Emergency Medicine) (Sheffield, UK)
SOUTH HALL 3AB

Monday 14 October

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D24
16:10 - 17:40

YEMD - Newest kids on the block
Prepared fresh just for you!
Communication, Fringe, Young Emergency Medecine

Moderators: Tom ROBERTS (Doctor) (Bristol, UK), Patricia VAN DEN BERG (Academic Clinical Fellow Emergency Medicine) (Manchester, UK)
16:10 - 17:40 Headache - cool new ideas for treatment. Dr Andrea DUCA (Emergency physician) (Bergamo, ITALY)
16:10 - 17:40 Cell salvage on the street? Dr Ross EVANS (Junior doctor) (Wolverhampton, UK)
16:10 - 17:40 The best of the best (yemd) abstracts. Youri YORDANOV (Médecin) (Paris, FRANCE)
17:10 - 17:20 #18213 - OP060 Bedside ultrasound in acute patients with suspected kidney involvement - a prospective observational study.
OP060 Bedside ultrasound in acute patients with suspected kidney involvement - a prospective observational study.

Background
Complicated urinary tract infections leading to treatment failure and readmissions is a common challenge in the emergency department (ED). An identified risk factor is obstructive uropathy. The diagnosis of hydronephrosis based on the initial clinical assessment and blood test in the emergency department is challenging.
Point-of-care ultrasound (POCUS) has the advantage of being non-radiating, rapid to apply and with increasing accessibility. POCUS has shown to be valuable when assessing the abdomen of trauma patients.
The aim of this study is to investigate incidence of hydronephrosis in patients presenting with symptoms of urinary tract infection or dehydration using POCUS in the ED and evaluate its clinical relevance and accuracy.

Methods
In this observational, prospective semi-blinded single-center study, patients were included based on preliminary diagnosis reported from general practitioner or from triage in the ED. Inclusion criteria were dehydration defined by laboratory values or urinary tract infections. In addition, patients had to present at least one of the following symptoms: Dysuria, flank pain, elevated creatinine or renal colic. Patients were collected as a convenience sample Patients were included if aged above 18 and able to perform written consent.
POCUS of the bladder and kidneys was performed within 4 hours after admission. Results from the POCUS was blinded to the treating physician (TP) until the first questionnaire concerning radiological prescriptions was completed. After revealing the POCUS results the TP evaluated the primary assessment through a second questionnaire.
Primary outcome was hydronephrosis and urinary retention. Secondary outcome was an evaluation of applicability. Relevance and applicability were answered by analysis of questionnaires and patient laboratory values using sensitivity and specificity, chi2-test and logistic regression. 

Results
153 patients were included during day and evening shift in the period November 4th 2018 to April 5th 2019. Hydronephrosis was found in at least one side in 10.5% (95% CI [0.98;0.22]) and urinary retention in 15.0% (95% CI [0.10;0.22]). 22.9% (95% CI [0.16;0.30]) presenting with either hydronephrosis or urinary retention. Hydronephrosis was not related to urinary retention in the study population (p=0.2384). 63 out of 150 TPs report by questionnaire POCUS to influence the clinical decision. TP prescribed further radiological examination in 9 of the 16 cases POCUS identified as having hydronephrosis (p=0.4340).

Discussion
Among limitations to this study is the single-center design and only two POCUS operators. Due to the sample size, correlations to predict subpopulations at risk for hydronephrosis remains weak. The non-coherence to urinary retention and TP assessment indicates the need for screening tools.
The use of questionnaires as measure of clinical consequence, lack specific values and actions, making it hard to analyze in terms of patient care and treatment.

Conclusion
This study found hydronephrosis in 1 in 10 included patients. Hydronephrosis based on clinical findings alone was rarely predicted, which supports POCUS as a valuable screening tool.

Pernilla G. BORGGAARD (Odense, DENMARK), Ole GRAUMANN, Christian LAURSEN B., Annmarie Touborg LASSEN, Stefan POSTH
17:20 - 17:30 #18301 - OP005 Implementation of ketamine-propofol (“ketofol”) in a 1 on 4 ratio for adult procedural sedation at a university hospital emergency department – case series report on safety and effectivity.
Implementation of ketamine-propofol (“ketofol”) in a 1 on 4 ratio for adult procedural sedation at a university hospital emergency department – case series report on safety and effectivity.

Background:

Procedural sedation is a frequently performed procedure at the emergency ward and emergency physicians should be capable of performing this safely, effectively and independently. For clinical guidance we composed an easy and unambiguous protocol for procedural sedation applicable for nearly all patients and procedures. Our sedative of choice is a mixture of ketamine and propofol (“ketofol”) in a 1 on 4 ratio. Both ketamine and propofol are known to neutralise each other’s undesirable effects and ketamine adds an analgesic quality. Ketofol has proven effective and safe in studies and is non-inferior to propofol. Though it is most often used in a 1 on 1 ratio, both pharmacological and clinical studies favour a 1 on 4 ratio. We hypothesize our protocol with ketofol 1 on 4 is safe and effective and will serve to facilitate procedural sedation by emergency physicians.

Methods:

All adults presenting at the emergency ward of the University Hospital of Ghent between February 2018 and April 2019 and in need of procedural sedation would be included in a prospective case series study. Informed consent was obtained for both the sedation and the study. Patients with an American Society of Anesthesiologist physical status classification system score (ASA-score) of III or more, with an anticipated difficult airway or intoxicated patients were discussed with the anaesthesiology department to decide the feasibility of sedation in the emergency ward setting. Pregnant patients were excluded. Ketofol 1 on 4 was prepared by mixing 1ml of ketamine (50mg) and 20ml of propofol (200mg) in a single syringe and administrated as a loading dose of 1ml/10kg, followed by a stepwise titration in aliquots of 0,5ml/10kg. Above 65 years the loading dose was halved. Registered patient outcomes were respiratory and hemodynamic events, vomiting, agitation or hallucinations, and amnesia. In addition we measured satisfaction of the physician with the performed sedation.

Results:

Sixty-one patients, between 18 and 89 years old, with an ASA-score ranging from I to III were included. Six respiratory events were registered in as many patients (9,8 %), none of them serious. All involved airway obstruction, alleviated by head tilt and chin lift and with no repercussion on vital signs save one brief episode of desaturation. There were no hemodynamic events. No vomiting was reported. Five patients (8,2%) experienced pleasant hallucinations or dreams and one patient (1,6%) was agitated upon awakening but calmed rapidly without additional medication. Amnesia was present in 58 patients (95,1%). Physician satisfaction rate was 93,4%.

Discussion & conclusions:

Implementation of our protocol ensured amnesia in majority of patients, with a low frequency of complications. Only minor respiratory events and agitation or hallucinations were observed. Respiratory events were reported slightly less than in studies using propofol or ketofol in different proportions. The rate of agitation or hallucinations is similar to that of propofol monotherapy, but lower than studies using ketofol 1 on 1. Our protocol, using ketofol in a 1 on 4 ratio, appears safe and effective and resulted in a high physician satisfaction rate.

Stig WALRAVENS (Ghent, BELGIUM), Evi STEEN , Walter BUYLAERT, Peter DE PAEPE
17:30 - 17:40 #19098 - OP114 Trends and Characteristics of Buprenorphine Sublingual Tablet Toxicities.
OP114 Trends and Characteristics of Buprenorphine Sublingual Tablet Toxicities.

Background: The number of patients with an opioid use disorder in the U.S. was estimated to be 2.6 million in 2015. Buprenorphine can be easily dispensed through office-based prescribers and community pharmacies, with 58% opioid treatment programs now offering buprenorphine. Buprenorphine sublingual tablets were discontinued in 2012 due to concerns about the misuse, abuse, and diversion. They were replaced with single dose sublingual films that are considered child-resistant and abuse deterrent. The objective of this study is to evaluate the trends, and characteristics of exposures to buprenorphine tablet formulations.

Methods: We retrospectively queried the National Poison Data System (NPDS) for all confirmed exposures to buprenorphine tablets from 1/1/2011 to 12/31/2016 as specified by the American Association of Poison Control Center Code (AAPCC) generic code and product name. We assessed the relevant characteristics of exposures descriptively. Frequencies and rates of buprenorphine tablet exposures (per 100,000 human exposures) were evaluated using Poisson regression methods, with the percent changes and corresponding 95% Confidence Intervals (95% CI) reported. Predictors of severe outcomes (major effects and death) to tablet exposures were also assessed with adjusted odds ratios (AOR) presented.

Results: Overall, there were 7,406 reports of exposures to buprenorphine sublingual tablets to the PCs during the study period. The reports of buprenorphine tablet exposures decreased from 1,780 to 468 during the study period, a decrease of 73.7% (95% CI: 64.1%, 78.7%; p<0.001), with exposures resulting in severe clinical outcomes decreasing from 49 in 2011 to 27 in 2016. The rate of exposures decreased by 71.3% during the study period. Children under 6 years of age represented 32.1% of the sample, while adults between 20 and 29 years of age accounted for 23.8% of the cases. The most common reason for exposure was unintentional (34.6 %), with intentional abuse (20.3%) being common (15.1%). Single substance exposures accounted for 63.9% of the cases and ingestion was the most common route of exposure. The case fatality rate for such exposures was 0.2%, with 3.9% cases demonstrating major effects. The proportion of major effects was highest among suspected suicides (9.5%) and abuse (4.5%) in comparison to cases of other exposure reasons such as unintentional. The Midwest region (37.4%) demonstrated the highest proportion of buprenorphine tablet exposures. An additional opioid was reported for 11.1% cases and naloxone was a commonly reported therapy for cases. Significant predictors of severe buprenorphine film exposures included suspected suicides (Ref: Unintentional reasons) (AOR: 1.96, 95% CI: 1.34 – 2.86), 3 or more co-occurring substances (AOR: 4.14, 95% CI: 1.87 – 9.14), and non-oral routes of exposure (AOR: 2.16, 95% CI: 1.31 – 3.56).   

Conclusions: Analysis of national data from the NPDS exhibited a significantly decreasing trend in the exposures to buprenorphine tablet products, with such exposures being frequent among children under 5 years of age. Considering the discontinuation of the sublingual tablets, it is imperative to explore in greater detail, the reasons for the observed exposures. Possible reasons for these observed exposures might be the continued availability despite discontinuation or potential diversion of the product

Saumitra REGE (Charlottesville, VA, USA), Marissa KOPATIC, Dr Christopher HOLSTEGE
SOUTH HALL 3C

Monday 14 October

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E24
16:10 - 17:40

PAEDIATRICS
Paediatric emergencies. Take your decision
INTERACTIVE SESSION, Pediatric, Trauma, Ultrasound

Moderators: Niccolò PARRI (Attending Physician) (Florence, ITALY), Patrick VAN DE VOORDE (Prof) (Ghent, BELGIUM)

16:10 - 17:40 Total body CT scan in trauma patients: Yes or No. Silvia BRESSAN (Moderator) (Padova, ITALY), Pr Said HACHIMI IDRISSI (head clinic) (Ghent, BELGIUM)
16:10 - 17:40 Ultrasound is the best modality to diagnose limb fractures in children. Yes or No. Dr Tom BEATTIE (Senior lecturer) (Edinburgh, UK), Dr Damian ROLAND (Paediatric EM) (@damian_roland, UK)
16:10 - 17:40 Head CT scan in headache: Yes or No. Pr Luigi TITOMANLIO (Head of Department) (Paris, FRANCE)
CHAMBER HALL

Monday 14 October

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F24
16:10 - 17:40

ABSTRACTS SESSION

Moderators: Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, GREECE), Bulut DEMIREL (Emergency Department Chief) (Ankara, TURKEY)
16:10 - 16:20 #18967 - OP055 “Mind your Head” – a quality improvement project assessing the advice given to patients following a head injury in a London Emergency Department.
OP055 “Mind your Head” – a quality improvement project assessing the advice given to patients following a head injury in a London Emergency Department.

Introduction 

Head injuries and concussion have been highlighted for years in the media due to athletes sustaining either fatal or life changing consequences. Therefore, managing patients with head injuries is an essential skill of all Emergency Physicians. An extensive literature analysis identified several areas for improvement, one of which was the head injury advice given to those who had sustained an injury needs to be consistent and adequate in its explanation for patients regarding further care. A quality improvement project was undertaken at a District General Hospital Emergency Department (ED) in London, to improve the safety and long-term care of patients who have sustained a head injury (HI), by ensuring they have up-to-date written advice regarding concussion and partaking in sports and exercise after their injury.  

Methods

There was concurrent analysis of the number of patients attending the ED with minor head injuries and review of the documentation by ED staff regarding the written HI and return to play (RTP) advice, over a six-month period. Three plan-do-study-act (PDSA) cycles were undertaken: doctors giving head injury and RTP advice, prompting patients to ask for advice and lastly empowering the triage nurses to give HI/RTP advice on first contact with the patient. The team analysed the numbers of documented written HI advice after each cycle and made modifications.

Results

National Institute for Health and Care Excellence (NICE) guidelines expect 100% of all patients to have written HI advice, therefore our aim was to have all patients given written HI advice, and 70% receiving RTP advice after an injury. Our results showed that with improving awareness, teaching and access to HI and RTP advice, the number of patients receiving written HI advice improved. Over 71% of patients received written head injury advice after the 2nd PDSA cycle, and our rate of written RTP increased to 13%, from a baseline of zero. The third cycle showed a decrease in patients receiving written HI (60%) and RTP (6%) advice.

Conclusions

The results demonstrate the positive outcome of regular teaching and awareness for staff as well as patients in a busy Emergency Department. Appropriately documented discharge advice to patients on head injuries, concussion and their day-to-day activities is good medical practice. Adequate explanation of concussive symptoms to patients with head injuries and advising them correctly about further exercise and activity is good medical practice, as well as documenting the advice given. Improving staff knowledge in early recognition and long-term management of head injuries increased staff confidence in supplying RTP/HI advice. Our next steps are to establish a head injury/concussion clinic within our ED, with due consideration of making an “App” designed for patient use during and after their attendance in the ED.

Dr Dominika GOROSZENIUK (London, UK), David SHACKLETON, Ashish JHALA, Patrick QUINN, Max FRIEDMAN
16:20 - 16:30 #18441 - OP056 Serum Cholesterol Level as Prognostic Factor in Post-cardiac Arrest Patients.
OP056 Serum Cholesterol Level as Prognostic Factor in Post-cardiac Arrest Patients.

Background: Low cholesterol level has been investigated as the risk factor of onset of sepsis and prognostic factor of mortality. Sepsis is complicated inflammatory process with ischemic-reperfusion injuries. Post-cardiac arrest syndrome also has global ischemic-reperfusion injury and considered as sepsis-like syndrome due to the severe inflammatory process. In previous study, oxidative stress was elevated and cholesterol levels were lower in post-cardiac arrest patients compared to normal patients. The aim of this study was to investigate whether initial serum cholesterol levels can predict the survival discharge and neurologic outcome in post-cardiac arrest patients.

Methods: This was a retrospective observational study performed in a tertiary care teaching hospital in South Korea from January 2012 to June 2018. Patients visiting emergency room (ER) with cardiac arrest or with recovery from cardiac arrest were screened. Patients followed by return of spontaneous circulation (ROSC) and admission for post cardiac arrest care were included. Patients who is younger than 18 years old and who did not take serum cholesterol level test were excluded. Patients were managed as Korean guideline of advanced cardiopulmonary life support (ACLS), 2015. After ROSC, all the patients were received post cardiac arrest care including targeted temperature management (TTM). Demographics, underlying disease, variables related to cardiac arrest, laboratory findings, radiologic data, received management, severity score as sequential organ failure assessment (SOFA) and variables related to outcome were collected. Cerebral performance category (CPC) was used as scoring system of neurological outcome. CPC 1 or 2 were defined as good neurological outcome and CPC 3 to 5 were defined as bad neurological outcome. The significance of intergroup differences was assessed by Fisher’s exact test or Mann-Whitney U test. Multiple logistical regression analysis was performed to identify the factors that could be considered independent factor for the prognosis. The performance to predict prognosis was checked using the area under the receiver operating characteristic curves (AUROC).

Results: 355 patients were enrolled. 192 patients (54.1%) were survived at discharge. 76 patients (21.4%) at discharge and 64 patients (18.0%) at 1 month after discharge had good CPC. Cholesterol levels at admission were significantly high in patients with survival (p=0.01), good CPC at discharge (p=0.00) and good CPC at 1 month after discharge (p=0.00). Multivariate logistic regression revealed that duration of CPR and cardiac cause, SOFA score were the predicting factor of survival (p=0.00). Predicting factors of good CPC at discharge were duration of CPR and cardiac cause, cholesterol level(p=0.000). Predicting factors of good CPC at 1 month after discharge were duration of CPR and cardiac cause, SOFA score, cholesterol level (p=0.000). AUROC of the cholesterol to predict survival, good CPC at discharge and 1 month after discharge were 0.603, 0.696 and 0.710, respectively.

Conclusions: Serum cholesterol level at admission was higher in survived patients and patients with good neurologic outcome. Duration of CPR, cause of arrest and SOFA score were predicting factor of survival and good neurological outcome. Serum cholesterol level at admission was one of the predicting factors for good neurological outcome in post cardiac-arrest patient.

Min Jung Kathy CHAE, Eun Jung PARK (Suwon, KOREA)
16:30 - 16:40 #18605 - OP057 The effects of thoracic cage dimension and chest subcutaneous adipose tissue on outcomes of adults with in-hospital cardiac arrest: A retrospective cohort study.
OP057 The effects of thoracic cage dimension and chest subcutaneous adipose tissue on outcomes of adults with in-hospital cardiac arrest: A retrospective cohort study.

Background: Increasing evidence has revealed that an adequate but uniform compression depth may not be suitable for all adults with various body sizes. The thoracic anteroposterior (AP) diameter is a commonly used parameter to reflect the thoracic cage dimension. Delivery of an adjustable compression depth based on thoracic AP diameter is recommended in pediatric resuscitation guidelines, but whether the thoracic cage dimension has impact on the prognosis for adult patients with cardiac arrest remains under debate. revealed the association between increasing SAT depth and compression inadequacy. But to date, whether the SAT-caused compression inadequacy leads to adverse outcomes of patients with cardiac arrest was unknown. This study aimed to investigate the associations between thoracic cage dimension, chest subcutaneous adipose tissue (SAT) depth and outcomes of adults with in-hospital cardiac arrest (IHCA).

Methods: We retrospectively evaluated patients with IHCA between January 2016 and October 2017. The thoracic cage transverse diameter, internal AP diameter, cross-sectional area, anterior and posterior SAT depths were measured in computed-tomography (CT) images using the three-dimensional visualization software (Mimics Interactive Medical Image Control System, Version 17.0, Materialize Company, Belgium). Using logistic regression models, we determined the adjusted associations between thoracic cage dimension, SAT depths and the prognosis for IHCA. The primary outcome was sustained return of spontaneous circulation (ROSC) and the secondary outcome was survival to hospital discharge.

Results: Among 423 IHCA patients, 258 patients achieved ROSC and 70 survived to discharge. Smaller cross-sectional area and posterior SAT depth were significantly related to ROSC. Smaller posterior SAT depth was associated with ROSC. After multivariate adjustment, the smaller cross-sectional area was independently associated with ROSC (Odds ratio [OR] 0.99, 95% confidence interval [95%CI] 0.99-1.00; p = 0.008) and survival to discharge (OR 0.99, 95%CI 0.98-1.00; p = 0.024), and the smaller posterior SAT depth was independently related to ROSC (OR 0.65, 95%CI 0.44-0.96; p = 0.030), whereas no relation to survival to discharge was found.

Conclusions: In adults with IHCA, the smaller thoracic cage dimension and posterior SAT depth are associated with better survival. An adjustable compression depth based on the thoracic cage dimension might be better than the “one-size-fits-all” compression depth for resuscitating CA patients. In addition, physicians should pay extra attention to compression efficacy when resuscitating obese patients.

Junzhao LIU (Chengdu, China, CHINA), Sheng YE, Yarong HE, Yu CAO
16:40 - 16:50 #18642 - OP058 Cut-off values of serum potassium and core temperature at hospital admission for extracorporeal rewarming of avalanche victims in cardiac arrest: a retrospective multi-centre study.
OP058 Cut-off values of serum potassium and core temperature at hospital admission for extracorporeal rewarming of avalanche victims in cardiac arrest: a retrospective multi-centre study.

Aim: About 165 avalanche deaths are recorded per year in Europe and in North-America. Survival analyses suggest that most completely buried avalanche victims die by asphyxiation between 15 and 35 minutes after burial. Unlike asphyxia, hypothermia develops after long burial if the completely buried avalanche victim is able to breathe. These avalanche victims may recover without neurological sequelae. Recommendations for the pre-hospital triage of avalanche victims were based on expert consensus and case series with, admittedly, low levels of evidence and have not previously been validated using a large dataset. This study attempted to find reliable cut-off values for the identification of hypothermic avalanche victims with reversible out-of-hospital cardiac arrest (OHCA) at hospital admission. This may enable hospitals to allocate extracorporeal life support (ECLS) resources more appropriately while increasing the proportion of survivors among rewarmed victims.

Methods: This was a retrospective multi-centre study. Seven European hospitals that are capable of ECLS and have admitted avalanche victims with OHCA participated in the study: Bern (Switzerland), Grenoble (France), Innsbruck (Austria), Krakow (Poland), Tromsø (Norway), Lausanne and Sion (Switzerland). Approval by local institutional review boards was provided by the participating hospitals. All admitted avalanche victims with OHCA from 1995 to 2016 were included. To identify parameters that contribute independently to survival we performed a stepwise logistic regression on survival with respect to sex, age, duration of burial, core temperature, serum potassium and pH. Optimal cut-off values, for the parameters identified by logistic regression, were determined by means of bootstrapping and exact binomial distribution and served to calculate sensitivity, rate of overtriage, positive and negative predictive values, and receiver operating curve (ROC) analysis.

Results: In total, 103 avalanche victims with OHCA were included. Of the 103 patients 61 (58%) were rewarmed by ECLS. Six (10%) of the rewarmed patients survived whilst 55 (90%) died. The observed maximum value for core temperature in survivors was 27.8 °C. For serum potassium the observed maximum value in survivors was 4.8 mmol/L. In multivariate analysis logistic regression the parameters core temperature (p=0.02) and serum potassium (p=0.03) were statistically, significantly related to survival. Using cut-offs of 7 mmol/L and 30°C resulted in an overtriage rate of 47% (95% CI 35%-60%), negative predictive value of 100% (95% CI 92%-100%) and positive predictive value of 19% (95% CI 8%-35%). We obtained optimal cut-off values of 7 mmol/L for serum potassium and 30°C for core temperature.

Conclusion: For in-hospital triage of avalanche victims admitted with OHCA, serum potassium accurately predicts survival. The combination of the cut-offs 7 mmol/L for serum potassium and 30°C for core temperature achieved the lowest overtriage rate and the highest positive predictive value, with a sensitivity of 100% for survivors. The presence of vital signs at extrication is strongly associated with survival. For further optimisation of in-hospital triage, larger datasets are needed to include additional parameters.

Hermann BRUGGER, Pierre BOUZAT, Mathieu PASQUIER, Peter MAIR, Julia FIELER, Tomasz DAROCHA, Marc BLANCHER, Matthieu DE RIEDMATTEN, Markus FALK, Peter PAAL, Giacomo STRAPAZZON, Ken ZAFREN, Dr Monika BRODMANN MAEDER (Bern, SWITZERLAND)
16:50 - 17:00 #19331 - OP059 The development of a resuscitation record at an academic hospital: a survey and focus group of Code Blue team members.
OP059 The development of a resuscitation record at an academic hospital: a survey and focus group of Code Blue team members.

Background: A Code Blue is activated when a hospitalized patient suffers a cardiac arrest. Accurate documentation of the resuscitation effort is required in order to provide reliable data that will facilitate decision-making, code team debriefing, and inform quality improvement initiatives related to Code Blues. The documentation of Code Blues is not well defined by current guidelines and varies considerably between institutions. Using a survey and focus group, we aimed to improve our Code Blue documentation record in order to increase its completion rate and capture evidence-based quality metrics.

Methods: This study was reviewed and approved by the Queen’s University Health Sciences & Affiliated Teaching Hospitals Research Ethics Board and conducted from January to May, 2019. We distributed a 16-question survey containing a mixture of short answer, multiple choice, ranked, and narrative feedback questions to volunteer Code Blue personnel, including staff from nursing, respiratory therapy, anesthesiology, and emergency medicine. The survey aimed to assess their perceptions of the current resuscitation record by evaluating: 1) the individual priorities of members of the resuscitation team as they pertain to information recording; 2) features of the documentation that facilitate or hinder accurate information recording; and 3) types of information necessary for making treatment decisions and debriefing after the event. We then conducted a focus group with the Code Blue team to foster an interprofessional dialogue about the purpose of the resuscitation record and to create a framework that would guide the record’s redesign. With the aggregate feedback, we created three new resuscitation record templates that reflected the team’s content and formatting suggestions.

Results: The survey identified key information that the Code Blue team would need for decision-making and debriefing. In addition, several features of the current resuscitation record were minimally or improperly used and slowed recording of the event. These included outdated medication fields and terminology, formatting that limited complete information recording, and a lack of prompts for key information. The focus group re-iterated this feedback and proposed suggestions that were separated into content redesign, which reflects the completeness and relevance of recorded information, and formatting redesign, which reflects the ease and accuracy of recording information. The three new templates contained increasing degrees of content and formatting redesign compared to the original resuscitation record. Our next steps are to select one template through consensus that best closes the gaps in information recording identified by the Code Blue team.

Discussion & Conclusion: Accurate documentation during a Code Blue is critical in order to provide high-quality data that will drive the improvement of decision-making, debriefing, and ultimately patient outcomes. This study aimed to highlight shortcomings in the current documentation and strategies to improve the relevance and accuracy of information recorded during a resuscitation. We used a survey and focus group to perform a needs assessment of Code Blue team members and guide the redesign process in an evidence-based manner.

Danny JOMAA (Kingston, CANADA), Tim CHAPLIN
17:10 - 17:20 #18469 - OP061 Novel wearable cooling device for early initiation of targeted temperature management in the emergency department: a retrospective cohort study.
OP061 Novel wearable cooling device for early initiation of targeted temperature management in the emergency department: a retrospective cohort study.

Aim: Targeted temperature management (TTM) is an important component of post-cardiac arrest care. Although the optimum cooling method is not known, studies have suggested that prompt and quick cooling is associated with better outcomes. The aim of this study was to evaluate the cooling efficacy of a protocol including a novel cooling device in the Emergency Department (ED).

Methods: This was a single-center pre-post cohort study of post-cardiac arrest patients with return of spontaneous circulation (ROSC), for whom TTM was initiated at a tertiary hospital between April 2010 and December 2017. A surface cooling device (CarbonCool, Global Healthcare Pte Ltd), which uses a graphite cooling material in an insulating suit, was introduced in July 2015. Control patients enrolled before the intervention period received icepacks in the ED and cold saline. For both periods, the target temperature was 34.0oC, with TTM continued in the ICUs. The primary outcome was time from ROSC to target temperature (TT).

Results: Of 124 patients included, 40 were in the intervention period and 84 in the control period. Time from ROSC to TT was significantly lower in the intervention period at 119 (Interquartile range (IQR): 65-250) minutes versus 482 (IQR: 356-596) minutes (p<0.001). There was no statistical difference in survival to discharge (30.0% versus 32.1%, p=0.839) and Glasgow-Pittsburg Outcome scores (1 or 2 in 17.5% versus 21.4%, p=0.811). The intervention period also had a faster cooling rate (initiation of TTM to TT of 73 (IQR: 40-150) versus 142 (IQR: 75-262) minutes, p=0.014). There were no reported serious adverse events associated with the device.

Conclusion: Use of a novel cooling device in the ED resulted in a shorter time to target temperature. As it is reusable and does not require a power source, it has potential to be an affordable solution for pre-hospital and transport cooling. 

Leong Gen YAP, Nur SHAHIDAH (Singapore, SINGAPORE), Sohil POTHIAWALA, Kenneth B.k. TAN, Aaron S.l. WONG, Duu Wen SEWA, Eric T.s. LIM, Chee Tang CHIN, Marcus E.h. ONG
17:20 - 17:30 #18535 - OP062 Thirty-day mortality in atrial fibrillation patients with gastrointestinal bleeding in the emergency department: differences between direct oral anticoagulant and warfarin users.
OP062 Thirty-day mortality in atrial fibrillation patients with gastrointestinal bleeding in the emergency department: differences between direct oral anticoagulant and warfarin users.

Background:

The ageing of the population, the better knowledge of the cardio-embolic risk and the availability of new oral anticoagulant drugs that do not require continuous laboratory monitoring, have allowed an exponential spread of oral anticoagulant therapy. More clinical data are required on the safety of direct oral anticoagulants (DOACs). Although patients treated with warfarin and DOACs have a similar risk of bleeding, short-term mortality after a gastrointestinal bleeding (GIB) episode in DOAC-treated patients has not been clarified.

Objectives: To assess differences in 30-day mortality in patients treated with DOACs or warfarin admitted to the emergency department (ED) for GIB.

Methods: This was a multicentre retrospective study conducted over two years. The study included patients evaluated at three different EDs for GIB during oral anticoagulant therapy. The baseline characteristics were included. The two treatment groups (DOACs vs warfarin) were compared to evaluate any possible imbalance in the anamnestic or clinical characteristics. Here, the use of propensity score matching had to be considered to equilibrate the two groups and to obtain a homogeneous cohort of patients for prognostic evaluation. Comparison with the clinical and anamnestic variables was performed using the Mann–Whitney U test and with Fisher’s exact test, as appropriate. Cox regression, adjusted for all variables that were significant to the previous univariate analysis, was performed to verify differences in mortality between the two treatment groups. Finally, the Kaplan–Meier method was used to compare 30-day survival between DOAC and warfarin users. Results: Among the 284 patients presenting GIB enrolled in the study period, 39.4% (112/284) were treated with DOACs, and 60.6% (172/284) were treated with warfarin. Propensity score matching was not needed, as the two groups did not show significant differences in anamnestic or clinical characteristics except for the concomitant platelet therapy (11.6% vs 2.7%, p = 0.007). Overall, 8.1% (23/284) of patients died within 30 days. The factors associated with 30-day mortality risk were age, history of chronic renal disease, active cancer, HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly) value, and bleeding type (major GIB) and site (upper GIB). After the univariate analysis, neither of the two anticoagulant treatments resulted in higher 30-day mortality risk (warfarin 8.7% vs DOACs 7.1%, p = 0.824). Cox analysis adjusted for age, chronic renal disease, major GIB, upper GIB, and baseline HAS-BLED, showed no difference in mortality within 30 days of the GIB episode between the two groups (p=0.533). The Kaplan–Meier curves showed no difference in 30-day survival between the warfarin and DOAC users (p = 0.651).

Conclusions: Despite their rapid diffusion, the available evidence ON DOACs is lacking, and the GIB prognosis of anticoagulated patients remains unclear. The present study shows no differences between DOACs and warfarin in short-term mortality after GIB.

Gianni TURCATO, Dr Antonio BONORA (VERONA, ITALY), Elisabetta ZORZI, Arian ZABOLI, Alice DILDA, Massimo ZANNONI, Giorgio RICCI, Antonio MACCAGNANI, Norbert PFEIFER, Andrea TENCI
17:30 - 17:40 #18586 - OP063 Survey to detect unmet palliative care needs in the emergency department: First results of a questionnaire-based two-level screening process.
OP063 Survey to detect unmet palliative care needs in the emergency department: First results of a questionnaire-based two-level screening process.

Background and Objectives: The use of a screening tool to identify palliative care needs leads to a reduction of unwanted and highly invasive interventions in emergency patients with terminal illnesses.

Many of these patients enter clinical care through prehospital emergency medical services (EMS) and the emergency department (ED). Screening for palliative care needs at this interface can reduce loss of information and strengthen the patient’s autonomy in further clinical treatment.

 

Methods: We developed a two-level questionnaire summarizing existent criteria which indicate palliative care needs. Terminal illness and/or progressive malignant disease and a negative answer to the “Surprise-Question - Would you be surprised if the patient dies within the next 12 months due to their condition?” function as inclusion criteria to the screening process.  

Level 1 asks for the patient´s wishes, advanced directives, load of symptoms, psychosocial background and resources, as well as assignment from a nursing home. These questions are meant to be answered by the preclinical emergency medical team.

Level 2 is directed to the emergency physician at the ED. It is meant to confirm the surprise question and gives further detail about the terminal illness of the patient. Furthermore, it assesses if the patient has already been admitted to the hospital within the last 3 months.

As the investigation progresses, our defined goal is to determine the sensitivity and specificity, as well as the predictive values of our screening questionnaire. Therefore, we compare the assessment to a specialised palliative care physician´s consultation as gold-standard to evaluate palliative care needs. For the statistical analysis, we will use the binary logistic regression model.

 

Results: The eligibility criteria were met in 15 cases in which the availability of a palliative care consultation was given, too. 73% (11/15) of the patients who underwent the screening process were assigned through EMS, the remaining quarter was detected in the triage process at the ED.

Screening level 2 confirmed in 93.3% (14/15) the underlying terminal disease and in every case (15/15) a “No” to the “Surprise-Question”. 40% (6/15) of the trial participants passed away before the consult took place. Palliative care needs were confirmed in 8 out of 9 consultations (88.8%). 46.6% (7/15) of the study population died within the ED under palliative treatment, four further participants died during the hospital stay – overall 80%.

 

Discussion: We present data deriving from the first two months of experience after initiating the survey to show the feasibility of the two-level questionnaire concept.

The implemented screening process was suitable to adopt the strategy of care in the emergency department. In several cases palliative care and support of the patients and their families can be performed.

Ellen GOEBEL (Essen, GERMANY), Sven BUECHNER, Bernhard MALLMANN, MD, MBA, Ute VON FRANTZKI, Simone LAPORTE, MD, Randi MANEGOLD, MD, Carola HOLZNER, MD, Dirk PABST, MD, Clemens KILL, MD, Joachim RISSE, MD
TERRACE 2B
17:40

Monday 14 October

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B25
17:40 - 18:45

DIPLOMA & CERTIFICATE

17:40 - 18:45 Introduction. Luis GARCIA-CASTRILLO (ED director) (AARTSELAAR, BELGIUM), Pr Lisa KURLAND (speaker) (Örebro, SWEDEN)
17:40 - 18:45 EMERGE EBEEM announcement.
17:40 - 18:45 European Board Examination of Emergency Medicine diplomates ceremony. Ruth BROWN (Speaker) (London, UK)
17:40 - 18:45 Best performance EBEEM Part A & B certificate.
17:40 - 18:45 EMDM (European Master Disaster Medicine) Diploma ceremony. Pr Francesco DELLA CORTE (Speaker) (Novara, ITALY), Pr Ives HUBLOUE (Chair) (Brussels, BELGIUM)
FORUM HALL
Tuesday 15 October
08:30

Tuesday 15 October

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A30
08:30 - 09:00

KEYNOTE LECTURE 2

Moderator: Senad TABAKOVIC (Zürich, SWITZERLAND)
08:30 - 09:00 What It Takes To Be a Leader: Leadership Concepts In The ED. Greg HENRY (USA)
CONGRESS HALL
09:10

Tuesday 15 October

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A31
09:10 - 10:40

Disaster medicine
Climate change impacts on health
Disaster medicine

Moderators: Pr Francesco DELLA CORTE (Speaker) (Novara, ITALY), Pr Ives HUBLOUE (Chair) (Brussels, BELGIUM)
09:10 - 10:40 Heat Waves. Dr Joris VAN LOENHOUT (Senior Research Fellow) (Brussels, BELGIUM)
09:10 - 10:40 Air Pollution. Paul WILKINSON (UK)
09:10 - 10:40 Floods. Johan VON SCHREEB (Professor) (Stockholm, SWEDEN)
CONGRESS HALL

Tuesday 15 October

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B31
09:10 - 10:40

Ethics and Philosophy
Do We Always Have to Save the Life?
Ethics, INTERACTIVE SESSION, Palliative Care, Philosophy

Moderators: Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, GREECE), Dorothea HEMPEL (Atteding Physician) (Magdeburg, GERMANY)

09:10 - 09:30 Possibilities & Perspectives for Palliative Care in the ED: The Next Frontier in EM? Robert LEACH (Head of Dept.) (BRUXELLES, BELGIUM)
09:30 - 09:50 Repeated Suicide Attempt - is there an obligation to live? Bernard FOEX (Consultant in Emergency Medicine and Critical Care) (Manchester, UK)
09:50 - 10:10 Treatment Strategies and Case Scenarios with TED Questions. Dorothea HEMPEL (Atteding Physician) (Magdeburg, GERMANY)
10:10 - 10:20 End-of-Life Care in the ED: Ethical Issues. Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, GREECE)
10:20 - 10:40 Panel Discussion. Dorothea HEMPEL (Atteding Physician) (Magdeburg, GERMANY), Bernard FOEX (Consultant in Emergency Medicine and Critical Care) (Manchester, UK), Robert LEACH (Head of Dept.) (BRUXELLES, BELGIUM), Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, GREECE)
FORUM HALL

Tuesday 15 October

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C31
09:10 - 10:40

Education in emergency medicine
Tips, tricks and politics in EM education
Education

Moderators: Cristian BOERIU (Assoc.Professor) (Targu Mures, ROMANIA), Eric DRYVER (Consultant) (Lund, SWEDEN)
09:10 - 09:25 Assessment. Greg HENRY (USA)
09:25 - 09:40 How to prove that what your teach makes a difference? Dr Damian ROLAND (Paediatric EM) (@damian_roland, UK)
09:40 - 09:55 Implementing New Processes in Your ED: Tips from the Trenches. Eric DRYVER (Consultant) (Lund, SWEDEN)
09:55 - 10:10 Catch as Catch Can. Judith TINTINALLI (Professor) (Chapel Hill NC, USA)
10:10 - 10:40 Panel discussion. Eric DRYVER (Consultant) (Lund, SWEDEN), Greg HENRY (USA), Dr Damian ROLAND (Paediatric EM) (@damian_roland, UK), Judith TINTINALLI (Professor) (Chapel Hill NC, USA)
SOUTH HALL 3AB

Tuesday 15 October

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D31
09:10 - 10:40

YEMD - Learn to lead!
Hear about personal experiences, learn why we need more women in EM and be part of the discussion!
Leadership, Women in EM, Young Emergency Medecine

Moderators: Dr Lina JANKAUSKAITE (MD, PhD) (Kaunas, LITHUANIA), Basak YILMAZ (Faculty) (Burdur, TURKEY)
09:10 - 10:40 Changing society and medicine. Martynas GEDMINAS (Physician / Quality control) (Šiauliai, LITHUANIA)
09:10 - 10:40 From hero to zero and back. Dr Pieter Jan VAN ASBROECK (Consultant in Emergency Medicine) (Genk, BELGIUM)
09:10 - 10:40 Female rollercoaster in Emergency Medicine. Dr Lina JANKAUSKAITE (MD, PhD) (Kaunas, LITHUANIA)
SOUTH HALL 3C

Tuesday 15 October

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E31
09:10 - 10:40

NURSES
Organization of emergency nursing care
Neurology, Nurses, Triage

Moderators: Dr Kris BRAEKERS (Assistant Professor) (Hasselt, BELGIUM), Dr Remco EBBEN (Associate professor/lecturer) (Nijmegen, THE NETHERLANDS)
09:10 - 10:40 Integrated triage. Tessa POSTUMA (Trainer) (DOETINCHEM, THE NETHERLANDS)
09:10 - 10:40 The organization of acute neurovascular care. Peter STAP (Nurse Practitioner) (The Hague, THE NETHERLANDS), Rianne LAM (NP) (Den Haag, THE NETHERLANDS)
09:10 - 10:40 What last years literature learned us about: ED crowding. Christien VAN DER LINDEN (Clinical Epidemiologist) (The Hague, THE NETHERLANDS)
CHAMBER HALL

Tuesday 15 October

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F31
09:10 - 10:40

ABSTRACTS SESSION

Moderators: Dr Rodrick BABAKHANLOU (M.D. M.Sc.) (Edinburgh, UK), Felix LORANG (Consultant) (Jena, GERMANY)
09:10 - 09:20 #18693 - OP064 Use of non invasive ventilation: experience of a tunisian emergency department.
OP064 Use of non invasive ventilation: experience of a tunisian emergency department.

Introduction:

Non Invasive Ventilation (NIV) use in acute respiratory failure (ARF) is mostly initiated in Emergency

Department (ED) before patient transfer to Intensive Care Unit (ICU) or Respiratory Ward (RW). In Tunisia, because of the limited ICU beds’ number and the absence of NIV in RW, patient requiring NIV are admitted in ED.

Aim: To describe our experience with non-invasive ventilation in emergency department (ED).

Methods:

A prospective observational monocentric study conducted for a six months period in the Emergency Department of the University Hospital FarhatHached, Sousse-Tunisia. We included patients consulting for non traumaticARF requiring NIV.

We analyzed the NIV characteristics in the first 24 hours and evaluated patients ‘outcomes. NIV success was defined as no need for endotracheal intubation (ETI).

Results:

During the study’s period, we included 63 patients. During the first 24 hours of the studied population’s ED

stay, 142 sessions were delivered with a mean duration of 9,47 ±3,38h. The median value of NIV initiating delay (defined by the time from the patients’ registration until NIV initiation) was one hour [0-3h]. The first-line ventilating mode used was BiPAP in 55 patients (87.3%) with a mean IPAP 11,8±1,2 cmH2O , a mean EPAP of 4,49±1,07 cmH2O and a mean FiO2= 39,38±11,26%.

NIV failed in 8 patients (12.7%) with a median value of intubation delay about 4 h [0-14].

After a median ED length of stay of 40 h [24-53 h] and total NIV duration of 15 h [8-31 h], 26 patients (41,3%) were transferred to ICU, 21 to medical ward and 13 patients (20,6%) were discharged at home. The global mortality in our studied population was 4.8% (3 patients).

Conclusion:

Our results confirm the global efficacy of NIV in an ED setting. Therefore, young emergency physicians should be provided with protocols and guidelines for NIV practice.

Mariem KHALDI, Mariem KHROUF, Dr Ahmad MAHMOUDI (sousse, TUNISIA), Hajer SANDID, Hayfa SNOUSSI, Zied MEZGAR, Mehdi METHAMEM
09:20 - 09:30 #18022 - OP065 Variability in utilization and diagnostic yield of Computed Tomography Pulmonary Angiography (CTPA) scans for pulmonary embolism among emergency department (ED) physicians: a retrospective observational study.
OP065 Variability in utilization and diagnostic yield of Computed Tomography Pulmonary Angiography (CTPA) scans for pulmonary embolism among emergency department (ED) physicians: a retrospective observational study.

Background:

Current data on utilization of CT imaging point to a trend of increasing overutilization of CT Angiography for the diagnosis of pulmonary embolism (CTPA) over time. Multiple educational and institution-wide interventions addressing this overutilization have been proposed, implemented and evaluated, with mixed results in terms of long-term impact on physician ordering behaviour. The objective of this study is to examine the inter-physician variability in ordering rates and diagnostic yield of CTPA, under a working hypothesis that a small number of physicians are responsible for a disproportionately high number of CTPA ordered in the ED, and that disproportionately high ordering rates are associated with lower diagnostic yield.

Methodology:

Data was collected on all CTPA studies ordered by ED physicians at two very high volume community hospitals and an affiliated urgent care centre during the 2-year period between January 1, 2016 and December 31, 2017. Analysis was limited to those ED physicians who had a total of greater than 500 ED visits over the course of the 2-year period. For each physician, two calculations were made: 1) CT PE ordering rate (total number of CTPA ordered divided by the total number of ED visits), and 2) CTPA diagnostic yield (total number of CTPA positive for PE divided by the total number CTPA ordered). Additional analysis was carried out in order to identify the highest orderers of CTPA and their diagnostic yield.

Results:

A total of 2,789 CTPA were ordered by 84 physicians for 461,045 total ED visits. Preliminary results show a great deal of variation in ordering rates, ranging from 0.9 to 22.2 CTPA per 1000 ED visits (median = 4.8 CTPA per 1000 ED visits, IQR = 4.5 CTPA per 1000 ED visits). Similarly, there was a high degree of variation in CT PE yield, ranging from 0% to 50% (median = 9.6%, IQR = 13.1%). Those physicians in the top quartile for ordering rate had a lower mean diagnostic yield, when compared to the lower quartiles (8.9% when compared to 11.5%, 11.9% and 18.2% for the physicians in the third, second, and first quartile respectively).

Conclusion:

The findings of this study indicate a wide degree of variability in CTPA ordering patterns and diagnostic yields among physicians working within the same clinical environment. There is some suggestion that those physicians who order disproportionately higher numbers of CTPAs have lower diagnostic yields. However, the more interesting lessons from this initial study center on the challenges in creating an audit-and-feedback program targeting CTPA ‘overutilizers’.

Leila SALEHI, Prashant PHALPHER, Christopher MEANEY, Marc OSSIP, Dr Rahim VALANI (Toronto, CANADA)
09:30 - 09:40 #18520 - OP066 Adding lung ultrasound to standard diagnosis procedure for the diagnosis of community-acquired pneumonia in the emergency department: prospective multicenter observational study (echopac)).
OP066 Adding lung ultrasound to standard diagnosis procedure for the diagnosis of community-acquired pneumonia in the emergency department: prospective multicenter observational study (echopac)).

Background

The diagnosis of community-acquired pneumonia (CAP) in the Emergency Department (ED) is often difficult due to limitations of clinical examination, chest X-ray and laboratory tests. A recent study showed that computerized tomography (CT) scan modified the clinical probability of CAP in 58% of the cases. However, CT scan is not applicable for all patients with suspected CAP in the ED. Thus, our goal was to investigate another tool, early Lung Ultrasound (LUS), to improve CAP diagnosis, by accessing changes in diagnostic probability and antibiotic initiation induced by LUS.

Methods

It was a prospective observational study in 4 French ED between 8/11/2016 and 31/12/2018. Included patients were a convenience sample of patients older than 18 years with a suspicion of CAP before medical exam. Exclusion criteria were documented palliative care or the need of immediate intensive care.

After informed consent approval and usual diagnosis procedure (UDP) (clinical, radiological and biology), the Emergency Physician established a CAP probability using a Likert scale (definite, probable, possible, excluded) and intention for antibiotics treatment initiation. A LUS was then performed, another probability (LUSP) for CAP diagnosis and treatment initiation was established. An adjudication committee established the final probability of CAP (COMP) at D28.

The main objective was the concordance rate between LUS and UDP probability according to COMP probability. Secondary objectives were probability changes induced by LUS and antibiotics changes. Categorical data expressed as percentage [95% confidence interval] were compared with Mac Nemar test.

The study was approved by the ethical committee and registered on clinicaltrial.gov (NCT03411824). There was no funding. For a probability concordance of 55% before LUS and 80% after with alpha 0.05 and beta 0.10, the required number of patients was 144.

Results

150 patients were recruited, two secondarily excluded because of wrong identification, leaving 148 analyzed patients: 70 women and 78 men, mean age 72 + 18 years old. UDP probability was definite in 34 patients (23%), probable in 52 (35%), possible in 56 (38%) and excluded in 6 (4%). LUS induced a probability modification in 109 patients (73 % [66-80%]). LUS probability was definite in 93 patients (63%), probable in 15 (10%), possible in 9 (6%) and excluded in 31 (21%). 82 of these modifications (77 % [68-84%]) were in accordance with the adjudication committee. COMP probability was definite in 81 patients (55%), probable in 16 (11%), possible in 12 (8%) and excluded in 39 (26%). When compared to COMP probability, 39 out of 148 UDP probabiliies were correct (27% [20-35]) while 109 LUSP were correct (77% [71-84]), p<10-4. There were 45 modifications in antibiotic prescription (30% [24-38%]): 21 were prescribed after LUS while 24 were discontinued.

Discussion and conclusion

In this population comparable to other studies in literature, LUS was a powerful tool to improve the diagnosis accuracy. In particular, it decreased the diagnostic uncertainty (possible and probable probability from 73 to 16% after LUS).

François JAVAUDIN, Nicolas MARJANOVIC, Hugo DE CARVALHO, Benjamin GABORIT, Estelle BOUCHER, Denis HAROCHE, Philippe LE CONTE (Nantes)
09:40 - 09:50 #19023 - OP067 Variability of cardiac activity evaluation between physician sonographers: a validation study.
OP067 Variability of cardiac activity evaluation between physician sonographers: a validation study.

Background:

The absence of cardiac activity (CA) on point-of-care ultrasound (POCUS) during the cardiopulmonary resuscitation (CPR) is a known predictive factor for worse patient outcomes. However, the assessment of CA is challenging due to the urgency of the situation and lack of clear definition of CA. Although a previous study has shown the considerable variability in interpretation of CA among physician sonographers, it is not validated in different populations. The aim of our study is to examine the inter-person agreement of CA evaluation among physician sonographers.

Methods:

This was a cross-sectional questionnaire survey conducted between August 2018 and April 2019. The participants were recruited from 7 hospitals in Japan. All participants evaluated the 20 second echocardiographic video and answered the presence or absence of CA. This video consisted of 15 cases that were either CA positive (strong myocardial contraction, weak myocardial contraction, ventricular fibrillation) or CA negative (no cardiac motion, cardiac motion by bag valve mask ventilation, and valve flatter without myocardial contraction). Other questionnaire contents were as follows: specialty of the physician sonographer, self-reported general POCUS skill level, experience of echocardiography in CPR and post-graduated year (PGY). Our primary outcome was the overall inter-person agreement of CA evaluation. The inter-person agreement of CA evaluation was investigated using Krippendorff's alpha coefficient. Additionally, we conducted sensitivity analysis with different subgroups (specialty, self-reported general POCUS skill level, experience of echocardiography in CPR, PGY).

Results:

A total of 41 physician sonographers were recruited [23 emergency physicians (56.6%), 6 intensivists (12.2%), and 7 residents (17.1%)]. Self-reported general POCUS skill levels were basic (68.3%), advanced (29.3%), and expert (2.4%). The number of experiences of echocardiography in CPR was 0 (17.1%), 1-5 (17.1%), 6-10 (19.5%), 11-25 (14.6%), and >25 (31.7%). PGY was 1-2 (17.1%), 3-6 (36%), 7-10 (29.3%), and >11 (14.6%). The overall agreement rate of CA evaluation was moderate (α=0.53). Sensitivity analysis showed similar results [Self-reported general POCUS skill levels: basic (0.53), advanced (0.48), and expert (NA). The   number   of   experiences   of echocardiography in CPR: 0 (0.58), 1-5 (0.64), 6-10 (0.5), 11-25 (0.48), and >25 (0.5). PGY: 1-2 (0.66), 3-6 (0.56), 7-10 (0.49), and >11 (0.44)].

Discussion & Conclusions:

Similar to the previous study, there was a considerable variability in interpretation of CA among physician sonographers. Hence, it may be difficult to use this finding as a guide to terminating CPR. A clear definition of CA is warranted to precisely detect cardiac arrest patients with poor outcomes.

Hirokazu MAEDA (Obama Fukui, JAPAN), Hiroshi OKAMOTO
09:50 - 10:00 #19252 - OP068 Identifying low risk trauma patients to avoid whole-body CT prescription in the emergency department:an observational study.
OP068 Identifying low risk trauma patients to avoid whole-body CT prescription in the emergency department:an observational study.

Background: The Whole-Body computed tomography (WBCT) is a mainstay that guides the management of severely traumatized patients. However, its systematic use in the emergency department results in a high proportion of normal examinations. Its direct cost is significant and the irradiation of 20mSV exposes an adult to a risk of 1 in 1000 to develop cancer. The purpose of this study is to determine predictive criteria for normal examinations in trauma patients who have had an WBCT to rationalize its use. Methods: A monocentric retrospective study included trauma patients over 16 years of age for whom a WBCT was performed during their visit to the emergency department from 2016 to 2018. The endpoint for asserting the abnormality of the WBCT was at least one injury categorized 2 by the Abreviated Injury Scale. Anamnestic, clinical, radiological findings and patient management data were collected. Two approaches were used. The first was to define criteria based on scientific data to define a low-risk patient profile and to test the discriminating ability of this set of criteria. The second approach consisted in performing a multivariate analysis with a logistic regression model. On this occasion, the population was divided into two random samples corresponding to 50% of the initial population, one to create the model and the other to test it. The objective was to define a low-risk patient profile by testing the discriminating ability of this set of criteria to avoid the WBCT. Results: Out of 810 patients included 41% had an abnormal WBCT (n=329). Seventeen "a priori" criteria were tested simultaneously. The test performance showed a sensitivity of 96.9%, specificity of 25.8%, negative predictive value of 89.7%, positive predictive value of 48.2%. This method avoided one in seven WBCT. In the multivariate logistic regression model, 9 variables were selected. The performance of this model showed a sensitivity of 87%, specificity of 44%, negative predictive value of 81.3% and positive predictive value of 50%. The OCR curves showed an area under the curve of 0.8 for the learning sample and 0.73 for the test sample. This method avoided one in four WBCT in the learning group and one in five WBCT in the test group. Discussion: The "a priori" approach seems more robust in predicting the normality of the WBCT. False-negative patients in the multivariate model are more numerous and have more serious injuries missed. Rationalization of the WBCT in trauma patients is possible by a predictive algorithm. Conclusions: An external validation through a multicentric prospective study is required to validate this predictive model.


Mehdi TAALBA (ROUEN), Clotilde BOUVY, Andre GILLIBERT, Luc-Marie JOLY, Stefan DARMONI, Matthieu SCHUERS
10:00 - 10:10 #18718 - OP069 Usefulness of the initial diagnostic point-of-care ultrasonography urinary stone protocol for emergency department patients with acute renal colic: a randomized controlled study.
OP069 Usefulness of the initial diagnostic point-of-care ultrasonography urinary stone protocol for emergency department patients with acute renal colic: a randomized controlled study.

Background Detection of hydronephrosis by ultrasonography in patients with renal colic has good sensitivity and specificity for diagnosing ureter stones. This study investigated the effects of length of stay and total medical expense on patients with urolithiasis by applying the point-of-care ultrasonography urinary stone (POCUS-US) protocol in the emergency department (ED).

Methods We conducted a prospective randomized controlled trial for evaluating patients who visited the ED of the tertiary university hospital with acute renal colic between March and May 2019. The patients were separately enrolled according to day number of visitation in the ED. For those with odd day numbers (conventional group [CG]), we performed basic laboratory blood tests, urine analyses after history taking and physical examination, and additional tests, such as abdominal non-contrast computerized tomography (CT) based on the test results. For those with even day numbers (ultrasonography group [UG]), we performed bedside sonography simultaneously with physical examination and history taking to evaluate hydronephrosis. If hydronephrosis was detected, we proceeded to perform abdominal non-contrast CT promptly and laboratory tests, including only urine and creatinine blood level analyses. If patients in the UG did not have hydronephrosis, we examined them as we did the other patients in the CG. The patients were followed-up for acute renal failure and urinary tract infection and acutely missed or delayed high-risk diagnosis within 30 days. We investigated the ED length of stay and total medical costs as outcomes.

Results Ninety-one patients were enrolled, of which 72 were finally diagnosed as having ureter stones. The ED length of stay for the UG was 156 minutes (95% confidence interval [CI], 137–176 minutes) and was 78 minutes lesser than that for the CG (234 minutes; 95% CI, 210–259 minutes). The medical expense for the UG in the ED was approximately 30% lower than that for the CG (239 USD vs. 332 USD, respectively; P < 0.001). The incidence of complications within 30 days and acutely missed or delayed high-risk diagnosis were not significantly different between the two groups.

Conclusion Therefore, applying the initial diagnostic POCUS-US protocol for patients with acute renal colic in the ED can significantly reduce the ED length of stay and medical expense.

Seok Goo KIM (Seoul, KOREA), Ik Joon JO, Hee YOON
10:10 - 10:20 #18334 - OP070 Prevalence and Utility of Point-Of-Care Ultrasound in the Emergency Department: a prospective observational study.
OP070 Prevalence and Utility of Point-Of-Care Ultrasound in the Emergency Department: a prospective observational study.

Abstract

 

OBJECTIVE: An observational study on the current diagnostic and procedural utility and impact of point of care ultrasound (POCUS) in Emergency Departments (ED).

 

BACKGROUND:Point of Care Ultrasound (POCUS) has been recognised as a useful noninvasive, bedside tool, providing additional information as well as it’s utility in procedural guidance for clinicians, However, its current use in the ED remains unknown.

 

METHODS: In October 2016, a 31-day prospective observational study was performed in three Monash Health Emergency Departments in Melbourne, Australia. Data regarding patients’ presenting complaints, frequency, operators’ qualifications, and POCUS module were collected and analysed. Factors associated with diagnostic impacts were identified.

 

RESULTS:A total of 390 (2.82%) POCUS examinations were performed among 13,822 adult presentationsin the three Monash Health EDs during the 31-day study period. 292 (74.9%) cases were retrieved from electronic medical records (Symphony), recorded as Clinician-Performed Ultrasound (CPU);and 98 (25.1%) cases from written records which were collected by research assistants. POCUS was performed as a diagnostic tool in 344 (88.2%) and procedural in 46 (11.8%) cases. eFAST/AAA and BELS were the two most frequently utilised diagnostic modalities. Overall, the majority of diagnostic POCUS cases were indicated for abdominal pain (35.3%), chest pain (14.0%) and trauma (5.8%). Procedural POCUS was most commonly used for vascular access (57.9%), where dyspnoea (21.6%) was the most common presenting complaint. Majority of the cases were performed by FACEMs (fellows of Australasian college of Emergency Medicine) (67.7%). 

 

CONCLUSIONS: Despite known diagnostic and procedural advantages, the prevalence of POCUS in our EDs was found to be lower than what was expected. However, as this is a sigle network/centre study in a limited period of time,it might have resulted in under-reporting of POCUS use. In our study, POCUS mostly served for diagnostic purposes. Prevalence was shown to be proportional to the level of clinical expertise among the operators. Training and utility of POCUS among physicians should be further advocated and supported.

 

Dr Pourya POURYAHYA (Melbourne, AUSTRALIA), Koo MEI-PING
10:20 - 10:30 #19301 - OP071 Influence of air pollution and climate variables on the number of hospital admissions due to exacerbation of COPD or asthma.
OP071 Influence of air pollution and climate variables on the number of hospital admissions due to exacerbation of COPD or asthma.

Background. A number of studies reported a link between air quality and negative health effects. Particularly, high levels of air pollutants are related to a worsening of chronic respiratory diseases, leading to an increased number of hospital admissions and outpatient visits. Several factors influence the exposure to intra-urban air pollution, such as traffic density and climate.

Aim. To assess the influence of air pollutant levels and climate data on the number of hospital admissions due to chronic obstructive pulmonary disease (COPD) and asthma exacerbations in Valladolid (Spain).

Material and methods. Retrospective ecological study. Time series of the number of COPD and asthma patients hospitalized in the Pneumology service between July 2014 and December 2017 due exacerbation of their condition were analyzed. Weekly average levels of sulfur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide (CO), ozone (O3), particulate matter with a diameter less than 2.5 (PM2.5) and 10 (PM10) micrometers, temperature (T), and rainfall (R) were obtained from publicly available data of the Valladolid city council. A generalized linear model with Poisson distribution was used to characterize the link between air pollution and climate variables with the number of admissions.

Results. A total of 1646 patients reported worsening of their COPD or asthma, which led to 2990 visits to the Emergency Department (ED) in the period of study: 1968 due to COPD and 1022 due to asthma exacerbation. 67.7% of patients visited ED one time, whereas 15.4% two times and 16.9% at least three times. Finally, 1644 individual admissions in the Pneumology service were assessed. Patients had a mean age of 66.0±5.9 years old (57.7% males). A significant correlation (p-value <0.05) between the number of hospitalizations and several independent variables (O3, PM2.5, NO2, CO, T, and R) was obtained. The CO concentration showed a significant high correlation (Rho 0.45; p <0.01) as well as the highest influence on the number of COPD/asthma-related admissions (odds ratio 3.06; CI95% 2.90-3.22). After considering confounding factors, the influence of carbon monoxide remains (odds ratio 1.33; CI95% 1.24-1.44). Similarly, the temperature also achieved a significant negative correlation (Rho -0.593; p <0.05) and showed a relevant link (odds ratio 0.96; CI95% 0.96-0.97) with the number of admissions.

Conclusion. Our results suggest that there is a significant association between the number of hospital admissions due to COPD and asthma exacerbations and ambient levels of carbon monoxide and temperature.

Dr Raul LOPEZ IZQUIERDO (Valladolid, SPAIN), Ana CEREZO-HERNANDEZ, Daniel ALVAREZ, Fernando MORENO, Del Campo FELIX, Virginia CARBAJOSA RODRIGUEZ, Samsara LOPEZ, Irene CEBRIAN RUIZ, Henar BERGAZ DIEZ, Henandez Gajate MARIO, Jesus ALVAREZ MANZANARES, Jesus Angel MOCHE LOERI, Isabel GONZALEZ MANZANO, Jose Ramón OLIVAS RAMOS, Mª Antonia UDAONDO CASCANTE, Francisco MARTÍN RODRIGUEZ
10:30 - 10:40 #18714 - OP072 Side effects and complications of non-invasive ventilation in patients admitted to emergency department with acute respiratory failure.
OP072 Side effects and complications of non-invasive ventilation in patients admitted to emergency department with acute respiratory failure.

Background: The use of Non-Invasive Ventilation (NIV) for acute respiratory failure has increased during the past few decades in emergency department (ED) and has become widespread considering its various benefits (reducing the need for mechanical ventilation, improving survival rate). On the over hand, with the newfound beneficial treatments come complications and side effects.  are reported but few studies were published.

The aim of our study was to assess the side effects and complications when using NIV in patients admitted to ED with acute respiratory failure

Methods:    prospective observational study over a seven month period.  Inclusion of all consecutive patients admitted to ED with acute respiratory failure requiring NIV (CPAP or Bi-PAP mode). Considered indications were acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD), acute heart failure with pulmonary oedema or other indication). We didn’t include patients requiring NIV as a pre-oxygenation prior to intubation. A local protocol to perform NIV was followed. Demographics and clinical data were collected. Side effects and complications appearing during the NIV procedure were reported.

Results: Inclusion of 239 patients. Mean age 68±13. Sex ratio=1,6. Comorbidities n(%) : COPD 81(34), hypertension 139(58), diabetes 113(47), chronic heart disease 54(23), coronary heart disease 68(28,5). Indication of NIV n(%): AE COPD 59(25), acute pulmonary oedema 167(70).

CPAP was used in 172 patients (72%). CPAP complications and side effects (%): mouth dryness (34),tearing (18), face erythema (30), face pain and headache (26), skin erosion(9), nausea (7), vomiting (3), hypotension (2), rhinorrhea (2), abdominal pain(1). Success was obtained in 154 patients (89%). Bi-PAP NIV was required in 13 patients after CPAP failure. Invasive ventilation was performed in only four patients.

First line Bi-PAP ventilation was used in 67 (28). Bi-PAP complications and side effects (%): mouth dryness (28), face erythema (21), skin erosion (17), facial pain and headache (14), tearing (10), hypotension (4), rhinorrhea (4). Success was obtained in 83% of patients. Eleven patients was intubated.

Median hospital length stay was 28 hours [1-450]. Overall in-hospital mortality rate was 5,4%.

Conclusions: side effects were generally not severe but require the optimization of interfaces, use of humidifier or adequate positioning of patients. No infectious complications were reported. Severe side effects such as hypotension appear in less than 4% of patients. Trained both emergency physicians and paramedics is the key to reduce these complications.

Raja FADHEL, Ines CHERMITI, Emna ENNOURI, Hanène GHAZALI, Sana TABIB (Tunis, TUNISIA), Rania ZAMMOURI, Monia NGACH, Mahbouba CHKIR, Sami SOUISSI
TERRACE 2B
10:40 COFFEE BREAK AND EXHIBITION - E-POSTER SESSION
11:10

Tuesday 15 October

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A32
11:10 - 12:40

Airway
Beyond the Larynx: Airway management from the A team
Airway, HOT TOPIC SPEAKER!

Moderators: Dorothea HEMPEL (Atteding Physician) (Magdeburg, GERMANY), Dr Reuben STRAYER (Emergency Physician) (Brooklyn, USA)
11:10 - 12:40 Psychology in the difficult airway. Dorothea HEMPEL (Atteding Physician) (Magdeburg, GERMANY)
11:10 - 12:40 HOT TOPIC SPEAK! Alternatives to RSI: Contemporary Airway Management with Ketamine. Dr Reuben STRAYER (Emergency Physician) (Brooklyn, USA)
11:10 - 12:40 If Carlsberg did… RSIs. Dr Clare BOSANKO (EM/PHEM) (Plymouth, UK, UK)
CONGRESS HALL

Tuesday 15 October

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B32
11:10 - 12:40

Disaster medicine
Mass casualty triage: panel discussion
Disaster medicine, INTERACTIVE SESSION, Pre Hospital

Moderators: Massimo AZZARETTO (Associate Researcher) (Novara, ITALY), Dr Abdo KHOURY (SENIOR ATTENDING) (Besançon, FRANCE), Luca RAGAZZONI (Scientific Coordinator) (Novara, ITALY)

11:10 - 12:40 Prehospital. Riccardo STUCCHI (Anesthetist Intensivist - Referent for MCI-MGE) (Milan, ITALY)
11:10 - 12:40 Emergency Department. Dr Eric WEINSTEIN (Disaster Medicine Researcher) (Summerville SC, USA)
11:10 - 12:40 Humanitarian Setting. Laura ARCHER (Senior Officer, Emergency Medical Services) (Geneva, SWITZERLAND)
FORUM HALL

Tuesday 15 October

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C32
11:10 - 12:40

Late breaking research
Research

Moderator: Barbra BACKUS (Emergency Physician) (Leiden, THE NETHERLANDS)
11:10 - 12:40 TXA in epistaxis. Adam REUBEN (EuSEM) (Exeter, UK)
11:10 - 12:40 New tools in the early diagnosis of acute coronary syndromes. Pr Edd CARLTON (Emergency Medicine Consultant) (Bristol, UK)
11:10 - 12:40 Sterile vs non-sterile sutures for wounds in the ED. Wouter RAVEN (Emergency Physician) (Leiden, THE NETHERLANDS)
SOUTH HALL 3AB

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D32
11:10 - 12:40

YEMD - Nightmares in ED
Your role models are telling their personal horror stories
Young Emergency Medecine

Moderator: Martin FANDLER (Consultant) (Bamberg, Germany, GERMANY)
Speakers: Simon CARLEY (Consultant in Emergency Medicine) (Manchester, UK), Dr David CARR (Associate Professor of Emergency Medicine) (Toronto Canada, CANADA), Christian HOHENSTEIN (PHYSICIAN) (Madgeburg, GERMANY)
SOUTH HALL 3C

Tuesday 15 October

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E32
11:10 - 12:40

NURSES
Emergency nursing education
Education, Nurses

Moderators: Tessa POSTUMA (Trainer) (DOETINCHEM, THE NETHERLANDS), Christien VAN DER LINDEN (Clinical Epidemiologist) (The Hague, THE NETHERLANDS)
11:10 - 12:40 Advanced Practice Nursing in Emergency Care. Bart HUYBRECHTS (Nurse practitioner) (Amsterdam, THE NETHERLANDS)
11:10 - 12:40 What last years literature learned us about: ED nursing education. Dr Thordis K. THORSTEINSDOTTIR (Associate Professor) (Reykjavik, ICELAND)
11:10 - 12:40 What last years literature learned uw about: simulation as an educational intervention. Thorsteinn JONSSON (RN, MS) (Reykjavik, ICELAND)
CHAMBER HALL

Tuesday 15 October

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F32
11:10 - 12:40

ABSTRACTS SESSION

Moderators: Roberta PETRINO (Head of department) (Italie, ITALY), Gregor PROSEN (EM Consultant) (MARIBOR, SLOVENIA)
11:10 - 11:20 #18300 - OP073 The feasibility and effectiveness of "e;Hour-1 Bundle"e; sepsis treatment in the emergency room: a retrospective before-after study.
OP073 The feasibility and effectiveness of "e;Hour-1 Bundle"e; sepsis treatment in the emergency room: a retrospective before-after study.

Background. In 2018, “Hour-1 Bundle” was proposed by The Surviving Sepsis Campaign group. It encourages clinicians to complete initial treatment of sepsis and septic shock within 1 hour. However, there is controversy about its feasibility and effectiveness. 

Methods. This is a retrospective before-after study conducted at an emergency room (ER) in Kobe City General hospital from September 2017 to April 2019. Five elements of Hour-1 Bundle (measure lactate level, obtain blood cultures before administering antibiotics, administer broad-spectrum antibiotics, begin rapid administration of 30mL/kg crystalloid for hypotension or lactate level ≥ 4 mmol/L, apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mm Hg) were introduced by installing a timer in the ER, putting up original posters, providing short lectures about the bundle to staff members. We compared the outcomes and the compliance rates for the entire 1h bundle elements of consecutive suspected sepsis or septic shock patients treated in the ER and admitted to the ICU during 5 months after implementation of bundle (implementation group, from December 2018 to April 2019) with a control group treated during 6 months before the implementation group (from September 2017 to March 2018). The primary outcome was in-hospital mortality and the secondary outcome was the compliance rates for entire Hour-1 Bundle elements. Statistically significant differences were evaluated by chi-square test or Mann-Whitney U-test. P value < 0.05 was considered significant.

Results. There were 61, 65 patients in the control group and the implementation group with mean ages were 78 (IQR 65-83), 75 (67-85) years old, respectively. Sequential Organ Failure Assessment (SOFA) scores at ICU admission were 8(IQR 5-11), and 9(IQR 5-12), respectively. The compliance rates for the entire Hour-1 Bundle elements were 16% in the control group and 40% in the implementation group (p<0.05). In-hospital mortality was 28% in the control group and 40% in the implementation group (p=0.15). Infectious diseases were ruled out in 33% of the control group and 18% of the implementation group after admission based on microbiological investigations and clinical courses. The compliance rates for the conventional 3-hour bundle in the control group and in the implementation group were 70%, 91%, respectively.

Discussions and Conclusions. By introducing Hour-1 bundle to the ER, the compliance rates for the bundle significantly improved. However, it was difficult to make a definite diagnosis of sepsis or septic shock within 1 hour at the ER. No significant reduction of in-hospital mortality was observed. Implementation of novel Hour-1 Bundle in the ER was still difficult and may not improve outcomes of the sepsis or septic shock patients.

Akira SASAKI (Kobe, JAPAN), Machi YANAI, Koichi ARIYOSHI
11:20 - 11:30 #18315 - OP074 Artificial intelligence outperforms early warning scores at detecting sepsis: a retrospective Danish study.
OP074 Artificial intelligence outperforms early warning scores at detecting sepsis: a retrospective Danish study.

Background:

Sepsis is a life-threatening condition, and it is essential that the healthcare system quickly identifies patients and treats them adequately. Unfortunately, the early detection of sepsis remains a challenging problem, and even experienced physicians have difficulties in detecting sepsis early and accurately. We aimed to develop an Artificial Intelligence-based Early Warning Score System (AI-EWS) for the early detection of sepsis that is better than the currently used Modified Early Warning Scores (MEWS) and Sequential Organ Failure Assessment (SOFA).

Methods:

In this register study, we included health data from the years 2010 to 2017 on all citizens 18 years or older with residency in one of four Danish municipalities (Odder, Hedensted, Skanderborg, and Horsens). All relevant hospital contacts from multiple hospitals within the region were identified by the unique national social security system number (1,002,450 contacts). 754,179 non-acute outpatient contacts and 89,202 inpatient contacts with a duration of less than six hours were removed. 134,983 contacts with no episodes of suspected infection were removed leaving 24,076 inpatient contacts included for analysis. After inclusion each inpatient contact underwent a binary classification process to denote them as either sepsis-positive or sepsis-negative. The classification was made based on patients meeting the gold standard for sepsis based on the Third International Consensus Definitions for Sepsis (Sepsis-3). 1,635 (6.8%) inpatient contacts were classified as sepsis positive. We included data about biochemical blood tests, vital signs and glasgow coma scores from the electronic health record.

We developed the AI-EWS early sepsis detection model as a deep neural network composed of an embedding layer followed by a temporal convolutional network (TCN). The TCN has four temporal blocks, each with 540 filters of kernel size 10. The dilation rate of the convolutional filters was exponentially increased for each of the stacked temporal blocks. The AI-EWS was trained using Adam optimization, with a learning rate of 0.0005 and a batch size of 200.

The AI-EWS was validated using 5-fold cross-validation. As comparative measures, we used the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC). The model was compared with TOKS (Tidlig Opsporing af Kritisk Sygdom), a Danish MEWS variant, and SOFA.

Results:

The following results are reported three, six, and twelve hours before sepsis with mean values and 95% confidence intervals. AI-EWS: (AUROC: 0.88(0.85;0.91), 0.83(0.79;0.87), 0.82(0.79;0.87); AUPRC: 0.41(0.40;0.43), 0.37(0.34-0.39), 0.30(0.26;0.33)), SOFA: (AUROC: 0.77(0.74;0.79), 0.73(0.71;0.74), 0.70(0.65;0-75); AUPRC 0.18(0.16;0.19), 0.16(0.15;0.18), 0.13(0.11;0.16)), and TOKS: (AUROC: 0.68(0.67;0.70), 0.59(0.58;0.59), 0.57(0.55;0.58); AUPRC: 0.12(0.10;0.14), 0.09(0.07;0.10), 0.10(0.09;0.10)). Furthermore, the AI-EWS reduced the number of false positives relatively by 84.6% and 79.4% compared to TOKS and SOFA, respectively, at the same sensitivity of 0.4.

Discussion and conclusions: 

The AI-EWS outperformed the SOFA and TOKS in the early detection of sepsis, with an increase in AUROC by 29.4% and AUPRC by 241.7% when compared to TOKS, the currently used early warning tool in Denmark. We conclude that the AI–EWS could be used to improve clinical utility by enabling earlier sepsis interventions and should be tested in a prospective randomized trial.

Simon Meyer LAURITSEN (Aarhus, DENMARK), Mads KRISTENSEN, Katrine Meyer LAURITSEN, Marianne Johansson JØRGENSEN, Jeppe LANGE, Bo THIESSON
11:30 - 11:40 #18411 - OP075 Impact of a qSOFA-based triage procedure on antibiotic timing in ED patients with sepsis: a prospective interventional study.
OP075 Impact of a qSOFA-based triage procedure on antibiotic timing in ED patients with sepsis: a prospective interventional study.

Background
It has not been investigated whether the quick sepsis-related organ failure assessment score (qSOFA), a new bedside tool for early sepsis detection, may help accelerating antibiotic initiation in ED patients with sepsis.

Methods
In this prospective pre/post quasi-experimental single-ED study, patients admitted with a suspected bacterial infection were managed using standard triage procedures only (baseline) or in association with qSOFA (intervention, with prioritization of patients with a qSOFA ≥2).


Results
A total of 151/328 (46.0%) and 185/350 (52.8%) patients with definite bacterial infection met the criteria for sepsis in the baseline and intervention periods, respectively. The sensitivity and specificity of a qSOFA ≥2 for sepsis prediction were 17.3% (95% confidence interval [CI], 13.6%-21.7%) and 98.8% (95% CI, 97.0%-99.5%). Eleven (7.3%) and 28 (13.5%) patients with sepsis in the baseline and intervention periods received a first antibiotic dose within one hour following triage (primary endpoint, absolute difference 6.2%, 95% CI [-0.5%, 12.7%], P = 0.08). The proportions of patients with sepsis receiving a first antibiotic dose within three hours following triage (39.7% [50/151] versus 36.8% [68/185], absolute difference -2.9%, 95% CI [-13.3%, 7.3%], P = 0.65), requiring ICU admission, or dying in the hospital were similar in both periods. The median ED occupation rate at triage was 104.3% (interquartile range [IQR], 80.4%-128.3%), with a median number of 157 ED visits per day (IQR, 147- 169).

Conclusions
A qSOFA-based triage procedure does not improve antibiotic timing and outcomes in patients with sepsis admitted to a high-volume ED. The qSOFA value at triage was poorly sensitive for early sepsis detection.

Julien PETIT (Orléans), Julien PASSERIEUX, Thierry BOULAIN, François BARBIER
11:40 - 11:50 #18500 - OP076 High-dose of beta-lactam therapy and associated outcomes in sepsis and septic shock patients in a university emergency department, Thailand.
OP076 High-dose of beta-lactam therapy and associated outcomes in sepsis and septic shock patients in a university emergency department, Thailand.

Introduction

Altered pharmacokinetics, including increased volume of distribution and reduced tissue perfusion, in sepsis and septic shock patients resulted in inadequate serum drug concentration with the given standard meropenem dose. Even though higher dose regimen of hydrophilic antimicrobials was proposed, high-dose meropenem and its associated clinical outcomes in sepsis and septic shock patients admitted in the emergency department (ED), Mahidol university hospital, Thailand has not been examined.

Study objective

To compare the clinical outcomes of high-dose meropenem versus standard-dose in sepsis and septic shock patients who were admitted to the ED, Ramathibodi Hospital, Bangkok, Thailand.

Method

All sepsis and septic shock patients, in whom treatment with meropenem was indicated, were included in the study. Patients were randomized into two groups: the high-dose group (meropenem 2 g, infusion 3 hours, every 8 hours) and the standard-dose group (meropenem 1 g, infusion 3 hours, every 8 hours). Dose adjustment was done according to the renal dose adjustment protocol. Data were collected on 35 patients over 1 year. Primary and secondary outcomes included changes of modified sepsis-related organ failure assessment (mSOFA), mortality rate, ICU length of stay, mechanical ventilator days, vasopressor days and hospital stay.

Results

The study included 35 patients with 17 patients receiving standard-dose and 18 patients receiving high-dose meropenem. Age, gender, body weight, comorbidities, severity of illness, and source of infection were comparable between groups. Among identified pathogens, more than 80% were gram negative pathogens and all of them had meropenem minimal inhibitory concentration (MIC) < 0.5 mg/dL. Delta mSOFA scores were not different between two groups (-2 [range -6 to 2] in standard-dose group vs -2 [range -9 to 4] in high-dose group, P-Value = 0.99). There was no difference between standard-dose group and high-dose group in ICU mortality (17.6% vs 11.1%, P-value = 0.66), ICU free days (16.6±10.6 vs 14.5±11.8, P-value = 0.59), mechanical ventilator free days (18 [range0-28] vs 20.5 [range 0-28], P-value = 0.57), vasopressor free days (9.7±5.7 vs 8.9±5.8, P-value = 0.68) and hospital free days (50.8±33.5 vs 47.1±36.0, P-value = 0.75).

Conclusion

Our study is the first study examining higher dosing of meropenem in the ED, Ramathibodi Hospital, Bangkok, Thailand. The high-dose group showed comparable clinical outcomes to the standard dose group. Even though higher dose of hydrophilic antimicrobials has been linked to the better clinical outcomes in sepsis and septic shock patients, high-dose meropenem in low MIC pathogen has not been associated with improved clinical outcomes. Further research might be needed in order to identify suitable septic shock patients who may benefit from receiving high-dose of meropenem.

References

1.Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017 Mar;43(3):304-377.

2.Roberts JA, Paul SK, Akova M, et al. DALI: defining antibiotic levels in intensive care unit patients: are current beta-lactam antibiotic doses sufficient for critically ill patients?. Clin Infect Dis. 2014 Apr;58(8):1072-83. 

Pitchaya DILOKPATTANAMONGKOL (Bangkok, THAILAND), Auranee TRISATAYA, Viratch TANGSUJARITVIJIT, Jetjamnong SUEAJAI, Preecha MONTAKARNTIKUL, Tospon LERTWATTANACHAI
11:50 - 12:00 #18799 - OP077 Albumin outperforms other novel biomarkers in prognosticating sepsis-associated mortality for sepsis patients in emergency department.
OP077 Albumin outperforms other novel biomarkers in prognosticating sepsis-associated mortality for sepsis patients in emergency department.

Background

Sepsis can be fatal without timely diagnosis and prompt intervention. Therefore, it is necessary to develop early predictive biomarkers to identify and risk-stratify patients with sepsis. Traditionally, albumin has been used as a nutritional biomarker in intensive care unit to predict the mortality of septic patients; however, its role in prognosticating patients with sepsis in the emergency department (ED) remains uncertain.

 

Objective

The aim of the current study is to evaluate the performance between conventional and novel biomarkers in predicting 28-days sepsis-associated mortality and bacteremia in the ED. 

 

Methods

This prospective hospital-based cohort study was conducted in the ED of two different tertiary medical centers in Northern Taiwan between 2012 and 2018. Patients with documented infectious diseases during initial 24 hours were enrolled. We applied the multiplex platform of Bio-Plex ProTM Assays to evaluate 14 novel biomarkers: angipoietin-2, pentraxin 3, triggering receptor expressed on myeloid cells 1 (TREM-1), intercellular adhesion molecule 1 (ICAM-1), vascular cell adhesion protein 1 (VCAM-1), soluble cluster of differentiation 14 and 163 (sCD14 and sCD163), E-selectin,  P-selectin, tumor necrosis factor alpha (TNF alpha), cluster of differentiation-64 (CD64), interleukin-6, interleukin-8 and interleukin-10. Besides, we assessed 7 conventional markers: albumin, procalcitonin (PCT), C-reactive protein (CRP), red cell distribution width (RDW), Sequential Organ Failure Assessment (SOFA) score, Systemic Inflammatory Response Syndrome (SIRS) and Chills, Hypothermia, Anemia, RDW and Malignancy (CHARM) score. Our main outcomes of biomarker performance included sensitivity, specificity, accuracy and area under the receiver operating characteristic curve (AUC). 

 

Results

We recruited 1478 patients in our study. Among them, 1155 subjects had SIRS (78.15%), 912 subjects had severe sepsis (or Sepsis 3.0, 61.71%), and 466 subjects had septic shock  (31.53%)  with a 28-day mortality rate of 8.15%. By using different cutoff values of albumin, we demonstrated relatively acceptable sensitivity, specificity and accuracy for sepsis-associated mortality prediction accordingly (albumin level of 2.5g/dL: 34.51%, 93.90%, 88.20%; albumin level of 3.5g/dL: 90.27%, 44.41%, 48.81%). Among all biomarkers, albumin alone possessed an AUC of 0.791 (95% CI 0.750-0.832) and its performance was similar to the SOFA score with an AUC of 0.792 (95% CI 0.750-0.833) in 28-days sepsis-associated mortality (p-value = 0.98). For bacteremia, procalcitonin had a higher AUC than CRP (0.799, 95% CI 0.744-0.854 versus 0.540, 95% CI 0.467-0.611; p-value < 0.0001), as well as other biomarkers and scoring systems.

 

Conclusion

Our finding suggests that albumin, as a single biomarker, is a promising early predictor for mortality in sepsis subjects, similar to SOFA score, and outweighs other markers. The role of biomarker in identifying bacteremia has proved that PCT is still a better tool in comparison with CRP. Further efforts are needed to evaluate and improve the reliability of combining two or more biomarkers in early prediction of sepsis-associated mortality.

Dr Su Ann YONG (Taipei, TAIWAN), Chia-Yu CHAO, Kuan-Fu CHEN
12:00 - 12:10 #18953 - OP078 Characteristics of low energy expenditure in the acute phase of sepsis.
OP078 Characteristics of low energy expenditure in the acute phase of sepsis.

Background: With regards to nutritional therapy in critical care, the guidelines recommend that hypocaloric nutrition (not exceeding 70% of the estimated needs) be administered in the early phase of acute critical illness. When indirect calorimetry (IC) was used to study resting energy expenditure (REE) in the acute phase of sepsis (within 72 hours of admission), it was found that patients showed lower energy expenditure than that calculated using simple weight-based equations (such as 20-25 kcal/kg/day). This study aimed to evaluate the characteristics of low energy expenditure in the acute phase of sepsis.

Method: This retrospective observational study included sepsis patients under ventilation in whom REE was measured using IC within the first 72 hours of admission. The patients were divided into two groups according to REE values: group A, REE <20 kcal/kg/day and group B, REE ≥20 kcal/kg/day. Age, sex, body mass index (BMI), comorbidities, Acute Physiology and Chronic Health Enquiry (APACHE II) score on admission, site of infection, causative microorganisms, ratio of positive blood culture, catecholamine administration, and corticosteroid therapy were compared between the two groups. The Wilcoxon rank-sum test and the Fisher’s exact test were used for statistical analysis. A p-value <0.05 was considered statistically significant. We conducted this study in accordance with the Declaration of Helsinki, and the study was approved by the institutional review board at Osaka University Hospital (approval no. 14186). The board waived the need for informed consent because this was a retrospective study using clinical data.

Results: This study included 28 patients. Group A included 39.3% (n=11) of the study population. Median (interquartile range) age was significantly higher in group A than in group B (81 [74-87] vs. 72 [62-76] years; p=0.02). APACHE II scores were significantly higher in group A than in group B (24 [22-34] vs. 19 [14-25], p=0.04). Median BMI was significantly lower in group A than in group B (19.6 [17.6-24.9] vs. 23.6 [21.4-27.7] kg/m2; p=0.05). Microorganism culture showed gram-negative rods in the following cases: seven cases in group A (63.6%) and three cases in group B (17.7%) (p=0.02). Sex, comorbidities, site of infection, ratio of positive blood culture, catecholamine administration, and corticosteroid therapy did not differ significantly between the two groups.

Conclusion: Low energy expenditure in the acute phase of sepsis was observed in patients with higher APACHE II scores and lower BMI. The type of causative microorganism could also be related to for metabolism.

Dr Takeshi EBIHARA (OSAKA, JAPAN), Kentaro SHIMIZU, Hiroshi OGURA, Takeshi SHIMAZU
12:10 - 12:20 #19016 - OP079 Bacteraemia in patients with accidental hypothermia: a retrospective cohort study.
OP079 Bacteraemia in patients with accidental hypothermia: a retrospective cohort study.

Background

Accidental hypothermia is not only caused by environmental exposure but also by various medical conditions, including sepsis, endocrinologic disease, and multiple trauma. Bacteraemia in accidental hypothermia is considered to be associated with significant morbidity and mortality, but little is known about bacteraemia in patients with accidental hypothermia. We aimed to investigate the clinical characteristics of patients with both accidental hypothermia and bacteraemia.

Methods

We conducted a retrospective analysis of all adult patients with accidental hypothermia who were brought to an urban emergency department between July 2011 and March 2019 in Kobe, Japan. Hypothermia was defined as a body temperature below 35°C.We compared clinical characteristics (vital signs, comorbidities, and laboratory tests) between patients with and without bacteraemia. To assess whether bacteraemia was associated with in-hospital mortality, we analysed odds ratios using a logistic regression model. Based on biological plausibility and pre-existing knowledge, we selected the following confounding factors: age, sex, severity (the Swiss system), and Charlson comorbidity index.

Result

A total of 245 patients with accidental hypothermia were enrolled. Median age was 78 (interquartile range, 68 to 87) years, and 49% of patients were male. In the emergency department, blood culture samples were collected from 217 patients (89%); of these, 36 patients (16.6%) showed positive blood cultures. None of the patients for whom blood culture was not performed in the emergency department were diagnosed with bacteraemia after admission. Body temperatures were lower (28.9 vs 30.1°C, p=0.009) and C-reactive protein levels were higher (9.99 vs 3.76 mg/dL, p<0.001) in patients with bacteraemia than in those without bacteraemia. Other clinical characteristics were not different between the two groups. The mortality was 11/36 (31%) in patients with bacteraemia and 29/209 (14%) in patients without bacteraemia (adjusted odds ratio, 2.47 [95% confidence interval, 1.04–5.88]).

Discussion and conclusion

Our study demonstrated that bacteraemia was common in patients with accidental hypothermia and was a prognostic factor, even after adjusting for confounding factors. Furthermore, except for body temperature and one inflammatory marker, other clinical characteristics did not differ between patients with and without bacteraemia. High mortality has been reported in accidental hypothermia patients with bacteraemia, but limited information was available for correctly suspecting bacteraemia in the emergency department. Our results were clinically acceptable and also consistent with a multi-centre study that demonstrated that hypothermia was associated with higher mortality in sepsis patients. Although several previous studies have focused on the association between mortality and hypothermia from the standpoint of treating sepsis patients, we evaluated all patients who presented with accidental hypothermia. Therefore, the present study emphasizes the importance of suspecting bacteraemia in patients with accidental hypothermia who do not show signs of sepsis. In conclusion, our study found that bacteraemia was common in patients with accidental hypothermia and was associated with higher mortality. Based on these findings, we recommend that we take blood culture routinely and consider empirical antibiotic treatment in patients with accidental hypothermia.

Dr Mayu KURIBAYASHI (kobe, JAPAN), Yoshinori MATSUOKA, Koichi ARIYOSHI
12:20 - 12:30 #19116 - OP080 Recognition of sepsis through emergency medical services.
OP080 Recognition of sepsis through emergency medical services.

Recognition of sepsis through emergency medical service

Background:

Sepsis is a common and serious disease process for which early recognition and intervention can significantly improve clinical outcomes. Despite this, sepsis remains underrecognized and therefore undertreated in the prehospital setting. Recent recommendations by the Society of Critical Care and European Society of Intensive Care Medicine advocate use of the qSOFA (quick Sepsis-related Organ Failure Assessment) score in non-ICU settings to screen for septic patients at greater risk for poor outcomes. Accordingly emergency medical services (EMS) in Bavaria were trained to identify septic patients in the prehospital setting. This retrospective cohort study sought to evaluate the effectiveness of this training intervention.

Methods:

We performed a retrospective study of all patients transported by EMS to our ED during two 6-month periods. All patients with a suspected or proven infection and sepsis after the ED workup were included. 303 patients were included during the 6 month period before the EMS training for sepsis recognition and 459 patients were included in the 6 month period following the EMS training. The sensitivity and specificity of a qSOFA score ≥2 for ED identification of patients at risk of complication was calculated.

Results:

During the 12 month study period 3.1% of all EMS-transported patients were diagnosed with sepsis in the ED. Mean age of the study cohort was 72 ±13 years, 59.4% were male, 60% needed intensive care, hospital mortality was 37.7%. No significant differences in clinical and outcome variables between the two study periods were noted. The proportion of patients identified with sepsis by EMS did not increase in the study period following the EMS training. In both study periods the identification of a septic disease in the pre-hospital setting was missed in 82% of the patients. Only in 3.8% a qSOFA score ≥2 was documented. Respiratory rate was the vital parameter most often missed by EMS (60%). In the ED the sensitivity and specificity of a qSOFA score ≥2 for identification of septic patients with poor outcome was 37.2% and 84.2%, respectively.

Conclusions:

A single EMS training period for identification of septic patients in the prehospital setting is not sufficient. A qSOFA score ≥2 had a low identification sensitivity in selecting septic patients at risk of complication upon arrival in the ED. An improved method for pre-hospital identification of septic patients is needed.

Markus WEHLER, Thomas HÄNDL (Augsburg, GERMANY), Jürgen NEUBAUER
12:30 - 12:40 #19200 - OP081 Sepsis after Sepsis-3: A prospective study of the incidence and the prognostic accuracy of the diagnostic tools for early detection of sepsis.
OP081 Sepsis after Sepsis-3: A prospective study of the incidence and the prognostic accuracy of the diagnostic tools for early detection of sepsis.

Background

Prospective studies of the incidence of sepsis and the prognostic accuracy of the different sepsis screening tools after the introduction of Sepsis-3 are limited. Definition of sepsis is now based on organ dysfunction characterized by a rise in the Sequential Organ Failure Assessment (SOFA) score of two or more. The new definition also proposed QuickSOFA (qSOFA) as a bedside screening tool to identify patient with potential risk of having sepsis. We have estimated the incidence based on qSOFA, SOFA and Systemic Inflammatory Response Syndrome (SIRS), and compared the prognostic accuracy in predicting the 28-day mortality.

 

Methods

A prospective observational cohort study of infected patients aged 18 years or older admitted to the emergency department (ED) of Slagelse Hospital during 01.10.2017 – 31.03.2018. The adult (≥18 years) population in the area was 198,000. All patients with suspected or documented infection on arrival to the ED, and treated with antibiotics, were included. Admission variables included in the qSOFA, SOFA and SIRS criteria were obtained from the triage forms and patient records. The applied SOFA values were calculated based on the clinical and paraclinical parameters at admission and with correction for chronic dysfunction of organs included in the SOFA score. Survival status was obtained from the Danish Civil Registration System. Incidence was estimated as (number of patients with sepsis/population in the area x 0.5) x 100.000.  The prognostic accuracy was assessed by analyses of sensitivity, specificity and area under the receiver-operating curve (AUROC) with 95% confidence intervals (CI).

Results

A total of 2,112 patients with median age of 73.1 years were included. The incidence of sepsis based on a qSOFA 2, a SOFA 2 and SIRS 2 was 175/100,000 (95% CI 150-203/100,000), 714/100,000 (95% CI 663-768/100,000) and 1,012/100,000 (95% CI 951-1076/100,000), respectively. The 28-day mortality in patients with qSOFA 2, SOFA 2 and SIRS 2 was 17.7% (95% CI 12.4-24.2), 13.6% (95% CI 11.2-16.3) and 8.3% (95% CI 6.7-10.2), respectively. qSOFA 2 had a sensitivity of 19.5% (95% CI 13.6-26.5) and a specificity of 92.6% (95% CI 91.4-93.7), SOFA 2 had a sensitivity of 61.0% (95% CI 53.0-68.6) and specificity of 68.4 (95% CI 66.3-70.59), and SIRS 2 had a sensitivity of 52.8% (95% CI 44.8-60.8) and a specificity of 52.5% (95% CI 50.2-54.7). The AUROC was 0.63 (95% CI 0.59-0.67) for qSOFA, 0.69 (95% CI 0.64-0.73) for SOFA and 0.52 (95% CI 0.48-0.57) for SIRS.

 

Discussion and conclusion

The sepsis-3 criteria have reduced the number of patients classified as having sepsis and the prognostic accuracy to predict 28-day mortality has been increased. However, the prognostic accuracy to predict patients with risk of death is still poor, regardless of the scoring system used. 

Dr S M Osama Bin ABDULLAH (Copenhagen, DENMARK), Rune Husås SØRENSEN, Ram Benny Christian DESSAU, Saifullah Muhammed Rafid Us SATTAR, Lothar WIESE, Finn Erland NIELSEN
TERRACE 2B
12:40 LUNCH BREAK AND EXHIBITION

Tuesday 15 October

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A32bis
12:40 - 14:10

EUSEM Annual General Assembly
for members only

CONGRESS HALL
14:10

Tuesday 15 October

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A33
14:10 - 15:40

Psychology in the Emergency Department
All in the Mind: The Psychology of an Emergency Physician
Psychology

Moderators: Simon CARLEY (Consultant in Emergency Medicine) (Manchester, UK), Christian HOHENSTEIN (PHYSICIAN) (Madgeburg, GERMANY)
14:10 - 15:40 Frust and Anger among Patients and Relatives - Understand their Perception of Reality. Dr Thomas FLEISCHMANN M.D. (Medical Director) (Rendsburg, GERMANY)
14:10 - 15:40 How to handle fear of failure and mutate from a fraidy-cat to a risk-taker. Simon CARLEY (Consultant in Emergency Medicine) (Manchester, UK)
14:10 - 15:40 Dr. Greg´s Travalin Medical Magic Show. Greg HENRY (USA)
14:10 - 15:40 Mistakes are for Learnin'. Judith TINTINALLI (Professor) (Chapel Hill NC, USA)
CONGRESS HALL

Tuesday 15 October

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B33
14:10 - 15:40

Bohemian Sono Rhapsody
Sonography, Ultrasound

Moderators: James CONNOLLY (Consultant) (Newcastle-Upon-Tyne, UK), Dr Nicolas LIM (Intensive Care Fellow) (Dublin, IRELAND), Eftychia POLYZOGOPOULOU (ED DIRECTOR) (ATHENS, GREECE), Senad TABAKOVIC (Zürich, SWITZERLAND)
14:10 - 15:40 Interactive ultrasound game show. Nils Petter OVELAND (NORWAY), Tomas VILLEN (Attending Physician) (Madrid, SPAIN), Rip GANGAHAR (Consultant) (Oldham, UK), Dr Kasia HAMPTON (Emergency Department Medical Director) (USA/Poland, USA), Dr Michael SWEENEY (Consultant) (Sligo, IRELAND), Arora MOHIT (Consultant Emergency Medicine) (Leeds, UK), Dr Laila HUSSEIN (Specialist Emergency Medicine) (AbuDhabi, UNITED ARAB EMIRATES)
FORUM HALL

Tuesday 15 October

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C33
14:10 - 15:40

Geriatric emergencies
Hot topics in the care of the elderly
Geriatric, HOT TOPIC SPEAKER!

Moderators: Pr Suzanne MASON (Professor of Emergency Medicine) (Sheffield, UK), Pr Christian NICKEL (Vice Chair ED Basel) (Basel, SWITZERLAND)
14:10 - 14:25 What you need to know about old people - and how to learn it. Dr Don MELADY (Associate Professor/Staff Physician) (Toronto, CANADA)
14:25 - 14:40 Risk stratification of older patients. Pr Christian NICKEL (Vice Chair ED Basel) (Basel, SWITZERLAND)
14:40 - 14:55 Short stay unit. Dr Camilla STRØM (MD. PhD Research Fellow) (Copenhagen, DENMARK)
14:55 - 15:10 Prehospital geriatric emergency medicine. Eric REVUE (Praticien Hospitalier Adjoint Chef de Service) (Paris, FRANCE)
15:10 - 15:40 Panel Discussion. Dr Don MELADY (Associate Professor/Staff Physician) (Toronto, CANADA), Pr Christian NICKEL (Vice Chair ED Basel) (Basel, SWITZERLAND), Eric REVUE (Praticien Hospitalier Adjoint Chef de Service) (Paris, FRANCE), Dr Camilla STRØM (MD. PhD Research Fellow) (Copenhagen, DENMARK)
SOUTH HALL 3AB

Tuesday 15 October

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D33
14:10 - 15:40

YEMD - Very difficult situations, once in a lifetime?
The situations we don't see everyday - but need be prepared for!
Hematology, Resuscitation, Young Emergency Medecine

Moderators: Bulut DEMIREL (Emergency Department Chief) (Ankara, TURKEY), Dr Dinka LULIC (Resident in Emergency Medicine) (Zagreb, CROATIA)
14:10 - 15:40 Surviving hematological emergencies. Eva DIEHL-WIESENECKER (Physician) (Berlin, GERMANY)
14:10 - 15:40 Jack in the box - uncommon presentations. Farah MUSTAFA (EMERGENCY MEDICINE CONSULTANT) (Drogheda, IRELAND)
14:10 - 15:40 To treat or not to treat. Or: Mr. Bayes - Take over! Dr Steven VAN DEN BROUCKE (Internal Medicine) (Kortrijk-Dutsel, BELGIUM)
14:10 - 15:40 Worst case: Resuscitating one of your own team - what now? Riccardo LETO (Chief of ED) (Overpelt, BELGIUM)
SOUTH HALL 3C

Tuesday 15 October

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E33
14:10 - 15:40

NURSES
Implementing evidence based care
Nurses

Moderators: Emmanuel ROHRBACHER (INFIRMIER) (MONCONTOUR DE BRETAGNE, FRANCE), Christien VAN DER LINDEN (Clinical Epidemiologist) (The Hague, THE NETHERLANDS)
14:10 - 15:40 Introduction to implementation science. Jochen BERGS (Professor) (Hasselt, BELGIUM)
14:10 - 15:40 Protocol adherence in emergency care. Dr Remco EBBEN (Associate professor/lecturer) (Nijmegen, THE NETHERLANDS)
14:10 - 15:40 Implementing nursing handover: a hospitals journey. Christian GILOT (Head Nurse) (Rumst, BELGIUM), Jochen BERGS (Professor) (Hasselt, BELGIUM)
CHAMBER HALL

Tuesday 15 October

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F33
14:10 - 15:40

ABSTRACTS SESSION

Moderators: Door LAUWAERT (Manager) (BRUSSELS, BELGIUM), Marc SABBE (Medical staff member) (Leuven, BELGIUM)
14:10 - 14:20 #18016 - OP082 Needs Assessment for Standardized Educational Program for Iranian Medical Students in Crisis and Disaster Management.
OP082 Needs Assessment for Standardized Educational Program for Iranian Medical Students in Crisis and Disaster Management.

Background: Early education and training are mandatory to raise the knowledge and awareness of the healthcare staff. Iran is a disaster prone area with a high number of emergencies. This study aimed to assess the need for disaster and emergency management education for Iranian medical students.

Methods: Using two-round Delphi technique in 2018, 15 experts within the field of disaster and emergency management were asked for their opinions concerning the education required for Iranian medical students. Highly important educational domains and their sub-domains selected with an agreement of above 70-80% were prioritized by AHP technique.

Results: Of 41 identified and prioritized educational subjects, four main groups were obtained: 1) crisis and disaster primary concepts, 2) disease control skills, 3) management skills, and 4) medical care skills. The medical care skills had the highest priority (with a weight of 0.546) compared to other areas after the final analysis.

Discussion and Conclusion: Different areas of competency are needed to raise awareness and preparedness in medical students in combating crisis and disasters. We propose a curriculum for Iranian medical students and suggest it to be used other professionals, who are involved in the process of disaster management.

Rezaee RITA, Peyravi MAHMOUDREZA (, IRAN, ISLAMIC REPUBLIC), Ahmadi Marzaleh MILAD, Khorram-Manesh AMIR
14:20 - 14:30 #18663 - OP083 ED impact of a mass gathering pre-hospital support system: the Rouen 2013 Armada event.
OP083 ED impact of a mass gathering pre-hospital support system: the Rouen 2013 Armada event.

ABSTRACT

Objective(s)

There is no data about the intra-hospital crowding effect of pre-hospital mass-gathering support systems. Our objective was to evaluate the impact on emergency departments (EDs) of the Rouen Armada event 2013 (RAE2013), a major French happening.

Methods

We performed a multicenter, observational study based on the prospective collection of data on-site (8 first aid stations) and from 5 EDs in the Rouen area.

The main study endpoint was the total number of patients presenting to EDs for an Armada-related reason (ARR). Secondary endpoints were: demographics, care pathways, final diagnosis, care characteristics and outcomes. Then, we performed a focussed analysis on two subgroups (with vs without pre-hospital examination).

Results

Among 1,261 patients examined on-site, 246 presented to ED with an ARR (63 % with accidental injury, 85% discharged home). Only 6 patients had severe injuries. 88% of patients required some technical support in the ED. In the subgroup without pre-hospital examination (49%), we found significantly higher rates of young and local patients, which mainly presented to a private hospital. In the other subgroup, we fund a higher significant rate of discomfort and more use of ED technical support (biology, EKG).

Conclusions

RAE2013 pre-hospital support system efficiently protected EDs from overcrowding. Most of the ED visits were appropriate. This study highlights the importance of sufficient on-site resources for the most common presentations, and the relevance of intra-hospital registers.

Julie DUMOUCHEL (Tours), Dr Melanie ROUSSEL, Mehdi TAALBA, Virginie Eve LVOVSCHI, Antoine LEFEVRE, Luc Marie JOLY
14:30 - 14:40 #18256 - OP084 Public Knowledge in basic life support maneuvers and attitude towards emergencies in Spain.
OP084 Public Knowledge in basic life support maneuvers and attitude towards emergencies in Spain.

Introduction: out-of-hospital cardiac arrest (OHCA) is a major public health problem. In Spain there are about 15,000 cases per year. The survival with a good neurological status of the OHCA is low, around 10%. Several studies have shown the relationship between the levels of training of citizens, the number of witnesses performing cardiopulmonary resuscitation (CPR) and the survival to the OHCA. The objective of this study was to determine the level of knowledge in basic life support (BLS) maneuvers of the Spanish population and their general attitude towards emergencies.

Methods: Descriptive study of cross-sectional survey by means of randomized sampling. 1,500 telephone interviews were made to subjects 18 years of age and older living in Spain. The sample was selected randomly from an automatic telephone number generator. The questionnaire used was designed specifically for the study. The information was collected by means of a computer-assisted telephone interview (CATI) through a structured and pre-codified questionnaire. Descriptive statistics was used to show the results.

Results: 51.3% of the people surveyed were men, the predominant age was between 35 and 54 years (44.9%), 59.7% were in active labor status and 32.8% had university studies. 75.6% of the population considers the training that Spanish people have in relation to first aid is "insufficient" or "very insufficient". 98.7% of respondents consider "very important" or "important" that citizens have knowledge of first aid. 60.8% of the population does not feel able to respond to a cardiac arrest. Only 41.3% of citizens recognize that they would know how to use an AED in case of need. 34.7% of Spanish people don´t know which is the unique European emergency number. 53.8% of the population has not received any training course related to first aid or BLS. 53.6% of citizens believe that caring for a person who has an emergency, without sufficient knowledge, could pose legal problems. 81.6% of the respondents believe that in our country everything is not done so that citizens have adequate training in first aid. 81.7% of the population believes that training in BLS should be initiated in the school (Primary Education and ESO).

Conclusions: Although the knowledge on BLS of the Spanish population and their ability to respond to an emergency situation has increased in the recent years, we are far from other European countries. The implementation of a National Plan of training and awareness in BLS along with public defibrillation programs, telephone CPR and public information and dissemination campaigns could increase the level of knowledge, the ability to respond, the number of witnesses that perform correctly CPR and use an AED, and, with all these things, can increase the survival of cardiac arrest.

Esther GORJÓN (Madrid, SPAIN), Raúl SÁNCHEZ, Daniel BARQUILLA, César FERNÁNDEZ, Miguel GARVI
14:40 - 14:50 #18173 - OP085 Outcome prediction in emergency elderly admissions: derivation and external validation of the Geriatric Emergency Risk on Admission Score.
OP085 Outcome prediction in emergency elderly admissions: derivation and external validation of the Geriatric Emergency Risk on Admission Score.

Background

The over 65 demographic have demonstrated the largest increase in emergency hospital admissions of any age group. Measures of acute illness severity using only physiological parameters have shortcomings in the older patient. Accurate risk scores combining acute physiology e.g. National Early Warning Score (NEWS), co-morbidities, and Clinical Frailty Score (CFS) in this cohort may support clinical decision making and inform discussions with patients and carers. This study aimed to derive and externally validate an in-hospital mortality risk score for the acutely unwell older patient.

Methods

This multicentre cohort study collected data on non-elective admissions in those aged ≥65 years from the emergency departments of two UK district general hospitals (2017-2018), which were treated as independent populations to derive and validate the score. Accessible and clinically significant variables underwent regression analysis for in-hospital mortality. Independent predictors of mortality from the derivation cohort were used to create GERAS. Model performance was assessed for discrimination and calibration in the validation cohort. Area under curve (AUC) analysis is presented with 95% confidence intervals. Secondary outcomes measured were 48-hour and seven-day mortality, 30-day readmission, and extended hospital stay.

Results

17,905 admissions were analysed in both derivation (n= 8,974) and validation (n=8,931) cohorts. GERAS was stratified into low, medium, high, and severe risk with corresponding mortality in each group of 0.4, 3.9, 9.3, and 24.1 percent, respectively. GERAS AUC for in-hospital mortality was 0.79 (0.77-0.80), compared to NEWS at 0.65 (0.62-0.67) and CFS at 0.76 (0.74-0.77) alone. GERAS demonstrated better calibration than NEWS and Clinical Frailty Score, Hosmer-Lemeshow: 0.302 vs 0.157 and 0.008, respectively. AUCs for mortality prediction at 48-hours and 7-days were 0.84 (0.78-0.90) and 0.83 (0.79-0.86), respectively. AUCs for 30-day re-admission and extended hospital stay were 0.68 (0.65-0.70) and 0.52 (0.50-0.54), respectively.

Conclusion

GERAS is an easy to use, high discriminating risk score that could be integrated into existing electronic hospital systems for use within hours of admission. Future studies could validate GERAS in external populations and consider impact analysis.

 

Khushal ARJAN (Brighton, UK), Luke HODGSON
14:50 - 15:00 #18310 - OP086 Nonspecific Complaints in the Emergency Department – A Systematic Review.
OP086 Nonspecific Complaints in the Emergency Department – A Systematic Review.

ackground Nonspecific complaint (NSC) is a common presenting complaint in the emergency setting, especially in the elderly population. Individual studies have shown that it is associated with significant morbidity and mortality. This systematic review aims to draw a synthesis of reported outcomes for patients presenting with NSC.

Methods We conducted a literature search for publications, abstracts and conference presentations from Ovid, Scopus and Web of Science for the period of past 20 years. Included were studies with adult patients presenting to the Emergency Medical Services or Emergency Department with NSC. 2057 studies were screened for eligibility and quality was assessed with the SIGN assessment for bias tool. We excluded any low-quality studies resulting in 9 studies for quantitative analysis. We analyzed included studies for in-hospital mortality, triage category, emergency department length of stay, admission rate, hospital length of stay, intensive care admissions and revisitation rate and compared outcomes to patients presenting with specific complaints (SC), where data was available. We grouped discharge diagnoses by ICD-10 categories.

Results We found that patients presenting with NSC were mostly older adults. Mortality for patients with NSC was significantly increased compared to patients presenting with SC [OR 4.22 (95% CI 1.39-12.88)]. They were triaged as urgent less often than SC patients [OR 2.10 (95% CI 1.06- 4.15)]. Emergency department length of stay was increased in two out of three studies. Hospital length of stay was increased by 1-3 days. Admission rates were high in most studies, 55 to 84%, and increased in comparison to patients with SC [OR 4.93(95% CI 1.97-12.31)]. These patients seemed to require more resources than patients with SC. There was no significant increase in intensive care admissions. Data was insufficient to make conclusions regarding revisitation rates. Discharge diagnoses were spread throughout ICD-10 main chapters, infections being the most prevalent.

Conclusions Patients with NSC have a high risk of mortality, their care in the Emergency Department is slower and requires more resources than for patients with SC. We suggest that NSC should be considered a major emergency presentation.

Dr Kemp KIRSI (Helsinki, FINLAND), Reija MERTANEN , Leila NIEMI-MUROLA, Lasse LEHTONEN, Maaret CASTREN
15:00 - 15:10 #18402 - OP087 A review of reviews of Emergency Department interventions for older people: outcomes, costs and implementation factors.
OP087 A review of reviews of Emergency Department interventions for older people: outcomes, costs and implementation factors.

Background

 

Internationally, emergency and urgent care of older people is a public health priority. The management of older people in the Emergency and Urgent Care system remains sub-optimal in the UK. Strategies are needed to manage older patients sensitively, effectively, and efficiently, understanding both their clinical and broader, holistic needs. It is important to consider the strategies and interventions that have been used in the emergency care of older people, and to evaluate the evidence as to their outcomes, costs, and implementation.

 

Methods

 

A number of reviews have previously taken place in this topic area, assessing diverse interventions with differing methods and variable outcomes. We developed and registered (PROSPERO, CRD42018111461) a protocol for a review of reviews. Database searches and complementary methods identified evidence from review articles and conference abstracts, which were screened according to pre-defined inclusion criteria relating to both subject and reporting standards. Data describing interventions for older people in Emergency Departments (ED) were extracted and summaries generated in tabular and narrative form. The quality and reporting of the reviews were assessed using AMSTAR2 and Joanna Briggs Institute tools. Due to the heterogeneity of interventions and outcomes, findings were analysed narratively. McCusker’s Elder-Friendly Emergency Department assessment tool was used as a framework to classify ED interventions.

 

Results

 

Eighteen review articles and three conference abstracts met our topic and reporting standard inclusion criteria. The majority were described as systematic reviews, with four of these using meta-analysis. Fourteen of the reviews reported interventions that were either initiated or wholly delivered within the ED. The remaining four reviews reported non-interventional studies focussed predominantly on quality indicators or patient preferences.

 

Confidence in (US-dominated) research was limited to each review’s interpretation of primary studies. Descriptions of interventions were inconsistent, and there was high variability in the standards to which reviews were conducted and reported. Interventions mostly focussed on screening and assessment, discharge planning, referrals and follow-up, and multi-disciplinary team composition and professional activities. In total, 26 patient and health service outcomes were reported, including admissions and readmissions, length of stay, mortality, functional decline, and quality of life.

 

Discussion

 

Our review of reviews demonstrated that the current, extensive evidence base of primary and review studies is lacking in complexity, with limited or no evidence for the effectiveness of ED interventions; a common feature of the reviews was a call for more primary research using rigorous evaluation methods. There is little evidence in review studies for factors that influence the implementation of interventions.

 

There was evidence that among interventions initiated in the ED, those which were continued into the community yielded better outcomes. Service metrics (as valued by care commissioners) were evaluated as outcomes of interventions more frequently than person-centred attributes (as valued by older people). The interventions were broadly holistic in nature, consistent with international literature supporting Comprehensive Geriatric Assessment to improve outcomes for older people with acute care needs.

Dr James VAN OPPEN (Leicester, UK), Louise PRESTON, Suzanne ABLARD, Helen BUCKLEY WOODS, Suzanne MASON, Simon CONROY
15:10 - 15:20 #19352 - OP088 Initial findings and feasibility of in-situ qualitative interviews exploring older adults’ experiences of emergency department care.
OP088 Initial findings and feasibility of in-situ qualitative interviews exploring older adults’ experiences of emergency department care.

Background

Optimisation of care for older adults who present to emergency departments, is an area of increasing interest and a top-ranking priority in a recent research priority setting exercise, led by the UK Royal College of Emergency Medicine and the James Lind Alliance.  

Questionnaires that enable patients to report the quality of their healthcare experience are known as Patient Reported Experience Measures (PREMs).  Each year millions of patients attend Emergency Departments (EDs), however no sufficiently reliable or validated PREM has yet been developed for use in this context. The Patient Reported Experience Measure for Adults aged over 65 years (PREM-ED 65+), is intended to be a validated and reliable PREM for use amongst older adults attending the ED. However, in order to generate items for the PREM, determinants of experience for older adults attending the ED need to be captured.

This study aims to describe the experiences of adults, aged 65 years or over, who attend the ED, focusing specifically on the feasibility and challenges of administering qualitative interviews in this clinical context (ED).

Methods

The study was conducted in a single large UK ED (100,000 attendances/year). English speaking patients aged 65 years or older, who consented to participate, were recruited between December 2018 and April 2019.  Sampling was purposive based on age, gender, presentation type and frailty score. Semi- structured interviews were conducted within the ED before discharge or inpatient disposition. Interviews were audio recorded and a standard question guide used. Ethics approval was obtained from the UK NHS Health Research Authority (18/LO/1194).

A ‘needs based’ conceptual model for patient experience, developed from a prior meta-synthesis of qualitative literature, informed our analysis, building on the descriptive themes which are ‘communication needs’, ‘emotional needs’, ‘physical/ environmental needs’, and ‘care needs’. Our intention is to triangulate new or emerging themes with the views of staff members, to inform PREM-ED 65+.

Results:

In total, 24 patient interviews were conducted. The average age of participants was 75 years (range 65—89years), 15/25 (60%) were female, and all lived in their own home prior to attending the ED.  The average clinical frailty scale score was 3/9 (Range 1—6).  A total of 10 hours of data was obtained during interviews which averaged 25mins in length (range 9min—51min).

Discussion & Conclusions

Initial findings from the thematic analysis will be presented. This will include key themes related to older adults’ experiences of ED care and suggested items for inclusion within a new PREM, aimed at older adults attending the ED. 

We conclude that ‘in-situ’ qualitative interviews are feasible within the Emergency Department, potentially being less affected by recall bias than retrospective interviewing. However, conducting qualitative research within emergency departments which are crowded, with high levels of ambient noise and with frequent interruptions, are key limitations to the recruitment of frail older adults into qualitative research.

Blair GRAHAM (Plymouth, UK), Jason E SMITH, Ruth ENDACOTT, Rosalyn SQUIRE, Pamela NELMES, Jos M LATOUR
15:20 - 15:30 #18161 - OP089 Prevalence and severity of traumatic intracranial hemorrhage in older patients with low-energy falls – a retrospective study.
OP089 Prevalence and severity of traumatic intracranial hemorrhage in older patients with low-energy falls – a retrospective study.

Background

Low-energy falls (LEF) in the older patient are a common reason for presentation to an emergency department (ED). Head injuries, including traumatic intracranial hemorrhage (tICH) are among the common fall related injuries in this population. Current clinical decision rules consider anticoagulation (AC) or antiplatelet (AP) therapy as potential risk factor for a tICH. The objective of the study was to analyze the prevalence and severity of tICH and the association to AC/AP therapy in a large cohort of older patients with LEF presenting without trauma-team activation.

Methods

We performed a bicentric retrospective study on patients of 65 years and older presenting to the ED with a LEF between 01 January 2016 and 31 December 2016. Patients presenting to one of the two tertiary care centers (Emergency Departments of the University Hospital Basel and the University Hospital Munich) who obtained cranial computed tomography (cCT) examinations were included. Primary data were retrieved from radiology databases, detailed chart review abstractions were conducted by two independent observers to obtain information about medication, clinical signs of head injury and final diagnosis in both study centers. The prevalence and severity of tICH of patients with and without AC/AP therapy were compared. Multivariate regression models were used to measure the association between AC/AP therapy and the risk for tICH after adjustment for known predictors.

Results

Overall 2567 patients met inclusion criteria, of these 1424 (55%) had an AC/AP therapy. Prevalence for a tICH detected by cCT was 176/2567 (6.9%). Multivariate regression models showed no differences for the risk of a tICH (OR: 1.05, 95% CI: 0.76–1.47, p = 0.76) or association with head specific injury severity (IRR: 1.08, 95% CI: 0.97–1.19, p = 0.15) in patients with or without AC/AP therapy. CT-detected skull fracture and injury signs above clavicle were the strongest predictors for tICH (OR: 4.28, 95% CI: 2.79- 6.51 respectively OR: 1.88, 95% CI: 1.3–2.73).

Discussion and Conclusion

In this retrospective bicentric cohort analysis we found an overall prevalence of 6.9% for tICH in older patients with LEF and ED presentation without trauma-team activation. Therapy with AP/AC agents resulted in a prevalence of 7.2%, compared to 6.8% in patients without AP/AC therapy. Multivariate analysis revealed that neither AC, nor AP therapy or the combined treatment with AC and AP were risk factors for tICH in older patients with LEF. Injury signs above the clavicle were the strongest clinical predictor for a tICH and should therefore be considered to trigger imaging of the head in older patients with LEF, independently of AC or AP medication history.

The study was planned using STROBE guidelines, in accordance with the declaration of Helsinki, approved by local ethic committees (EKNZ 2017-01078, EK LMU 17-217).

Alina LAMPART, Tobias KUSTER, Isabelle ARNOLD, Nina MAEDER, Sandra NIEDERMEIER, Christian NICKEL, Roland BINGISSER, Dr Vera PEDERSEN (Munich, GERMANY)
15:30 - 15:40 #18976 - OP090 A Retrospective Chart Analysis of Early Postpartum Complications Resulting in Visits to the Emergency Department.
OP090 A Retrospective Chart Analysis of Early Postpartum Complications Resulting in Visits to the Emergency Department.

Background: With increasing fiscal restraints and the need for efficient delivery models, women are being discharged sooner postpartum. As a consequence, complications that would easily be dealt with are now being captured later. These patients present to the Emergency Department (ED) to access quicker care to manage these complications. The purpose of this study was to review the reasons that postpartum women present to the ED in the short term (≤10 days post delivery).

Methods: This was a retrospective study based out of a large community hospital, which has the highest birth rate in the province of Ontario, Canada. Research ethics approval was obtained. Women who delivered at William Osler Health Services (WOHS) between January 1, 2018 and December 31, 2018 and who presented to the ED within 10 days of delivery. Patient demographics, obstetrical parameters, type of delivery, time of ED visit, and management were all extracted. The primary outcome is the rate of and reasons for postpartum visits to the emergency department. The secondary outcome is to identify maternal characteristics that are associated with postpartum visits to the emergency department. Descriptive statistics were used to summarize the findings.

Results/Findings: In 2018, there were approximately 8000 deliveries across WOHS. There were 429 unique postpartum ED visits between January 1 and December 31, 2018, of which 382 were included in the analysis. The mean age was 31.21 years (range 19.00 to 43.00, SD 4.83). The mean gravidity was 2.28, and the median gestational age at delivery was 39.14 weeks (range 20.00 to 41.43, SD 2.29). Most of the patients delivered via spontaneous vaginal delivery (52.36%), and the rate of operative vaginal delivery and caesarean section was 7.85% and 39.79% respectively. Group B Streptococcus status was positive in 17.80% of all patients. The median time of presentation to the ED was 5.00 days (IQR 4.00 to 8.00, SD 2.51). The most common reasons for presentation were abdominal pain (17.02%), wound issue (13.09%), and fever or vaginal/rectal pain (9.95%). Only a quarter of cases required an obstetrical consultation, and 85.86% of all visits were discharged home. The rate of admission and transfer to another centre is 12.04% and 2.09% respectively.

Conclusion: This study was the first in a busy community setting that looked at return ED visits in the short-term postpartum period. Educating patients on pain management and wound care can potentially decrease the rate of ED visits by this patient population given the high incidence of patients presenting with this problem. Further studies are needed to review the role of patient education, home care, and the need for early obstetrical follow up to reduce ED visits.

Dr Prabhpreet HUNDAL (Brampton, CANADA), Cassandra QUAN, Shayan ASSAIE, Leila SALEHI, Prashant PHALPHER, Maher ABOU-SEIDO, Rahim VALANI
TERRACE 2B
15:40 COFFEE BREAK AND EXHIBITION - E-POSTER SESSION
16:10

Tuesday 15 October

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A34
16:10 - 17:40

Geriatric emergencies
Providing better care for older ED patients
Geriatric, HOT TOPIC SPEAKER!

Moderators: Dr Don MELADY (Associate Professor/Staff Physician) (Toronto, CANADA), Pr Christian NICKEL (Vice Chair ED Basel) (Basel, SWITZERLAND)
16:10 - 17:40 Geriatric principles in the care of the older ED patient. Simon. P. MOOIJAART (Internist-geriatrician) (LEIDEN, THE NETHERLANDS)
16:10 - 17:40 HOT TOPIC !!! How to create a geriatric ED. Dr Don MELADY (Associate Professor/Staff Physician) (Toronto, CANADA)
16:10 - 17:40 Older people in the ED: Usual care vs. Optimal care. Pr Suzanne MASON (Professor of Emergency Medicine) (Sheffield, UK)
CONGRESS HALL

Tuesday 15 October

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B34
16:10 - 17:40

Disaster medicine
Hospital safety
Disaster medicine, Mass casualty, Violence

Moderators: Sofie PAUWELS (Consultant) (BRUSSEL, BELGIUM), Evert VERHOEVEN (consultant) (Etterbeek, FRANCE)
16:10 - 17:40 Cybersecurity. Dr Jeffrey FRANC (Clinical Professor) (Edmonton, CANADA)
16:10 - 17:40 Recovery of hospital functions after mass casualty incident. Pr Pinchas HALPERN (department chair) (Tel Aviv, Israel, ISRAEL)
16:10 - 17:40 Violence towards personnel. Eric REVUE (Praticien Hospitalier Adjoint Chef de Service) (Paris, FRANCE)
FORUM HALL

Tuesday 15 October

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C34
16:10 - 17:40

Breaking the waves
What is the future of emergency ultrasound?

Moderators: Dr Laila HUSSEIN (Specialist Emergency Medicine) (AbuDhabi, UNITED ARAB EMIRATES), Senad TABAKOVIC (Zürich, SWITZERLAND)
16:10 - 17:40 AI in POCUS - Artificial Intelligence or Actually Incompetent? Dr Chris YAP (Consultant) (Sheffield, UK)
16:10 - 17:40 How to use CEUS in the emergency department. Beatrice HOFFMANN (USA)
16:10 - 17:40 US simulation - from high to low cost. Nils Petter OVELAND (NORWAY)
SOUTH HALL 3AB

Tuesday 15 October

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D34
16:10 - 17:40

YEMD - Innovation in EM - check this out!
From the cutting edge directly to you!
Fringe, Innovation, Young Emergency Medecine

Moderators: Dr Dinka LULIC (Resident in Emergency Medicine) (Zagreb, CROATIA), Dr Pieter Jan VAN ASBROECK (Consultant in Emergency Medicine) (Genk, BELGIUM)
16:10 - 17:40 Alternatives to aBGA - better, faster...? Stefano MALINVERNI (Emergency Consultant) (BRUSSELS, BELGIUM)
16:10 - 17:40 High flow nasal oxygen! Bojana RADULOVIC (Emergency medicine specialist) (Zagreb, CROATIA)
16:10 - 17:40 Follow me into the twittersphere. Dr Dinka LULIC (Resident in Emergency Medicine) (Zagreb, CROATIA)
16:10 - 17:40 Squeeze the aorta where it hurts. Dr Kasia HAMPTON (Emergency Department Medical Director) (USA/Poland, USA)
SOUTH HALL 3C

Tuesday 15 October

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E34
16:10 - 17:40

NURSES
Emerging topics in emergency nursing
Nurses

Moderators: Thorsteinn JONSSON (RN, MS) (Reykjavik, ICELAND), Emmanuel ROHRBACHER (INFIRMIER) (MONCONTOUR DE BRETAGNE, FRANCE)
16:10 - 17:40 Operations research & simulation: a case study. Dr Kris BRAEKERS (Assistant Professor) (Hasselt, BELGIUM)
16:10 - 17:40 Pediatric sedation by nurses in the ED. Koen VANHONSEBROUCK (Nurse Specialist) (Leuven, BELGIUM)
16:10 - 17:40 Preventing Occupational Exposure to Health Care Workers in the ED. Eftychia POLYZOGOPOULOU (ED DIRECTOR) (ATHENS, GREECE), Saskia VAN KEMSEKE (PharmD) (Brussels, BELGIUM)
CHAMBER HALL

Tuesday 15 October

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F34
16:10 - 17:40

ABSTRACTS SESSION

Moderators: Pr Abdelouahab BELLOU (Research) (Boston, USA), Dr Steven VAN DEN BROUCKE (Internal Medicine) (Kortrijk-Dutsel, BELGIUM)
16:20 - 16:30 #18105 - OP092 Tetanus prophylaxis: are we doing it right? About vaccines.
OP092 Tetanus prophylaxis: are we doing it right? About vaccines.

Background: Patients presenting to the Emergency Department (ED) with wounds prone to tetanus infection, are administered prophylaxis according to specific guidelines, which are based on the immune status of the patient. In some Hospitals, the immune status of the patient can be known through the use of a Point of Care Testing (POCT), the Tetanos Quick Stick (TQS). However, several studies demonstrated that tetanus prophylaxis guidelines were correctly followed only in a minority of the EDs.

 

Methods: This study takes into account the data of 4248 patients who referred to the ED of the Brugmann University Hospital between January 2017 and December 2018, with wounds potentially at risk for tetanus infection. 

Results: In the 12 months of 2017, 2800 patients presented with wound