Saturday 12 October
08:00

Saturday 12 October

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PC07
08:00 - 18:00

Emergency Medicine Core Competences
Saturday October 12th: 08:00-18:00 & Sunday October 13th: 08:00-12:00

Pre-Course Directors: Eric DRYVER (Consultant) (Lund, Sweden), Gregor PROSEN (EM Consultant) (MARIBOR, Slovenia)
Speakers: Veronique BRABERS (Emergency Physician) (Mol, Belgium), Brian DE LANGE (Resident) (Utrecht, The Netherlands), Dr Adam GROVES (Doctor) (Edinburgh, United Kingdom), Caroline HÅRD AF SEGERSTAD (Senior consultant) (Ystad, Sweden), Dr Harri PIKKARAINEN (Chief Physician) (Lahti, Finland), Nikolas SBYRAKIS (Specialty doctor) (Brighton, United Kingdom)

CLUB B

Saturday 12 October

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PC06
08:00 - 18:00

SafeER PSA - Procedural sedation and analgesia for Emergency
Saturday October 12th: 08:00-18:00

Pre-Course Director: Christian HERINGHAUS (Emergency Physician) (Leiden, The Netherlands)
Speakers: Linda BEL (Emergency physician) (Netherlands, The Netherlands), Yannick GROUTARS (Den Haag, The Netherlands), Harald HENNIG (Emergency Physician) (Neumarkt i.d.OPf., Germany), Dr Ruth SNEEP (Senior Research & Clinical Fellow) (London, United Kingdom), Rebekka VEUGELERS (Emergency Physician) (Goes, The Netherlands), Egon ZWETS (Emergency Physician) (Rhoon, The Netherlands)

CLUB H
08:30

Saturday 12 October

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PC09
08:30 - 17:30

Advanced Paediatric Emergency Care (APEC)
Saturday October 12th: 08:30-17:30 & Sunday October 13th: 09:00-12:30

Pre-Course Director: Said HACHIMI IDRISSI (head clinic) (Ghent, Belgium)
Speakers: Dr Rodrick BABAKHANLOU (M.D. M.Sc.) (Edinburgh), Dr Thomas BEATTIE (Senior lecturer) (Edinburgh), Javier BENITO FERNANDEZ (DIRECTOR) (BILBAO, Spain), Naveen POONAI (Physician) (London, Canada), Dr Roberto VELASCO (Pediatrician) (Laguna de Duero, Spain), Pr Yehezkel WAISMAN (Director, Dept. of Emergency Medicine) (Petach-Tikva, Israel), David WALKER (Speaker) (New York, NY, USA)

CLUB D

Saturday 12 October

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PC03
08:30 - 18:00

EUSEM leadership course in cooperation with IEDLI and RCEM
Saturday October 12th: 08:30-18:00

Speakers: Raed ARAFAT (Romania), Luis GARCIA-CASTRILLO (ED director) (Oruna, Spain), Dr John HEYWORTH (Consultant) (Southampton, United Kingdom), Dr Ian HIGGINSON (Emergency Physician) (Plymouth, United Kingdom), Luis LOBON (IEDLI Course Director) (Boston, USA), Robert LEACH (Head of Dept.) (BRUXELLES, Belgium), Riccardo LETO (Chief of ED) (Overpelt, Belgium), Roberta PETRINO (Head of department) (Italie, Italy)

SOUTH HALL 3AB
09:00

Saturday 12 October

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PC05
09:00 - 17:00

Ultrasound Beginner & Advanced
Saturday October 12th: 09:00-17:00 & Sunday October 13th: 08:15-12:30

Animators: Andrew FRIED (Portland, USA), Kavita GHANDI, Dr Kasia HAMPTON (Emergency Department Medical Director) (USA/Poland, USA), Beatrice HOFFMANN (Boston, USA), Dr Laila HUSSEIN (Specialist Emergency Medicine) (AbuDhabi, United Arab Emirates), Dr Nicolas LIM (Intensive Care Fellow) (Dublin, Ireland), David MACKENZIE (Director of Emergency Ultrasound) (Portland, USA), Pr Joseph OSTERWALDER (Head of Hospital) (St. Gallen, Switzerland), Arthur ROSENDAAL (Emergency Physician) (Rotterdam, The Netherlands), Tomas VILLEN (Attending Physician) (Madrid, Spain), Peter WEIMERSHEIMER, Dr Chris YAP (Consultant) (Sheffield, United Kingdom)
Pre-Course Directors: James CONNOLLY (Consultant) (Newcastle-Upon-Tyne, United Kingdom), Michael LAMBERT (Burr Ridge, USA), Dr Joseph WOOD (Ultrasound instructor) (Phoenix, Arizona, USA)
Speakers: Zeki ATESLI (BRIGHTON, United Kingdom), Mohit ARORA (Consultant Emergency Medicine) (Leeds, United Kingdom), Eric CHIN (Residency Program Director) (San Antonio, USA), Peter CROFT (Serratus Anterior Plane Block) (North Yarmouth, USA), Rip GANGAHAR (Consultant) (Oldham, United Kingdom), Hani HARIRI (Besançon, France), Najib NASRALLAH (PHYSICIAN) (SHEFAMER, Israel), Farooq PASHA (CONSULTANT EMERGENCY) (RIYADH, Saudi Arabia), Eftychia POLYZOGOPOULOU (ASSISTANT PROFESSOR OF EMERGENCY MEDICINE) (ATHENS, Greece), Ruhina SAJID (Emergency Medicine Specialist) (Dubai, United Arab Emirates)

CHAMBER HALL

Saturday 12 October

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PC08
09:00 - 17:00

Young Investigators pre-course on Research
Saturday October 12th: 09:00-17:00

Pre-Course Director: Said LARIBI (PU-PH, chef de service) (Tours, France)
Speakers: Zerrin-Defne DUNDAR (ASSOCIATE PROFESSOR) (Konya, Turkey), Luis GARCIA-CASTRILLO (ED director) (Oruna, Spain), Mehmet Akif KARAMERCAN (Chair of EuSEM Research Committee) (ANKARA, Turkey), Pr Martin MOECKEL (Head of Department, Professor) (Berlin, Germany), Pr Anna SLAGMAN (Senior Research Associate) (Berlin, Germany)

CLUB C

Saturday 12 October

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PC10
09:00 - 17:00

Non-Invasive Ventilation
Saturday October 12th: 09:00-17:00

Pre-Course Director: Roberto COSENTINI (Head of Emergency Medicine) (BERGAMO, Italy)
Speakers: Dr Rodolfo FERRARI (MD) (Bologna, Italy), Paolo GROFF (Director) (Perugia, Italy), Dr Abdo KHOURY (Senior attending Physician) (Besançon, France), Roberta MARINO (Chief of Borgosesia Hospital ED) (Vercelli, Italy), Patrick PLAISANCE (Head of Department) (Paris, France)

CLUB E

Saturday 12 October

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PC01
09:00 - 17:30

Simulation Master : Train the Trainers Precourse
Saturday October 12th: 09:00-17:30

Pre-Course Directors: Pier Luigi INGRASSIA (Novara, Italy), Anne-Laure PHILIPPON (Médecin) (Paris, France)
Speakers: Guillem BOUILLEAU (Responsable Urgences - SHCD) (Chinon, France), Dr Abdo KHOURY (Senior attending Physician) (Besançon, France), Felix LORANG (Consultant) (Jena, Germany), Mohammed MOUHAOUI (Professeur) (CASABLANCA, Morocco), Youri YORDANOV (Médecin) (Paris, France)

NORTH HALL

Saturday 12 October

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PC04
09:00 - 18:00

Disaster Medicine
Saturday October 12th: 9:00 - 18:00 & Sunday October 13th: 8:30-13:00

Animators: Lien MESTDAGH (PHYSICIAN) (DENDERMONDE, Belgium), Philippe NOYNAERT (nurse) (DENDERMONDE, Belgium), Frederic VANEESBECK (Technician), Sabien VLEESCHOUWERS (trainee) (Brussel, Belgium)
Speakers: Dr Mick MOLLOY (Consultant in Emergency Medicine) (WEXFORD, Ireland), Sofie PAUWELS (Consultant) (BRUSSEL, Belgium), Saskia VAN KEMSEKE (MPharm) (Brussels, Belgium)

09:00 - 18:00 Mass Casualty Incident Response Plan: Riceland Simulation Exercise. Massimo AZZARETTO (Associate Researcher) (Novara, Italy), Luca RAGAZZONI (Scientific Coordinator) (Novara, Italy), Pr Francesco DELLA CORTE (Speaker) (Novara, Italy), Dr Jeffrey FRANC (Clinical Professor) (Edmonton, Canada), Dr Eric WEINSTEIN (Disaster Medicine Researcher) (Summerville SC, USA), Matteo PAGANINI (Research Fellow, Emergency Medicine Physician) (Padova, Italy), Evert VERHOEVEN (consultant) (Etterbeek, France)
SOUTH HALL 3C

Saturday 12 October

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PC02
09:00 - 18:00

Non-vital Trauma
Saturday October 12th: 09:00-18:00 & Sunday October 13th: 08:00-11:00

TERRACE 2B
Sunday 13 October
08:30

Sunday 13 October

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PC11
08:30 - 13:00

Geriatric Emergency Medicine
Sunday October 13th: 08:30-13:00

Pre-Course Directors: Jacinta A. LUCKE (Emergency Phycisian) (Haarlem, The Netherlands), Pr Christian NICKEL (Vice Chair ED Basel) (Basel, Switzerland)
Speakers: Laura BLOMAARD (MD, PhD-student) (Leiden, The Netherlands), Pr Simon CONROY (Prof.) (Leicester, United Kingdom), Rosa MCNAMARA (Consultant) (Dublin, Ireland), Dr Ruth SNEEP (Senior Research & Clinical Fellow) (London, United Kingdom), Dr Arjun THAUR (Consultant) (London, UK, United Kingdom), Bas DE GROOT (Amsterdam, The Netherlands), Dr James VAN OPPEN (Academic Clinical Fellow) (Leicester, United Kingdom)

CLUB C

Sunday 13 October

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PC12
08:30 - 12:30

Airway Management Precourse for inner-clinical Emergency Med
Sunday October 13th: 08:30-12:30

Pre-Course Directors: Christian HOHENSTEIN (PHYSICIAN) (Madgeburg, Germany), Eric REVUE (Chef de Service) (Paris, France)

CLUB E
09:00

Sunday 13 October

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G09
09:00 - 10:30

NATIONAL TRACK - Prehsopital care - Alone in the field
Přednemocniční péče - sám vojákem v poli
Pre Hospital

Moderators: Ondrej FRANEK (senior physician) (PRAHA, Czech Republic), Dr Anatolij TRUHLAR (Medical Director EMS) (Hradec Kralove, Czech Republic)
09:00 - 10:30 Specifika urgentní péče o pacienty s kardiovaskulárními implantáty. Roman SKULEC (Head of research and science department) (Kladno, Czech Republic)
09:00 - 10:30 Současné trendy v péči o závažné úrazy. Dr Anatolij TRUHLAR (Medical Director EMS) (Hradec Kralove, Czech Republic)
09:00 - 10:30 Moderní analgetika v přednemocniční neodkladné péči. Ondrej FRANEK (senior physician) (PRAHA, Czech Republic)
09:00 - 10:30 Máme se bát dětí nebo děti nás? Jana DJAKOW (Deputy Head) (Praha 5, Czech Republic)
PANORAMA HALL
10:30

Sunday 13 October

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G10
10:30 - 12:00

NATIONAL TRACK - Welcome at ED!
Vítejte na urgentním příjmu!
General EM

Moderators: Jaromír KOCI (Chair) (Hradec Kralove, Czech Republic), Vladislav KUTEJ (chief of department) (Olomouc, Czech Republic)
10:30 - 12:00 Zásady fungování urgentního příjmu ve 21. století. Jaromír KOCI (Chair) (Hradec Kralove, Czech Republic)
10:30 - 12:00 Umění triáže a její kouzla na urgentním příjmu. Jakub DEDEK (Registered nurse / EMT) (Hradec Kralove, Czech Republic)
10:30 - 12:00 Pacient přichází s bolestí břicha. Jana BERKOVA (physician) (Hradec Kralove, Czech Republic)
10:30 - 12:00 Tripple killer - pacient přichází s bolestí na hrudi. Tomáš VELETA (physician) (Hradec Králové, Czech Republic)
PANORAMA HALL
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 (United Kingdom)
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, United Kingdom), Simon CARLEY (Consultant in Emergency Medicine) (Manchester, United Kingdom)
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 (PUPH) (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)
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, United Kingdom)
13:00 - 14:30 Hemochezia. Cornelia HAERTEL (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 quatrième 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, United Kingdom)
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

Sunday 13 October

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G11
13:00 - 14:30

NATIONAL TRACK - Rare situations - really uncommon?
Mimořádné situace - opravdu mimořádné?
Disaster medicine

Moderators: Dr Petr JASSO (Chief of education) (Ostrava, Czech Republic), Jana KUBALOVA (Czech Republic)
13:00 - 14:30 Bariatrický pacient - fenomén doby. Tomas JEZEK (head of education and training center) (Hradec Králové, Czech Republic)
13:00 - 14:30 Mimořádné události v seniorském prostředí. Dr Petr JASSO (Chief of education) (Ostrava, Czech Republic)
13:00 - 14:30 Handicapovaní v roli zachránce a pacienta - umíme komunikovat? Jana KUBALOVA (Czech Republic)
13:00 - 14:30 Vliv infekčních nemocí na poskytování přednemocniční neodkladné péče. Aleš RYBKA (physician) (Hradec Kralove, Czech Republic)
PANORAMA HALL
14:30 COFFEE BREAK AND EXHIBITION - E-POSTER SESSION
14:35

Sunday 13 October

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EPOSTER 1.1
14:35 - 14:55

ePoster 1.1 - Short Oral Presentation - Screen 1

Moderator: Barbra BACKUS (Emergency Physician) (Leiden, The Netherlands)
14:40 - 14:45 #18325 - SP002 Diagnostic value of Coronary Artery Disease Consortium and updated Diamond–Forrester scores in predicting obstructive coronary artery disease among emergency department patients with chest pain.
SP002 Diagnostic value of Coronary Artery Disease Consortium and updated Diamond–Forrester scores in predicting obstructive coronary artery disease among emergency department patients with chest pain.

Objective Assessing the pretest probability of coronary artery disease (CAD) is crucial for patients with chest pain at an emergency department (ED). Current guidelines recommend the use of the updated Diamond–Forrester (DF) method and Coronary Artery Disease (CAD) Consortium models by the American College of Cardiology/Amercian Heart Association (ACC/AHA) and European Society of Cardiology (ESC), respectively. In the situation which methods or models have not been proved definitely superior over others for assessing it, we studied to compare the performance of these models among patients with chest pain presented in the ED.

Methods We compared three scores (DF, CAD consortium basic, and clinical) among 536 patients with chest pain who underwent coronary computed tomographic angiography (CTA). Invasive angiography was performed to confirm the stenosis shown on CTA, if clinically indicated. Primary outcome was the presence of obstructive CAD (≧50% stenosis).

Results Overall, 174 (32.5%) patients were diagnosed with obstructive CAD. CAD consortium clinical model underestimated the prevalence of CAD (26.1%), and on the other hand, DF model overestimated (53.1%). To predict obstructive CAD, the CAD consortium clinical model had superior area under the receiver-operating curve (0.754), followed by the CAD consortium basic (0.736), and finally, the DF model (0.718). Whereas the CAD consortium models more accurately classified patients without any CAD or nonobstructive CAD as low-risk patients, the DF model more accurately classified high-risk patients with obstructive CAD. The net reclassification improvement of CAD consortium basic and clinical models were 15.3% and 18.0%, respectively.

Conclusion Compared with the DF model, the CAD consortium clinical model appears to be superior for the prediction of low-risk patients with <15% probability of having obstructive CAD. However, this model needs caution when using in high-risk population.

Yosep SHIN (SEOUL, Korea, Republic of), Ahn SHIN, Un Woo LEE
14:45 - 14:50 #18822 - SP003 Multilevel Prediction model of acute myocardial infarction in chest pain patients of emergency department.
SP003 Multilevel Prediction model of acute myocardial infarction in chest pain patients of emergency department.

Background

Prediction models have been developed for acute myocardial infarction (AMI) among chest pain patients in the emergency department (ED). But usually, they included many variables or high-sensitive cardiac biomarkers which make them less optimal for generalization. We developed 3-level (prehospital, ED triage, ED doctor’s initial exam) prediction model that could be used in many emergency medical systems.

Methods

Multivariable logistic regression model (LR) and gradient boosting model (GBM) were developed on data from 8,673 ED visit for chest pain. Only variables which would be available shortly after patient presentation were used. 3-level modeling have been done and variables obtained in each level were chosen. Electrocardiogram (ECG) and high-sensitive cardiac biomarker were excluded for their fundamental diagnostic value. We evaluated performance by area under receiver operating characteristic curve (AUROC). Developed models were validated on validation data of 1,767 ED visit.

Results

About 8,673 subjects, patients diagnosed as AMI in ED were 866. AMI patients more likely to be older male, show higher triage severity, use emergency medical service and present typical chest pain. Variables chosen for 3-level were as follows: age, sex, time from symptom onset, mental status, ambulance use in prehospital level, triage result, shock state, tachycardia or bradycardia in ED triage level and atypical presentation of chest pain, hemoglobin, glutamic oxaloacetic transaminase (AST), glutamic-pyruvic transaminase (ALT), abnormal chest radiograph result for ED doctor’s initial exam level. We calculated AUROC of LR/GBM model: 0.697/0.703 in prehospital, 0.731/0.732 in ED triage and 0.773/0.787 in ED doctor’s initial exam level.

In validation data of 1,767 patients, AMI patients were 222. We applied same prediction model developed in test data and AUROC were as follows: 0.695/0.704 in prehospital, 0.724/0.725 in ED triage and 0.784/0.788 in ED doctor’s initial exam level.

Discussion & Conclusions
We developed multi-level prediction model of AMI for chest pain patient who visit ED. GBM models showed slightly better performance in both data.

Dr Kihong KIM (Seoul, Korea, Republic of), Jeong Ho PARK, Young Sun RHO

Sunday 13 October

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EPOSTER 1.2
14:35 - 14:55

ePoster 1.2 - Short Oral Presentation - Screen 2

Moderator: Jochen BERGS (Hasselt, Belgium)
14:35 - 14:55 #18338 - SP005 The “Stroke Code” model in a low-resources first-level Emergency Department.
SP005 The “Stroke Code” model in a low-resources first-level Emergency Department.

Background: Systemic thrombolysis (STL) protocols are currently used in stroke centres around the world to reduce the treatment delay. These models were designed and most applied in tertiary hospitals with wide availability of neurology physicians and a dedicated stroke team. We brought  the American Heart Association/American Stroke Association (AHA/ASA) “Target: Stroke” initiative guidelines in a first-level Emergency Department (ED), where acute stroke patients are entirely managed by Emergency Physicians (EPs) with only radiology specialists consultants.

 

Methods: In 2018 a “Stroke Code” model was implemented in the ED of the Santa Maria Nuova first-level Hospital in Florence, including key components of the Helsinki model such as EP, radiologyst and laboratory technicians allert since ambulance transport, rapid Triage protocol, rapid EP evaluation, creation of a “stroke bag” with every stroke tool in use, early tissue plasminogen activator (Alteplase, tPA) preparation and infusion in the contrast tomography (CT) area, and prompt data feedback. A phone-alert protocol was established with our Territoral Emergency Service (TES): the EP of the TES operative base remotely identify the stroke codes from the ambulance team information and alert the ED. ER nurse apply a dedicate Triage protocol, characerized by the fast confirmation of ongoing deficit and acute (<4.5h) onset and immediate transfert in the emergency room (ER). EPs collect essential anamnestic and clinical data to identify indications and controindications to STL, while the ER nurses obtain at least one large-bore peripheric venous access, blood test samples  and check vital parameters before going to the CT-area. After the non contrast head CT-scan the radiology consultant give immediately a temporary answer reporting only the presence or absence of intracranial bleedings and/or radiologic STL contraindications, in order to allow the EP to start STL. After tPA bolus the patients undergo a contrast CT-scan. The 1-hour tPA infusion is beginned back in the ER. When a large-vessel obstruction is detected, a neuroradiological consultation is performed, and if indicated the patient is trasfered to local stroke hub centre for local treatment. Everyone involved in the stroke-code pathway had a specific 2-hour theorical training, implemented with one high-fidelity in-site simulation. Door-to-needle time (DTN) is registered, and all stroke patients data are collected in a dedicated registry to identify and correct specific delays and monitor activity.

Results: Before the stroke-model application the DTN [mean±standard deviation, (interquartile range)] was 76±33 (56-99) minutes. In the first year of stroke code model implementation the DTN was significantly lower 38±26 (20-50) minutes, p<0.001. Patient who received STL were more likely to experience a complete neurological recovery (59% treated vs 41% non-treated, p=0.002). Three (6%) patient had haemorragic complications, all of them had an acute stroke final diagnosis, and no one had permanent sequaele (mRs 0, 0 and 1, respectively).

Conclusion: The stroke-code model can be successfully applied after a brief training period  in a low-resources first-level ED in order to reduce DTN for acute ischaemic stroke treatment. In our experience the stroke-model performing was associated with a better functional outcome without any clinically relevant harm.

Dr Simone BIANCHI (Firenze, Italy), Francesco PROSPERI IOVI, Alessandra GIUELLO, Gabriele BANDINELLI, Federico LISI, Chiara ALAMANNI, Michele LANIGRA, Rita MARINO, Angela KONZE, Roberto CARPI, Vieri VANNUCCHI, Fererico MORONI, Giancarlo LANDINI
14:35 - 14:55 #18341 - SP006 Is LP useful in suspected SAH?
SP006 Is LP useful in suspected SAH?

Utility of lumbar puncture (LP) after a normal brain computed tomography (CT) scan in patients presenting to the emergency department with suspected Subarachnoid Haemorrhage: a retrospective cohort study

Background:


The diagnostic approach for patients presenting to EDs with severe, sudden-onset headache suspected for SAH remains challenging. 

Modern third generation computed tomography is shown to be extremely

sensitive in identifying subarachnoid haemorrhage when it is carried out

within six hours of headache onset and interpreted by a qualified radiologist, therefore may eliminate the need for lumbar puncture. However, some clinicians still perform LP even after a normal CTB even within this time frame, which is an invasive, time consuming procedures with known complications (i.e. post LP headache, Infection and bleeding at the site, Transient or permanent Neurological complications etc). 

 

 



Objective: To assess the utility of LP in emergency patients being evaluated for

possible subarachnoid haemorrhage after a negative non-contrast brain CT scan

 

 

Method:
We conducted a retrospective data analysis in three emergency departments in Monash Health in Victoria, Australia, focussing on patients presenting with concerning headache and being evaluated for possible subarachnoid haemorrhage between June 2013 and June 2018. Patients were excluded if they had a history of recurrent headaches or were discharged without further investigations. A diagnosis of Subarachnoid haemorrhage was defined by any of subarachnoid blood on computed tomography, xanthochromia in cerebrospinal fluid, or any red blood cells in final tube of cerebrospinal fluid collected with positive results on cerebral angiography.

 

Results: 
Of 5746 enrolled eligible cases, 2039 (35.5%) were further investigated with a CT brain based on history and examination. 397 patients (19.5%) were diagnosed with SAH after CT, while 1642 (80.5%) had a negative CT scan. Of this remaining cohort, 388 (23.5%) patients underwent LP, and neither of them demonstrated a true positive SAH.

 
The 1254 patients with a negative CT scan whom did not undergo a lumbar puncture were followed up for 6 months by hospital and community record review. In this cohort of patients, 401 cases were lost to follow-up owing to a lack of available data. Of those followed-up, 1 patient died from haemorrhage stroke during his third hospitalisation.

 

Conclusion:

 

LP is not required in all patients with suspected subarachnoid haemorrhage with a negative CT scan and it should be decided on a case by case basis. Further analysis is to determine if there are defining characteristics that eliminate the need for LP which can result in unnecessary risks and complications, with minimal benefit in diagnosing SAH.

 

Dr Pourya POURYAHYA (Melbourne, Australia), Alastair MEYER, Easaw-Mamutil NAOMI, Yan TAN, Hui (Glen) TENG
14:35 - 14:55 #18911 - SP007 A retrospective cohort study analyzing whether the ottawa ankle rules are correctly applied in the emergency department of a university hospital.
SP007 A retrospective cohort study analyzing whether the ottawa ankle rules are correctly applied in the emergency department of a university hospital.

ABSTRACT

Purpose

The Ottawa Ankle Rules (OAR) were developed in 1992 in order to develop decision rules for the use of radiography in the emergency department (ED) and reduce unnecessary imaging. The purpose of this study is to evaluate how these OAR were applied in the ED of a university hospital between the 1st of July and the end of December of the year 2016. It examines how the OAR application in the ED has evolved compared to a similar study with data from 2015. The previous study led to changes in protocol as well as the implementation of training to improve the application of the OAR in triage. This study evaluates the success of these changes and trainings as well as whether predictive factors can be identified that drive the application of the OAR in the ED.

Method

In a retrospective cohort study, a sample of patient records aged between 6 and 98 years old with ankle trauma were analyzed, using descriptive statistics, for the application of the OAR at triage and for use of imaging. Logistic regression was used to identify predictive factors.

Results

The OAR were applied at triage in 90% of the cases. This is up from the 60% established by a previous, similar study a year before. However, imaging was still taken in 60% of cases where the OAR were negative. The study could identify some statistically significant predictive factors, but their predictive power is low as they explain 10% of the variation in the data of the OAR application.

Conclusion

The application of the OAR at triage has achieved a high level in this university hospital. The progress from 60% in 2015 to 90% now can be attributed to the training of medical staff in OAR application. The high percentage of imaging taken in OAR negative cases remains an area for further research to identify root causes.

Pauline SCHAUMANS (Jette, Belgium), Carol CLINCKAERT, Ives HUBLOUE
14:35 - 14:55 #18954 - SP008 Screening for pulmonary embolism in patients with chest pain in the emergency department: a retrospective multicenter study.
SP008 Screening for pulmonary embolism in patients with chest pain in the emergency department: a retrospective multicenter study.

Introduction Chest pain is a common chief complaint in the emergency department. Among its associated differential diagnoses, pulmonary embolism (PE) remains a key concern for the clinician. There are no clear recommendations on which patients should undergo a formal work-up for PE diagnosis. The purpose of our study was to determine the percentage of chest pain patients who are investigated for PE diagnosis and to determine the clinical profile of these patients. 

Methods We performed a retrospective multicenter study in 3 French Emergency Departments. We included all patients who visited these centers for a chest pain during a two month period. Patients were excluded if they were already treated for, or diagnosed with a thrombo-embolic event at the time of ED presentation. The primary outcome was the initiation of PE workup. This was defined by any evidence or mention in the chart of this diagnosis and reason for its rule-out or confirmation, namely order of D-dimers, CTPA, V/Q scan or lower limbs venous Doppler ultrasound. We also aimed to find factors associated to this outcome. 

Results We included 881 patients with a chief complaint of chest pain. Mean age was 49 years and 481 (56%) were men. A total of 263 patients (30%, 95% confidence interval 27% to 33%) underwent a formal PE workup, 235 (89%) of them had a D-dimer testing and 50 underwent a CTPA. Four patients had a lower limb venous doppler, and PE was explicitly ruled out on the basis of a PERC score of zero in 22 (8%) patients. PE was ultimately diagnosed in 7 cases (prevalence of 2.6%, 95% confidence interval 1.1% to 5.3%). In the multivariate logistic regression model, five factors were identified as independently associated with a workup for PE diagnosis: female gender, young age, no ischemic heart disease, recent flight, and associated dyspnea. 

Conclusion Among patients visiting the emergency department with a chest pain, 30% underwent work up for PE. We report five clinical variables independently associated with a higher probability of PE workup in our sample.

Antoine LEFEVRE-SCELLES, Dr Melanie ROUSSEL (Rouen), Paul JEANMAIRE, Anne-Laure PHILIPPON, Luc-Marie JOLY, Yonathan FREUND

Sunday 13 October

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EPOSTER 1.3
14:35 - 14:55

ePoster 1.3 - Short Oral Presentation - Screen 3

Moderator: Youri YORDANOV (Médecin) (Paris, France)
14:35 - 14:40 #18297 - SP009 Comparing of CPR related trauma: mechanical chest devices vs. manual CPR.
SP009 Comparing of CPR related trauma: mechanical chest devices vs. manual CPR.

Introduction:

Resuscitation (CPR) with mechanical chest devices are not recomanded for routine CPR according to randomised trials. One of possible explanation could be CPR related trauma caused with mechanical chest devices. Current data are based on subanalysis from randomised trial, but autopsies are limitated by law and autopsy results are not objectivised.

Aim:

To compare injuries after CPR in autopsy results by manual resuscitated and mechanical (LUCAS 2, AutoPulse, CORpulse) resucitated patients and establish possible proportion of CPR related injuries on death without respect to cause of cardiac arrest.

Methods:

Retrospective multicentric study based on autopsy reports by patients died after CPR, patients with traumatic cause of cardiac arrest were excluded. Patients were devided in two groups: mechanical and manual CPR. For objective evaluation of injury seriousness we used Abbreviated injury scale scoring for the most serious injury and New Injury Scale Score for summary of all injuries.

Results:

We have enroled 704 patients, after trauma exclusion we have analyzed 630 autopsies. Manual CPR were provided by 559 patients and mechanical by 64 patients. Both groups are no diferent in age, gender, bystander CPR anad cardiac etiology of Arrest. Mechanical CRP was significantly longer (p=0,0005). Both groups have no diferences in incidency of injuries of thoracic vessels, lungs, heart, pericard, pleura, stomach, liver and spleen. We have observed injuries by 80% of manual and 87,5% of mechanical CPR. The most frequent was thorax sceleton injury 85,5% vs. 87,5%. Median of the most seriuos injury was 3 ( serious by Abbreviated injury scale scoring) without statistical difference, median of summary of injuries (New Injury Severity Score) was 13 in both groups ( low probability of fatal injury). If we analysed CPR by LUCAS 2 compared to manual, results are similar, only pericard injuries are higher with LUCAS 2.

Conclusion:

Incidency a seriousness of CPR related injuries according to autopsy reports are no diferent in comapring of manual and mechanical CPR. Mechanical CPR is significant longer a LUCAS 2 leads to significant more pericard injuries without influence to total seriousness of injury.

Jiri KARASEK (Prague, Czech Republic), Betka BLANKOVA, Andrea DOUBKOVA, Tereza PITASOVA, David NAHALKA, Tomas BARTES, Jiri HLADIK, Tomas ADAMEK
14:40 - 14:45 #18371 - SP010 Correlation between serum levels of lactate dehydrogenase and neurological outcomes in patients who undergo target temperature management after cardiac arrest.
SP010 Correlation between serum levels of lactate dehydrogenase and neurological outcomes in patients who undergo target temperature management after cardiac arrest.

Background: The optimal time to measure serum lactate dehydrogenase level (SLL) to predict prognosis in cardiac arrest (CA) survivors has not been elucidated. We aimed to compare the relationships between time-related SLL and neurological prognosis in CA survivors.

Methods: We conducted a retrospective study examining patients with CA who were treated with target temperature management (TTM). SLL was checked repeatedly at 24-h intervals after return of spontaneous circulation (ROSC). SLL at ROSC and 24-, 48-, and 72-h outcomes were the relationships between each time interval SLL and the neurological outcome 3 months post-CA.

Results: A total of 256 comatose patients with CA were treated with TTM. Seventy-three patients were included, and 31 patients (42%) experienced a good neurological outcome. At 24, 48, and 72 h, there was a significant difference between good and poor outcome groups (p<0.001), except at ROSC (p = 0.056). The area under the receiver operating curve (AUC) of at ROSC was 0.631 (95% confidence interval [CI], 0.502–0.761). The AUC at 48 h (0.830; 95% CI, 0.736 – 0.924) was higher than that at 24 and 72 h (0.786; 95% CI, 0.681–0.892 and 0.821; 95% CI, 0.724–0.919).

 Discussion & Conclusions: A higher SLL was strongly associated with and seemed predictive of poor outcomes. Furthermore, at 48 and 72 h, SLL may be a useful predictor of poor neurological outcomes. Prospective studies should be conducted to confirm these results.

Jin Hong MIN, Dr Hoil KIM (Daejeon, Korea, Republic of)
14:45 - 14:50 #18574 - SP011 The prognostic value of pre-arrest neutrophil-to-lymphocyte ratio for in-hospital mortality in adult patients with in-hospital cardiac arrest.
SP011 The prognostic value of pre-arrest neutrophil-to-lymphocyte ratio for in-hospital mortality in adult patients with in-hospital cardiac arrest.

Background

  As an indicator of systemic inflammation, the neutrophil-to-lymphocyte ratio (NLR) has been proved to be associated with a prognosis of a range of inflammation-related diseases. Although the study found that post-arrest NLR can predict the poor outcomes in patients with in-hospital cardiac arrest (IHCA), the relationship between pre-NLR and worse prognostic of IHCA patients was unclear. This study aimed to investigate the association between pre-arrest NLR and in-hospital mortality in patients of IHCA. We hypothesized that pre-arrest NLR is related to in-hospital mortality of IHCA patients.

Methods

  This was a single-center retrospective cohort study recruited IHCA patients in the emergency department (ED) of West China hospital of Sichuan University between January 2016 and May 2017. This hospital is a 4300-bed tertiary teaching hospital and is one of the largest medical centers in the southwest of China. Consecutive patients with cardiac arrest in the ED were included in this study. We excluded patients younger than 18 years, major trauma, lack of necessary data for analysis and hematological diseases or receiving any treatment which might affect the pre-arrest NLR values. Patients were divided into two groups according to the outcomes of in-hospital mortality. Clinical information and blood sample results were collected. Multivariate regression models were used to evaluate the associations between pre-arrest NLR and in-hospital mortality. The receiver operating characteristic (ROC) curve was used to assess the predictive value of pre-NLR.

Results

  Out of 488 IHCA patients during the study period a total of 385 (78.89%) patients were eligible for analysis, of those 267(69.35%) were male and mean age was 60.63±17.27. Of 385 patients, 64 (16.62%) survived to discharge. Patients with in-hospital mortality had a significantly higher pre-arrest NLR compared with survival to discharge patients (11.32[6.98,17.68] vs. 3.65[3.16,6.01], p<0.001). In the univariate model, pre-arrest NLR was associated with in-hospital mortality (OR: 1.347, 95% CI: 1.222-1.484, p<0.001). In the multivariate adjustment, higher pre-arrest NLR was independently associated with in-hospital mortality (AOR=1.276, 95%CI:1.160-1.403, p<0.001) after adjusting for age, gender, history of renal insufficiency, total CPR duration, globulin, alanine transaminase and aspartate aminotransferase.Furthermore, the prognostic performance of pre-arrest NLR was excellent (AUC: 0.86 [95%CI: 0.80-0.92, p<0.001]).

Discussion 

  In this retrospective observational study, we found that the excellent predictive ability of pre-NLR to predict in-hospital mortality for patients resuscitated from IHCA. We demonstrated the pre-arrest NLR is also a predictor for in-hospital mortality in IHCA patients. Therefore, we have reason to speculate that the systemic inflammatory response and the potential immune dysfunction before resuscitation in critically ill patients are associated with poor prognosis after resuscitation. Timely and effective medical interventions for critically ill patients might improve the survival when IHCA occurs.

Conclusions

  Pre-arrest NLR is a useful predictor of in-hospital mortality in adults with IHCA.  

Ethical approval and informed consent

   The study was conducted in line with the Declaration of Helsinki and gained approval by the Ethical Committee of West China Hospital of Sichuan University(Reference number: 2019201).

Dr Sheng YE (ChengDu, China), Junzhao LIU, Yarong HE, Yu CAO
14:50 - 14:55 #18776 - SP012 EVALUATION OF CARDIOPULMONARY RESUCITATION (CPR) TRAINING IN HEALTH CENTRE STAFF.
SP012 EVALUATION OF CARDIOPULMONARY RESUCITATION (CPR) TRAINING IN HEALTH CENTRE STAFF.


Introduction

Knowledge of Basic Life Support (BLS) techniques generates an undisputed benefit by improving survival prognosis in any CPR case, provided that BLS measures are initiated within the first 4 minutes of the CPR, and the comprehensive emergency system included within the "Chain of Survival" is implemented. International experience has shown that learning the instrumental management of the airway by the "first responders" is useful for increasing survival rates. For early defibrillation to be possible, knowledge about the use of semi-automatic defibrillation needs to be widely disseminated among staff in different health units.

Objectives

To know the degree of knowledge in Cardiopulmonary Resuscitation (CPR) among the health personnel of 10 urban and rural health centers prior to the realization of a plan of fromación in the form of workshops of eminently practical content.

Method

Prior to the workshop, 120 surveys were distributed among the participants consisting of 20 questions with 2 or 3 answers in Likert format referring to demographic data (profession, age and sex) and different aspects of basic resuscitation techniques with instrumental support and drugs. The surveys were analyzed with the SPSS version 20 database.

Results

The response rate was 100%. The degree of knowledge of the different techniques is shown in the tables provided, although in general terms, a knowledge deficit is detected in all the techniques analysed, which increases as the complexity of these techniques increases. This is despite the fact that 94.9% of the professionals admit to having received a course in CPR and 89.8% are aware of the ABCDE alert system.

Conclusions

The level of knowledge in cardiopulmonary resuscitation techniques demonstrated in this study by health professionals working in Primary Care is scarce, which makes it very necessary for health authorities to implement training programmes if we want to improve the response of these professionals to cardiac arrests in the hospital setting.

Álvaro MARTÍN PÉREZ (BADAJOZ, Spain), Rosario PEINADO CLEMENS, Concepción DE VERA GUILLEN, Juan M FERNÁNDEZ NÚÑEZ, Milagros LUCAS GUTIERREZ

Sunday 13 October

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EPOSTER 1.4
14:35 - 14:55

ePoster 1.4 - Short Oral Presentation - Screen 4

Moderator: Dr Thomas BEATTIE (Senior lecturer) (Edinburgh)
14:35 - 14:40 #18200 - SP013 Salivary biomarkers role in pain diagnostics.
SP013 Salivary biomarkers role in pain diagnostics.

Introduction

The key to adequate pain management is assessing its presence and identifying exact severity of the pain. Current ‘gold-standard’ pain assessment tools rely on self-reporting, requiring an ability to communicate this personal experience. Self-reporting varies from patient to patient and could be inaccurately understood by healthcare professionals. According to the study results, acute as well as chronic pain remains one of the most misunderstood, under-diagnosed, and under-treated medical problems, particularly in children. Pain diagnosis and management would benefit from the development of objective markers of nociception and pain.

Aims

To investigate concentration of salivary cortisol and melatonin in children with acute pain and compare it with severity of pain and changes in vital signs.

Methods

We conducted a pilot observational study in Lithuanian University of Health Sciences Hospital Kauno Klinikos Pediatric emergency department (PED). Twenty six patients complaining of acute pain referred to PED were included into the study. Patients having chronical conditions (cancer, immunodeficiency, diabetes etc.), fever, dehydration or chronic pain were excluded. We recorded patient’s gender, age, vital signs (heart rate (HR), blood pressure (BP), respiratory rate (RR), temperature (t°) and oxygen saturation (SaO2)), pain characteristics (severity and duration of pain according the used pain scale and its localization). Saliva samples were collected and were stored in -80°C till analysis was performed. Samples were analyzed using cortisol and melatonin ELISA kits.

Results

Sixteen boys and 10 girls were involved in our research. Age median was10 (4-16) years. Fourteen cases were trauma patients, 12 cases referred due to pain of other origin then trauma. Analyzing vital signs, we noticed HR and BP increase with regard to pain. Other parameters (RR, t°, SaO2) were within the age range. The median of cortisol and melatonin levels were 287.5 (68-1330) pg/ml and 17,6 (8,6-46,8) pg/ml respectively. There were several findings related to saliva hormone level and intensity of pain, duration of pain and it’s link to vital signs There was a tendency to melatonin reduction with increased intensity of pain (p=0,136). The longer the pain lasted, the higher cortisol levels were identified (p=0.01). However, there was no link between abnormal vital signs and changes in our biomarkers.

Conclusion

Our primary results show a cortisol rise with regard to pain in time dependent manner. Melatonin levels decreased in relation to increased pain intensity. These results show a potential of cortisol and melatonin as biomarkers in acute pain diagnostics. 

Kristina GANZIJEVA (Kaunas, Lithuania, Lithuania), Lina JANKAUSKAITE
14:40 - 14:45 #18203 - SP014 Association of Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio with In-Hospital Mortality in Patients with Gastrointestinal Perforation Undergoing Surgery.
SP014 Association of Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio with In-Hospital Mortality in Patients with Gastrointestinal Perforation Undergoing Surgery.

Objective: The Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) are recognized markers of inflammation associated with poor outcomes in various clinical situations. Gastrointestinal perforation (GIP) is a life-threatening disease with a high mortality rate. We analyzed the prognostic significance of NLR and PLR in patients with gastrointestinal perforation (GIP) undergoing surgery.

Methods: This was a multi-center observational retrospective study. We reviewed electronic medical records of adult patients with GIP admitted to three academic hospitals between January 2009 and December 2018, who also received surgical operation. We obtained demographic and clinical data of GIP patients. Multivariate logistic regression model was used to determine the predictive value of NLR and PLR on in-hospital mortality and to evaluated risk factors associated with in-hospital mortality. The primary outcome was all-cause in-hospital mortality.

Results: Among 9279 patients, 879 adult patients with GIP underwent surgical operation. Seventy eight patients (8.9%) were died and 801 (91.1%) were survived. In the Multivariate logistic regression analysis, factors associated with in-hospital mortality were female, underlying chronic renal failure, C-reactive protein >100mg/l and Albumin <3.5g/dl (Adjusted odds ratio [95%CI]; 2.73 [1.07-6.97], 4.20 [1.83-9.68], 8.43 [2.29-31.03], 5.36 [2.29-12.59], respectively).

Conclusion: NLR and PLR are not associated with mortality in patients with gastrointestinal perforation undergoing surgery in the study. Female, underlying chronic renal failure, C-reactive protein>100 mg/l and Albumin<3.5 g/dl may help to identify high-risk patients.
Yeonghoon BAE (Seoul, Korea, Republic of)
14:45 - 14:50 #19059 - SP015 Utility of s-tryptase in Emergency Department patients with possible anaphylaxis.
SP015 Utility of s-tryptase in Emergency Department patients with possible anaphylaxis.

Background: Diagnosing anaphylaxis is straight forward in typical cases but can be challenging if the presentation is atypical. Generally it requires that patients have acute symptoms from more than one of the following systems; skin or mucosa, respiratory, cardiovascular or gastrointestinal. In addition to clinical diagnosis it has been shown that in patients with vague or atypical symptoms considered possibly due to an acute allergic reaction, evaluating s-tryptase can give additional diagnostic information, ideally if done within 30-180 min from onset of symptoms. Measuring s-tryptase also has the potential to diagnose mastocytosis, a rare but probably underdiagnosed condition of mast cell proliferation.

In our emergency department (ED), staff has been educated since 2011 on obtaining a s-tryptase level in cases where a patient could possibly be having an acute allergic reaction but a definitive diagnosis cannot be made based on clinical evaluation. Further evaluation by an allergist during an outpatient follow up is also recommended. The aim of this study was to assess how useful obtaining a s-tryptase level was on the work up of patients with possible anaphylaxis in the ED.

Methods: With institutional review board approval, all cases where a s-tryptase level was obtained from ED patients during the period from 2011-2018 were retrospectively reviewed. A database was collected including information on patient demographics, presenting symptoms and signs, treatment given, diagnosis, s-tryptase level and follow up.

Results: During the study period a total of 214 patients in the ED had s-tryptase measured. Females were 131 (61.2%) and average age 40.6 years (range 11-88). When evaluating patients, 60 (28.0%) of patients had only symptoms from one organ system, 70(32.7%) from two, 55(25.7%) from three and 26(12.1%) of the patients had symptoms from four organ systems. Three patients (1.4%) did not have symptoms from any of the four target organ systems.  Of the patients, 86.4% had skin or mucosal symptoms, 47.7% cardiovascular symptoms, 49.5% respiratory symptoms and 36.0% had gastrointestinal symptoms. Blood was drawn for s-tryptase analaysis within the recommended time frame in 133(62.1%) of the cases. Serum tryptase was elevated (>12µg/l) in 36 (16.8%) cases.

Of the 214 cases, 126 returned for further evaluation by an allergist and 65 (51.6%) of those were considered to have had an episode of anaphylaxis.

When evaluating the cases where blood samples for s-tryptase analysis had been collected within the recommended time frame of 30-180 minutes and returned for further evaluation by an allergist, the sensitivity of s-tryptase to diagnose anaphylaxis was 40,91% (95% CI 26,34% - 56,75%) and specificity 96,30% (95% CI 81,03% - 99,91%). No case of mastocytosis was identified in the patient cohort.

Discussion and conclusions: Obtaining a s-tryptase level on ED patients with possible anaphylaxis is specific but not sensitive in diagnosing atypical cases of anaphylaxis. No cases of mastocytosis were identified in the patient cohort suggesting that mastocytosis is uncommon among ED patients in our community.

Karolina HANSEN, Hjalti Mar BJORNSSON (Reykjavik, Iceland), Maria I GUNNBJORNSDOTTIR
14:50 - 14:55 #19219 - SP016 High cortisol levels predict worse outcome in patients with community pneumonia.
SP016 High cortisol levels predict worse outcome in patients with community pneumonia.

Critical Illness-Related Corticosteroid Insufficiency (CIRCI) is a condition still not completely understood. Although the current guidelines suggest the administration of corticosteroids only in septic patients who do not respond to the initial fluid resuscitation, it is not clear how it works and the signaling pathways that may affect its efficacy.

Therefore, we made the hypothesis that corticosteroids therapeutic action may be related not only to cortisol levels, but also to the degree of glucocorticoids receptors (GR) expression.

We included in this study 181 patients presented to the Emergency Room with the diagnosis of community pneumonia. Blood samples were collected at the admission and outcomes were evaluated during hospital stay and after 30 days.

Cytokines were measured by Multiplex method, and glucocorticoid receptors α and β were measured in leukocytes homogenates by ELISA. Data are presented here as mean±SEM. 

Patients’ ages vary from 18.2 to 100.0 y.o (average = 61.7±1.5). From the 181 patients, 96 were also septic and 40 had septic shock. Mortality was 17.7% (32 patients). Seventeen of these patients were chronic corticoid users and were evaluated separately. 

The main discriminators between survivors and non survivors were SOFA (2.9±0.2 vs 4.8±0.4, respectively, p<0.05) and total cortisol levels (18.5±2.1 vs 39.7±8.2, respectively, p<0.05). There was no difference in GR α or β expression between survivors and non survivors. Previous corticosteroid use also did not affect the levels of GRs expression, suggesting that these receptors are not subjected to feedback regulation.

In addition none of the inflammatory markers measured at admission (proadrenomedulin, procalcitonin, C-reactive protein or cytokines) were able to distinguish the patients who would survive.  

In conclusion, we showed that cortisol levels are a good predictor of outcome in patients with community pneumonia and GR expression did not affect this outcome. 

Lucas MARINO (Sao Paulo, Brazil), Hermes BARBEIRO, Denise BARBEIRO, Luzmarina GOMEZ, Julio ALENCAR, Julio MARCHINI, Rodrigo BRANDAO, Heraldo SOUZA

Sunday 13 October

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EPOSTER 1.5
14:35 - 14:55

ePoster 1.5 - Short Oral Presentation - Screen 5

Moderator: Isabel LUECK (Resident) (Hamburg, Germany)
14:35 - 14:40 #18284 - SP017 Temporal evolution of the PCVCO2-PaCO2 / CaO2-CcvO2 ratio versus serum lactate during resuscitation in septic patients with hypotension.
SP017 Temporal evolution of the PCVCO2-PaCO2 / CaO2-CcvO2 ratio versus serum lactate during resuscitation in septic patients with hypotension.

Bakground: Lactate as a target for resuscitation in patients with septic shock has important limitations. The PcvCO2-PaCO2 / CaO2-CcvO2 ratio may be used as an alternative for the same.The primary objective of the study was to evaluate the correlation between serum lactate and PcvCO2-PaCO2 / CaO2-CcvO2 ratio measured at various time points to a maximum of 24h in patients with septic shock (Mean arterial pressure < 65mmHg). The secondary objectives were to study the  1) Relationship between the PcvCO2-PaCO2 / CaO2-CcvO2 ratio and lactate clearance at 6, 12 and 24 hrs as compared to the initial serum lactate. 2) To study the correlation between the arterial lactate and the PcvCO2-PaCO2 gap at each measurement. 3) Outcome in terms of ICU length of stay, organ dysfunction and mortality at day 28.

Methods: This prospective observational cohort study was conducted at the mixed ICU(Medical/Surgical)   of the All India Institute of Medical Sciences (AIIMS), New Delhi from July,2016 to April,2018.Thirty patients with sepsis-induced hypotension (MAP < 65mmHg) who were being actively resuscitated were enrolled. Paired arterial and central venous blood samples were obtained 0.5 hourly till stabilisation of MAP (maximum of two samples), and 6 hourly thereafter for the first 24h. Patients were followed up to day 28 of enrolment for mortality and organ system failure. All statistical analysis was performed using ‘Stata’ software (Ver 15.1; StataCorp LLC, Texas, USA). Correlation between the various variables was done using the Spearman coefficient. Subgroup analysis of variables between survivors and non-survival groups was done using the Wilcoxon-Mann-Whitney test. Sensitivity and specificity of the PcvCO2-PaCO2)/(CaO2-CcvO2) ratio and arterial lactate were calculated and Receiver-Operating-Characteristic curves were constructed.

Results: A positive correlation was observed between arterial lactate and  PcvCO2-PaCO2 / CaO2-CcvO2 ratio at 0h, 6h, 12h, 18h (R=0.413 P=0.02; R=0.567 P=0.001; R=0.408 P=0.025; R=0.521 P=0.003, respectively). No correlation was seen between  PcvCO2-PaCO2 / CaO2-CcvO2 ratio and  lactate clearance. The subgroup analysis showed that neither an abnormal arterial lactate (> 2mmol/L) nor an abnormal PcvCO2-PaCO2 / CaO2-CcvO2 ratio (>1) at the time of enrolment could distinguish survivors from non-survivors (at D28 of enrolment). The median (PcvCO2-PaCO2)/(CaCO2-CcvO2) ratio was higher in non-survivors than in survivors at all time points. However, this reached statistical significance only at the 24h time point9 P=0.004). A PcvCO2-PaCO2 / CaO2-CcvO2 ratio>1.696 at 24h of resuscitation predicted mortality at 28d (Sensitivity: 80%, Specificity 69.2%, AU-ROC 0.82). This threshold also distinguished survival at D28 in the Kaplan Meier estimates (Chi-square=6.00, P=0.014). An arterial lactate > 1.6mmol/L at 24h of resuscitation predicted mortality at 28d (Sensitivity 73.33%, Specificity 69.23%, AU-ROC 0.853). This threshold also distinguished survival at D28 in the Kaplan Meier estimates (Chi-square=5.62, P=0.018)

Discussion and Conclusion(s): The (PcvCO2-PaCO2)/(CaCO2-CcvO2) ratio and the lactate are positively correlated during the first 24h following active resuscitation from sepsis-induced hypotension. The (PcvCO2-PaCO2)/(CaCO2-CcvO2) ratio at 24h is significantly higher in non-survivors, and a threshold of 1.696 mmHg/mL/dL for (PcvCO2-PaCO2)/(CaCO2-CcvO2) ratio at 24h significantly differentiates survivors from non-survivors. The (PcvCO2-PaCO2)/(CaCO2-CcvO2) ratio may be used as an end-point of haemodynamic resuscitation from septic shock.

Pr Vimi REWARI (New Delhi, India), Shyam MADABHUSHI, Anjan TRIKHA, Rahul Kumar ANAND, Rashmi RAMACHANDRAN
14:40 - 14:45 #18475 - SP018 P25/30 somatosensory evoked potential is superior to N20 in predicting neurological recovery after cardiac arrest: A prospective, observational study.
SP018 P25/30 somatosensory evoked potential is superior to N20 in predicting neurological recovery after cardiac arrest: A prospective, observational study.

Background

The absence of N20 somatosensory evoked potential (SEP) is regarded as a predictor of poor outcome after cardiac arrest with very high specificity. However, its sensitivity in predicting the poor outcome is unsatisfactory. The P25/30 SEP is a positive deflection following N20 with a latency of 25-35 msec. According to our prior study, N20 without following P25/30 is related to poor outcome, while N20 followed by P25/30 is highly related to good outcome. In this study, we evaluated whether the amplitude of P25/30 predicts neurologic recovery after cardiac arrest more accurately than the amplitude of N20.

Methods

This is a prospective multicenter observational study. Patients were consecutively enrolled in four university-affiliated teaching hospitals. SEPs of comatose survivors after out-of-hospital cardiac arrest treated by 33℃-targeted temperature management were recorded 72 hours after return of spontaneous circulation. The cutoff value of P25/30 and N20 amplitude showing 100% specificity in predicting poor neurological recovery was determined by receiver operating characteristic (ROC) analysis. We defined poor neurological recovery as the worst Cerebral Performance Category score higher than three during the admission period. We performed penalized maximum likelihood estimation in logistic regression analysis. Thereafter, we compared the area under curve (AUC) of the P25/30-based model predicting poor outcome to AUC of the N20-based model. According to the previous study, a total of 86 subjects would be required to detect a 0.05 difference in AUC with a power of 80% and a type I error of 5%. Values of p less than 0.05 were considered statistically significant.

Results

Out of a total of 87 patients included in the study, 43 patients showed good neurological recovery, while 44 patients showed poor neurological recovery. The cutoff values of SEP amplitudes showing 100% specificity in predicting poor neurological recovery were 0.63 μV (P25/30) and 0 μV (N20). Sensitivity in predicting poor neurological recovery of P25/30 was 0.86 (95% confidence interval 0.73 - 0.95), while N20 was 0.7 (95% confidence interval 0.55 - 0.83). In addition to N20 or P25/30, cardiac arrest rhythm and anoxic time were selected as independent variables for the multivariable logistic regression models. The AUC of the P25/30-based model was 0.958 (95% confidence interval 0.92 - 1), while the AUC of the N20-based model was 0.911 (95% confidence interval 0.85 - 0.98). AUC comparison between the N20-based model and the P25/30-based model showed a statistically significant difference (p = 0.02).

Conclusions

P25/30 showed superior value in predicting poor neurologic recovery after cardiac arrest than the N20. P25/30 showed higher sensitivity in predicting poor neurologic recovery than the N20, which implies potential as a predictor of good neurologic recovery.

Sang Hoon OH, Pr Joo Suk OH (Seoul, Korea, Republic of), Hyunho JUNG, Jungtaek PARK, Ji Hoon KIM, Jeong Ho PARK, Jung Hee WEE, Seung Pill CHOI, Kyu Nam PARK
14:45 - 14:50 #18956 - SP019 Eligibility for organ donation: Is there a place in emergency department ?
SP019 Eligibility for organ donation: Is there a place in emergency department ?

Introduction: Actually, 60% of organ procurement is perfomed in patients who died of brain death due to a severe stroke, mainly haemorrhagic stroke (75%). The objective of this study is to identify patients in emergency departments for severe stroke who may be eligible for organ retrieval procedures. 

Methods: We realized an epidemiological, descriptive, observational, monocentric, retrospective study at a university hospital emergency department for one year including all strokes with a Glasgow coma scale ≤ 12 and/or a NIHSS score ≥ 17. We considered patients who died early (death < 3 days) and with no neoplasia as potentially eligible for organ donation and compared the characteristics of eligible patients to patients whose brain death has been confirmed.

Results: 1582 patients were hospitalized for stroke, 312 patients had a severe stroke. 201 patients, with severe stroke, was not managed in intensive care. In this cohort according to predefined criteria, 34 patients were considered eligible for multi-organ procurement. Fifteen (44%) had an ischemic stroke and 19 (56%) had a hemorrhagic stroke. The initial mean Glasgow coma scale was 6 (± 3). The median age was 84 years [77-89]. We compared patients with confirmed brain death (N=32) to potentially eligible donors (N=34). Age was significantly higher in potentially eligible patients (65 years vs 84 years; p < 0.0001). There was no significant difference in the Glasgow coma scale for antiaggregant or anticoagulant treatment between the 2 groups. 13 patients were cared for and died in neurology, 15 patients in the emergency department and 6 patients in short-term hospital units. Among potentially eligible patients, 75% of patients died within 48 hours. For patients with confirmed brain death, 75% of patients died within 72 hours. 

Conclusion: The identification of patients who may be eligible for organ retrieval is difficult in the emergency department. A better awareness of practitioners could make it possible to better filiarize the management of these patients.

Dr Melanie ROUSSEL (Rouen), Antoine LEFEVRE-SCELLES, Edgar MENGUY, Mathieu BENHADDOUR, Luc-Marie JOLY
14:50 - 14:55 #19102 - SP020 Analysis of Single Substance Heroin Exposures reported to the U.S. Poison Centers from Healthcare Facilities.
SP020 Analysis of Single Substance Heroin Exposures reported to the U.S. Poison Centers from Healthcare Facilities.

Background: Heroin use has reached a public health crisis in the U.S. Since 2010, the rate for deaths involving heroin has almost tripled, from 1.5 per 100,000 in 2011 to 5.1 in 2016. The number of people using heroin for the first time in the U.S. has increased in recent years. Hence it is important to track heroin overdoses, especially those reported from the healthcare facilities (HCF) as these may greatly increase resource use. The objective of the current study is to use outline the epidemiology of single substance heroin exposures reported to the National Poison Data System from the HCFs.

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

Results: There were 15,692 single substance heroin exposures reported to the PCs from HCFs. The number of calls increased from 1,142 to 3,865 during the study period. Among these calls, 90.2% were reported from acute care hospitals and emergency departments (EDs), 6.5% were reported from freestanding EDs, while 3.3% were reported from physician offices.  Acute exposures to heroin were responsible for 67.7% of the calls from HCF. Approximately 19% of the patients reporting such heroin exposures were admitted to the critical care unit (CCU), with 56.6% patients treated and released. Residence was the most common site of exposure (69.7%). Among the patients, m were male, with the majority of the individuals between ages 20 and 39 years (70.9%). Pediatric cases accounted for 6.3% of the exposures. Intentional abuse (74.5%) and misuse (10.5%) were commonly observed reasons for exposure. During the study period, the proportion of heroin abuse cases increased (73.3% to 76.1%). Major effects were seen in 19.1% cases and the mortality rate for single substance heroin exposures from HCF was 1.8%. Notably, the number of heroin-related fatalities in this group doubled during the study period.  Coma (26.8%) and respiratory depression (27.3%) were frequently observed clinical effects. Naloxone (60.7%) was the most frequently reported therapy. During the study period, the frequency of heroin exposures increased by 238.4% (95% CI: 215.8%, 261.5%; p<0.001), and the rate of heroin exposures increased by 187.6% (95% CI: 149.8%, 231.2%; p<0.001).

Discussion: There was a significant increase in single substance heroin exposures reported to the PCs from HCFs during the study period. This increase may be a result of the lower cost of heroin and the tighter regulations on the prescribing of opioids. Changes in the sources of supply and potency of heroin products can result in substantial adverse events seen in the HCFs. Exposures reported to the poison centers further highlight the need for sustained, targeted, and multifactorial responses to the ongoing opioid epidemic, including timely surveillance.

Saumitra REGE (Charlottesville, VA, USA), Dr Christopher HOLSTEGE
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, United Kingdom), Senad TABAKOVIC (Medical director emergency department) (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 (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 HAERTEL (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, United Kingdom)
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, United Kingdom), 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, United Kingdom)
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 (MD) (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)
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, United Kingdom)
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, United Kingdom), 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

Sunday 13 October

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G12
15:00 - 16:30

NATIONAL TRACK - Forever young?
Věčně mladí?
Geriatric, Wellbeing

Moderators: Roman GREGOR, MBA (Director) (Ostrava, Czech Republic), Jiri KNOR (medical doctor with specialisation) (Kladno, Czech Republic)
15:00 - 16:30 Věkové (a jiné) limity pro specifické léčebné postupy u seniorů - PRO. Jiri KNOR (medical doctor with specialisation) (Kladno, Czech Republic)
15:00 - 16:30 Věkové (a jiné) limity pro specifické léčebné postupy u seniorů - CON. Dr Jana SEBLOVA (Emergency Physician) (PRAGUE, Czech Republic)
15:00 - 16:30 Nároky na poskytovatele nad rámec zákonů - PRO. Jaroslav PEKARA (lecturer, paramedic) (Praha 10, Czech Republic)
15:00 - 16:30 Nároky na poskytovatele nad rámec zákonů - CON. Roman GREGOR, MBA (Director) (Ostrava, Czech Republic)
PANORAMA HALL
16:40

Sunday 13 October

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A13
16:40 - 18:10

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 (Immediate Past 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

Sunday 13 October

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B13
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, United Kingdom)
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, United Kingdom)
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, United Kingdom)
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 (Consultant) (Glasgow, United Kingdom)
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, United Kingdom), 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, China), 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

Sunday 13 October

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G13
16:40 - 18:10

NATIONAL TRACK - EM in questions, riddles and quizzes
Urgentní medicína v otázkách, hádankách a kvízech
Education, INTERACTIVE SESSION

Moderators: Vladislav KUTEJ (chief of department) (Olomouc, Czech Republic), Dr Jana SEBLOVA (Emergency Physician) (PRAGUE, Czech Republic)

16:40 - 18:10 Jak umíme řešit krize na urgentním příjmu? Dr Jana SEBLOVA (Emergency Physician) (PRAGUE, Czech Republic), Vladislav KUTEJ (chief of department) (Olomouc, Czech Republic)
16:40 - 18:10 Interaktivní kazuistiky. Roman SKULEC (Head of research and science department) (Kladno, Czech Republic)
16:40 - 18:10 Umíme si poradit s pacientem v bezvědomí? Jaromír KOCI (Chair) (Hradec Kralove, Czech Republic)
16:40 - 18:10 Infekční a dermatologické hádanky. Roman SYKORA (Czech Republic)
PANORAMA HALL
18:10

Sunday 13 October

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A14
18:10 - 19:00

OPENING CEREMONY

18:10 - 19:00 Opening words & introduction. Ahmed KAZMI (eusem) (London, United Kingdom)
18:10 - 19:00 25th anniversary of EUSEM: EUSEM President. Luis GARCIA-CASTRILLO (ED director) (Oruna, Spain)
18:10 - 19:00 Introduction to Prague: ECOC President. Patrick PLAISANCE (Head of Department) (Paris, France)
CONGRESS HALL
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

Monday 14 October

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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, United Kingdom)
09:10 - 10:40 IFCC practice recommenations for hs-troponin. Pr Rick BODY (Professor of Emergency Medicine) (Manchester, United Kingdom), Paul COLLINSON (Consultant Chemical Pathologist) (London, United Kingdom), Allan JAFFE (Speaker) (Rochester, USA)
10:10 - 10:40 Panel discussion. Barbra BACKUS (Emergency Physician) (Leiden, The Netherlands), Pr Edd CARLTON (Emergency Medicine Consultant) (Bristol, United Kingdom)
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 (Medical director emergency department) (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, United Kingdom)
09:10 - 10:40 How to set up a wellbeing program for your ED. Shweta GIDWANI (United Kingdom)
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, United Kingdom)
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, United Kingdom), 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, United Kingdom)
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, United Kingdom), 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, United Kingdom), 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
10:45

Monday 14 October

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EPOSTER 2.1
10:45 - 11:05

ePoster 2.1 - Short Oral Presentation - Screen 1

Moderator: Pr Luigi TITOMANLIO (Head of Department) (Paris, France)
10:45 - 10:50 #18355 - SP021 Left holding the baby: reasons and outcomes of neonatal emergency department attendance, a 2-year retrospective observational study in a UK tertiary hospital.
SP021 Left holding the baby: reasons and outcomes of neonatal emergency department attendance, a 2-year retrospective observational study in a UK tertiary hospital.

Background and Objective

Neonates attending the paediatric emergency department (ED) pose challenges. The presenting problems differ from older children and are unique to this age group, prescribing requires attention to detail and consideration of physiological quirks and even resuscitation algorithms are irritatingly idiosyncratic. So who are these babies that are brought to the ED by their parents, what serious illness needs consideration and why are they attending the ED in the first place? We present a large data set with a view of identifying attendance patterns, population characteristics and potential pathway issues.

Methods

Retrospective review of all neonatal attendances (age less than 28 days) to the paediatric ED of a UK tertiary hospital during a two year period (01/04/2017 to 31/03/2019) from the electronic patient record database for age at presentation, presenting complaint, source of referral, length of stay in ED and disposal. Where necessary, individual records were accessed and any missing information added. Acuity of visits was determined by the need for admission, duration of in-patient stay and follow-up arrangements. 

Results 

1,699 attendances involving 1,467 neonates were identified, constituting 3.81% of all paediatric ED attendances (n=44,571) and 16.2% of all births in the hospital (n=10,515). The peak of attendance occurred at age 2-3 days, with over 60% presenting with jaundice. Monthly attendance mirrored the birth rate, there was no seasonal variation. The most common presenting problems were jaundice, respiratory symptoms, weight-loss and vomiting. Only 23.7% of all visits were self-referred. Most referrals came from midwifes (37.3%), other primary healthcare professionals (24.1%) and after contacting the UK’s 111 helpline (9.83%). 5.1% of babies came by emergency ambulance. As expected, the ratio of acute to non-acute visits was higher in referrals by ambulance (r=1.00) and primary healthcare professionals (r=0.808) compared to self-referrals (r=0.728) but not significantly so. On average, these infants spent 165 minutes in the ED. There were 111 breaches of the 4-hour target (6.42%). The admission rate was 42.1%, and the top reasons for hospital admissions were jaundice (44.3%), feeding problems (18.2%), respiratory (11.3%) and infection including suspected sepsis (7.97%). 32.9% of neonates admitted were discharged within 48 hours of admission. 4 deaths including two neonatal sepsis deaths were identified, both of which had disseminated Herpes-Simplex Virus (HSV) infection. 

Discussion

ED attendance is common during the neonatal period, notably over half of the visits are for non-acute complaints and do not require immediate medical intervention except parental reassurance.

The large number of jaundice-related attendances calls for a review of the jaundice care pathway. We will be discussing possible interventions that may help reduce unnecessary attendances in the ED like feeding support following postnatal discharge and improved awareness of neonatal normal variants by primary care professionals.

We suggest that the current referral algorithms for the UK's national telephone advice service 111 may significantly increase inappropriate ED attendances.

The neonatal deaths due to sepsis were both caused by HSV infection, our local incidence matching published evidence and we postulate Aciclovir to be first-line treatment in neonates presenting with sepsis to ED.

Yishen WANG (Cambridge, United Kingdom), Peter HEINZ
10:50 - 10:55 #18445 - SP022 Analysis of limited-sequence head computed tomography for children with ventriculo-peritoneal shunt: potential to reduce diagnostic radiation exposure.
SP022 Analysis of limited-sequence head computed tomography for children with ventriculo-peritoneal shunt: potential to reduce diagnostic radiation exposure.

Background and Objectives

Complications related to ventriculoperitoneal shunt (VPS) are common, and multiple revisions are almost expected throughout a patient's lifetime. Standard noncontrast head computed tomography (CT) that is currently the gold standard for diagnosis of VPS dysfunction, consists of an average of 35 to 40 sequences and causes severe radiation exposure. However, it is stated that the evaluation of four sequences which show 4 ventricles, 3 ventricles, lateral ventricles and basal ganglia may be sufficient for the diagnosis of VPS malfunction. This may significantly reduce the radiation exposure. The aim of this study was to determine the feasibility of the four-sequence limited head CT for predicting VPS malfunction.

Methods

We performed a retrospective analysis of the PED medical records (MRs) between January 2013 and December 2017 that involved all patients who received a head CT for suspected VPS malfunction. MRs were reviewed to describe demographic, clinical characteristics surgical interventions and full head CT reports. For all enrolled patients, a limited series was generated from the last CT scan by selecting four representative axial slices based on the sagittal scout image. Four slices selected at the level of the fourth, third ventricle, basal ganglia level, and lateral ventricles, respectively. A blinded neuroradiologist evaluated the limited 4- slice CT to determine the VPS malfunction. After this review, we compared the standard full head CT reports with the limited 4- slice CT, and analyzed the sensitivity and specificity of the 4- slice CT to predict VPS malfunction. We also calculated the real 4 –slice CT sensitivity and specificity for children  who received surgical shunt revision.

Results

A total of 164 patients were enrolled in the study. The mean age was 54 ± 24 months and 85 (52%) were males. The most common presentation complaints were vomiting (27%) and seizure (17%). V-P shunt revision was performed in 60 patients (37%) as a result of clinical and radiological evaluation. When we compared the standard complete head CT reports with the limited modality, the limited 4-slice CT had sensitivity, specificity 83% and 97% respectively, for the evaluation of the changes in ventricular size. However, when the analyze performed based on surgical V-P shunt revision, only one case would have been missed with the limited 4-slice CT. The  sensitivity was 98% and specificity 78%. The effective dose (ED50) of limited 4-slice head CT was 0.32 mSv, while the ED50 of the standard head CT was 2.7 mSv. In this way, the prefer of a limited head CT instead of a complete head CT may provide about 88% reduction in radiation dose.

Conclusion

The present study demonstrates that utilization of limited head CT scan in the evaluation of children with suspected VPS malfunction is a feasible strategy for the evaluation of the ventricular size as well as prediction of surgical intervention. Further prospective, well designed studies are needed to evaluate the reliability of limited head CT for the clinical evaluation of VPS malfunction.

Dr Ali YURTSEVEN (İzmir, Turkey), Caner TURAN, Eren ERSEVEN, Cenk ERASLAN, Eylem Ulas SAZ
10:55 - 11:00 #18534 - SP023 Assessment of rewarming methods in unplanned out-of-hospital births from a prospective cohort.
SP023 Assessment of rewarming methods in unplanned out-of-hospital births from a prospective cohort.

Background and Objectives: Mobile intensive care units frequently manage unplanned out-of-hospital births (UOHB). Rewarming methods during pre-hospital management of UOHB have not yet been compared. The aim was to compare rewarming methods used during pre-hospital management in a large prospective cohort of UOHB in France.

Methods: We analyzed UOHB from the prospective AIE cohort from 25 prehospital emergency medical services in France. The primary outcome was the change in body temperature from arrival at scene to arrival at hospital. Our database was approved by the French Data Protection Authority and by a French research ethics committee. Maternal consent was systematically requested before or during birth management (left at the physician’s discretion).

Results: From 2011 to 2018, 1,854 UOHB were recorded, of whom 520 were analyzed. We found that using incubator care was the most effective rewarming method (+0.8°C during transport; P < 0.001), followed by the combination of plastic bag, skin-to-skin and cap (+0.2°C). The associations plastic bag + cap and skin-to-skin + cap did not allow the newborn to be warmed up but rather to maintain initial temperature (+0.0°C). The results of the multivariate model were consistent with these observations, with better rewarming with the use of an incubator (Adjusted temperature difference = +0.33 95CI(0.13; 0.52)). According to the classification and regression tree (CART) method, we also identified circumstances of increased risk of hypothermia according to classification and regression tree, like premature birth (< 37 weeks of gestation) and/or low outside temperature (< 8.4°C).

Conclusions: Using an incubator was the most effective rewarming method during pre-hospital management of UOHB in our French prospective cohort. Based on our model, in cases of term less than 37 weeks of gestation or between 37 and 40 weeks with a low outside temperature, using such a method would be preferred.

François JAVAUDIN (Nantes), Mélodie ROCHE, Lucile TRUTT, Isabelle BUNKER, Valérie HAMEL, Sybille GODDET, François TEMPLIER, Christine POTIRON, Quentin LE BASTARD, Philippe PES, Gilles BAGOU, Jean-Louis CHABERNAUD, Emmanuel MONTASSIER, Brice LECLERE
11:00 - 11:05 #19167 - SP024 Clinical decision rules in cervical spine injury assessment: a prospective study in a paediatric trauma centre.
SP024 Clinical decision rules in cervical spine injury assessment: a prospective study in a paediatric trauma centre.

Background:

Paediatric cervical spine injury (CSI) is rare but can have devastating consequences. In an attempt to identify all children with CSI, many children are assessed for possible injury and may either be “clinically cleared” or receive imaging to exclude radiologically apparent injury. Clinical decision rules (CDRs), or proposed rules, are commonly used to guide imaging decisions despite limited evidence for their use in paediatric populations.

 

Objectives:

To determine the frequency of previously identified risk factors for CSI in children presenting to a single Australian centre and to assess the performance of commonly used CDRs or proposed rules when strictly applied to our population, including the projected impact on imaging rates if these CDRs were strictly applied.

 

Method:

Prospective observational study across one year of all children under 16 years presenting to Emergency Department (ED) with possible CSI as defined either immobilization for possible CSI, neck pain the context of trauma or otherwise considered at risk by the ED team. Those with imaging prior to arrival were examined as separate cohort. CDR variables for the National Emergency X-ray Utilization Study (NEXUS) rule, Canadian Cervical Spine Rule and proposed Paediatric Emergency Care Applied Research Network (PECARN) rule were collected prospectively and applied post hoc.

 

Results:

1010 children were enrolled; 973 had not received prior imaging. Of these 973, two thirds were male, median age was 10.9 years and 16% were aged under 5. 40.7% received imaging of their cervical spine with 32.4% receiving X- Rays, 13.4% Computed Tomography and 3% Magnetic resonance imaging. 5 children had CSI.  Nine children of the 37 with prior imaging had CSI.

 All 3 CDRs identified the 5 children with CSI who had not received prior imaging (Sens 100%, 95%CI 56-100). The NEXUS rule did not identify 2 out of the 9 children with prior imaging. 

If strictly applied as a rule for imaging, all 3 CDRs or proposed CDRs would increase imaging rates in our setting, with individual CDR guided rates ranging between 44 and 68%. Despite these higher projected imaging rates, and while all but 2 imaged children were positive for at least one of the three rules (i.e. imaging indicated according to the CDR), no single rule suggested that all children  imaged in current practice should actually be imaged; individual NEXUS and PECARN CDRs were  positive in 82 and 91% of those imaged respectively.

 Conclusion:

Paediatric CSI is rare, and while many children are clinically cleared without imaging, a considerable percentage receive imaging for relatively few injuries detected. CDRs have been proposed to guide imaging decisions, however the use of those currently available to the paediatric practitioner, could, if strictly applied, result in more children receiving imaging than occurs in current practice. Research with a larger cohort is required to assess whether a more refined CDR can be designed to limit discomfort, cost and radiation exposure, and to formally determine the performance of current rules (including sensitivity in injury detection) in the paediatric setting.

 

Dr Natalie PHILLIPS (Brisbane, Australia), Katie RASMUSSEN, Sally GRAY, Kerrie Ann ABEL, Geoff ASKIN, Robyn BRADY, Mark WALSH, Jason ACWORTH, Franz BABL

Monday 14 October

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EPOSTER 2.2
10:45 - 11:05

ePoster 2.2 - Short Oral Presentation - Screen 2

Moderator: Robert LEACH (Head of Dept.) (BRUXELLES, Belgium)
10:45 - 10:50 #18014 - SP025 Effective Factors in Improving the Emergency Department Preparedness of Hospitals in Radiation and Nuclear Incidents and Nuclear Terrorism: A Systematic Review.
SP025 Effective Factors in Improving the Emergency Department Preparedness of Hospitals in Radiation and Nuclear Incidents and Nuclear Terrorism: A Systematic Review.

Background: Due to existence of nuclear power plant sites in various parts of the world, as well as political threats in disaster-prone areas throughout the world, there is a probability of nuclear and radiation incidents. The present study was carried out with the purpose to extract effective criteria in emergency department preparedness of hospitals in radiation, nuclear incidents and nuclear terrorism in different countries around the world.

Methods: A systematic search was carried out in Cochrane Library, PubMed, Scopus, Science Direct, Web of Science, ProQuest and EmBase databases between January 1970 to July 2018. The systematic search was carried out according to the PRISMA standard. The required information was extracted from the papers based on the abstract and collection form.

Results: After searching the databases, 1091 papers were finally extracted. The initial search included research papers. After reviewing the papers’ titles, abstracts and full texts, 15 papers were selected for final analysis. Next, 32 criteria were extracted. The criteria were divided into 3 categories. The categories included staff, stuff and systems (structure). The most frequent criteria included training criteria, personal protective equipment, decontamination and practice.

Discussion and Conclusion: The results of the systematic review provided an overview of the effective factors in improving the emergency department preparedness during radiation and nuclear incidents. In addition to the mentioned criteria in different studies, there are other hidden factors that affect the emergency department preparedness in radiation and nuclear incidents, thus, the highest level of preparedness should be considered.

Ahmadi Marzaleh MILAD, Rezaee RITA, Rezaianzadeh ABBAS, Rakhshan MAHNAZ, Haddadi GHOLAMHASSAN, Peyravi MAHMOUDREZA (Shiraz, Iran, Islamic Republic of)
10:50 - 10:55 #18157 - SP026 Medical assistance coordination of terrorist attack.
SP026 Medical assistance coordination of terrorist attack.

Introduction: In case of mass casualty incident (MCI) abroad, medical assistance companies are entrusted to provide a rapid and appropriate response. In addition to a standardized and regularly updated operating process, exercises are key component to ensure performance. The purpose of the present report was to evaluate the effectiveness of our primary casualty plan on our different platforms around the world.

Methods and Setting: Our medical assistance company is present in 28 countries but only 5 large regional platforms are accredited to deal with MCIs. A primary casualty plan, common to all entities, governs all aspects of MCI management (activation, coordination, forwarded team on the spot, relation with Foreign Affairs, communication with media…) under the responsibility of the Group Medical Direction. The present simulation was a tabletop exercise (no field deployment). The scenario was a terrorist attack (fire arms, no bomb) in a touristic place in Senegal with 10 killed and 20 severely injured people from 6 different countries. Coordination of the exercise was performed by the Group Medical Direction with the help of an external team of facilitators located in the country of occurrence, following a detailed chronogram and giving inputs/responding to the different platforms involved. There were also observers on each platform. The exercise was kept secret toward platforms. The main evaluative criterion was the concordance between the response each platform provided and the primary casualty plan (considered as the standard). 

Results: Alert was sent to 6 platforms with victims involved at 8:00 GMT on Sept 19, 2018. After 60 min, 1 regional platform had implemented a specific desk with dedicated staff, activated the local medical correspondent, contacted the other platforms within its region and the other regional platforms, and been in touch with Foreign Affairs Ministry. This platform was designated as leading platform for the entire group. After 90 min, this leading platform had collected a brief description of injuries for all victims and initiated local evacuations for those who required urgent/invasive procedures. One of the doctors of the team was ready to fly over there for local coordination of repatriation, agents having flight options ready. Secrecy was disclosed at this point and exercise ended.

Discussion: This simulation clearly identified platforms in which our primary casualty planis mature and those that need further attention or training. Since most managers and head of platforms were not present at the time of the exercise, it was also interesting to challenge on how not to rely on them. Also the email server of the company was down that morning, which invited to further think on communication tools. Formal debriefing was conducted with heads of platform and chief medical officers 10 days after the exercise and improvement measures were discussed and decided. The program of simulation will be continued.

François-Xavier DUCHATEAU (Paris), Anne LEPETIT, Eic VANHALEWYN, Massemba DIOP
10:55 - 11:00 #18482 - SP027 Somatic complaints in survivors after Typhoon Haiyan 2013 in the Philippines.
SP027 Somatic complaints in survivors after Typhoon Haiyan 2013 in the Philippines.

Background

Somatic complaints (i.e., somatization symptoms and pain) in survivors of natural disaster are frequent symptoms and a complicating factor in the treatment of these patients.

The main objective of this study is to analyze the prevalence of possible somatic complaints in survivors during phase 3 post Typhoon Haiyan 2013 in the Philippines.

Methods

One month after-disaster, between 23th of November  and 22th of December  2013, ARES Emergency Medical Team Type 1 Fixed have managed health care of survivors in Esteban – Burauen (Leyte - Eastern Visayas) and collected data: anagraphic data, prevalent symptoms and final diagnosis of these survivors. We defined pssible psychosomatic complaints those cases in which the prevalent symptom was either chest pain or abdominal pain or headache or malaise or hypertension and it was not possible to obtain an organic diagnosis after the diagnostic pathway. We analyzed the prevalence of psychosomatic complaints in our population and by using simple logistic regression we looked for predictive factors for or against the diagnosis of psychosomatic symptoms.

Results

1890 patients were visited: median age 31 (standard deviation 24), 54% female. 407 patients (21%) had possible somatic symptoms (40% abdominal pain, 25% chest discomfort/pain and palpitations, 19% headache, 11% malaise and 5% hypertension). 225 of these 407 patients (55%) were diagnosed as psychosomatic complaints (12% of the entire study population). The predictive factors for diagnosis of psychosomatic symptom were: malaise with OR of 1.40 (95% CI 1.15-1.71, p<0.01), headache with RR of 1.34 (95% CI 1.11-1.62, p<0.01), abdominal pain with RR of 1.06 (95% CI 0.89-1.26, p=0.5) and hypertension with RR of 1.25 (95% CI 0.91-1.72, p=0.2). The predictive factor against diagnosis of psychosomatic symptom was chest discomfort/pain and palpitations (RR 0.54, 95% CI 0.41-0.73, p<0.01).

Discussion and conclusions

The importance of diagnosing a psycosomatic complaint in patient who experinced natural disaster is the possibility of special treatment options. In the literature the prevalence rates of psycosomatic complaints, such as patients presenting persistent pain symptoms, after natural disaster range from 10 to 50%. Our data confirmed this moderately high prevalence,  in particular in a selected subgroup of patients with pain and/or malaise.

Elisa ANDREOLI, Andrea BARTOLUCCI, Vincenzo G MENDITTO (Ancona, Italy), Marta BUZZO, Francesca RICCOMI, Mattia SAMPAOLESI, Alessia RAPONI, Lara MONTILLO, Francesca FULGENZI, Sirio LOMBARDI, Alessandro MOR, Mario CAROLI
11:00 - 11:05 #18488 - SP028 Comparing training techniques in personal protective equipment use.
SP028 Comparing training techniques in personal protective equipment use.

Introduction:

While an emphasis has been placed on the importance of personal protective equipment (PPE), there are no standardized PPE training guidelines for EM physicians, though many hospitals require brief in-person annual trainings.  Physicians’ response to hazardous material events require PPE utilization to ensure the safety of victims, facilities, and providers; therefore, providing effective and accessible training is crucial. In the event of a real event, circumstances may not allow for an in-person presentation and an accessible video training may provide a useful alternative.

 

Methods:

A randomized trial was performed with sixteen EM residents divided into two sets of groups, with Groups 1 and 2 viewing a demonstration video and Groups 3 and 4 receiving a separate in-person training. The groups then donned and doffed while blinded evaluators assessed critical tasks utilizing a prepared evaluation tool.

 

Results:

Donning

During donning, the four groups were evaluated on fourteen individual critical tasks.  These tasks were meant to happen in sequence and were specifically included in both the video and in-person trainings.

Groups 1 and 2 (video trained) had a total of nine failures out of fifty-five evaluated possibilities - an error rate of 16.0% (95% CI 11.2% to 32.0%).  Frequently failed tasks involved checking the PAPR for functionality, and not performing a final Buddy check prior to entering the decontamination showers.

Groups 3 and 4 (in-person trained) had a total of eleven failures out of fifty-six evaluated possibilities - an error rate of 19.6% (95% CI 8.6%-28.5%).  Most frequently failed tasks also involved PAPR inspection and final Buddy check but had additional common failures in checking vital signs and providing hydration during the process.

Using a Fisher’s exact test to compare the number of failed demonstrated a two-tailed P value of 0.81, demonstrating no statistically significant difference between donning errors in the two sets of groups.

 

Doffing

During doffing, each of the four groups were evaluated on eleven individual critical tasks, also meant to happen in sequence.

Groups 1 and 2 had a total of fifteen failures out of forty-four evaluated possibilities with an error rate of 34.1% (95% CI 21.8% to 48.9%).  The failed tasks were largely evenly distributed.

Groups 3 and 4 had a total of twelve failures out of forty-four evaluated possibilities - an error rate of 27.3% (95% CI 16.2% to 42.0%).  Frequently failed tasks involved the removal of the PAPR hood and rechecking vital signs.

A Fisher’s exact test demonstrated a two-tailed P value of 0.64, showing no statistically significant difference in doffing errors between the two sets of groups.

 

Discussion:

In this pilot study, video and in-person training were equally effective in preparing residents for donning and doffing Level C PPE, with no statistically significant difference between the error rates in each modality.  Further research into this subject with an appropriately powered study is warranted to determine if this equivalence persists.

Dr Richard James SALWAY (New York City, USA), Trenika WILLIAMS, Camilo LONDONO, Kristi KOENIG, Bonnie ARQUILLA

Monday 14 October

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EPOSTER 2.3
10:45 - 11:05

ePoster 2.3 - Short Oral Presentation - Screen 3

Moderator: Jochen BERGS (Hasselt, Belgium)
10:45 - 10:50 #17980 - SP029 Prospective study using a combined didactic and web-based learning curriculum to enhance emergency medicine education.
SP029 Prospective study using a combined didactic and web-based learning curriculum to enhance emergency medicine education.

Background:


Intern doctors are required to complete a term of at least eight weeks in emergency medical care in Australia to gain general registration.  This requirement along with a significant increase in medical graduates in recent years has created challenges in delivering a quality educational experience for intern doctors rotating through busy emergency departments.  This study attempts to assess the effectiveness of a blended emergency medicine intern education program that incorporates web-based learning into traditional classroom-based didactic sessions.

Methods:


This prospective study involved a convenience sample of intern doctors doing their emergency medicine term at two urban Australian emergency departments between April 2015 and January 2017.  Participation in the study was voluntary.  The Emergency Department General Education (EDGE) program is an emergency medicine intern education program that utilises a blended curriculum which incorporates web-based modules into weekly didactic and skills sessions.  All intern doctors rotating through the emergency departments of each study site hospital are given protected off the floor time each week to attend the program's educational sessions.  The program runs throughout the ten-week emergency medicine term and is run five times each academic year.  All interns are given access to the program's corresponding web-based learning modules (www.moodle.learnem.com.au) with completion of the web-based material being voluntary.

To assess change in medical knowledge base during the program, participants were administered two multiple choice examinations covering a variety of emergency medicine topics at the beginning (Week 1) and during the final week (Week 10) of the term.  To determine the study's primary endpoint, the impact of the program's web-based resources on improving participants' emergency medicine knowledge base, the median % of online modules completed by participants (75%) was used as a cut off to create two groups; those that completed < 75% and those that completed >75% of the web-based modules.  Student T-test was used to compare the improvement between Week 1 and 10 scores for all interns as well as the improvement between the two groups.  Mean Week 1 and Week 10 examination scores, Standard Deviation, and 95% confidence intervals (CI), were carried out for the two groups.  Intern satisfaction with the program was also assessed using a satisfaction survey.

Results:


The Average examination score obtained in Week 10 (80%) for all participating interns (N=85) was significantly greater than that achieved in Week 1 (68%; P<0.001).  The % improvement between the Week 1 and Week 10 scores of those that completed <75% (N=42) of web-based modules (16% mean; 95% CI 12-20%) and those that completed >75% (N=43) of web-based modules (27% mean; 95% CI 20-34%) showed a statistically significant difference (p=0.03).  Interns when surveyed were also highly satisfied with all aspects of the EDGE program. 

Discussion & Conclusions:


Educational programs that incorporate web-based learning into didactics have several advantages over traditional lecture-based education and have shown promise in the literature.  This study of a blended curriculum that utilizes web-based learning material shows promise in enhancing intern emergency medicine education.

Dr Ryan WINDISH (Brisbane, Australia), Peter STUART, Raymund DE LA CRUZ, Alistair MURRAY
10:50 - 10:55 #18771 - SP030 The Impact of Clinical Supervision Shifts on the Resident Supervision Index in the Emergency Department of Qatar.
SP030 The Impact of Clinical Supervision Shifts on the Resident Supervision Index in the Emergency Department of Qatar.

Background: Clinical supervision (CS) is an important foundational requirement to maximize education and assure patient safety. The resident supervision index (RSI) has been proposed as a validated tool in GME programs in the United States to measure the quality of CS. CS in a busy emergency department (ED) setting can be challenging due to the demands of clinical service.

Aim/Objectives: The Impact of Clinical Supervision Shifts on the RSI in the ED

 Method: We implemented special four hours shifts to commit faculty time for CS and measured its impact on the RSI. The study was done in a busy academic ED in Qatar with an annual patient attendance of around 450,000 and staffed by around 240 emergency medicine (EM) physicians including 48 residents and 58 fellows.

Results: A total of 336 responses of individual CS encounters were collected over a period of 8 months of CS shifts. The CS encounters were a mix of case discussion, review of test results, supervision of clinical procedures, WBAs and Ultrasound. The faculty was fully involved in patient care in 20.8% of encounters, partially involved in 46.4% and offered advice in 25.6%. The CS contributed to the understanding of the case by the supervisee in 94.0%. The CS resulted in significant impact on all aspects of the RSI – changes were noted in history in 12.2%, examination findings in 14.4%, interpretation of diagnostic data in 23.1%, diagnosis in 13.6%, overall assessment in 21.6% and in the management plan in 35.1%.

 

Discussion:  Unlike other instruments to assess the quality of supervision, RSI provides quantitative measures of resident supervision. Better supervision will help residents to become skilled physicians and will also help the importantly in patient care.

Conclusion:  

CS shifts in a busy ED resulted in a significant overall impact on the RSI and have the potential to offer major benefits to the educational experience of learners and to patient safety.

 Further studies are recommended to assess the use of RSI to assess outcomes of educational programs on patient’s outcomes

Ayman HEREIZ, Dr Khalid BASHIR (Doha, Qatar), Saleem FAROOK, Mohamed Ahmed SEIF MOHAMED, Thomas PROF. STEPHEN
10:55 - 11:00 #19289 - SP031 Pulseless electric activity as the last rhythm recorded before first adrenaline administration is associated with sustained return of spontaneous circulation in out-of-hospital cardiac arrest cases with adrenaline administration.
Pulseless electric activity as the last rhythm recorded before first adrenaline administration is associated with sustained return of spontaneous circulation in out-of-hospital cardiac arrest cases with adrenaline administration.

Backgrounds and Aims: Adrenaline is administered to patients with out-of-hospital cardiac arrest (OHCA) after basic life support and/or advanced airway management. Time interval between start of CPR by emergency medical service (EMS) and adrenaline administration varied depending on regions, levels of EMS and circumstances of OHCA. It is not rare that ECG rhythm conversion from the initial rhythm to other rhythms are recorded during the BLS period. The first goal of basic and advanced life supports in OHCA cases is sustained return of spontaneous circulation (SROSC) although benefit of each resuscitation procedure should be determined by neurologically favourable outcome. This study aimed to identify the factors associated with SROSC in OHCA groups with adrenaline administration before and after hospital arrival (prehospital and in-hospital first adrenaline groups), with consideration of ECG rhythm changes before adrenaline administration.

Methods: In this retrospective analysis of prospective data collection, we extracted the data for 3,729 adult (≥ 8 y) OHCA cases with adrenaline administration before hospital arrival and 4,070 cases with adrenaline from the population-based OHCA data that were prospectively collected during the period of 2011‒218. Univariate and stepwise multivariable logistic regression analysis were applied to disclose the factors associated with SROSC.

Results: The rates of ECG rhythm conversion in prehospital and in-hospital first adrenaline groups correlated with the initial rhythm (P <0.01): 59.5% and 72.9%, respectively in cases with ventricular fibrillation/tachycardia (VF/VT) as initial ECG rhythm , 24.3% and 43.0% in pulseless electric activity (PEA), 7.0% and 5.6% in asystole. In univariate analyses, both initial rhythms and the last rhythms recorded before first adrenaline administrations were associated with SROSC (P <0.01). However, the rate of SROSC was highest when the initial ECG rhythm was VF/VT (43.1% and 35.9%, in prehospital and in-hospital first adrenaline groups respectively) and when the last rhythm recorded before adrenaline administration was PEA (46.1% and 35.9%.respectively). Stepwise multiple logistic regression analyses revealed that PEA as the last rhythm recorded before adrenaline administration was better predictor of SROSC than VF/VT as initial ECG rhythm and that an interaction for SROSC exists between the initial and last ECG rhythms. Any prehospital defibrillation attempt before the first adrenaline administrations was not a major factor associated with SROSC: P = 0.23 and P = 0.69, in prehospital and in-hospital adrenaline groups, respectively. The overall rate of SROSC in the prehospital first adrenaline group (24.9%, 928/3729) was higher than that in the in-hospital first adrenaline group (15.8%, 644/4070).

Conclusions: Rhythm conversions to PEA before first adrenaline administration are likely to be associated with SROSC. PEA as the last rhythm recorded before adrenaline administration is a good predictor of SROSC.

Hideo INABA, Kurosaki HISANORI (Kanazawa, Japan), Kohei TAKADA, Keisuke OHTA, Yukihiro WATO
11:00 - 11:05 #19072 - SP032 The effectiveness of teaching limited compression ultrasound for diagnosing lower extremity DVT in primary health care.
SP032 The effectiveness of teaching limited compression ultrasound for diagnosing lower extremity DVT in primary health care.

Background: According to current literature a limited compression ultrasound (LCUS) protocol is safe to diagnose or exclude lower extremity deep venous thrombosis (DVT). It is a good option to a whole leg ultrasound performed by a radiologist especially in remote health care units where the availability of radiological services is limited and also in emergency department performed by emergency physician (EP).

Objective: To determine whether teaching LCUS to general practitioners (GP) reduces the number of patients with a suspected lower extremity DVT referred to a hospital for US examination safely.

Methods: During 2015-2016, a physician with 5 years of experience in diagnostic US (author Hannula) trained the GPs (n=13 working in Saarikka Primary Care Public Utility (catchment area 18.000 inhabitants) to use LCUS. The number of annual referrals due to a suspected DVT from Saarikka to the closest hospital were evaluated before and after training. The incidence of DVT was considered to be constant, thus the reduction of referrals was interpreted to happen because these patients were diagnosed and treated in primary health care without referring them to hospital. Safety was evaluated by examining all patients from Saarikka area who were diagnosed pulmonary embolism (PE) in nearest hospital during study years and following 3-month periods. Also patients referred to consultant radiologist were examined to find any possible false negative DVTs in LCUS.

Results: In 2014, the number of annual referrals due to a suspected DVT was 60. In 2017 the amount had reduced to 16 with a decrease of 73,3%. The incidence of referrals per 1000 person-years decreased from 3.21 to 0.89. (IRR 3.58, 95% CI 2.04 – 6.66, p<0.001). The annual numbers of PEs were 12 and 23 respectively. None of PE patients had a LCUS performed prior to diagnosis.  There were 13 and 16 referrals to consulting radiologist respectively with no false negative DVTs found.

Conclusions: Teaching a LCUS protocol to GPs seems to effectively and safely reduce the number of referrals to hospital due to a suspected DVT.

Ossi HANNULA (Jyväskylä, Finland), Harri HYPPÖLÄ, Suvi RAUTIAINEN, Ritva VANNINEN

Monday 14 October

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EPOSTER 2.4
10:45 - 11:05

ePoster 2.4 - Short Oral Presentation - Screen 4

Moderator: Nisanth MENON NEDUNGALAPARAMBIL (Moderator/ Faculty) (India, India)
10:45 - 10:50 #18477 - SP033 Mdivi-1 protects CD4+T cells against apoptosis via balancing mitochondrial fusion-fission and preventing the induction of endoplasmic reticulum stress in sepsis.
SP033 Mdivi-1 protects CD4+T cells against apoptosis via balancing mitochondrial fusion-fission and preventing the induction of endoplasmic reticulum stress in sepsis.

Background:

Apoptosis of CD4+T cells plays a central role in the progression of sepsis because it is associated with subsequent immunosuppression and the lack of specific treatment. Thus, developing therapeutic strategies to attenuate apoptosis of CD4+T cells in sepsis is critical. Several studies have demonstrated that Mdivi-1, which is a selective inhibitor of the mitochondrial fission protein dynamin-related protein 1 (Drp1), attenuates apoptosis of myocardial cells and neurons during various pathologic states. The present study revealed the impact of Mdivi-1 on apoptosis of CD4+T cells in sepsis and the potential underlying mechanisms. We hypothesized that Mdivi-1 ameliorated apoptosis in CD4+T cells by re-establishing mitochondrial fusion-fission balance and preventing the induction of endoplasmic reticulum stress in experimental sepsis.

Methods:

It is an original study. We used lipopolysaccharide (LPS) stimulation and cecal ligation and puncture (CLP) surgery as sepsis models in vitro and in vivo, respectively. Apoptosis and cell viability of CD4+T cells were assessed by TUNEL assay and CCK8 assay. Protein levels were measured by western blotting. And mitochondrial morphology was observed by electron miscrosope.

The data were represented as the mean ± standard deviation (SD) using PSS (version 20.0). A one-way ANOVA was used to analyze significant differences between three or more groups and an unpaired Student’s t-test was used to analyze significant differences between two groups and significance was defined as P<0.05. GraphPad Prism 6 (San Diego, CA, USA) were used for the figure design.

Results:

Firstly, Mdivi-1 increased the cell viability of CD4+T cells and attenuated apoptosis of CD4+T cells both in vitro and in vivo. Secondly, the potential mechanism underlying the protective effect of Mdivi-1 involved Mdivi-1 re-establishing mitochondrial fusion-fission balance in sepsis, as reflected by the expression of the mitochondrial fusion proteins MFN2 and OPA1, Drp1 translocation, and mitochondrial morphology, as observed by electron microscopy. Moreover, Mdivi-1 treatment reduced reactive oxygen species (ROS) production and prevented the induction of endoplasmic reticulum stress (ERS) and associated apoptosis. After using tunicamycin to activate ER stress, the protective effect of Mdivi-1 on CD4+T cells was reversed. Together, Mdivi-1 attenuated apoptosis of CD4+T cells is probably through re-establishing mitochondrial fusion-fission balance and prevented the induction of ER stress.

Discussion and Conclusion:

Recent studies and clinical findings have demonstrated that apoptosis of T lymphocytes has a considerable involvement in immunosuppression and is critically related to the outcome of sepsis. Here, our study showed that apoptosis in CD4+ T cells was increased after LPS administration and CLP surgery. Consequently, it is urgent to develop novel therapeutic strategies to attenuate apoptosis in CD4+ T cells during sepsis to affect the outcome. Our results demonstrated that Mdivi-1 protected against apoptosis of CD4+T cells and balancing mitochondrial fusion-fission and preventing the induction of endoplasmic reticulum stress in experimental sepsis are probable mechanisms involved in it. Mdivi-1 is a probable novel therapeutic strategy that targeted apoptosis in CD4+ T cells to affect the outcome of septic patients.

You WU, Lu ZHONG-QIU (Wenzhou, China)
10:55 - 11:00 #19089 - SP035 An observational study of intravenous drug users presenting with groin swelling/pain to the Emergency Department.
SP035 An observational study of intravenous drug users presenting with groin swelling/pain to the Emergency Department.

Background

 

Intravenous drug users (IVDUs) commonly present to the emergency department (ED) complaining of pain and/or swelling in the groin after recent injection. Clinicians concerns include necrotising fasciitis, psuedoaneurysms, abscess and DVT. There is little data available on how common these diagnosis are or what antibiotics to give. Therefore, decisions regarding imaging, antibiotics and specialty involvement are challenging. This study aimed to address this by answering the following questions: what is the best antibiotic to give, do they need imaged in the ED and how do we identify the particularly sick patient?

 

Methods

This was an observational study of patients presenting to the ED at a large tertiary hospital in Aberdeen, Scotland. Those patients that were included attended the ED between 1st January 2015 and 31st December 2016 and had a diagnosis of ‘local infection of skin and cutaneous’, ‘cellulitis’, ‘other bacterial infections’, ‘cutaneous abscess’, ‘necrotising fasciitis’, ‘septic shock’ or ‘septicaemia’ or had a CT or USS in the ED.

 

Patients who did not present with pain and/or swelling of the groin and a history of recent intravenous drug injection were excluded, as were those with no microbiology samples.

 

The remaining group consisted of 30 patients. Documentation, radiology and laboratory results were analysed for these patients.

 

Results

Within the 30 patients, 13 different combinations of antibiotics were administered. 11 patients were bacteraemic. Samples obtained from blood cultures, deep tissue samples, pus/fluid samples and superficial samples all grew similar organisms, with a significant presence of anaerobes, as well as Staphylococcus, Streptococcus and gram negative bacteria.  

 

3 patients had a pseudoaneurysm (one of which was not identified on CT as an abscess was compressing the vessel), 5 had features of necrotising fasciitis on CT and required multiple debridements, 1 had necrotising myositis, 12 had an abscess and 11 had a DVT. 6 required HDU or ICU care.

 

Patients with significant pathology were difficult to recognise. Most were given a low triage category, had relatively normal observations and only mildly raised lactates even if they ultimately required theatre from the ED and then ICU. A LRINEC score of ≥ 6 or 8 was not a good discriminator of need for urgent theatre but none of those who had a score of <6 had time critical findings on CT or at theatre. In 4 out of the 5 cases of requiring urgent repeated debridments in theatre, the CT in the ED did change management because it had not been clinically apparent how significnant the pathology was.

 

17% of these patients have subsequently died (as of January 2019).

 

Conclusions

Based on the organisms that were grown and the resulting sensitivities, if the patient does not warrant necrotising fasciitis specific antibiotics, Flucloxacillin 2g IV and Metronidazole 500mg IV are advised, with Vancomycin to be used in cases of penicillin allergy.

 

A substantial proportion of these patients will have significant time-critical pathology and it is challenging to clinically identify this. We therefore propose that all these patients should have CT angiography in the ED.

 

Heather GRAY (Aberdeen, United Kingdom), Caroline ROBINSON
11:00 - 11:05 #19253 - SP036 CHARACTERISTICS OF THE PATIENT WITH BACTERIEMIA IN EMERGENCY DEPARMENT.
SP036 CHARACTERISTICS OF THE PATIENT WITH BACTERIEMIA IN EMERGENCY DEPARMENT.

INTRODUCTION

The bacteriemia is an important cause of morbidity and mortality in spite of the availability of a powerful antimicrobial therapy and the advances in the support attention. In the Hospitable first aid services, after the clinical evaluation of the feverish syndromes there is habitual the achievement of complementary tests, between which they emphasize the capture of hemocultivos.

TARGETS 

Main: To evaluate the patient's profile with bacteriemia in our health area 

Secondary: To determine the most frequent comorbidities that these present.

 

METHODOLOGY 

Observacional has designed an epidemiologic study to himself with retrospective character, in our hospital that is classified as of the second level and a population of 250000 inhabitants attends. The firs aid service receives approximately 9000 urgencies a month. There were selected patients who consulted for feverish syndrome in the year 2017 and it extracted them to itself hemocultivos. There were checked the case histories of the chosen episodes, variables being gathered as: age and sex, microorganism that isolated itself in the hemocultivo, pathologies previous to the patients, established treatment, I number of returns and mortality.

 RESULTS 

131 patients included with hemocultivos positives. The entire distribution of the sample for sex belonged to 73 males (55,7 %) and 58 women (44,3 %), being the median of age of 76 years, the minimal age 11 and the maxim 97. Of the obtained sample, 14 patients re-entered after being discharged and the mortality in whole was 10,7 %.

As for previous pathologies that they were presenting, it was obtained that 80 (61,06 %) was diagnosed of HTA, their 25 (19,08 %) of DM. As for the cardiovascular diseases, their 28 (21,37 %) had arrhythmias precedents, 6 (4,58 %) had suffered previous IAM, 7 (5,34 %) was presenting cardiovascular disease and 9 (6,87 %) heart failure. If we speak about respiratory illnesses, we are that their 19 (14,50 %) had been diagnosed previously of EPOC and 3 (2,29 %) of bronquiectasias. As for the renal illnesses, 28 of them were presenting ERC (21,37 %), receiving 4 of them hemodiálisis. If we speak about present digestive illnesses in our patients' sample, their 5 (3,81 %) was presenting hepatopatía established and 2 (1,52 %) ulcus. Finally as for the illnesses of neurological origin, their 23 (17,55 %) was presenting cerebrovascular illness and 20 (15,26 %) dementia.

CONCLUSIONS 

The bacteriemias collaborate to a high morbimortalidad incidence. In our series we obtained that the patient's profile is usually a 76-year-old male, with some associate comorbidity, being the pathology more often associated the HTA. On having analyzed the most frequent pathologies for systems, we obtain that the most frequent pathology associated with our patient's profile is that of cardiovascular origin, followed by the neurological one, in the third place the renal one, being the least frequent the digestive one

Alba HERNANDEZ SANCHEZ, Gaelia BORNAS CAYUELA, Sergio Antonio PASTOR MARÍN, Elena Del Carmen MARTÍNEZ CÁNOVAS, Jose Andres SANCHEZ NICOLAS, Maria Encarnacion SANCHEZ CANOVAS, Pascual PIÑERA SALMERÓN (MURCIA, Spain)

Monday 14 October

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EPOSTER 2.5
10:45 - 11:05

ePoster 2.5 - Short Oral Presentation - Screen 5

Moderator: Dr Thomas BEATTIE (Senior lecturer) (Edinburgh)
10:45 - 10:50 #18323 - SP037 Comparison of a subjective triage and Emergency Severity Index.
SP037 Comparison of a subjective triage and Emergency Severity Index.

Background: A three-level subjective triage was used to sort patients at the Emergency Department of University Hospital Motol, Prague, until 2018. P1 priority was defined as an emergency (a life- and/or health-threatening condition) to be seen by a physician immediately, P2 as an urgent case to be seen within an hour and P3 as conditions where the care can be delayed according to the current capacity. This was replaced by an objective triage using Emergency Severity Index v. 4 in 2018. Results of both approaches were compared during a one-month period.

Methods: Triage nurses were instructed to triage all the patients using both conventional subjective triage (P1-P3) and ESI v. 4 (P1-P5) and record both the priorities during December 2017. Former subjective P1 priority was replaced by P1 and P2 priorities, P2 by P3 and former P3 by new categories P4 and P5. Their decision making was supported by a paper ESI flow-chart and a computer application.

Results: Both priorities were recorded in 1,010 out of total 1,782 patients (56.7 %), 376 out of them were admitted to the hospital (37.2 %). The average priority using a subjective triage was 2.37 (median 2) and 3.11 using ESI (median 3). The correlation between both priorities was 0.71 (p < .00001). The new ESI priority was, in comparison to the previous subjective triage, lower in 62.9 %, the same in 35.0 % and higher in 2.1 %. A priority obtained by a subjective triage corresponded to ESI as stated above in only 62.2 % cases, in 33.7 % cases (340 cases, 139 out of them were admitted to the hospital, i.e. 40.9 %) it can be evaluated as a possible undertriage and in 4.1 % cases as an overtriage.

Discussion & Conclusions: Despite inevitable errors when using any objective triage system, a subjective triage, although done by an experienced triage nurse, might be burdened by errors in approximately 37 % cases, therefore a more sensitive five-level triage system using objective criteria and values is highly recommended.
Dr Jan BYDŽOVSKÝ (České Budějovice, Czech Republic)
10:50 - 10:55 #18345 - SP038 Direct Admission to the Intensive Care Unit from the Emergency Department and Mortality in Critically ill Hematology Patients.
SP038 Direct Admission to the Intensive Care Unit from the Emergency Department and Mortality in Critically ill Hematology Patients.

Background: The aim of this study was to assess the benefit of direct ICU admission from the emergency department (ED) compared to admission from wards, in patients with hematological malignancies requiring critical care.

Methods:Post hoc analysis derived from a prospective, multicenter cohort study of 1,011 critically ill adult patients with hematologic malignancies admitted to 17 ICU in Belgium and France from January 2010 to May 2011.The variable of interest was a direct ICU admission from the ED and the outcome was in-hospital mortality. The association between the variable of interest and the outcome was assessed by multivariable logistic regression after multiple imputation of missing data. Several sensitivity analyses were performed: complete case analysis, propensity score matching and multivariable Cox proportional-hazards analysis of 90 day-survival.

Results: Direct ICU admission from the ED occurred in 266 (26.4%) cases, 84 of whom (31.6%) died in the hospital versus 311/742 (41.9%) in those who did not. After adjustment, direct ICU admission from the ED was associated with a decreased in-hospital mortality (adjusted OR: 0.63; 95%CI: 0.45-0.88). This was confirmed in the complete cases analysis (adjusted OR: 0.64; 95%CI: 0.45-0.92) as well as in terms of hazard of death within the 90 days after admission (adjusted HR: 0.77; 95%CI 0.60-0.99). By contrast, in the propensity score matched sample of 402 patients, direct admission was not associated to in-hospital mortality (adjusted OR: 0.92; 95%CI: 0.84-1.01).

Conclusions: In this study, patients with hematological malignancies admitted to the ICU were more likely to be alive at hospital discharge if they were directly admitted from the ED rather than from the wards. Assessment early predictors of poor outcome in cancer patients admitted to the ED is crucial so as to allow early referral to the ICU and avoid delays in treatment initiation and mis-orientation.

Olivier PEYRONY (Paris), Sylvie CHEVRET, Anne-Pascale MEERT, Pierre PEREZ, Achille KOUATCHET, Frédéric PÈNE, Djamel MOKART, Virginie LEMIALE, Alexandre DEMOULE, Martine NYUNGA, Fabrice BRUNEEL, Christine LEBERT, Dominique BENOIT, Adrien MIROUSE, Elie AZOULAY
10:55 - 11:00 #19262 - SP039 Experimental use of machine learning to generate next-activity recommendations in the emergency department.
SP039 Experimental use of machine learning to generate next-activity recommendations in the emergency department.

Background

Patients in the emergency department (ED) need a diagnostic work-up from complaints upon presentation to a correct treatment. The intent is to recognize frequently occurring diagnoses and to not miss serious, potentially life-threatening disorders. Emergency physicians continuously refine information to rearrange the probabilities of seriousness and likelihood of potential diagnoses. They consider the patient characteristics and results of technical investigations and implement clinical decision rules. However, the environment of the ED (e.g., the availability of resources) and the personal characteristics of the physician (e.g., experience, memory, interpersonal skills) also contribute to the decision-making.  Therefore, a secondary source of knowledge proposing the next activity to perform (e.g. take an X-ray) and reflecting all preceding experiences with similar patients in the setting of the specific ED would be an improvement.

Methods

Design Science methodology was applied to develop techniques that generate recommendations for the next activity to be executed for patients in an ED, using a combination of historic data, process management and machine learning. In this project, historic data were used from the ED of the Maria Middelares hospital in Ghent, Belgium consisting of 41657 patients. For each patient, the timeline of all registered events in diagnosis and treatment was reconstructed, starting from the registration at the entrance and ending with either a discharge or hospital admission. Additionally, keywords (e.g., “anemia” in the medical history) and other data values (lab and X-ray) were identified.

Forty strategies that each prioritize different similarities between the current and historic patients based on either activities, data or both, were prototyped to generate probabilities that serve as next-activity recommendations. They were trained on a subset of the patients and evaluated by comparing the predicted with the actual next activities of the other patients. The evaluation criteria were the calculation time and five performance measures:  rank, accuracy, brier score, log loss and rank score.

Results

The Design Science methodology identified 1350465 data events with 625758 activities and 117 unique activities in patient timelines with a maximum of 128 subsequent activities. The best performing strategy achieved an average top ranked recommendation accuracy of 60% and the correct next activity was ranked in the top 3 on average, with an average calculation time of less than 0.4 seconds.

 

Conclusions and future directions

The proposed strategies were fast and sufficiently accurate to help remind emergency physicians of alternatives or forgotten activities, without impacting their decision freedom. These experiments are to be seen as operational process support, i.e. not to try to impose a specific diagnosis or therapy but merely suggesting suitable next activities. It could prevent medical errors and promote a more uniform diagnostic approach. Future research is aiming to further improve the accuracy of the first recommendation and to allow the introduction of clinical pathways. The ultimate goal is to provide real-time recommendations for the possible next-step activities of all patients present at the same time in the ED and for the prioritization of patients, based on their characteristics and results of their preceding processes.

Diederik VAN SASSENBROECK (Ghent, Belgium), Steven MERTENS
11:00 - 11:05 #19317 - SP040 A cross-sectional survey among asylum seekers with non-urgent complaints: Why do they seek help in the ED?
SP040 A cross-sectional survey among asylum seekers with non-urgent complaints: Why do they seek help in the ED?

Background

In line with global trends, European countries have witnessed increase usage of Emergency Departments (ED) services for low acuity complaints. Research on ED utilization in Europe has shown that AS comprise a greater proportion of non-urgent ED visits. Although a variety of factors associated with the use of ED services for low acuity complaints, studies have yet to examine the reasoning underlying hospital-based ED usage for low acuity complaints among patients with asylum seeker (AS) status.

Methods

We conducted a prospective cross-sectional, single center study. Data was collected during 01/12/2016 and 31/07/2017 among AS and Swiss residents attending the ED of the University Hospital, Bern (Switzerland). The survey included questions about motives to present in the ED for low acuity complaints, patients and the treating physicians were asked to answer a questionnaire.

Study participation was voluntary, free of any compensation and individual verbal and written patient consent was obtained before answering the survey. The study was presented to and approved by the regional ethics committee of the Canton of Bern, Switzerland.

Results

AS and Swiss residents differed in several reasons for seeking care in the ED. 30.2% of the AS patients reported to have no knowledge about the Swiss healthcare system (HCS). The perception of medical urgency as reported by the AS and the treating physician showed a significant mismatch, e.g. only 14.2% of the AS-patients perceived their problem as non-urgent in contrast to 43.3% given by the treating ED physician.

With more than half of the AS, direct communication was impossible and in 70.2% of this cases family and friends were used as translators.

Outcomes, like length of stay (LOS), discharge type, and time of visit did not differ between the two groups.

Conclusion

Lacking knowledge about the healthcare setting in the reception country, language barriers, and the perceived urgency of medical care are the main reasons for AS to seek care in ED for primarily low-acuity medical issues. In both groups, convenience and the perceived level of urgency played a role in the decision-making to present themselves in the ED.

Measures to increase health literacy and provision of easily accessible primary care could improve quality of care and reduce the usage of ED as primary care providers in AS. Implementation and usage of professional translator service will relieve family and friends from this role and might provide better and equal care.

Dr Karsten KLINGBERG, Adrian STOLLER, Martin MÜLLER, Sabrina JEGERLEHNER, Anne JACHMANN, Adam D BROWN, Aristomenis EXADAKTYLOS, David SRIVASTAVA (Bern, Switzerland)
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 (Chef de Service) (Paris, France)
CONGRESS HALL

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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 (Medical director emergency department) (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, United Kingdom)
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), Stephen SMITH (Speaker) (Minneapolis, MN, USA, USA), Tomas VILLEN (Attending Physician) (Madrid, Spain)
11:40 - 11:55 Do we still need the ECG in the high-sensitivity troponin era? Stephen SMITH (Speaker) (Minneapolis, MN, USA, USA)
11:55 - 12:10 Panel discussion 2. Barbra BACKUS (Emergency Physician) (Leiden, The Netherlands), Stephen SMITH (Speaker) (Minneapolis, MN, USA, 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), Stephen SMITH (Speaker) (Minneapolis, MN, USA, USA), Barbra BACKUS (Emergency Physician) (Leiden, The Netherlands)
SOUTH HALL 3AB

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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 (.....) (SUNDSVALL, 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: 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, United Kingdom)
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, United Kingdom)
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

Monday 14 October

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SPEED NTW
12:40 - 14:10

YEMD SPEED NETWORKING

Moderators: Martin FANDLER (Consultant) (Bamberg, Germany, Germany), Blair GRAHAM (Research Fellow) (Plymouth, United Kingdom), Basak YILMAZ (Faculty) (Burdur, Turkey)
Speakers: Pr Rick BODY (Professor of Emergency Medicine) (Manchester, United Kingdom), Simon CARLEY (Consultant in Emergency Medicine) (Manchester, United Kingdom), Pr Yonathan FREUND (PUPH) (Paris, France), Colin GRAHAM (Director and Professor of Emergency Medicine) (Hong Kong, Hong Kong), Greg HENRY (USA), Dr Barbara HOGAN (Past President of the European Society for Emergency Medicine, EuSEM) (HAMBURG, Germany), Christian HOHENSTEIN (PHYSICIAN) (Madgeburg, Germany), Dr Abdo KHOURY (Senior attending Physician) (Besançon, France), Pr Suzanne MASON (Professor of Emergency Medicine) (Sheffield, United Kingdom), Tom ROBERTS (Doctor) (Bristol, United Kingdom), Dr Reuben STRAYER (Emergency Physician) (Brooklyn, USA), Judith TINTINALLI (Professor) (Chapel Hill NC, USA)
CLUB H
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, United Kingdom), Dr Susie HEWITT (Consultant) (Derby, United Kingdom), Bernard FOEX (Consultant in Emergency Medicine and Critical Care) (Manchester, United Kingdom)
FORUM HALL

Monday 14 October

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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, United Kingdom)
14:10 - 15:10 HOT TOPIC SPEAK! Subtle ECG Findings of LAD Occlusion Myocardial Infarction. Stephen SMITH (Speaker) (Minneapolis, MN, USA, USA)
15:10 - 15:40 Challenge Steve Smith! Stephen SMITH (Speaker) (Minneapolis, MN, USA, USA)
SOUTH HALL 3AB

Monday 14 October

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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, United Kingdom)
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, United Kingdom)
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

Monday 14 October

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F23
14:10 - 15:40

ABSTRACTS SESSION

Moderators: Marco BONSANO (YEMD Communication Lead) (London, United Kingdom), Christoph DODT (Head 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, China)
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, Republic of), 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
15:45

Monday 14 October

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EPOSTER 3.1
15:45 - 16:05

ePoster 3.1 - Short Oral Presentation - Screen 1

Moderator: Niccolò PARRI (Attending Physician) (Florence, Italy)
15:45 - 15:50 #18268 - SP041 Health promotion in emergency departments with a digital tablet: an observational study.
SP041 Health promotion in emergency departments with a digital tablet: an observational study.

Background: In European countries, an increasing number of patients consult the emergency department (ED) instead of a general practitioner for non-urgent primary medical care. These patients may benefit from ED-based preventive care but overloaded ED physicians are reluctant to be involved. The primary objective of this study was to evaluate the proportion of patients accepting a preventive care intervention using a digital tablet (DT) during their ED visits; the secondary objective was to evaluate the proportion of patients benefitting from counselling.

Methods: Single-center observational study conducted in the minor section of a tertiary-care ED in August and September 2018. Inclusion of consecutive patients ≥18 years with decision-making capacity, admitted during the investigator's presence (rotating 8-hour shifts within a 24h/7d schedule). The DT presented a menu of nine validated health questionnaires with, after completion, a personalized report with health recommendations based on individual scores, and links to support material or details of specialized services. The report could be printed or emailed to the patient.

Results presented as proportions, mean and standard deviation (SD) or median and interquartile range (IQR). The ethics committee approved this study.

Results: 500 eligible patients were approached and 317 (63%) included. Median ED length of stay: 5.2h (3.7; 7.6). Mean age: 44 ± 17 years, women: 45%; 98% Swiss residents; 54% professionals and 20% retired; 27% with a postgraduate degree, 83% registered with a GP, of whom 84% had visited at least once in the preceding year. Patients filled a median of 4 (2;9) questionnaires. Questionnaires presented by frequency of choice: 1) physical activity 71%: 55% below the recommendation of ≥2x30 minutes/week of moderate activity; 2) alcohol consumption 62%: 55% at-risk drinkers; 3) 62% tobacco: 53% active smokers and 58% contemplating smoking cessation; 4) diabetes 62%: 14% at high risk of developing diabetes, with 62% accepting a bedside capillary glucose check with one new diabetes diagnosis; 5) vaccination status 60%: 24% not up to date; 6) colon cancer 56%: 26% of those aged 50-69 years never screened by colonoscopy or fecal occult blood testing, and 14% having failed to keep up with screening schedules; 7) HIV 50%: 40% accepting a rapid non-targeted opt-in capillary test; no reactive test;7) interpersonal violence 46%: 21% victims of verbal and/or physical violence, of whom 10% wished to discuss this issue with the ED physician; 9) drug misuse 48%: 35% reporting recent misuse.

Discussion & Conclusions: A majority of patients accepted a digital screening and health-counseling offer, and 50% chose at least four domains. The questionnaires revealed that a significant proportion of this mostly young and active ED population could benefit from advice to improve their health. Although we did not measure the long-term impacts of our intervention, a significant proportion accepted immediate bedside tests for diabetes and HIV. Our results suggest that a DT screening offer would allow the ED to play a complementary role in promoting health in Switzerland. However, further research on its clinical impact is needed before widespread dissemination of this intervention is attempted in Swiss EDs.

Thibaut JOSSEIN (Lausanne, Switzerland), David CAILLET-BOIS, Olivier HUGLI
15:50 - 15:55 #18567 - SP042 Mass casualty incidents digital transformation - a reloaded project.
SP042 Mass casualty incidents digital transformation - a reloaded project.

Background:

Six years ago a mass casualty incident digitalization project began under the acronym SICAD. The aim of the project was to completely transform the mass casualty incident management on the field and remotely by using current communication technology. This implies using a mobile and server solution as well as electronic patient tags. After a long period of extensive testing of all modules and given several technical drawbacks due to the complexity of the overall solution, a completely redesigned project emerges to carry on the future version of the initial project. The new solution is renamed EMERSYS and it is designed primarily for the use of Romanian emergency agencies.

Methods:

The technical backbone of the previous solution was redesigned in terms of modularity and interconnectivity. Initial requirements for the software solutions are set, allowing for each module to receive and output data independently. The previous Parse.com database integration is completely replaced by an SQL database. Trafficked data is managed by a store-and-forward algorithm in order to maintain a steady flow of operation despite probable moments of lack of data signal. Data logging is significantly augmented. The solution also expands in terms of purpose to several individual applications – mobile and web-based – to address both professionals and bystanders. Improvements are also integrated in terms of power efficiency, graphics, software solution size and operation optimization and security.

Results:

Three distinct packages are set. EMERSYS ONE is an entry level pack designed to digitize the mass casualty incident paper chart and integrate several electronic patient tags. It comprises of a dedicated mobile app for prehospital physicians and paramedics and a web-based app for data output. EMERSYS TWO is a professional pack designed to integrate the majority of functions of the project. It addresses all professionals involved as well as bystanders and it comprises of a dedicated extensive mobile app and six distinct web-based apps: 112 Dispatch, Hospitals, Analysis, Press, Simulator and Backoffice. EMERSYS THREE is based on the same structure as the previous pack but it allows for more advanced algorithms and functions for a more detailed integration of the event digitalization.

Discussion & Conclusions:

The current EMERSYS project carries on the purpose of the previous project to take full advantage of the current technology, especially mobile communications technology. Current work is under way to allow for full offline operation. Further tests are also necessary in order to assess a reliable operation of all packs. Moreover, there is a strong need of simulation by professionals and tech team alike, as well as integrating their feedback. This report refers to the current progress in terms of the overall structure and design and modules operability.