|Sunday 24 September
Trauma (Cutting Edge)
Moderators: Katrin HRUSKA (Farsta, SWEDEN), Suzanne MASON (Professor of Emergency Medicine) (Sheffield, UK)
Coordinator: Rick BODY (UK)
13:00 - 14:30 Paediatric concussion - recent updates. Silvia BRESSAN (Padova, ITALY)
13:00 - 14:30 Transcranial doppler in traumatic brain injury : what's news? Karim TAZAROURTE (Chef de service) (Lyon, FRANCE)
13:00 - 14:30 Top 10 news on paediatric trauma. Ross FISHER (Consultant Paediatric Surgeon) (Sheffield, UK)
Education (How To)
How to build up a local training program? Podium discussion
Moderators: Christoph DODT (München, GERMANY), Riccardo LETO (Chief of ED) (Overpelt, BELGIUM), Nikolas SBYRAKIS (GREECE)
Coordinator: Senad TABAKOVIC (Zürich, SWITZERLAND)
13:00 - 14:30 The Odyssey of a Speciality - Arriving at last to Ithaka? Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, GREECE)
13:00 - 14:30 The Standardized Training for Emergency Medicine Residency in China. Jie WEI (Director) (Wuhan,China, CHINA)
13:00 - 14:30 Development of emergency medicine training in USA: Who, why, how and what? Judith TINTINALLI (Chapel hill, USA)
13:00 - 14:30 Panel Discussion. Eric DRYVER (Consultant) (Lund, SWEDEN), Ruth BROWN (Speaker) (London, UK), Christoph DODT (München, GERMANY), Judith TINTINALLI (Chapel hill, USA), Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, GREECE), Jie WEI (Director) (Wuhan,China, CHINA)
Pulmonary (Game Changers)
Moderators: Panos AGOURIDAKIS (GREECE), Abdo KHOURY (PH) (Besançon, FRANCE)
Coordinator: Nikolas SBYRAKIS (GREECE)
13:00 - 14:30 Diaphragmatic ultrasound in COPD exacerbation. Gianmaria CAMMAROTA (MD, PhD) (Novara, ITALY)
13:00 - 14:30 Case based discussion: NIV in the Emergency Department - When and how? Panos AGOURIDAKIS (GREECE), Abdo KHOURY (PH) (Besançon, FRANCE), Roberto COSENTINI (Milano, ITALY)
FOAM in Europe
Moderators: Martin FANDLER (Doctor) (Nuremberg, GERMANY), Laura HOWARD (UK)
Coordinator: Basak YILMAZ (Ankara, TURKEY)
13:00 - 14:30 acilci.net - how to build a non-english FOAM site. Haldun AKOGLU (Faculty Member) (Istanbul, TURKEY)
13:00 - 14:30 FOAM in germany, from zero to hero? New concepts in emergency medicine training. Martin FANDLER (Doctor) (Nuremberg, GERMANY)
13:00 - 14:30 #FOAMed and accountability - beyond traditional peer review. Laura HOWARD (UK)
Free Papers Session 1
Moderators: M Ashraf BUTT (CAVAN, IRELAND), Anna SPITERI (Consultant) (Malta, MALTA)
13:00 - 14:30 #10829 - OP001 Management of non-vital polytrauma patients in the Emergency Department: A retrospective study.
OP001 Management of non-vital polytrauma patients in the Emergency Department: A retrospective study.
Severe trauma remains a major issue for public healthcare worldwide. Management of these polytrauma patients is mostly performed in intensive care units (ICU) that provide mutlidisciplinary care. The radiological evaluation is a vital part of their management and is essentialy based on performing a whole-body computed tomography (WBCT). However, less attention has been paid to the management of non-vital polytrauma patients in the Emergency Departments (ED). The aim of the study was firstly to evaluate the management of non-vital polytrauma patients who had a WBCT in our ED. We also performed this study to find predicting factors of severity at hospital admission.
We present here a retrospective and monocentric study. We reviewed the chart of all patients who had a WBCT (for trauma) in 2014. We collected epidemiological, clinical and biological parameters and all therapeutic measures during the ED stay. A long-term survival follow-up was also performed. All patients directly admitted to the ICU were excluded.
A total of 210 patients were included for statistical analysis and 64% (CI95% : [57.8-70.8]) of them had one or more lesion(s) in the WBCT (36% normal WBCT). The mean ISS score was 10.1±8.8. 42 patients (20% ; CI95%: [14.6-25.4]) underwent urgent surgical procedures or were admitted to the ICU. We have defined these patients (n=42) as severely injured trauma patients. The mean ISS score for these patients was 16,1±10.8 compared to others 8,5±7.5 in the remaining cohort (p<0.0001). The mortality rate predicted by the TRISS model was 3,1% compared to 1,5% in the whole cohort (p<0.0001). The average length of stay in the ED was 5,4±2.9 hours for the severely injured trauma patients versus 7,2±4.6 hours for the other patients of the study (p=0.003) and the average lenght of stay was 16,2±18.9 days for the severely injured group versus 3,1±6.4 days for the non-severely injured patients (p<0.0001). In multivariate analysis, heart rate (>100/min) and Vittel score (³2 criterias) were related to the probability of belonging to the severely injured trauma group (p=0.03). The 24-hour mortality rate was 0.5% in the ED and the 30-day mortality rate was 1.5%.
The development of a specific network in the ED hosting non-vital but severly injured polytraumas remains crucial. The primary goal of this future network will be to meet technical and time requirements and establish new in-hospital triage algorithms based on clinical variables (such as heart rate), in order to detect these patients at an early stage and offer them priority care in our overcrowded EDs.
13:00 - 14:30 #10838 - OP002 Predictive factors of intracranial bleeding after head trauma in patients under antiplatelet therapy admitted to emergency unit.
OP002 Predictive factors of intracranial bleeding after head trauma in patients under antiplatelet therapy admitted to emergency unit.
Introduction. Traumatic brain injury (TBI) is very common in emergency department. Most of them are the results of mild head injury defined by a Glasgow coma scale score greater or equal to 13. In case of head trauma under antiplatelet agent, guidelines of the French Society of Emergency Medicine required to perform a CT scan to detect brain lesions. In this indication, 90% of CT scan are normal. The utility of CT is still debate given controversial and scarce number of studies.
Methods. We used the RATED registry (Registry of patient with antithrombotic agents admitted to an Emergency Department, NCT02706080) to assess factors of cerebral bleeding related to antiplatelet agent after head trauma. RATED is a monocentric, ongoing (from January 2014), observational registry of consecutive patients under antithrombotic drugs admitted to an emergency department. For this study, only patients under antiplatelet drugs at admission, with a head trauma who benefit a CT scan, were considered. Those under anticoagulants drugs were excluded.
Results. From January 2014 to December 2015, 993 patients under antiplatelet agent were recruited. Of these, 293 (29.5%) underwent a CT scan for trauma brain injury. Intracranial bleeding was found in 26 patients (8.9%). After multivariate analysis, these patients were more likely to have a history of severe hemorrhage (OR = 8.47, 95%CI: 1.56-45.82), a dual antiplatelet therapy (OR = 6.46, 95%CI:1.46-28.44), headache or vomiting (OR = 4.27, 95%CI: 1.44-2.60) and less frequently a glasgow coma scale of 15 (OR = 0.11, 95%CI: 0.03-0.35) than those without intracranial bleeding. The predictive model derived from these variables had a specificity of 98.9% and a Negative predictive value of 92%. The area under curves of the ROC curve was 0.85 (95%CI: 0.77-0.93).
Conclusions. Our study showed that the absence of a history of severe hemorrhage, dual antiplatelet therapy, headache or vomiting, and normal Glasgow coma scale score seems to predict a normal CT scan after trauma brain injury under antiplatelet. This founding need to be confirmed by prospective studies.
13:00 - 14:30 #10979 - OP003 Fall-related injuries in the aged.
OP003 Fall-related injuries in the aged.
Falls constitute a significant challenge in health care, particularly in the oldest age groups. We aimed to investigate the incidence of fall-related injuries among the older Finns.
Materials and methods
In this retrospective population-based study, we registered all consecutive emergency admissions due to fall-related injuries in a high-volume emergency department (ED) during a 2-year study period (January 2015 to December 2016). The catchment area of the study hospital exceeds 1 million inhabitants in tertiary care services, and it provides both primary and tertiary care ED services for a population of 226,696 inhabitants (10,991 aged 80 years or more). Patients were eligible for this study if they were 80 years or older. Patient demographics and diagnoses were retrieved from hospital records. The key factor under analysis was the incidence of fall related injuries.
During the study period, 2,951 patients (median age 87, range 80-104; 73 % females) had 3,802 emergency admissions due to fall-related injuries (2.2% of all ED visits and 11% of all visits in this age group). The incidence of these injuries increased from 49/1,000/year in inhabitants aged 80-89 years to 87/1,000/year among those aged ≥90 years (p<0.001). The risk was also higher among females (p<0.001), the incidence was 60/1,000/year among females and 45/1,000/year among males. Typical injuries caused by falls included, fractured femur (21%), intracranial injury (19%, with intra-cranial hemorrhage in 5% of patients), open head wound (15%) and forearm fracture (7%). The number of injurious falls of all ED visits varied from 253-358 from month to month, with no association with time of year. Recurrent falls were registered in 39% of patients (range 1-5 falls). When single fallers and recurrent fallers were compared, older age and female gender were not associated with higher risk of recurrences (p>0.05). In community-dwellers, most injuries (64%) occurred in domestic setting. Ten percent of all patients were admitted to hospital from nursing homes.
The observed incidence of fall-related injuries is lower than in earlier reports. Nevertheless, these incidents cause a significant burden to emergency services. While the risk of single falls increased with age and was also higher among females, these risk factors were not associated with higher risk of fall recurrences.
13:00 - 14:30 #11629 - OP004 The role of bedside US in detection of early expanding traumatic pneumothorax in-patient who require positive pressure ventilation.
OP004 The role of bedside US in detection of early expanding traumatic pneumothorax in-patient who require positive pressure ventilation.
One of the most important factors for total morbidity and mortality in traumatized emergency patients is chest trauma; the complexity of injury in trauma patients makes it challenging to provide an optimal oxygenation while protecting the lung from further ventilator-induced injury to it. Ultrasound has a well-known established role in the diagnosis of a traumatic pneumothorax.
Case series: We are reported 46 patients with traumatic pneumothorax who require positive-pressure ventilation recruited from Alexandria Main University Hospital Emergency Department who examined pre and post CT-Chest scanning by the same operator between November 2015 and September 2016.
Inclusion criteria: Any patient with either blunt or penetrating chest trauma regardless the age or gender who require positive-pressure ventilation.
Exclusion criteria: patients with open or tension pneumothorax.
The chest scanned (using the superficial probe 7.5 MHz type L7M-A of our CHISON device model ECO 2) at three lines and two views for each hemithorax as the following (1)anterior second through sixth intercostal spaces at the parasternal line, (2) anterior second through sixth intercostal spaces at the mid-clavicular line, (3) fourth through sixth intercostal spaces at the anterior axillary line,(4) fourth intercostal space at the mid-axillary line, (5) fourth intercostal space at the posterior axillary line, to assess for the presence of a sliding lung.
We analyzed 46 patients, 85% were men, with median age of 27 for the total number of patients. The results of ultrasound scanning of intubated patients’ pre CT scan in comparison to the result of ultrasound scanning after the CT scan of the chest to detect the behavior of traumatic pneumothorax. Six patient (13%) had expanding pneumothorax detected by CT chest and comforted by bedside US. One patient developed right tension pneumothorax after 6 hours, in which pre CT US scanning was Right minimal pneumothorax and Left minimal pneumothorax, post CT after 35 minute was Right mild pneumothorax and left minimal pneumothorax. Another patient developed massive left pneumothorax discovered accidental during CT abdomen, pre CT US scanning was Right mild pneumothorax and free left pneumothorax, post CT was Right mild pneumothorax and left minimal pneumothorax.
Conclusion: Bedside US lung could be used a predictive tool in detection of early expanding traumatic pneumothorax in-patient on positive-pressure ventilation.
13:00 - 14:30 #11634 - OP005 Scand-Ankle – The effect of alcohol intervention regarding complications after acute ankle fracture surgery (RCT).
OP005 Scand-Ankle – The effect of alcohol intervention regarding complications after acute ankle fracture surgery (RCT).
M.D., PhD-student Egholm JWM1,2, PhD Pedersen B1,3, M.D. Oppedal K4, Professor M.D. Lauritzen JB5, M.D. Madsen BL6, Professor M.D. Tønnesen H1,3
1WHO-CC, Clin Health Promotion Centre, Bispebjerg-Frederiksberg Hospital, University of Copenhagen, Denmark; 2Orthopedic Dept, Hospital of Southern Jutland, University of Southern Denmark; 3Clin Health Promotion Centre, Dept Health Sciences, Lund University, Sweden; 4Alcohol and Drug Research Western Norway, Stavanger University Hospital, Norway; 5Dept Orthopaedic Surgery, Bispebjerg-Frederiksberg Hospital, University of Copenhagen, Denmark; 6Dept Orthopaedic Surgery, Hvidovre Hospital, University of Copenhagen, Denmark.
Patients with hazardous alcohol intake are overrepresented in emergency departments and surgical departments. In elective surgery, preoperative alcohol cessation interventions can reduce postoperative complications but no studies have investigated the effect of alcohol cessation intervention at the time of surgery for acute fractures.
To evaluate the effect of the Gold Standard Programme for alcohol cessation intervention (GSP-A) for patients undergoing acute ankle fracture surgery regarding postoperative complications.
Our RCT design included a total number of 70 patients from Hvidovre and Bispebjerg Hospitals with an excessive intake of alcohol and an ankle fracture that required osteosynthesis. They were allocated to either standard care or a 6-weeks GSP-A aiming to complete alcohol abstinence peri- and postoperatively.
GPS-A involved a patient educating programme and weekly sessions at the orthopedic outpatient clinics. Furthermore, patients were provided with thiamine and B-vitamins, prophylaxis and treatment for alcohol withdrawal symptom and disulfiram to support abstinence.
Biochemical validation of alcohol intake was carried out. Follow-up took place after 6 weeks and 3, 6, 9 and 12 months.
The main outcomes were postoperative complications (requiring treatments), alcohol intake and cost-effectiveness.
In the GSP-A group 12 patients (34%) developed complications compared to 14 patients (42%) in the control group (p=1.0).
Interestingly, 14% in the control group versus 51 % in the in the GSP-A group had abstained completely from alcohol at 6 weeks follow up. (p=0.001).
We found no statistically significant differences in the number of complications between the intervention and control group.
We are looking forward to evaluate the cost-effectiveness of the study to see if there is a difference between the two groups. Biochemical analysis is still ongoing.
However, the majority of the intervention group completely abstained from alcohol in the intervention period.
 Tønnesen et al. Smoking and alcohol intervention before surgery: evidence for best practice. Br J Anaesth. 2009 Mar;102(3):297-306.
13:00 - 14:30 #11672 - OP006 Comparison of time to return to work for different injured body regions following moderate and severe trauma in Hong Kong.
OP006 Comparison of time to return to work for different injured body regions following moderate and severe trauma in Hong Kong.
Head, neck, extremity, thorax and abdominal injuries are the main injury sites for trauma in Hong Kong. Return to work (RTW) status is an indicator of their outcome and an important element in their social reintegration. Besides physical recovery, RTW may be affected by the psychological characteristics of patients, available technologies that can assist their functional recovery and socioeconomic factors. Some of these are modifiable and may vary between injury sites. The aim of this study was to compare the time to return to work (RTW) and time to reach Hong Kong norm of SF36 of patients who sustained moderate to severe injuries at these sites. This may help to identify the type of injury where research is most needed to bridge the gap between time to recovery and return to work.
This was a multicenter, prospective cohort study of patients entered into the trauma registry of the three regional trauma centres in Hong Kong. Patients were included if they were aged between 18 and 70, with an ISS³9 and were working or seeking employment before injury. Outcome measures included physical component summary (PCS) and mental component summary (MCS) scores in SF36 and their return to work status over 5 years. The Hong Kong norm for PCS is defined as >52.83 and that for MCS is >47.18.
189 patients were recruited to the study from 1 January to 31 September 2010 (mean age 41.4 years; 80.4% male). 99 (52.4%) patients had head or neck injuries, 44 (23.3%) had extremity injuries, 39 (20.6%) had thoracic or abdominal injuries, and 7 (3.7%) had spinal or other body region injuries. 5-year mortality rate was highest in head injury patients (12/99, 12.1%, 95%CI 6.4-20.2%), followed by extremity injury (1/44, 2.3%, 95%CI 0.1-12.0%). There was no death in patients with injury in other parts of the body. For patients that are still alive at 5 year follow-up (n=87, 43 and 39 for head/neck, extremity and thorax/abdomen injuries respectively), Kaplan-Meier curves of time to RTW were different between the three principal injury sites (log-rank test p=0.041). Mean time to RTW for head/neck injury was 2.2 years (95%CI 1.6-2.8 years), 2.3 years (95%CI 1.5-3.1 years) for thoracic/abdominal injury and 3.6 years (95%CI 2.8-4.5 years) for extremity injury. However, Kaplan-Meier curves of time to reaching the Hong Kong normal PCS or MCS showed no significant difference between the three injury sites (log-rank test p=0.386 and 0.482 respectively; mean time to PCS>52.83 ranged from 3.3-4.0 years and mean time to MCS>47.18 ranged from 2.0-2.3 years).
Among the factors that affect the RTW status besides health status, some of them are specific to extremity (limb) injuries. This may represent a specific group for targeted rehabilitation to shorten the time to RTW.
The study has been conducted with the support of the Health and Health Service Research Fund from Hong Kong government (HHSRF 07080261).
13:00 - 14:30 #11790 - OP007 Is the use of collar in Whiplash Associated Disorders (WAD) more associated to a worse recover? A retrospective study.
OP007 Is the use of collar in Whiplash Associated Disorders (WAD) more associated to a worse recover? A retrospective study.
Background: whiplash Associated Disorders (WAD) are very frequent reasons for request of health care interventions in acute setting. They involve about 30-40% of people after a car accident, and they are a growing problem in terms of both health and insurance costs. The “gold standard” of WAD in acute management is not established and the application of cervical collar continues to represent a common practice, although it is known that it does not to improve the course of disease.
Aim: the goal of this study is to assess whether the use of cervical collar in patients with WAD is associated to a higher risk of readmission within 90 days from trauma and the likely onset of post-traumatic associated syndrome
Methods: we retrospectively evaluated all the patients observed in the Emergency Department (ED) of the University Hospital of Verona for WAD, according to the Quebec Task Force definition. We considered only the patients with isolated WAD within 48 hours from a car accident, excluding those with associated head trauma. At the ED evaluation time we registered for each patient: the demographic and clinical features; the time and mechanism of trauma; the grade of WAD and if the application of cervical collar was performed or not. Moreover, we excluded the patients in case of rx assessment of cervical spine fracture (WAD 4). We carried out a multivariate analysis to verify the impact of the cervical collar on the outcome adjusted for grade of WAD. Finally, we submitted our series of patients to propensity score matching, in order to reduce the bias of a retrospective study, and then we repeated the statistical analysis on the selected cohort of patients.
Results: from January 2013 to December 2014 we observed 2156 patients with WAD (grade 0 to 3). In most of the cases (85.5% of the patients) a cervical collar was applied. An overall number of 162 patients (7.5%) had a readmission within 90 days from trauma and 154 (7.1%) out of them used a cervical collar (p = 0.001). Cervical immobilization resulted to be a significant risk factor for readmission both in univariate (OR 3.663, 95% IC 1.684-7.122) and in multivariate analysis (adjusted OR 3.561, 95% IC 1.255-7.349). After the propensity score matching we selected 482 patients equally divided (50% with and 50% without cervical collar). Even in the selected series readmission rate was higher in patients with cervical collar (10.4% vs 2.9%, p < 0.001). The risk was confirmed both in univariate (OR 3.869, 95% IC 1.640-9.127, p = 0.002) and in multivariate analysis (adjusted OR 3.878, 95% IC 1.643-9.153, p = 0.001).
Conclusion: the application of cervical collar in WAD appears to be an independent risk factor for the onset of post-traumatic associated syndrome. These results are not related with the grade of WAD and they have been confirmed even when propensity score matching was performed.
13:00 - 14:30 #11845 - OP008 Prognostic factors for severe blunt trauma patients according to chest injury severity. Analysis from the FIRST study.
OP008 Prognostic factors for severe blunt trauma patients according to chest injury severity. Analysis from the FIRST study.
INTRODUCTION: Severe blunt trauma is associated with a high risk of morbidity and mortality. The chest wall and vital organs inside the chest are commonly affected. The purpose of the present analysis was to determine whether the prognostic factors in patients with severe trauma were modified by the severity of the chest trauma.
METHODS: This is an ancillary analysis of the FIRST study, a multicenter cohort study on consecutive patients with severe blunt trauma requiring admission to intensive care units at university hospital trauma centers within the first 72 hours. The analysis was restricted to patients admitted directly to a university hospital trauma center. The main endpoint was the survival within the first 30 days after the trauma.
RESULTS: Of the 2,052 patients analyzed, 583 (28%) had a severe chest trauma (chest AIS > 3). The 30-day mortality was 22% in the chest AIS > 3 group and 17% in the chest AIS ≤ 3 group (p = 0.006). In bivariate analysis, only age and accident type comparing motorcycle/ bicycle crashes with motor vehicle crashes had a significant interaction term with chest trauma severity (p=0.003 and p=0.0015). In multivariate analysis, the interaction between age and severe chest trauma became non-significant (p= 0.12) after adjustment for the Glasgow Coma Scale (GCS) and/or head AIS whereas that between motorcycle/ bicycle crashes and severe chest trauma remained significant (p= 0.042) even after adjustment for GCS, heart rate, age, sex and head AIS. In the severe chest trauma group, motorcyclists/bicyclists had a higher mortality risk than did victims of motor vehicle crashes (SHR: 1.66; 95% CI, 1.08–2.55; p= 0.02), whereas in the non-severe chest trauma group, motorcyclists/bicyclists had the same mortality risk as victims of motor vehicle crashes (SHR: 0.97; 95% CI, 0.66–1.42; p= 0.87).
CONCLUSION:there is a surplus mortality risk among motorcyclists when they have severe chest trauma, contrary to the vehicle accident victims and pedestrians. This high-risk mortality group must be identified to establish preventive priorities and efficient management of existing injuries, in order to improve the outcome.
13:00 - 14:30 #11940 - OP009 Inhibition of potassium voltage-dependent channels and hydrogen disulfide production restores the blood pressure and improves the survival in anaphylactic shock in Wistar rat model.
OP009 Inhibition of potassium voltage-dependent channels and hydrogen disulfide production restores the blood pressure and improves the survival in anaphylactic shock in Wistar rat model.
Introduction: Anaphylactic shock (AS) is a life-threatening condition in which blood circulation fails to meet oxygen demands of organs in the body. Restoring effective circulation is the major objective of treatment which can sometimes be resistant to conventional treatments available. We evaluated novel drugs targeting specific pharmacological pathways to define therapeutic alternatives or supplements to epinephrine. The role of potassium voltage-dependent channels (Kv) and hydrogen disulfide (H2S), a potent vasodilator, was not explored in AS.
Objectives: Our objective was to demonstrate that the inhibition of Kv with 4 aminopyridine (4-AP) alone or combined with the inhibition of the production of H2S with dl-propargylglycine (PEG) or betacyanoalanine (BCA) restores blood pressure and improves survival.
Methods: Rats were sensitized with ovalbumin (OVA, 1mg s.c), and AS was induced by i.v. injection of OVA (1mg) through jugular vein catheter. Experimental groups included NA=non-allergic rats (N=6); Controls=allergic rats (N=10); allergic rats treated with 4-AP (1 mg/kg) (N=10); epinephrine (EPI)=allergic rats treated with EPI (10 µg/kg) (N=10), allergic rats treated with PEG (N=10), allergic rats treated with BCA (N=10). Treatments were administered 1 minute after induction of AS. Mean arterial blood pressure (MAP), heart rate (HR) were measured through carotid artery catheter
Results: MAP, HR, and survival were measured for 60 minutes. MAP was normal in the NA group; severe hypotension and high mortality were observed in controls; normalization of MAP, HR, and increased survival were observed in 4-AP, DPG, BCA, 4-AP+DPG or BCA, and EPI groups. Survival time was: controls=22±3 min, EPI=59±1 min, 4-AP=60 min, DPG=49±5 min, BCA=44±7 min, 4-AP+DPG=58±2, 4-AP+BCA=60 min. All allergic 4-AP and 4-AP+BCA-treated rats survived after the induction of AS (p<0.05).
Conclusion: We demonstrated that the allergen-activation of Kv is a probably a new pathway involved in the vasodilation induce by AS in a rat model. It seems that H2S is a major mediator released during AS in endothelial and vascular smooth muscle cells and could play a role in the induction of AS. Inhibition of Kv alone or combined with the inhibition of H2S production improves significantly survival and restore blood pressure.
Pulmonary (Cutting Edge)
Moderators: Panos AGOURIDAKIS (GREECE), Roberto COSENTINI (Milano, ITALY)
Coordinator: Nikolas SBYRAKIS (GREECE)
15:00 - 16:30 POCUS in dyspnoea: What does the probe add to the stethoscope? Nicolas LIM (Dublin, IRELAND)
15:00 - 16:30 Asthma and COPD: Latest guidelines and practical tools for the Emergency Physician. Michael RADEOS (USA)
15:00 - 16:30 Invasive Mechanical Ventilation: an update for the emergency physician. Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, GREECE)
Trauma (How To)
Moderators: Anil CHOPRA (CANADA), Burak KATIPOGLU (Faculty) (Ankara, TURKEY)
Coordinator: Rick BODY (UK)
15:00 - 16:30 Paediatric trauma is different. Ross FISHER (Consultant Paediatric Surgeon) (Sheffield, UK)
15:00 - 16:30 Are we failing the frail falling? Katrin HRUSKA (Farsta, SWEDEN)
15:00 - 16:30 How can I manage an urgent invasive procedure for a patient taking oral anticoagulants? Karim TAZAROURTE (Chef de service) (Lyon, FRANCE)
Education (Game Changers)
LIVE SCENARIOS! TEST YOUR DIAGNOSTIC SKILLS!
Moderators: Eric DRYVER (Consultant) (Lund, SWEDEN), Gregor PROSEN (MARIBOR, SLOVENIA)
Coordinator: Senad TABAKOVIC (Zürich, SWITZERLAND)
Speakers: Eric DRYVER (Consultant) (Lund, SWEDEN), Caroline HÅRD AF SEGERSTAD (Senior consultant) (Ystad, SWEDEN), Gregor PROSEN (MARIBOR, SLOVENIA)
Scenario based training as the future European education perspective
YEMD - MSF
Moderators: Luca CARENZO (SIMULATION COMPETITION ONLY) (NOVARA, ITALY), Aposotolos VEIZIS (GREECE)
Coordinator: Basak YILMAZ (Ankara, TURKEY)
15:00 - 16:30 Who is MSF. Aposotolos VEIZIS (GREECE)
15:00 - 16:30 What about Emergency Medicine in MSF. Victor ILLANES (FRANCE)
15:00 - 16:30 How can I get involved. Luca CARENZO (SIMULATION COMPETITION ONLY) (NOVARA, ITALY)
Disaster Medicine I
How to prepare doctors to face the new threats
Moderators: Francesco DELLA CORTE (ITALY), Abdo KHOURY (PH) (Besançon, FRANCE)
Coordinator: Abdo KHOURY (Besançon, FRANCE)
15:00 - 16:30 Damage control Ground Zero. Vitor ALMEIDA (PORTUGAL)
15:00 - 16:30 Damage control resuscitation. Benoît VIVIEN (Paris, FRANCE)
15:00 - 16:30 Training of Emergency Medical Teams. Luca RAGAZZONI (Novara, ITALY)
Free Papers Session 2
Moderators: Tom BEATTIE (UK), Anna SPITERI (Consultant) (Malta, MALTA)
15:00 - 16:30 #10087 - OP010 Significance of the thrombo-inflammatory status-based novel prognostic score as a useful predictor for in-hospital mortality of patients with type B acute aortic dissection.
OP010 Significance of the thrombo-inflammatory status-based novel prognostic score as a useful predictor for in-hospital mortality of patients with type B acute aortic dissection.
Background: Inflammation and thrombosis are involved in the progression of acute aortic dissection (AAD). The aim of this study was to assess the prognostic significance of the Simplified Thrombo-Inflammatory Prognostic Score (sTIPS) in patients with early phase type B AAD.
Methods: We retrospectively reviewed 491 patients with type B AAD between November 2012 and September 2015. sTIPS was calculated using data obtained at the time of admission, and patients were assigned a score of 0, 1, or 2. Kaplan-Meier curves and multivariable Cox regression analyses were used to investigate the associations between the score and hospital survival.
Results: Of 491 type B AAD patients included in this analysis, 24 patients (4.9%) died while hospitalized. Compared to those with lower sTIPS, patients with higher sTIPS had higher rates of in-hospital mortality (P = 0.001). Kaplan-Meier analysis also showed that cumulative mortality was significantly higher in patients with higher sTIPS (P = 0.001). Multivariable Cox regression analysis further revealed that scores of 2 or 1 (versus 0) were strong predictors of in-hospital mortality (sTIPS 2: hazard ratio: 5.620, 95%; confidence interval [CI]: 1.320-16.167; P = 0.017; sTIPS 1: hazard ratio: 2.012, 95%; CI: 1.254-3.204; P = 0.043) after controlling for all of the confounding factors. Subgroup analysis showed sTIPS was also positively associated with the hazard of in-hospital mortality in patients with different therapies.
Conclusions: sTIPS was a useful tool for risk-stratifying type B AAD patients at admission for outcomes such as in-hospital mortality in the early phase.
15:00 - 16:30 #10839 - OP011 Impact of Beta-blockers on the clinical diagnosis of patients with pulmonary embolism.
OP011 Impact of Beta-blockers on the clinical diagnosis of patients with pulmonary embolism.
Introduction. The morbidity and mortality of patients with pulmonary embolism is high with 8 to 23 deaths per 100,000. In order to make the diagnosis, the emergency physician uses clinical scores that involve the presence or absence of a tachycardia. The objective of our study was to assess the impact of beta-blockers on the heart rate of patient with a pulmonary embolism.
Methods. We performed a retrospective, observational, monocentric study from June 2014 to May 2015. All consecutive patients admitted to our department with an objectived pulmonary embolism were included.
Results. Among the 117 patients included, more than a quarter was under beta-blocker (n = 31). The mean age was 68+/-17 years. Patients with beta-blockers were older than those without (respectively, 76+/-11 vs. 66+/-18 years, p = 0.03). The mean heart rate was lower in patient with beta-blockers than in those without (76.714 vs. 90.719 bpm, p <0.001, respectively). Moreover, regarding the heart rate item in the revised Geneva score, those with beta-blockers were more likely to have a heart rate < 75 bpm (42% vs. 19%, p = 0.015, respectively) and less likely > 95 bpm (13% vs. 41%, p = 0.04, respectively) than those without. However, for the sPESI score, there was no difference between the mean score of those with and without beta-blockers (respectively, 1.2+/-0.9 vs. 0.9+/-0.8, p = 0.104). Interestingly, regarding the heart rate item of sPESI score, none of the patient with beta-blocker had a heart rate > 110 bpm whereas 9 (10.5%) of those without beta-blocker had it (p = 0.11).
Conclusions. Our study showed that 26.5% of PE patient admitted in an emergency department were under beta-blockers. Moreover, PE patient with beta-blockers had a lower mean heart rate than those without. This could have an impact on the different scores used by emergency physicians to diagnose PE. Thus, 42% of PE patients with beta-blockers did not obtain the point assigned to tachycardia in the revised Geneva score. This could therefore have an impact on emergency physician diagnosis which could underestimated the PE score of some patient with beta-blocker. This results should be validated by multicentric and prospective studies.
15:00 - 16:30 #10885 - OP012 A real life study of patients under direct oral anticoagulants admitted to an emergency department and their bleeding events.
OP012 A real life study of patients under direct oral anticoagulants admitted to an emergency department and their bleeding events.
Introduction. The use of direct oral anticoagulants (DOACs) is increasing due to an easier used and a decreased bleeding risk. The objective of our study was to describe the clinical characteristics of patients under DOACs, the type of hemorrhage and their management.
Methods. We performed a retrospective, monocentric and descriptive study on patients under DOACs and admitted to our emergency department between January 2014 and June 2015. We used the RATED registry (Registry of patient with antithrombotic agents admitted to an Emergency Department, NCT02706080) which is a monocentric, ongoing (from January 2014), observational registry of consecutive patients under antithrombotic drugs admitted to an emergency department.
Results. Of the 357 patients under DOACs included, 51 (14.3%) were under apixaban, 109 (30.5%) under dabigatran and 197 (55.2%) under rivaroxaban. Atrial fibrillation was the most frequent indication for DOACs (79.3%) with an average CHA2DS2-VASc score of 3.9 ± 1.8. The mean age was 73 ± 15 years with 78 ± 12 years for apixaban, 74 ± 13 years for dabigatran and 71 ± 16 years for rivaroxaban. Our cohort identified 211 (59%) prescribing errors related to the combination of a treatment which could increase the bleeding risk (33.6%), a dose not adapted to the age of the patient (28.0%), a dosage not adapted to creatinine clearance level (15.9%) or an additional treatment with antiplatelet agent for more than 1 year (13.3%). Of the 357 patients under DOACs, 64 patients (17.9%) were admitted for hemorrhage with 23 major bleeding (6.4%). Bleeding occurred in 8 patients (15.7%) under apixaban, in 13 under dabigatran (11.9%), in 43 (21.8%) under rivaroxaban with, respectively, 2-5-16 major bleeding. The management of those with major bleeding (n=23) was transfusion for 9 (39%) of them (5 under rivaroxaban, 3 under dabigatran and 1 under apixaban), reversion by prothrombin complex concentrate for 1 (4.3%) under rivaroxaban or by FEIBA for 4 (17.4%) under rivaroxaban.
Conclusions. Our study showed that more than half of patients under DOACs admitted to the emergency department had a prescription error and that only 1 major bleeding over 5 were treated with a reversal agent. Even if DOACs are easier to use, clinicians must be aware of interaction and contraindication, and must improve the management of major bleeding.
15:00 - 16:30 #10899 - OP013 Importance of delay for management of STEMI: does the helicopter HEMS is better than ground transport with MICU ambulance? Analyze of the French region Centre Registry of Acute Coronary (CRAC) model.
OP013 Importance of delay for management of STEMI: does the helicopter HEMS is better than ground transport with MICU ambulance? Analyze of the French region Centre Registry of Acute Coronary (CRAC) model.
Introduction: In the treatment of ST-segment–elevation myocardial infarction (STEMI), faster times to reperfusion result in better outcomes. Primary prehospital Helicopter Emergency Medical Service (HEMS) interventions may play a role in reperfusion therapy. We analyzed data from our Cardiologic Regional Interventional Observatory Registry involving patients with STEMI aimed at the evaluation of the potential benefit of HEMS interventions as compared with EMS ground transport with MICU (Mobile Intensive care Unit).
Materials and Methods:Retrospective multicentric study conducted from January 2014 to January 2015. All successive patients with STEMI eligible for percutaneous coronary intervention (PCI) were included. Access times were computed allowing the estimation of dispatch French System (SAMU) delay from emergency the phone call to admission to one of the 6 cath labs using standard data collection from the French region Centre Registry of Acute Coronary (CRAC). We analyze pre admission transport time (FMC-DTB) according to distance between FMC to cath lab location and mode of transport (HEMS vs MICU)
Results: During the study period, 1699 patients with STEMI were included in the Registry.In the overall population, Mean age was 63,2 y-o, sex ratio male was 2,7. The mean time from the emergency phone call to the dispatch center (Number 15 or 112) to the ECG as the First Medical Contact (FMC) is 1h40 mn. Of these patients 82 % were transferred for primary PCI, 2% fibrinolytic therapy, 7% secondary angioplasty.The mean response time FMC to Door-to Balloon (DTB) time was longer using the helicopter HEMS (2h20 mn) than road transport with MICU ambulances (2h:06 min).For short distances (25-74 km) the median delay using road transport was shorter (1h: 54 min) whereas this time by air transport (2h: 12 min).The median transport delay gain was shorter (15 min) for distances over 75 km by using HEMS.
Discussion: In many European countries, patients with STEMI , guidelines have called for device activation within 90 minutes of initial presentation. Our results offer important insights of the impact of transfer time and mode of transport on achievement of guideline goals for D2D time in the treatment of STEMI patients as HEMS transport did not offer D2D time advantages for STEMI patients better than ambulances for short distances. Several explanations: (1) time for air transportation, (2) cases with more complexity (3) distance .In our study for patients with STEMI, benefits of air transportation with HEMS are not significant for short (< 50 km) or long (> 75 km) distances and may encourage the dispatch center to use the MICU ambulances for a rapid access to PCI .
Conclusions In our CRAC registry for management of STEMI, strategy of decision was associated with longer DTB times with HEMS versus MICU ambulances.Our findings suggest the need for evaluation and continued systems improvement of the use of effective resources for transport of STEMI to the PCI.
15:00 - 16:30 #10949 - OP014 The Clinical epidemiology and prognosis in patients with non-specific chest pain.
OP014 The Clinical epidemiology and prognosis in patients with non-specific chest pain.
The purpose of this study was to assess the prognosis for patients with suspected acute coronary syndrome (ACS) after the implementation of high sensitivity troponins (hstn). The first objective was to investigate if there had been a change in the incidence of patients diagnosed with ischemic heart disease and non-specific chest pain(NSCP) after the implementation of hsTn. The second objective was to determine the mortality in the NSCP group before and after hsTn and the third objective to evaluate the prognosis and mortality in patients discharged with the diagnosis ACS, stable angina pectoris (SAP), other heart related conditions (OHC) and NSCP after hstn implementation.
This study is a register based prospective multicentre cohort study. All patients aged 18 and older in the region of southern Denmark with an acute contact to the emergency department or cardiology department in 2013 and who had at least one troponin measurement were included. Depending on their discharge diagnosis and the Troponin value, the patients were stratified into 4 groups, consisting of
a) Patients with myocardial infarction and elevated Troponin measurement.
b) Patients with other serious heart disease than ACS
c) Patients with clinical assessed stable SAP and normal troponin
d) Patients with normal troponin and without acute heart disease, who were discharged without an explanatory diagnosis of the chest pain, NSCP.
Patients arewere identified by their troponin measurements from the biochemical system. Endpoint during follow up was obtained from the National Patient Registry and Civil Registration System. Endpoints were readmission with myocardial infarction, ventricular fibrillation/cardiac arrest and all-cause death. Endpoints were reported for one year follow up or until emigration.
6037 patients were eligible for final analyses. The group consisted of 2 513 patients before and 3 491 after the hstn implementation. Comparing the diagnosis before and after hstn, there was a relative increase in MI of 25% and OHC with 9%, NSCP and SAP decreased with 6% and 43% respectively. The 12 months-mortality for NSCP was 3.4% before hstn and 2% after. No significant difference was shown between in mortality before and after hstn. The prognosis for the four groups after implantation of hstn showed that MI had the highest risk of future MI with 4% event rate during one year. NSCP had 5 times lower risk of future MI compared to the MI group. No significant differences in mortality was shown when comparing the MI group with the NSCP, OHC or SAP groups.
The number of NSCP patients decreased after the hstn implementation and had a low risk for future cardiac events No significant differences in mortality was shown comparing the mortality rate in this group before and after hstn implementation. The risk of future MI is significantly lower in NSCP than in the MI group
15:00 - 16:30 #10981 - OP015 Anticoagulation at emergency department – can we do better?
OP015 Anticoagulation at emergency department – can we do better?
Atrial fibrillation (AF) increases the risk for stroke and other thromboembolic complications. Properly carried out anticoagulation (AC) is the most important treatment for AF patients in stroke prevention, and it has been found to prevent up to 60-70 % of strokes. In clinical practice, the need for anticoagulation in AF is estimated by using CHA2DS2VASc and HAS-BLED scores. CHA2DS2VASc score assesses the thromboembolic risk and HAS-BLED score the risk for bleeding.
According to recent national and international studies, anticoagulation is underused among AF patients. In particular, the Finnish FinFib study showed that as many as 29% of high risk patients did not receive anticoagulation (1). Therefore, we wanted to examine how well the AF treatment is carried out at Tampere University Emergency Department (ED).
Materials and methods
From 1 October 2014 to 30 November 2014 all patients with AF or atrial flutter (ICD-10 code I48) at ED were identified from hospital records. We collected the following data: age, gender, what type of AC was used and whether the diagnosis was new or previously existing. We also investigated if the CHA2DS2VASc and HAS-BLED scores were calculated during the patients stay. Additionally, we counted both scores for all the patients, regardless of whether they were calculated during the ED visit. For this purpose, we collected data on all patients with any type of risk factors. Finally, we investigated whether the bridge therapy was started with warfarin, and furthermore, what were the INR values of all the patients on warfarin therapy.
A total of 470 patients with 537 unique ED visits were included in the study. Patients had a mean age of 70 years (range 21 -100 yrs). Out of the unique ED visits, CHA2DS2VASc and HAS-BLED scores were calculated in 19% and 3% of the cases. 87% of all the high-risk and 72% of new high-risk AF patients had AC therapy when leaving the ED. 57% of the patients on warfarin had an INR in therapeutic range (2.0-3.0). Furthermore, only 53% of patients with newly diagnosed AF referred to cardioversion had received bridging AC therapy with small molecular heparin (LMWH).
We found that although CHA2DS2VASc and HAS-BLED scores were calculated in a minority of the cases, relevant AC therapy for high-risk patients was well executed. However, over every fourth of the high-risk patients with new onset AF did not receive AC therapy when leaving the ED. Furthermore, only half of the patients who began warfarin therapy were prescribed to use bridge therapy with LMWH. Based on these results, we have developed a standardized treatment protocol for AF patients. This protocol includes evaluation of the optimal treatment (rhythm or rate control) and execution of suitable AC treatment for each patient. We have also developed a special program to our ED’s patient data system in which the CHA2DS2VASc and HAS-BLED scores shall be filled in for each patient.
15:00 - 16:30 #10985 - OP016 Interobserver variability of the HEART score.
OP016 Interobserver variability of the HEART score.
Introduction: The HEART score is a validated risk score for chest pain patients presenting at the Emergency department (ED). The HEART score consists of five elements; history, ECG, age, risk factors and troponin. All of the elements are scored zero, one or two points, depending on the severity of the abnormality. Two of its elements, history and ECG, are subjective for interpretation by the ED physician. Little is known about the interobserver variability of history and ECG scoring and how this influences the interobserver variability of the final HEART score. The purpose of this study is to assess if the HEART score can be calculated reliably by different physicians.
Methods: For this study data from 125 patients was used. Each patient was scored by two cardiologists, two emergency physicians and two residents. Each physician scored the history and ECG of the 125 cases independently and blinded for the other elements of the HEART score. Interobserver agreement was measured by calculation of the intraclass correlation coefficient (ICC), using R statistics.
Results: Mean HEART score was 4.7 (95% CI 0.7-8.7). The analysis of the separate components yielded an ICC of 0.617 (range 0.0-1.0) for the history and an ICC of 0.512 for the ECG. On top of that, the agreement of the total HEART score between physicians was even higher, with an ICC for the HEART score of 0.888. The ICC for the total HEART score was 0.887 for the cardiologists, 0.882 for the emergency physicians and 0.986 for the residents.
Conclusion: This study shows a very high ICC between different physicians at the ED, demonstrating a very high interobserver reliability of the HEART score. This supports the use of the HEART score by several physicians.
15:00 - 16:30 #11058 - OP017 The randomized controlled trial: Comparison of success rate of standard and modified valsalva maneuvers to terminate supraventricular tachycardia.
OP017 The randomized controlled trial: Comparison of success rate of standard and modified valsalva maneuvers to terminate supraventricular tachycardia.
Purpose: The purpose of the study is to detect whether using modified valsalva maneuver (VM) be more effective than standard VM in terminating SVT.
Material and Method:This prospective randomized control trial, was conducted in an emergency department with patients who diagnosed SVT between 01.12.2015 - 31.12.2016. Participants were divided into two groups, randomly as standard VM or modified VM, as the first treatment with two-dimensional permutation blocks; in the order of arrival of the patients. The randomization was performed by envelope method. In both groups; the determined procedure for standard or modified VM were repeated up to three times in unresponsive patients. In both groups; if the maneuver is unsuccessful after three attempts, rescue medication with anti-arrhythmic treatment used. The primary outcome was defined to compare the success rate of achieving sinus rhythm after standard VM and modified VM.
Results: Totally, 56 patients were included randomly to this study; 28 were assigned to the standard VM, and 28 were assigned to the modified VM. Three of 28 patients(10.7%) in VM group and 12 of 28 patients(42.9%) in modified VM group were returned to sinus rhythm after intervention (p=0.007). Number of patients who need rescue treatment was lower in modified VM group, 16 (57.1 %) of 28, than in standard VM group, 25 (89.3%) of 28 (p=0.007).
Conclusion: Modified VM therapy is more effective than standard VM for terminating of SVT. It also indirectly reduces the need for anti-arrhythmic medication and indirectly causes fewer side effects. Therefore, we believe that modified VM can be considered as a first line treatment option in management of SVT according to results of this and previously studies.
15:00 - 16:30 #11619 - OP018 Multicentre, prospective validation of the Troponin-only Manchester Acute Coronary Syndromes decision aid using a single point of care troponin test in the Emergency Department.
OP018 Multicentre, prospective validation of the Troponin-only Manchester Acute Coronary Syndromes decision aid using a single point of care troponin test in the Emergency Department.
Chest pain is the most common reason for emergency hospital admission, although the majority could be avoided with improved diagnostic technology. The Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid ‘rules in’ and ‘rules out’ acute myocardial infarction (AMI) with one blood test at the time of arrival in the Emergency Department (ED). T-MACS estimates the probability of AMI using basic data about a patient’s symptoms, signs, electrocardiogram and a single concentration of high sensitivity cardiac troponin (hs-cTn), a central laboratory assay.
Successful validation with a point of care (POC) cardiac troponin (cTn) assay would reduce turnaround time, helping to unburden crowded EDs. We aimed to prospectively validate T-MACS with a contemporary POC cTn assay.
In this multi-centre prospective diagnostic accuracy study nested within the Bedside Evaluation of Sensitive Troponin (BEST) programme, we recruited patients with suspected cardiac chest pain presenting to nine EDs. Patients with another medical condition requiring hospital admission and those whose symptoms peaked >12h ago were excluded. Ethical approval was obtained and all participants provided written informed consent.
Blood samples drawn on arrival were analysed for cTnI using the POC i-Stat assay (Abbott Point of Care, New Jersey, 99th percentile 80ng/L, LoD 20ng/L). The primary outcome was a diagnosis of AMI, which was defined in accordance with the Third Universal Definition based on central laboratory cTn analysis. To provide an adequate reference standard, the protocol required that all patients also undergo serial central laboratory cTn testing over at least 3 hours (for high sensitivity assays) or at least 6 hours (contemporary assays).
T-MACS was computed using the original reported formula. We calculated sensitivity, specificity, positive and negative predictive values and positive and negative likelihood ratios.
A total of 622 patients were included in this analysis, of which 78 (12.5%) had AMI. Key results are summarised in Table 1. With a single POC cTn test, T-MACS would have ‘ruled out’ 41.6% (n=259) patients with a sensitivity of 97.4% (95% CI 91.0–99.7%) and a negative predictive value of 99.2% (95% CI 97.0–99.8%). Two AMIs were missed based on serial laboratory cTn concentrations. One patient did not receive a clinical diagnosis of AMI, received no treatment, did not undergo further investigation and had no adverse events within 30 days.
T-MACS would have ‘ruled in’ 7.1% (n=44) patients with a specificity of 99.2% (95% CI 98.0–99.8%) and a positive predictive value of 90.9% (95% CI 78.5–96.5%).
To our knowledge this is the first successful validation of a single test ‘rule out strategy’ using a POC cTn assay. Its use could enable almost immediate reassurance and discharge for >40% of patients with suspected cardiac chest pain.
Education (Cutting Edge) decision making
How to help our Stone Age minds to make good decisions?
Moderators: Eric DRYVER (Consultant) (Lund, SWEDEN), Senad TABAKOVIC (Zürich, SWITZERLAND)
Coordinator: Senad TABAKOVIC (Zürich, SWITZERLAND)
16:40 - 18:10 Creating evidence to improve safety and effectiveness of ED patient care. Ian STIELL (Physician) (Ottawa, CANADA)
16:40 - 18:10 Decision-making through the lense of quantum physics. Eric DRYVER (Consultant) (Lund, SWEDEN)
16:40 - 18:10 Can big data replace gut feeling? Catherine CHRONAKI (Secretary General) (Brussels, BELGIUM)
Thrombosis (How To)
Moderators: Cem OKTAY (FACULTY) (ANTALYA, TURKEY), Karim TAZAROURTE (Chef de service) (Lyon, FRANCE)
Coordinator: Rick BODY (UK)
16:40 - 18:10 Update on the management of anticoagulant-related bleeding. Anil CHOPRA (CANADA)
16:40 - 18:10 Cutting edge controversies in the management of pulmonary embolism. Anil CHOPRA (CANADA)
16:40 - 18:10 Ultrasound and venous thromboembolism. Eleni SALAKIDOU (Rethymno, GREECE)
Trauma (Game Changers)
Moderators: Silvia BRESSAN (Padova, ITALY), Karim TAZAROURTE (Chef de service) (Lyon, FRANCE)
Coordinator: Rick BODY (UK)
16:40 - 18:10 Challenges in managing head injuries in patients who are anticoagulated. Suzanne MASON (Professor of Emergency Medicine) (Sheffield, UK)
16:40 - 18:10 Top ten trauma papers. Judith TINTINALLI (Chapel hill, USA)
16:40 - 18:10 It's the end of the world as we know it: should we stop immobilizing all trauma patients? Demetrios PYRROS (GREECE)
YEMD - Toxicology
Drugs & Alcohol
Moderators: Martin FANDLER (Doctor) (Nuremberg, GERMANY), Pieter Jan VAN ASBROECK (Consultant in Emergency Medicine) (Hasselt, BELGIUM)
Coordinator: Basak YILMAZ (Ankara, TURKEY)
16:40 - 18:10 Chemical warfare and terrorism. Bulut DEMIREL (Emergency Department chief) (Ankara, TURKEY)
16:40 - 18:10 Toxic ECGs. Pieter Jan VAN ASBROECK (Consultant in Emergency Medicine) (Hasselt, BELGIUM)
16:40 - 18:10 Emergency Sedation of the agitated intoxicated patient. Martin FANDLER (Doctor) (Nuremberg, GERMANY)
Disaster Medicine II - (Game changers)
Moderators: Vitor ALMEIDA (PORTUGAL), Benoît VIVIEN (Paris, FRANCE)
Coordinator: Abdo KHOURY (Besançon, FRANCE)
16:40 - 18:10 Humanitarian opportunities for young doctors. Luca RAGAZZONI (Novara, ITALY)
16:40 - 18:10 Triage in MCI: still needed? Benoît VIVIEN (Paris, FRANCE)
16:40 - 18:10 Education in disaster medicine: the TDMT experience. Marta CAVIGLIA (NOVARA, ITALY)
Free Papers Session 3
Moderators: Tom BEATTIE (UK), M Ashraf BUTT (CAVAN, IRELAND)
16:40 - 18:10 #11025 - OP020 Clinical decision rule to improve the adequacy of CT scan for syncope in the emergency department.
OP020 Clinical decision rule to improve the adequacy of CT scan for syncope in the emergency department.
BACKGROUND: In the last two decades we have observed a dramatically increase of the CT scans use at the emergency department (ED). As a result, there has been growing concern around the increase of medical radiation exposure and cancer. The positive rate of head CT in non-trauma patients presenting to the ED is low. Currently, indications for imaging are based on the individual experience of the emergency physician, which contributes to overuse and variability in imaging indication. In adult patients with syncope, without cranioencephalic trauma and with no alarm signs, there is variability and inadequacy in deciding to request a CT scan. The aim of this study is to ascertain the predictors of a positive head CT scan in patients with syncope and demonstrate the feasibility of clinical decision rule (CDR) to improve the adequacy.
METHODS: A systematic search for evidence was made based on a PICO question (Haynes pyramid). After the search PubMed and Embase (2005-2014) was consulted. Four reviewers reviewed all citations and select eligible ones for inclusion. Two authors independently appraised the quality of the studies and their degree of recommendation (GRADE). All disagreements among reviewers were discussed and resolved by a third independent reviewer. After the systematic review CDR was developed and included in the Electronic Clinical Record System at the Emergency department. We retro/prospectively reviewed all ED syncope patients 6 months before and after implementing the CDR. Medical records were assessed for analyzing the adequacy of the CDR and a telephone call was made after 30 days from discharge, in order to ensure that a related event had not occurred.
REUSLTS: The CDR has 5 items (alarm signs) and if any of them was present the CT scan should be performed. The items were: abrupt/severe headache after vigorous exercise, neurological focus, alteration of the level of consciousness, meningism and hypertension emergency. Both in the pre and post-implantation groups, 10% of the syncope had alarm signs. From patients with alarm signs, 10% had a positive CT result. In the cases that did not show alarm signs (90%) an evident differentiation was detected resulting in the Pre-CDR group being 46% unsuitable indications, compared to 7.6% after the CDR implantation, which shows that the goal of adapting CT indications was achieved. None of the patients that were discharged from the emergency department without a CT scan had a new event related with the syncope (CDR had a safety of 100%). Finally, a cost analysis was carried out. We found a reduction of total expenditure of CT scan from 50% to 20% post-intervention, which accounts a total of 85,848 euros savings annually.
DISCUSSION: We can conclude that, the implementation of the CDR for the indication of a CT scan, being the reason of the consultation the syncope at the emergency department, is safe and increases the adequacy reducing not only the costs but also the medical radiation exposure.
16:40 - 18:10 #11622 - OP021 Predicting good outcome after in-hospital cardiac arrest -validation of the GO-FAR score.
OP021 Predicting good outcome after in-hospital cardiac arrest -validation of the GO-FAR score.
Approximately 2300 in-hospital cardiac arrests (IHCA) occur annually in Sweden and the prognosis for those affected is poor with 29% survival to hospital discharge. A do-not-attempt-resuscitation (DNAR) order is issued when it is against the wishes of the patient that cardiopulmonary resuscitation (CPR) is performed, or when CPR is considered medically futile; that is when the chances of good quality survival are minimal. Emergency physicians are required to address the question of futility in the emergency department, but scientific support to fulfill this task is sparse. The Good Outcome Following Attempted Resuscitation (GO-FAR) score was developed in 2013 and has not been validated on a population basis outside the index population. The GO-FAR score is a summed score consisting of 13 prearrest variables with values ranging from -15 to 11 points reflecting the likelihood of good neurological survival at discharge measured as CPC 1 (patient is alert, able to work and lead a normal life, may have minor psychologic or neurologic deficits). A prearrest prediction tool for good outcome after IHCA would substantially contribute to daily clinical practice and reduce barriers for discussing DNAR orders.
This validation study is based on a retrospective cohort of adult IHCA in Stockholm County 2013 to 2014 identified through the Swedish Cardiopulmonary Resuscitation Registry (SCRR). SCRR provides patient and event characteristics, personal identification numbers and CPC score at discharge. Data for the GO-FAR variables was obtained from manual review of hospital electronic patient records. The model performance was evaluated by quantifying discrimination and calibration, calculating the area under the receiver operating curve (AUROC) and evaluating the calibration plot with calibration-in-the-large and calibration slope.
The final cohort included 717 patients with a 30-day survival of 27.5% and survival with good outcome at discharge of 22.3%. 61.9% were male, mean age was 72 years (SD 14 years) and 22.1% presented with ventricular fibrillation or ventricular tachycardia. In complete case analysis (526 cases) AUROC was 0.82 (95% CI 0.78 to 0.86) indicating good discrimination. The calibration slope was 1.38 (95% CI 1.08 to 1.68) and calibration-in-the-large -0.84 (95% CI -1.05 to -0.63) indicating that the GO-FAR score systematically underestimates the probability of good neurological survival.
The GO-FAR score shows satisfactory discrimination but dissatisfactory calibration in a cohort representing a Swedish population. It has the ability to distinguish a patient with good outcome from a patient with adverse outcome, but good outcome is systematically underestimated. Recalibration of the GO-FAR score is suggested before taken into clinical practice in Sweden.
16:40 - 18:10 #11722 - OP021b The Copenhagen Triage Algorithm is superior to a traditional triage algorithm - A cluster-randomized study.
OP021b The Copenhagen Triage Algorithm is superior to a traditional triage algorithm - A cluster-randomized study.
Triage systems have been implemented in most emergency departments (EDs) worldwide to minimize crowding and treatment delays that may adversely affect outcomes in acutely admitted patients. Triage systems are designed firstly to identify patients in need of immediate care, and second to provide risk stratification and ensure the optimal distribution of resources.
However, pre-existing triage systems are time consuming, supported by limited evidence, and could potentially be of more harmful than beneficial.
This trial prospectively compared a new simplified triage system with emphasis on clinical judgement with a traditional triage system with focus on clinical endpoints.
The Copenhagen Triage Algorithm (CTA) study was a large prospective, two-center, cluster-randomized, parallel, cross-over, open trial comparing CTA to a traditional triage system, Danish Emergency Process Triage (DEPT), which is a local adaptation of the internationally used ADAPT system.
All patients ≥17 years admitted to the ED in two large hospitals in a 10-month period were randomly cluster allocated to either CTA or DEPT triage with subsequent crossover. Based on vital signs and a subsequent clinical assessment by the ED nurse, CTA stratifies patients into 5 acuity levels.
The study had a non-inferiority design with 30-day all-cause mortality as the primary endpoint. The non-inferiority margin was set at 0.5%. As a secondary endpoint, the study aimed to assess if CTA was superior in predicting 30-day mortality as assessed by C-statistics.
A total of 45,977 patient visits were included. Of these 23,415 (50.9%) visits were triaged using CTA and 22,562 (49.1%) visits using DEPT. Patients were well matched on baseline characteristics. The non-inferiority criteria was met, with the 30-day mortality among patients triaged with CTA and DEPT at 3.35% and 3.28%, respectively (p=0.68), a difference of 0.07% (95% CI: -0.26-0.40). Comparable results were observed for mortality at 48 hours (0.63% and 0.68%, p=0.58 using CTA and DEPT, respectively) and at 90 days (6.18 % and 6.36 %, p=0.41 using CTA and DEPT, respectively).
The triage level of patients in the CTA group was significantly lower (P<0.001) and CTA was superior in predicting 30-day mortality with an AUC of 0.670 (95% CI 0.650-0.690) compared to 0.638 for DEPT (95% CI 0.618-0.659) (P=0.03). Still there was no significant increase in mortality among low risk patients. A sensitivity analysis including vital signs, age, and sex showed no added risk among patients in the CTA arm for mortality at 48 hours (HR 1.07, 95% CI 0.97-1.18), 7 days (HR 0.98, 95% CI. 0.98-0.99), 30 days (HR 0.98, 95% CI 0.89-1.08) or 90 days (HR 1.03, 95% CI 0.96-1.1).
A new triage system based on vital signs and a clinical assessment by an ED nurse was non-inferior to a traditional triage algorithm with regards to mortality and superior at predicting 30-day mortality.
16:40 - 18:10 #10536 - OP022 Straddle compared with conventional chest compressions in manikin model.
OP022 Straddle compared with conventional chest compressions in manikin model.
Terapat Chantawong*, Pilaiwan Sawangwong*, Warawut Khangmak*, Chaiyaporn Yuksen MD, Yuwares Sittichanbuncha ,MD. Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
Backgrounds: Out of hospital cardiac arrest (OHCA) is one of the main causes of death in Thailand. Chest compression in narrow space may occur in ambulance or aircraft. Straddle chest compression is one of the technique to help the stability of chest compression.
Objective: To compare the quality of chest compressions and exhaustion of healthcare provider between straddle chest compression and conventional chest compression in manikin model.
Methodology: This is an experimental study randomization into two different group, by using the SNOSE and block of four randomization by dividing them into group A (Straddle chest compression) and group B (conventional chest compression). Each participants were performed maximum 4 minutes hands only compression, quality parameters were recorded: compression rate and depth. The blood pressure, heart rate and respiratory rate of each participant were recorded both before and after chest compression.
Result: 124 participants (mean age 25.8 years and 27.6 percent are male, 40), the rate of chest compressions in conventional CPR and straddle CPR (126.2±17.1 and 127.0±21.0, p = 0.811), the average depth (43.8±9.6) and 43.4±9.0), p = 0.830). The blood pressure, heart rate and respiratory rate before and after chest compression in both method was no clinical significantly.
Conclusion: The quality of straddle chest compression was as good as conventional chest compression. The exhaustion of healthcare provider between Straddle and conventional chest compression was no clinical significantly.
16:40 - 18:10 #10592 - OP023 Traumatic cardiac arrest in Sweden 1990-2015 - a population-based national cohort study.
OP023 Traumatic cardiac arrest in Sweden 1990-2015 - a population-based national cohort study.
Background: Trauma is a main cause of death among young adults worldwide. Patients experiencing a traumatic cardiac arrest (TCA) certainly have poor prognosis but population-based studies are sparse.
Aim: Primarily to describe characteristics and 30-day survival following a TCA as compared with a medical out-of-hospital cardiac arrest (medical CA).
Material and methods: A cohort study based on data from the nationwide, prospective population-based Swedish Registry for Cardiopulmonary Resuscitation (SRCR) between 1990 -2015. The definition of a TCA in the SRCR is, a patient who is unresponsive with apnoea where cardiopulmonary resuscitation and/or defibrillation have been initiated and in whom the Emergency Medical Services (EMS) reported trauma as the aetiology. Outcome was overall 30-day survival. Descriptive statistics as well as multivariable logistic regression models were used.
Results: In all, between 1990-2015, 1 710 (2,4%) cases had a TCA and 69 123 had a medical CA. Overall 30-day survival gradually increased over the years and was in total among TCAs 3,8% compared to 8.0% following a medical CA (p<0.01). Factors associated with a higher 30-day survival were bystander witnessed TCA and having a shockable initial rhythm (adjusted OR 2.65, 95% C.I. 1.13–6.21 and OR 9.38 (4.44-19.85, respectively) while those given adrenaline had a poorer survival (adjusted OR 0.40, 95% C.I. 0.19 - 0.83).
Conclusion: Even if the prevalence of TCAs is low and survival is poorer than in medical CAs, many affected individuals are young. Therefore, resuscitation in TCAs should not be seen as futile, but rather an area considered for improvements.
16:40 - 18:10 #11103 - OP024 Outcome Determinants in Pediatric Out of Hospital Cardiac Arrests Post 2010.
OP024 Outcome Determinants in Pediatric Out of Hospital Cardiac Arrests Post 2010.
To determine which factors had the most impact on outcomes after pediatric out-of-hospital cardiac arrest (POHCA) now that protocol guidelines have become more aligned with those for adults, including emphasis on quality CPR.
In an EMS jurisdiction using a comprehensive Utstein-style database, all POHCA cases over the previous 5 calendar years (1/1/12 through 12/31/16) -- since implementation of the latest international guidelines -- were analyzed to identify current predictors for return of spontaneous circulation (ROSC), hospital admission (HA) and survival to successful hospital discharge (SURV). Logistic regression models of traditional predictors were performed using JMP 12.0 for Mac.
Of 133 consecutive POCHA cases studied (61 % male), the interquartile range (IQR) for response intervals was 16 to 47 minutes (range: 0-490). As traditionally predicted, shorter times from arrest to EMS arrival were associated significantly with ROSC, HA and SURV (all p<0.0001) whereas witnessed arrest cases (only 13%) were not (p=NS). Still, in 95% of cases, the arrest was identified by a bystander prior to EMS arrival and, contrary to previous studies, chest compressions were performed by bystanders in 59% of cases. While the earlier CPR was provided by EMS personnel was itself significantly associated with ROSC, HA and SURV (all P<0.0001), some form of treatment before EMS arrival was provided in 54% of cases and such actions were strongly associated with ROSC, HA and SURV (p<0.0001 for all) whereas AED placement (50% of cases) was not.
Whereas witnessed arrests and AED placement were not identified as contributing factors in this subpopulation of arrests, 1) shorter elapsed intervals from the moment of arrest to EMS arrival, 2) performance of CPR prior to EMS arrival and, in fact, 3) any treatment provided before EMS arrival, resulted in significantly higher rates of ROSC, hospital admission and survival beyond hospital discharge.
16:40 - 18:10 #11196 - OP025 Evolution of the survival of non-traumatic out-of-hospital cardiac arrests due to ventricular fibrillations over a 10 years’ period.
OP025 Evolution of the survival of non-traumatic out-of-hospital cardiac arrests due to ventricular fibrillations over a 10 years’ period.
Goal: The aim of this study was to assess the survival of victims of out-of-hospital cardiac arrests due to ventricular fibrillations of three successive cohorts over a 10 years’ period.
Materials and methods: This was a retrospective observational study that compared three successive cohorts. The study was approved by an ethics committee. Inclusion criteria were: non-traumatic out-of-hospital cardiac arrests due to ventricular fibrillations shocked by an automated external defibrillator, and having benefited from prehospital advanced life support by a team managed by an emergency physician. Collected variables were: the period of occurrence of the cardiac arrest (1st period = P1 - September 2005 to March 2007, 2nd period = P2 - June 2011 to December 2012, 3rd period = P3 - June 2014 to December 2015), the patient’s age and gender, the location of the cardiac arrest, the presence of a witness, the initiation of chest compressions by a bystander, the number of external electric shocks delivered by the automated external defibrillator, and the number of adrenaline injections administered by the advanced life support team. The primary endpoint was the hospital discharge. The secondary endpoint was the admission to the hospital with a palpable pulse. We used a logistic regression model to estimate the relationship between hospital discharge and the variables that were collected. We show the median [interquartile range] or the rate (%) according to the quantitative or qualitative nature of variables.
Results: A total of 2,648 patients (843 for P1, 830 for P2, 975 for P3) were included (62 years-old [51–74]; 1,608 (60.7%) men). Patients admitted to the hospital with a pulse during P1, P2, P3 were respectively 361 (43%), 464 (56%), 555 (57%) (p < 0.001). Patients discharged from the hospital during P1, P2, P3 were respectively 101 (12%), 166 (20%), 204 (22%) (p <0.001). In the multivariate analysis, factors associated with hospital discharge were: being a woman, a younger age, the occurrence of the cardiac arrest in a public area, and chest compressions by a witness. The rate of witnesses who performed chest compressions increased considerably over time (28% of cases for P1, 50% for P2, and 67% for P3). Adjusted odds-ratio associated with hospital admission were respectively: 1 for P1, 2.3 [1.8–3.0] for P2, and 1.8 [1.4–2.3] for P3.
Discussion: The survival of out-of-hospital cardiac arrests due to ventricular fibrillations shocked by an automated external defibrillator has improved over the past ten years. The increase of the rate of victims who benefited from chest compressions provided by a witness is one of the explanatory factors.
Conclusion: Efforts undertaken to improve the chain of survival, especially the early recognition of out-of-hospital cardiac arrests, an early cardiopulmonary resuscitation, and an early defibrillation must be continued.
16:40 - 18:10 #11200 - OP026 Factors associated with the recurrence of ventricular fibrillations in the case of out-of-hospital cardiac arrests - preliminary results of a retrospective observational study.
OP026 Factors associated with the recurrence of ventricular fibrillations in the case of out-of-hospital cardiac arrests - preliminary results of a retrospective observational study.
Background: In the case of out-of-hospital cardiac arrests, 50% of ventricular fibrillations reoccur at least one time, mainly after the resumption of chest compressions. The aim of this study was to identify factors associated with the time between the resumption of chest compressions and the recurrence of the ventricular fibrillation (“CC-VF”).
Materials and methods: We conducted a retrospective observational study. Collected variables were: patients’ age and gender, the presumed origin of the cardiac arrest, its location, the presence of a witness, the initiation of chest compressions by a bystander. We extracted from automated external defibrillators the rate of chest compressions, the time and length of each chest compressions’ interruption, the time between external electric shocks and the resumption of chest compressions (“EES-CC”), and “CC-VF”. Inclusion criteria were: out-of-hospital cardiac arrests, being over 18 years-old, one or more recurrences of a ventricular fibrillation shocked by an automated external defibrillator of basic life support teams. We performed a univariate analysis followed by a multinomial regression on repeating data; only variables associated with “CC-VF” with p < 0.2 in the univariate analysis were included in the multivariate analysis. We show the median [interquartile range] or the rate (%) according to the quantitative or qualitative nature of variables.
Results: Between 2010 and 2013, we recruited 266 patients (62 years-old [51.5–76]; 212 (80%) men) for a total of 1,047 episodes of recurrent ventricular fibrillations. A witness was present in 129 (48%) cases and performed chest compressions in 57 (21%) cases. The number of external electric shocks by automated external defibrillator ranged from 1 to 19. Concerning recurrences of ventricular fibrillations, 342 (32.7%) episodes occurred before the resumption of chest compressions, 129 (12.3%) were concomitant of the resumption of chest compressions, 170 (16.2%) occurred between 2.5 and 10 s after the resumption of chest compressions, and 406 occurred more than 10 s after the resumption of chest compressions. In the univariate analysis, factors associated with a shorter “CC-VF” were: being a male, an older age, a presumed cardiac origin of the cardiac arrest, the presence of a witness, a longer “EES-CC”, faster chest compressions’ rates, and greater chest compressions’ ratios. In the multivariate analysis, an older age and a faster rate of chest compressions were associated with a shorter “CC-VF”. A longer time between the first alert to the dispatch center and the initiation of chest compressions was associated with a longer “CC-VF”.
Discussion: This is the first study to identify factors associated with the time between the resumption of chest compressions and the recurrence of a ventricular fibrillation. If preliminary results presented above are confirmed, new approaches could be suggested to deal with the recurrence of ventricular fibrillations.
16:40 - 18:10 #11605 - OP027 Variations in occurrence of out-of-hospital cardiac arrest in time in the Czech and Slovak republics.
OP027 Variations in occurrence of out-of-hospital cardiac arrest in time in the Czech and Slovak republics.
Background: Circadian variation in occurrence of out-of-hospital cardiac arrest (OHCA) is an observation which has been reported from several parts of the world. Mostly, diurnal variation was shown exhibiting low incidence of OHCA at night and a two daytime peaks, in the morning and late afternoon. However, this variation can be related to geographical regions and the validity of the results is extremely dependent on the quality of the data collection. Therefore we have analyzed the Czech and Slovak data from the EuReCa ONE study to investigate whether there is any local significant variation of OCHA events treated by Emergency Medical Services (EMS) in time and if so, whether it depends on geographic variables.
Methods: In an international clinical study EuReCa ONE (European Registry of Cardiac Arrest), data on all EMS treated OHCA events were collected from the entire territory of the Slovak Republic (5421352 inhabitants) and several administrative regions of the Czech Republic (4350000 inhabitants) in the period from 1.10.2014 to 31.10.2014. Data were processed and analyzed for circadian and infradian variability.
Results: For the selected period, a total of 659 cases of confirmed resuscitated OHCA events was reported. Significant circadian variation was observed, with very low occurrence in the night (approximately 2% of all episodes each hour) followed by three peaks in the daytime, in the 9th, 16th and 20th hour (8.2, 6.4 and 7.4 % of all episodes, respectively, p<0.05). During the week, OHCA events were the most frequent on Fridays while the least common on Tuesdays (16.8 versus 12.1 % of all events, p=0.019). In the Czech Republic, OHCA was more frequent at weekends than in Slovakia (31.2 versus 22.4 % of all episodes, p=0.013). The lowest thirty-day survival or survival to hospital discharge was observed in OHCA events that occurred on Tuesdays, while highest in episodes that occurred on Thursdays (6.2 versus 20.6 %, p=0.011). Time dependent variation of survival patterns were We did not found any differences between the Czech and Slovak republics in survival variation.
Discussion: In the selected regions and time interval we have identified a marked circadian and infradian variability of OHCA events occurrence and of their survival as well. While the variability of the events in time was partly country-dependent, survival was not. Further investigation of this phenomenon may lead to a better understanding of the circumstances leading to cardiac arrest and improve prevention of this cardiovascular catastrophe.
References: Gräsner JT et al. EuReCa ONE-27 Nations, ONE Europe, ONE Registry: Aprospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation 2016;105:188-95.
EUSEM 2017 Opening Ceremony
18:15 - 19:00 Welcome Addresses. Roberta PETRINO (Head of department) (Italie, ITALY), Panos AGOURIDAKIS (GREECE), Christoph DODT (München, GERMANY)
18:15 - 19:00 Official Opening of the Congress.
Dr Andreas XANTHOS, Minister of Health & Social Welfare of Greece
18:15 - 19:00 Opening Lecture with Narration Traumatic Injuries in Homer’s Iliad.
The Emergence of Emergency Medicine in Greek Antiquity? Helen ASKITOPOULOU, on behalf of HeSEM
Nantia SPILIOTOPOULOU, narration of Homer’s verses
18:15 - 19:00 Recital - Songs from Greece & the Mediterranean.
Savina YANNATOU, voice & Kostas GRIGOREAS, classical guitar
|Monday 25 September
Keynote Lecture 1
Moderator: Senad TABAKOVIC (Zürich, SWITZERLAND)
08:30 - 09:00 Pitfalls in the management of older patients. Christian NICKEL (Vice Chair) (Basel, SWITZERLAND)
Pre-hospital (Cutting Edge)
Moderators: Christian NICKEL (Vice Chair) (Basel, SWITZERLAND), Jana SEBLOVA (Emergency Physician) (PRAGUE, CZECH REPUBLIC)
Coordinator: Christian HOHENSTEIN (JENA, GERMANY)
09:10 - 09:40 OHCA: Only the dispatcher can save lives!? Ondrej FRANEK (CZECH REPUBLIC)
09:40 - 10:10 Air support - Helicopter intervention in special situations. Carmen Diana CIMPOESU (Prof univ. Head of ED) (IASI, ROMANIA)
10:10 - 10:40 Airway Mangement - prehospital life-hacks you definitely need to know! Christian HOHENSTEIN (PHYSICIAN) (JENA, GERMANY)
Resuscitation (Cutting Edge)
Moderators: Clifton CALLAWAY (Pittsburgh, PA, USA), Othon FRAIDAKIS (GREECE)
Coordinator: Christian HOHENSTEIN (JENA, GERMANY)
11:10 - 12:40 Resuscitation from cardiac arrest. Clifton CALLAWAY (Pittsburgh, PA, USA)
11:40 - 12:10 Optimized therapy for patients after ROSC. Wilhelm BEHRINGER (Director) (Jena, GERMANY)
12:10 - 12:40 Neurologic prognosis and withdrawal of life-sustaining therapy after cardiac arrest: if, when and how? Tobias CRONBERG (SWEDEN)
Geriatric (Cutting Edge)
Moderators: Mehmet Akif KARAMERCAN (ANKARA, TURKEY), Christian NICKEL (Vice Chair) (Basel, SWITZERLAND)
Coordinator: Senad TABAKOVIC (Zürich, SWITZERLAND)
14:10 - 14:40 Implementation of a screening program for older patients visiting the Emergency Department; pitfalls and opportunities. Simon. P. MOOIJAART (LEIDEN, THE NETHERLANDS)
14:40 - 15:10 How to geriatrisize your ED. Simon. P. MOOIJAART (LEIDEN, THE NETHERLANDS)
15:10 - 15:40 Delirium. Christian NICKEL (Vice Chair) (Basel, SWITZERLAND)
Analgesia and Sedation (Cutting Edge)
Moderators: Jim DUCHARME (Mississauga, CANADA), Christian HOHENSTEIN (PHYSICIAN) (JENA, GERMANY)
Coordinator: Christian HOHENSTEIN (JENA, GERMANY)
16:10 - 16:40 Pain treatment in the addict. Jim DUCHARME (Mississauga, CANADA)
16:40 - 17:10 Ketadex, Ketofol or Dexofol – foolish sedation procedures? Christian HOHENSTEIN (PHYSICIAN) (JENA, GERMANY)
17:10 - 17:40 Sedating small adults - ketamine as the safe option? Santiago MINTEGUI (Barakaldo, SPAIN)
Digitalisation in the ED
"Rage against the machine, the digital revolution in the ED"
Moderators: Catherine CHRONAKI (Secretary General) (Brussels, BELGIUM), Tiziana MARGARIA STEFFEN (IRELAND)
Coordinator: Senad TABAKOVIC (Zürich, SWITZERLAND)
09:10 - 09:40 Digitalisation in the ED, the role of patient summary. Catherine CHRONAKI (Secretary General) (Brussels, BELGIUM)
09:40 - 10:10 Digitalised health departments as part of a digitalised health community. Simon DE LUSIGNAN (EUSEM 2017) (Guildford, UK)
10:10 - 10:40 Panel discussion. Roberta PETRINO (Head of department) (Italie, ITALY), Catherine CHRONAKI (Secretary General) (Brussels, BELGIUM), Simon DE LUSIGNAN (EUSEM 2017) (Guildford, UK), Tiziana MARGARIA STEFFEN (IRELAND)
Prehospital (Game Changer)
Moderators: Steffen HERDTLE (MD) (Jena, GERMANY), Jana SEBLOVA (Emergency Physician) (PRAGUE, CZECH REPUBLIC)
Coordinator: Christian HOHENSTEIN (JENA, GERMANY)
11:10 - 11:40 EMS: fundamental for ED Lean Management? Eric REVUE (Head of the ED and prehospital EMS) (Paris, FRANCE)
11:40 - 12:10 Rescuing the rescuers - necessary? Jana SEBLOVA (Emergency Physician) (PRAGUE, CZECH REPUBLIC)
12:10 - 12:40 Do we really need an EMS-Physician for Stroke-Patients? Steffen HERDTLE (MD) (Jena, GERMANY)
Resuscitation (How To)
Moderators: Tobias CRONBERG (SWEDEN), Othon FRAIDAKIS (GREECE)
Coordinator: Christian HOHENSTEIN (JENA, GERMANY)
14:10 - 14:40 To intubate or not to intubate during cardiac arrest. Clifton CALLAWAY (Pittsburgh, PA, USA)
14:40 - 15:10 Glucose and Insulin during cardiac arrest. Roman SKULEC (KLADNO, CZECH REPUBLIC)
15:10 - 15:40 33°C or 36°C after resuscitation from cardiac arrest? Wilhelm BEHRINGER (Director) (Jena, GERMANY)
Geriatric (How to)
Moderators: Jacinta A. LUCKE (LEIDEN, THE NETHERLANDS), Christian NICKEL (Vice Chair) (Basel, SWITZERLAND)
Coordinator: Senad TABAKOVIC (Zürich, SWITZERLAND)
16:10 - 16:25 Diagnosis and management of UTI in older patients. Roberta PETRINO (Head of department) (Italie, ITALY)
16:25 - 16:40 Sepsis in older patients. Abdelouahab BELLOU (BOSTON, USA)
16:40 - 16:55 Silver trauma, pre-hospital and in-hospital. James WALLACE (Consultant in Emergency Medicine) (Warrington, UK)
16:55 - 17:10 Polypharmacy/De-prescribing. Jacinta A. LUCKE (LEIDEN, THE NETHERLANDS)
17:10 - 17:25 How to apply scientific evidence to older patients. Simon. P. MOOIJAART (LEIDEN, THE NETHERLANDS)
17:25 - 17:40 The unstable older patient. Mehmet Akif KARAMERCAN (ANKARA, TURKEY)
Geriatric (Game Changers)
Moderators: Abdelouahab BELLOU (BOSTON, USA), Simon. P. MOOIJAART (LEIDEN, THE NETHERLANDS)
Coordinator: Senad TABAKOVIC (Zürich, SWITZERLAND)
09:10 - 09:40 Evidence-based medicine in older patients: why and how is it different from what you know. Simon. P. MOOIJAART (LEIDEN, THE NETHERLANDS)
09:40 - 10:10 Approach to the acutely presenting older patient. Jacinta A. LUCKE (LEIDEN, THE NETHERLANDS)
10:10 - 10:40 Geriatric Emergency Medicine – our new bread and butter. Suzanne MASON (Professor of Emergency Medicine) (Sheffield, UK)
Mental Health (Cutting Edge)
Moderators: Greg HENRY (USA), Christian HOHENSTEIN (PHYSICIAN) (JENA, GERMANY)
Coordinator: Christian HOHENSTEIN (JENA, GERMANY)
11:10 - 11:40 Difficult patient or misinformed staff? Jim DUCHARME (Mississauga, CANADA)
11:40 - 12:10 Clearing patients in the ED for psychiatric admission. Greg HENRY (USA)
12:10 - 12:40 Physician burnout and suicide - Are you at risk? Julius KAPLAN (Immediate Past President) (NEW ORLEANS, LA, USA)
Ultrasound (How to)
"Breaking the waves, new ways to use ultrasound in the ED"
Moderators: Gregor PROSEN (MARIBOR, SLOVENIA), Senad TABAKOVIC (Zürich, SWITZERLAND)
Coordinator: Senad TABAKOVIC (Zürich, SWITZERLAND)
14:10 - 14:40 How ultrasound is going to influence decision making in the future. Eftychia POLYZOGOPOULOU (ATHENS, GREECE)
14:40 - 15:10 New ways to use ultrasound in the ED. James CONNOLLY (Newcastle upon Tyne, UK)
15:10 - 15:40 How to teach ultrasound in the future. Gregor PROSEN (MARIBOR, SLOVENIA)
Resuscitation (Game Changers)
Moderators: Wilhelm BEHRINGER (Director) (Jena, GERMANY), Alice HUTIN (PARIS, FRANCE)
Coordinator: Christian HOHENSTEIN (JENA, GERMANY)
16:10 - 16:40 Emergency Preservation and Resuscitation - not CPR: delayed resuscitation from traumatic death. Samuel TISHERMAN (USA)
16:40 - 17:10 Emergency Cardio-Pulmonary Bypass (ECPB) in the prehospital setting. Alice HUTIN (PARIS, FRANCE)
17:10 - 17:40 Refractory cardiac arrest: Ethical dilemma? Tobias CRONBERG (SWEDEN)
YEMD - Violence in the ED
Moderators: Monika BRODMANN MAEDER (Senior Consultant, Head of Education and Mountain Emergency Medicine) (Bern, SWITZERLAND), Basak YILMAZ (Ankara, TURKEY)
Coordinator: Basak YILMAZ (Ankara, TURKEY)
09:10 - 09:30 The Hague Protocol: 'A succesful method for detecting Child Maltreatment at the Emergency Department'. Hester DIDERICH-LOLKES DE BEER (policy officer family maltreatment) (THE HAGUE, THE NETHERLANDS)
09:30 - 09:50 Acute Behavioural Disturbance (ABD). Blair GRAHAM (Research Fellow) (Plymouth, UK)
09:50 - 10:10 Role of self protection and team training. Monika BRODMANN MAEDER (Senior Consultant, Head of Education and Mountain Emergency Medicine) (Bern, SWITZERLAND)
10:10 - 10:30 Interpersonal violence/ assaults towards healthcare professionals. Basak YILMAZ (Ankara, TURKEY)
YEMD - POCUS
Moderators: Adan ATRIHAM (MEXICO), Jennifer TRUCHOT (Paris, FRANCE)
Coordinator: Basak YILMAZ (Ankara, TURKEY)
11:10 - 11:40 The impact of ultrasound on the critical patient. Gregor PROSEN (MARIBOR, SLOVENIA)
11:40 - 12:10 Ultrasound and simulation: choosing the right teaching tool. Erden Erol UNLUER (TURKEY)
12:10 - 12:40 Ultrasound in the ED in 2017: an ethical imperative? Adan ATRIHAM (MEXICO)
YEMD - How to communicate in the ED
Moderators: Roberta PETRINO (Head of department) (Italie, ITALY), Basak YILMAZ (Ankara, TURKEY)
Coordinator: Basak YILMAZ (Ankara, TURKEY)
14:10 - 14:30 How to communicate with other clinics. Oktay ERAY (Speaker) (Antalya, TURKEY)
14:30 - 14:50 How to communicate with hospital management. Greg HENRY (USA)
14:50 - 15:10 How to please patients and still practice good medicine. Adan ATRIHAM (MEXICO)
15:10 - 15:30 How to build great ED staff. Roberta PETRINO (Head of department) (Italie, ITALY)
YEMD - Prehospital
Moderators: Gerhard ADAMEK (Praticien Hospitalier (M.D.)) (Saint-Renan, FRANCE), Mohomed ASHRAF (ACCS - EM) (Reading, UK)
Coordinator: Basak YILMAZ (Ankara, TURKEY)
16:10 - 16:30 Controversy in Airway management. Sanela RADOSAVLJEVIC (emergency phisician) (Belgrade, SERBIA)
16:30 - 16:50 Debating between scoop and run versus stay and play in the pre-hospital setting. Gerhard ADAMEK (Praticien Hospitalier (M.D.)) (Saint-Renan, FRANCE)
16:50 - 17:10 Major incident/Disaster planning: how to manage resources and skills as a young doctor better. Michael SPITERI (Mosta, MALTA)
17:10 - 17:30 Being a HEMS doctor & how it has influenced my practice in the ED. Leonieke VLAANDEREN (HEMS registrar) (London, UK)
Telephone triage / Toxicology update
Moderators: Borja GOMEZ (Barakaldo, SPAIN), Henriette MOLL (paediatrician) (rotterdam, THE NETHERLANDS)
Coordinator: Henriette MOLL (rotterdam, THE NETHERLANDS)
09:10 - 09:40 Improvement areas in the management of childhood poisoning exposures. Santiago MINTEGUI (Barakaldo, SPAIN)
09:40 - 10:10 Recognizing the sick child: the role of vital signs in triage. Joany ZACHARIASSE (PhD-student) (Rotterdam, THE NETHERLANDS)
10:10 - 10:40 How risky is it to get up in the morning? Ian MACONOCHIE (UK)
Children as refugees
Moderators: Said HACHIMI IDRISSI (head clinic) (Ghent, BELGIUM), Santiago MINTEGUI (Barakaldo, SPAIN)
Coordinator: Santiago MINTEGUI (Barakaldo, SPAIN)
11:10 - 11:40 Refugee children's health. Ruud NIJMAN (academic clinical fellow) (London, UK)
11:40 - 12:10 Health problems of refugee children: more than we think. Ozlem TEKSAM (PEDIATRICS) (ANKARA, TURKEY)
12:10 - 12:40 Children among the refugees – (un)usual needs in unusual conditions. Zsolt BOGNAR (Head of Department) (Budapest, HUNGARY)
Moderators: Mark LYTTLE (Bristol, UK), Itay SHAVIT (ISRAEL)
Coordinators: Said HACHIMI IDRISSI (Ghent, BELGIUM), Said HACHIMI IDRISSI (head clinic) (Ghent, BELGIUM)
14:10 - 14:40 Fluid resuscitation in sick children: Yes-No. Tom BEATTIE (UK)
14:10 - 14:40 Fluid resuscitation in sick children: Yes-No. Ruth FARRUGIA (Paediatrician) (Malta, MALTA)
14:40 - 15:10 Tranexamic Acid in trauma resuscitation: Yes-No. David WALKER (JACKSON HEIGHTS, USA)
14:40 - 15:10 Tranexamic Acid in trauma resuscitation: Yes-No. Said HACHIMI IDRISSI (head clinic) (Ghent, BELGIUM)
15:10 - 15:40 Flumazenil for benzodiazepine overdose: Yes-No. Cathelijne LYPHOUT (Consultant in EM) (Ghent, BELGIUM)
15:10 - 15:40 Flumazenil for benzodiazepine overdose: Yes-No. Lisa AMIR (ISRAEL)
Moderators: Silvia BRESSAN (Padova, ITALY), Luigi TITOMANLIO (Paris, FRANCE)
Coordinator: Niccolò PARRI (Florence, ITALY)
16:10 - 16:55 Ultrasound scenario. Ron BERANT (Staff Physician) (Ramat-Gan, ISRAEL)
16:55 - 17:40 Ultrasound scenario. Niccolò PARRI (Attending Physician) (Florence, ITALY)
Coordinators: Guillem Bouilleau (France), François Lecomte (France), Youri Yordanov (France)
Faculty: Cindy Bouzin (France), Lucie Desmond (France), Mohamed El Ouali (France), Sébastien Faucher (France), Christelle Hermand ( France), Laura Ribardière (France), Lucie Marchais (France)
Jury: Pier Luigi Ingrassia (Italy), Felix Lorang (Germany), Mohamed Mouhaoui, Carl Ogereau (France)
Free Papers Session 4
Moderators: Youri YORDANOV (Médecin) (Paris, FRANCE), Anastasia ZIGOURA (GREECE)
09:10 - 09:20 #10110 - OP028 Comparing outcomes between ICU patients referred directly from A&E, and those referred within 48 hours of admission to hospital.
OP028 Comparing outcomes between ICU patients referred directly from A&E, and those referred within 48 hours of admission to hospital.
To compare mortality, length of stay and cause for admission in adult emergency department (ED) patients at the Royal Infirmary of Edinburgh with a delay in intensive care unit (ICU) admission of up to 48h with a group of patients admitted directly from the ED to the ICU.
There had been no study of the differences in patient cohort, or patient outcome between patients being referred directly for critical care support, or those being admitted from a ward within 48 hours. We aimed to identify a cohort of patients who had not been referred in ED, but who required critical care support early on during their hospital admission, and therefore may have benefitted from an earlier referral to ICU.
Sample & method:
We performed a retrospective cohort study in a 900-bed university teaching hospital over a 3 month period analysing data for all ITU admissions over the time period. One hundred and twenty-four adult emergency department patients admitted to the intensive care unit either directly from the emergency department (direct group) or within 48h of ward admission (delayed group) were identified. The main outcome measures investigated were mortality, length of hospital stay and cause for admission to ITU. Exclusions included those transferred to the hospital directly to a ward, those who were admitted from recovery or theatres, and those assessed in the Primary Assessment Area.
- Mortality in the delayed group was 8% lower than the direct group (34% vs 26%).
- Length of hospital stay was 11.5 days longer in the delayed group compared with the direct group (25 days vs 13.5 days).
- Of the patients in the delayed group, 59% of the cohort presented with sepsis.
Our study showed that patients in the delayed group had a lower mortality compared with the direct group which we hypothesize to be secondary to a less critically ill patient cohort. We noted an almost double length of hospital stay in the delayed group, which holds significant implications for increased morbidity in that cohort. Of these delayed patients requiring ITU care, we noted that over half presented with sepsis. These results raised the question of whether our sepsis identifiers in the ED are being utilised appropriately and/or are clinically effective. There are two sepsis tools used: Systemic Inflammatory Response Syndrome (SIRS) criteria “ and “Quick Sepsis Organ Failure Assessment” (qSOFA).
We performed further work to assess whether the sepsis tools of SIRS criteria and qSOFA would have helped identify the delayed patients with sepsis earlier. It identified that 60% of patients scored positive based on the SIRS criteria, but only 10% of patients scored positive based on the qSOFA criteria. It highlights that while there is a strong evidence base for qSOFA in risk stratification, it may be a poor indicator of the presence of sepsis in these patients and therefore should not be the sole sepsis screening tool within the department.
09:20 - 09:30 #11316 - OP029 OXYGEN THERAPYIN EMERGENCY DEPARTMENT: IS IT OVERUSED?
OP029 OXYGEN THERAPYIN EMERGENCY DEPARTMENT: IS IT OVERUSED?
Background: Though oxygen is one of the oldest drugs available, it is still the most inappropriately administered drug. It is a very commonly used therapeutic agent and is the treatment for hypoxaemia. There has been increasing criticism of the unrestricted use of O2 therapy over the past few years, and it is still controversial. This has led to over utilization of this very expensive resource.
Methodology:This was a cross sectional observational study done in the Emergency Department (ED) of a large tertiary care hospitals in South India. All patients who were administered oxygen over a 3 week period in April 2016 were included in the study. Details of oxygen administration and outcome were analyzed. Oxygen administered without hypoxia was considered as inappropriate.A basic cost analysis was also done. This study was approved by the ethics committee of Christian Medical College, Vellore and patient confidentiality was maintained using unique identifiers.
Results: 15.4 % (363/2356) of the patients presenting to the ED were administered oxygen. The mean age was 50.2 ± 17 years. There was a male predominance (66.4%). Majority (67.2%) were triaged as priority 1 patients. The common reasons for initiation of oxygen therapy were dyspnea (56.7%), low sensorium (14.0%), intubated elsewhere (11.0%), polytrauma (7.2%) and seizures (4.4%).The mean duration of Oxygen therapy was 7.3 ± 4.6 hours. 36.6% of patients were administered oxygen inappropriately. This resulted in wastage of 1376 euros in three weeks through treatment cost. 65.3% were admitted, 20.1% were discharged stable from ED and 11.8% left against medical advice. ED mortality rate was 2.8% and an additional 11.6% expired during hospitalization.
Conclusion:Oxygen is inappropriately administered in 1/3 of patients presenting to ED and increases the treatment cost for patients. Oxygen therapy should be strictly regulated to minimize its wastage.
09:30 - 09:40 #11763 - OP030 Sepsis-induced myocardial dysfunction: is it reversible?
OP030 Sepsis-induced myocardial dysfunction: is it reversible?
Background: Sepsis-induced myocardial dysfunction (SIMD) is established in about 50% of septic patients; aim of this study was to assess if SIMD is a reversible condition by mean of strain echocardiography.
Methods: Unselected patients affected by severe sepsis and septic shock admitted consecutively to a High Dependency Unit from the Emergency Department between October 2012 and December 2016 were prospectively enrolled. An echocardiogram was performed within 24 hours from the diagnosis of sepsis (ECHO1). LVEF was calculated using LV volumes derived by LV planimetry by manual tracing (Simpson’s rule) and was considered normal if >55%. The global longitudinal strain (GLS) was evaluated from apical LV views, with a commercially available system (Philips Q-LAB ver. 8.1) and was considered normal if <-14%; RV systolic function was evaluated through Tricuspidal Annular Systolic Posterior Excursion (TAPSE). In a consecutive group of survivors we repeated an echocardiogram 3 months after hospital discharge (ECHO2).
Results: Among 177 patients who underwent an echocardiogram within 24 h from sepsis diagnosis, 127 (72%) survived at 28 days and 44 patients (35% of survivors) accepted to repeat an echocardiographic evaluation after three months and they represent our study population; no significant differences were found between participants and non participants in term of LV (LVEF: 54 ±14% vs 50 ±15%; GLS -12.9 ±3.7 vs -11.8 ±3.4, tutti p=NS) and RV systolic function (TAPSE: 2.1 ±0.5 vs 1.9 ±0.5, p=NS). ECHO1 showed an LV systolic dysfunction in 26 (59%) and RV systolic dysfunction in 9 (21%); at ECHO2 LV systolic function returned to normal values in 13 patients and RV systolic function in 7, but a new systolic dysfunction was appreciated in 2 patients for LV and in 7 for RV. Considering LVEF analysis, the prevalence of LV dysfunction at ECHO1 was 49% and dropped to 23% at ECHO2; according to GLS it fell from 59% to 29% p=0.010 between ECHO1 and ECHO2, p <0.001 between evaluation by mean of GLS or by LVEF). Overall 50% of patients presented at ECHO2 a mono- or biventricular systolic dysfunction: patients with persistent dysfunction did not have a higher prevalence of coronary heart disease (14 vs 9%) or, during the acute phase, they did not develop more frequently a septic shock (29 vs 20%) or needed high-dosage vasopressors (11 vs 9%, all p=NS). Biomarkers levels in the acute phase were comparable between patients with reversible or irreversible dysfunction (Troponine: 0.43 ±1.57 vs 0.83 ±1.61 microgr/L; NTproBNP 6615 ±6501 vs 7501 ±12785 pg/mL).
SIMD has a significant incidence and it persists beyond the acute phase of the septic process in a relevant proportion of patients, but we did not find any useful parameter to predict SIMD reversibility; strain echocardiography was superior to conventional methods in identifying systolic dysfunction.
09:40 - 09:50 #11765 - OP031 Sepsis-induced myocardial dysfunction: which role for cardiac biomarkers in diagnostic and prognostic assessment?
OP031 Sepsis-induced myocardial dysfunction: which role for cardiac biomarkers in diagnostic and prognostic assessment?
Background: Left (LV) or right (RV) systolic ventricular dysfunction has been found in about 50% of septic patients. The aims of this study were: 1) to evaluate biomarkers’ diagnostic accuracy in identifying patients who develop SIMD; 2) to evaluate prognostic significance of biomarkers.
Methods: In 177 patients diagnosed with severe sepsis/septic shock and admitted in our ED-High Dependency Unit between August 2012 and December 2016; an echocardiogram was performed within 24 hours from admission. We evaluated LV systolic function using Global Longitudinal Strain (GLS) and Ejection Fraction (EF) measurement and RV systolic function with Tricuspidal Annular Plane Systolic Excursion (TAPSE). We divided our population in two subgroups: patients who had a mono- or biventricular systolic dysfunction (D+) and those who hadn’t (D-). We referred to a GLS > -14% for LV systolic dysfunction and TAPSE <16 mm for RV systolic dysfunction. Biomarkers’ levels were measured both at the time of admission (T0) and after 24 hours (T1), considering them both as continue and dichotomized values (TnI: ≤0.1 or > 0.1 µg/L; NTproBNP: > or ≤ 6000 pg/mL). Day-7 and day-28 mortality were our primary end-point.
Results: Most frequent comorbidities were diabetes (27%), hypertension (55%) and neoplastic disease (31%); lung was the most common primary infection site (54%). One hundred twenty-seven patients (72%) showed an LV dysfunction and 54 (30%) a RV dysfunction; overall D+ group included 136 patients.
TnI T0 and TnI T1 levels were significantly higher in D+ patients compared with D- subjects (T0: 0.78 ±2.43 vs 0.15 ±0.29; T1: 1.00 ±2.60 vs. 0.19 ±0.48). T0 NTproBNP value was significantly higher in D+ than in D- patients (18292 ±34019 vs 9329 ±15616); dichotomized values did not show a significant different distribution between D+ and D- patients. ROC analysis showed an area under the curve (AUC)= 0.64 for T0
TnI,0.67 for T1 TnI, 0.60 for T0 NTproBNP and 0.65 for T1 NTproBNP.
Day-28 mortality was 28% (n=50). Biomarkers’ values did not show any significant association with an
increased mortality rate at univariate analysis; a more compromised value of GLS, TAPSE and EF was significantly associated with an increased day-7 and day-28 mortality; ; after adjustment for age and SOFA, an increased GLS was associated with an increased day-7 mortality (RR 1.18, IC 95% 1.04-1.35, p=0.010) while abnormal TAPSE and GLS were associated with increased day-28 mortality rate (respectively, RR 0.30, IC 95% 0.12-0.72, p=0.007 and RR 1.11, IC95% 1.01-1.25, p=0.041) while EF did not demonstrated any prognostic significance in a similar multivariable model.
Conclusion: SIMD has a significant incidence and is associated with an increased mortality rate; the levels of biomarkers, commonly considered as a result of myocardial damage, are higher in patients who present ventricular systolic dysfunction than in others but the prognostic discrimination ability is poor.
09:50 - 10:00 #11768 - OP032 Echocardiographic assessment of fluid-responsiveness: a preliminary experience in a High-Dependency Unit.
OP032 Echocardiographic assessment of fluid-responsiveness: a preliminary experience in a High-Dependency Unit.
Background: Aim of this study was to examine the feasibility and diagnostic accuracy of VCCI and velocity time integral variation after passive leg raising (PLR) in an unselected population of critically ill patients admitted to a sub-intensive clinical setting.
Methods: This is a prospective, observational, pilot study. Unselected critical patients admitted in an Emergency Department High-Dependency Unit (ED-HDU) were evaluated by transthoracic echocardiography to measure vena cava collapsibility index (VCCI) and aortic velocity (AoV) variation during PLR. Conventional LV and RV diastolic dimensions and systolic function (LV ejection fraction, EF, and Tricuspid Annulus Systolic Posterior Excursion, TAPSE) were measured. According to VCCI, patients were considered fluid-responders when the value was ≥40%. According to AoV variation after PLR, a positive hemodynamic response was defined as an increase in AoV ≥ 10%. Whenever possible, both VCCI and AoV variation during PLR were evaluated. According to echocardiographic evaluation, three therapeutic options were considered: no intervention, administration of fluids or diuretics. Any change in the therapeutic strategy by the treating physician in the following 12 hours was annotated into the clinical records.
Results: we enrolled 53 patients, mean age 73±14 years; the two most frequent reasons for ED-HDU admission were sepsis (75%) and COPD re-exacerbation (8%); in 5 (10%) patients echocardiographic evaluation was not feasible. VCCI was feasible in 35 (66%) patients, while PLR could be performed in 33 (62%). Eighteen patients were managed according to VCCI: 13 were non FR, while 5 were FR and were treated with fluid boluses. In the following 12 hours, in 4 non FR patients and in 3 FR patients therapeutic strategy was modified (7/18, 39%). Thirty-one patients were treated according to PLR: among 18 FR patients, 16 received a fluid bolus while 13 non FR did not receive fluids and this therapeutic strategy was maintained in all but one FR patient in the following 12 hours (1/31, 3%, p=0.002). In the group of patients managed by PLR 18 also underwent VCCI evaluation which was discordant with PLR in 3 patients. Finally we compared LV and RV dimensions and systolic function between patients in whom VCCI correctly identified FR (n=26) or it did not (n=10): presence of LV dilatation (LV diastolic diameter >55mm; 10% in both groups), RV dilatation (At least 2 of the three conventional RV diameter over normal limits; 62% in patients correctly identified vs 46% in patients not correctly identified), LV systolic dysfunction (LVEF <50%; 44% vs 33%) and RV systolic dysfunction (TAPSE
Conclusions: we confirmed a poor diagnostic accuracy for VCCI independent to LV and RV dimensions and systolic function; VTI variation during PLR showed a very good diagnostic performance.
10:00 - 10:10 #11772 - OP033 MEWS and lactate dosage variation: which is the best time-interval for the prognostic assessment of septic patients?
OP033 MEWS and lactate dosage variation: which is the best time-interval for the prognostic assessment of septic patients?
Introduction: The aim of this study was to compare the prognostic value of MEWS (Modified Early warning System) score and lactate dosage absolute value and trend over 2, 6 and 24 hours after admission, in order to identify the most appropriate timing to evaluate score’s evolution.
Methods: In the period November 2011-December 2016, 269 patients enrolled in a prospective study aiming to find reliable biomarkers for an early sepsis diagnosis. Patients admitted to our High-Dependency Unit from the Emergency Department with a diagnosis of severe sepsis/septic shock were eligible. At ED-admission (T0), after 2 hours (T2), 6 hours (T6) and 24 hours (T24) from the initial diagnosis, we evaluated lactate and MEWS score; score differences over 2-hour (ΔMEWS-2H), 6-hour (ΔMEWS-6H) and 24-hour time interval (ΔMEWS-24H)were calculated. Lactate absolute values (analyzed as continuous values and ≤ or >2 meq/L) and lactate clearance (dichotomized as ≤ or >10%) were evaluated at the same time intervals. The primary end-point was in-hospital mortality.
Results: Mean age of the study population was 74±14 year, 59% male gender; main comorbidities were arterial hypertension (61%), diabetes (33%), neoplasia (22%) and chronic kidney disease (24%). The most frequent infection source was respiratory (45%) and 41% of patients developed a septic shock. Overall in-hospital mortality was 26%. Mews score was significantly higher in non-survivors compared with survivors at all evaluations (T0: 4.3±2.1 vs 3.6±2.0, p=0.028; T2: 4.1±1.6 vs 2.9±1.7, p<0.001; T6: 4.3±2.1 vs 2.6±1.7, p<0.001; T24: 3.9±2.6 vs 2.3±1.7, p<0.001); repeated measures analysis confirmed a significant difference within subjects (p<0.001) and between survivors and non survivors, with a continuous decrease in the first group and a flat trend in the second one. Score variation was negligible in non survivors (T2: -0.15±1.51 vs -0.71±2.03, p=0.062; T6: -0.19±2.15 vs 0.97±2.01, p=0.023; T24: 0.11±2.61 vs -1.31±2.01, p<0.001); after dichotomization of the score variation on the basis of the median value of this study population (≤ or >-1), only at 24-hour evaluation a variation>-1 was significantly more frequent among non survivors (60 vs 34%, p=0.004). Lactate dosage was significantly higher in survivors at all evaluations except for T2 (T0: 3.8±3.9 vs 2.7±2.5, p=0.043; T2: 3.5±3.8 vs 2.4±2.6, p=0.067; T6: 3.4±3.8 vs 1.7±1,3, p=0.003; T24 4.1±5.7 vs 1.4±0.9, p=0.002); a value>2 meq/L was significantly more frequent among non-survivors only at T24 (43 vs 19%, p=0.001). A lactate clearance >10% was significantly more frequent among survivors at T6 (71 vs 48%, p=0.006) and tendentially at T24 (67 vs 50%, p=0.053), not significant at T2 (59 vs 47%, p=.208).
Conclusions: Vital signs aggregated into MEWS score and lactate dosage were significantly worst in non-survivors compared with survivors at the moment of sepsis diagnosis; a 2-hour interval appears too short to allow a prognostic evaluation.
10:10 - 10:20 #11774 - OP034 SOFA score variation: which is the best time-interval for the prognostic assessment of septic patients?
OP034 SOFA score variation: which is the best time-interval for the prognostic assessment of septic patients?
Introduction: The aim of this study was to compare the prognostic value of score trend at 6 and at 24 hours after admission, in order to identify the most appropriate timing to evaluate score’s evolution.
Methods :In the period November 2011-December 2016, 269 patients enrolled in a prospective study aiming to find reliable biomarkers for an early sepsis diagnosis. Patients admitted to our High-Dependency Unit from the Emergency Department with a diagnosis of severe sepsis/septic shock were eligible. Exclusion criteria included presence of severe cognitive impairment inducing associated with immobilization syndrome lasting from more than three months; age
Results: Mean age of the study population was 74±14 year, 59% male gender; main comorbidities were arterial hypertension (61%), diabetes (33%), neoplasia (22%) and chronic kidney disease (24%). The most frequent infection source was respiratory (45%) and 41% of patients developed a septic shock. Overall in-hospital mortality was 26%. SOFA score was significantly higher non-survivors compared with survivors at all the evaluations (T0: 6.1±2.7 vs 5.0±2.7, p=0.013; T6: 7.8±3.1 vs 6.1±2.9, p<0.001; T24: 8.5±3.5 vs 5.3±2.6, p<0.001). Discriminative analysis by ROC curves showed an improving prognostic stratification ability in following evaluations (T0: area under curve, AUC, 0.62, 95%CI 0.54-0.70, p=0.007; T6 AUC 0.67, 95%CI 0.59-0.775, p<0.001; T24 AUC 0.77, 95%CI 0.70-0.85, p<0.001). Based on ROC curve analysis, we identified the value 3.5 as that having a good sensitivity a specificity (98 and 74%): a SOFA score lower than 3.5 was significantly more frequent among survivors at all evaluation points (T0: 32 vs 17%, p=0.039; T6: 21 vs 6%, p=0.022; T24 26 vs 2%, p=0.001). ΔSOFA-T6 (1.8± 2.3 vs 1.1± 2.0, p=0.025) and ΔSOFA-24H (2.5±3.3 vs 0.3±1.9, p<0.001) were significantly higher in non-survivors compared with survivors. A ΔSOFA value at either evaluation point >1 (median value in our study population) was significantly more frequent among non-survivors (T6: 57 vs 35%, p=0.006; T24: 61 vs 28%, p<0.001). Patients with a SOFA score >3.5 and a score variation >1 showed a significantly higher mortality rate at either T6 and T24 evaluation, compared with patients who presented only one of the previous values or neither (T6: 57% vs 38% vs 6%, p=0.003; T24: 61% vs 37% vs 2%, p<0.001).
Conclusions: Prognostic value of SOFA score was modest at the moment of sepsis diagnosis; at a 6-hour interval, useful prognostic information could be obtained both from absolute score values and score variation, which were further confirmed at the 24-hour evaluation.
10:20 - 10:30 #10116 - OP035 Spanish Pediatric residents: Variability In Education and Research In Pediatric Emergency Medicine.
OP035 Spanish Pediatric residents: Variability In Education and Research In Pediatric Emergency Medicine.
To analyze the education in pediatric emergency medicine (PEM) given to pediatric residents and the research carried out by them in Spain.
Descriptive cross-sectional study based on web surveys. First survey, regarding characteristics of PEM education and research in the Emergency Department (ED), was distributed to the directors of pediatric EDs included in the Spanish Society of Pediatric Emergencies. Respondents were asked to distribute a second survey to their residents and pediatric assistants. Only EDs with more than 30% of respondents were included for the descriptive analysis of all the variables.
Main outcome variables were the level of satisfaction within resident education (on a scale from 0 to 10) and the number of papers published in a peer-reviewed journal in the last 5 years. Multivariate analysis was made to assess associated factors between them.
First survey was sent to 83 directors and 42 (50.6%) answered it. In 33 (78.6%) EDs more than 30% of respondents fulfilled the second survey, including finally 376 (92.8%) for analysis (196, 52.1%, fulfilled by residents).
Median value of resident’s satisfaction with PEM training in each hospital ranked from 5 to 9. Factors associated with higher values were having education quality indicators, closer supervision of clinical practice and a structured evaluation of resident’s PEM skills when finishing the working shift or the rotation in the ED period.
In the previous 5 years, the average of research training activities by ED was 1 (IQR 0-3), with 11 EDs (33.3%) having no activity. Around 50% of respondents considered that research was not adequately supported at their EDs.
Level of resident’s satisfaction with research in PEM in each hospital are shown in figure 1. Sixty-eight respondents (18.1%) had published at least one paper on a peer-reviewed journal (residents, 17, 25%). Associated factors with having a paper published were the existence of a research director in the ED, having research quality indicators, self-perception of residents that the research was supported in the ED and having performed any research training activity in the previous 5 years.
Those residents with at least one paper published rated higher their education [mean= 8 (CI95% 7.34-8.66) vs those with no publications, 7.1 (CI95% 6.87-7.33)]
Significant variability in PEM education and the research was noted among Spanish pediatric residents. An adequate organization of the EDs seems to be essential to improve education and research.
10:30 - 10:40 #11675 - OP036 Comparison of two protocols of intravenous insulintherapy in the management of diabetic ketoacidosis.
OP036 Comparison of two protocols of intravenous insulintherapy in the management of diabetic ketoacidosis.
Diabetic ketoacidosis (DKA) is an acute and potential life-threatening complication of diabetes mellitus. The mainstay in the treatment of DKA involves the administration of regular insulin. However, the route and the dose of insulin remains controversial. This study was designed to compare the safety and the efficiency of two protocols of intravenous insulin (IV): Protocol (A) Intravenous bolus of regular insulin 0,1UI/Kg followed by a continuous IV infusion at the dose of 0,1UI/Kg/H; Protocol (B) a continuous IV infusion of regular insulin at the dose of 0,14UI/Kg/H without bolus.
Prospective randomized study of patients aged more than 18 years with moderate to severe DKA hospitalized in the emergency department. Patients were devised into two groups: Group (A) received protocol (A) and Group (B) received protocol (B). Standardization of:1) the fluid therapy with normal saline and 5% dextrose 2)the potassium replacement. Data on glucose level, pH, serum bicarbonate, anion gap, intravenous fluid administration, and length of stay were collected. Outcomes data were: time to recovery, time to glucose control (<250mg/l), insulin dose to recovery, occurrence of complications: hypoglycemia, hypokalemia, recurrence of DKA.
We enrolled 164 consecutive DKA patients. Exclusion of 39 patients. The mean age = 39 +/- 18 years, sex ratio =0.97. DKA occurs more in type 1 diabetes n=87(47.6%) than in type 2 n= 64(39%) and was inaugural in 22 patients (13.4%). There were no differences between the two groups in clinical and biochemical data Group (A) versus Group (B) : mean age (37+/-17 vs. 37+/-17 years; p=0.95),sex ratio(0.84 vs. 0.88),Blood glucose level (30.2+/-9.9 vs. 32.5+/-11.9 mmol/l; p=0.27), pH(7.14+/-0.13 vs. 7.15+/-0.12; p=0.7), anion gap (28.63+/ 5.74 vs. 28.9+/-7.21; p=0.8) ; also in outcomes data Group(A) vs. Group(B): time to recovery (17.6+/-13 vs. 17.4+/-21.5 hours; p=0.9), insulin dose to recovery (76.5+/-55.1 vs. 74.9+/-35.3 UI; p=0.8) length of stay in intensive care unit (28.3+/-18.2 vs. 32.4+/-20.3 hours; p=0.3),complications : hypoglycemia(n= 4 vs. 10; p=0.12 ) , hypokalemia (n= 32 vs. 31; p=0.33) , recurrence of DKA (n=1 vs. 7; p=0.31) .
These two protocols of IV insulin infusion were safe and had a comparable efficiency without majoring the risk of complications.
Free Papers Session 5
Moderators: Felix LORANG (Consultant) (Leipzig, GERMANY), Anastasia ZIGOURA (GREECE)
11:10 - 11:20 #9835 - OP037 Hygiene in the emergency medical service calls for attention.
OP037 Hygiene in the emergency medical service calls for attention.
Background Contaminated environmental surfaces are known provide an important potential source for transmission of healthcare associated pathogens and prehospital treatment have been associated to increased risk of infection. Nevertheless, few studies present and discuss prehospital hygiene, resulting in limited knowledge and understanding of related challenges. Our aim was to assess microbial contamination and influencing factors in order to assess the extent of the risks and illuminate eventual solutions.
Methods A nationwide, semi-blinded, cross-sectional study was conducted in Denmark from August to November 2016. Using a combined swab/agar method, samples from environment, equipment and personnel were randomly collected from 80 ambulances and crew, in-between patient courses, after cleaning. Focus was on colony forming units (cfu) and healthcare associated pathogens. In addition, explanatory variables e.g. hours from last thorough cleaning, area of service (rural/city) and number of patient courses within the shift, were collected and used in bivariate analyses.
Results 800 sites, showed an average of 11.3 cfu/cm2 (environmental sites e.g. blood pressure cuff, patient harness and defibrillator 5.01 cfu/cm2, hands of the personnel 11.1 cfu/cm2 and uniforms 30.6 cfu/cm2). Staphylococcus aureus, Enterococcus and Enterobacteriaceae were found on 10, 3.4 and 0.5 % of the imprints, respectively. One imprint was MRSA, two were VRE but none was ESBL. Furthermore, we found no correlation between the explanatory variables and the degree of microbial burden.
Conclusion Our study underlines that microbial contamination and related challenges in the EMS calls for further attention. As seen in prior studies, several sites were contaminated with healthcare associated pathogens. However, neither time from cleaning, number of patients nor area of service were of influence on the degree of contamination, hence not contributing to an explanation. Future research on hygienic challenges and routes of transmission is recommended.
11:20 - 11:30 #11059 - OP038 Prehospital echocardiography during resuscitation impacts treatment decisions in a physician-staffed helicopter emergency medical service: a prospective observational study.
OP038 Prehospital echocardiography during resuscitation impacts treatment decisions in a physician-staffed helicopter emergency medical service: a prospective observational study.
Patients in cardiac arrest must receive algorithm-based management such as basic life support and advanced (cardiac) life support. International guidelines dictate diagnosing and treating any factor that may have caused the arrest or may be complicating the resuscitation. Ultrasound is recognized to be of potential value in this process. Also, it is shown to be feasible in a prehospital setting. We aim to determine the impact of prehospital echocardiography during cardiopulmonary resuscitation (CPR) and its impact on treatment decisions in a Dutch physician-staffed helicopter emergency medical service (HEMS).
We conducted a prospective, observational study from February 2014 through October 2016 of patients treated by the Nijmegen HEMS. Inclusion criteria were CPR irrespective of its cause and concurrent echocardiography. Echocardiography-trained physicians performed the examinations within the same time window where chest compressions are interrupted to analyze heart rhythm. Data collection included patient demographics; type of incident; CPR details and outcome; vital signs; ultrasound findings (ventricular dimensions; global myocardial function; any pericardial fluid); physician-reported image quality and ease of procedure; impact on treatment decisions. Outcome parameters were: impact on treatment decisions; characteristics of the population; feasibility of echocardiography in this setting.
Of 6694 recorded scrambles and 3229 patients treated, 425 underwent CPR. In 56 patients 102 ultrasound examinations were documented. Treatment decisions were impacted in 49 patients (88% - CI 79.5-96.5%) and in 62 (61% - CI 51.5-70.5%) ultrasound examinations. Overall, we found 78 changes. They were termination of CPR in 32 patients (57%) and continuation hereof in 21 (38%). Other changes were related to fluid management (14.3%), adjustment of drugs and doses (14.3%), and choice of receiving hospital (5.4%). The causes of cardiac arrest were trauma (48%), cardiac (21%), medical (14%), asphyxia (9%), and other (7%). The ease of the entire procedure was scored a median of 7 (numeric rating scale 1-10) and image quality per examination good (59%), moderate (29%), or poor (12%).
Ultrasound impacts management in 88% of patients. This is in accordance to results of (peri-) resuscitation studies by Breitkreutz (78%) and Shokoohi (12%-31% in different categories, overall unknown). Ultrasound images can help explain futile care to caregivers and relatives, even if the sensible decision already is to terminate CPR. Prehospital (traumatic) CPR is often impeded by stress, time pressure, environmental factors including a restricted workspace, and an inaccessible ultrasound machine. This likely explains the limited number of inclusions. In conclusion, prehospital ultrasound during CPR in our HEMS significantly impacts patient treatment. This suggests echocardiography should be a standard tool in every prehospital resuscitation.
11:30 - 11:40 #11071 - OP039 Can additional ems call triage time improve resource utilisation?
OP039 Can additional ems call triage time improve resource utilisation?
Time based standards have been used as a key performance measure for EMS internationally, despite a lack of evidence that they actually lead to good clinical care. Achievement of standards in an environment of rising demand potentially leads to operational behaviours that may be inefficient such as dispatching multiple vehicles before the problem is known. In England, the Ambulance Response Programme is developing new operational models of care. One strategy has been to test if additional call triage time before starting the response interval clock start can lead to better use of resources and improved dispatching.
A controlled before and after time series analysis of a new intervention – Dispatch on Disposition (DoD)– comprising a short set of pre-triage questions to identify time critical emergencies needing immediate dispatch of a resource and up to 4 minutes to triage all other calls (compared to the existing 60 seconds). DoD was implemented in 6 of the 10 regional services in England and 4 services were control sites. We measured weekly trends in average resource allocation per call and resources on scene for different call types (life-threatening, emergency, urgent) for 1 year before and 7 months after implementation, and used time series regression models to compare changes between intervention and control sites adjusted for seasonality, call volumes and hours lost at hospital handover. We also conducted a survey of dispatch and operational staff.
There was a statistically significant reduction in average resources allocated per incident of -0.1 for life-threatening calls, -0.06 for emergency and -0.12 for urgent, and a reduction in resources arriving on scene per incident of -0.006 for life-threatening calls and -0.02 for urgent in the intervention groups compared to control. Scaled up the resource allocation reductions will potentially produce an additional 10243 whole resources available to respond per week in England. Dispatch staff reported they were better able to manage call queues and allocate the right rather than any response. Operational staff reported a substantial reduction in calls where they were cancelled before arriving on scene.
Prior to DoD ambulance services in England had to dispatch a resource within 60 seconds of receiving an emergency call and in order to achieve a response time of 8 minutes for the most serious calls multiple resources could be sent before establishing if the call was serious. Allowing additional time to properly triage calls other than those likely to be life-threatening has created efficiencies by substantially reducing multiple resource allocations and freeing up vehicles for other calls. In an environment of increasing demand and diminishing resources this allows better use of existing resources.
11:40 - 11:50 #11172 - OP040 Improving data quality in a United Kingdom registry of Out-of-Hospital cardiac arrests through data linkage between the Out-of-Hospital Cardiac Arrest Outcomes (OHCAO) project and the Office for National Statistics.
OP040 Improving data quality in a United Kingdom registry of Out-of-Hospital cardiac arrests through data linkage between the Out-of-Hospital Cardiac Arrest Outcomes (OHCAO) project and the Office for National Statistics.
Background: The Out-of-Hospital Cardiac Arrest Outcomes (OHCAO) project aims to understand the epidemiology and outcomes of out-of-hospital cardiac arrests (OHCA) across the UK. Significant variation exists between ambulance services in outcomes for patients with attempted resuscitation following OHCAs. Importantly, a great deal of the variability of reported outcomes can be traced back to the quality of data that results are based on.
This study is a sub-project of OHCAO and aims to establish the feasibility of producing a registry of OHCAs by linking OHCAO data to the Office for National Statistics (ONS) mortality data, via NHS (National Health Service) Digital, to improve data quality and establish accurate 30-day survival outcomes for OHCAs.
Methods: Data were collected from 1st January 2014 to 31st December 2014 as part of a prospective, observational study of all OHCAs attended by ten English NHS Ambulance Services. 28,729 OHCA cases had resuscitation attempted by Emergency Medical Services and were included in the study. Of these, a randomly selected sample of 3,120 cases (10% of total) were securely transferred to the ONS. This allowed OHCAO demographic data to initially be matched to NHS patient demographic data, using the NHS Digital list cleaning service to return previously missing data. Following this, cases were linked to ONS mortality data to provide accurate death dates where applicable to calculate 30 day survival.
Results: A total of 80.5% of OHCAO cases were matched to the ONS database. OHCAO collected complete demographic datasets on 868 (27.8%) cases. Using the linkage process, missing demographic data was retrieved for 72.7% of the 2,249 cases with incomplete data. Confirmation of 30-day survival improved by 37.6% with a reduction in unknown 30-day survival status from 46.1% to 8.5%. The most important data point required for linkage was the NHS number which provides a unique patient identifier. However, it was only retrieved by the OHCAO project for 31.7% of cases. This study found that if at least 3 other demographic data points were collected, the NHS number could be retrieved using the linkage process in up to 89.9% of cases.
Discussion: Ensuring high data quality is essential as this forms the basis of decisions that ultimately impact on changes in care and healthcare resource allocation. Data linkage was shown to successfully improve the quality of OHCA demographic data and survival status 30 days after OHCA. Importantly, this process has allowed the provision of demographic details to allow patients to be followed longitudinally, potentially to assess morbidity following OHCAs. The linkage process can be used to produce a registry of OHCAs and information gained from this can be fed back to institutions providing source data to improve OHCA outcomes.
11:50 - 12:00 #11602 - OP041 Fire Medical Response Early Indications of Clinical Value.
OP041 Fire Medical Response Early Indications of Clinical Value.
Fire Medical Response Early Indications of Clinical Value
In the UK, response to serious medical emergencies has been solely provided by the National Health Service (NHS), but UK Fire and Rescue Services (FRS) are increasingly establishing a presence as ‘Fire Medical Responders.’ FRS are highly developed organisations with the potential to offer a rapid response to medical emergencies. They also operate with ‘latent capacity,’ compared to health care resources, creating an opportunity to assist in meeting urgent patient need. The aim of this study was to investigate the impact of FRS co-responding on the delivery of emergency medical response.’
An observational study generating data from 42/50 Fire & Rescue Services, FRS, during 2016 to assess current involvement in EMS co-response. We have a) compared response time distributions between Fire and Ambulance services b) described the types of calls attended by FRS crews c) estimated the likely survival benefit based on optimal response time curves for successful defibrillation in out of hospital cardiac arrest and d) conducted an economic evaluation.
There was a statistically significant difference in response performance between the Fire and NHS Ambulance Services, with FRS arriving first in 62% of cases, NHS Ambulance Service arriving first in 23% and no record of who arrived first in 25%. For every 10% increase in the proportion of ‘whole time duty fire stations’ [stations with 24 hrs/day staffing], there was an 8.4% improvement in response time and mean 84 second shorter response time compared to stations using retained staff utilised via an “on call” system. The top 5 clinical categories attended by FRS were: cardiac problems/chest pain (23%); breathing problems (13%); unconsciousness (13%); cardio-respiratory arrest (9%), and fitting (9%). From the response time improvement data, we have estimated a potential survival benefit of 1.2 Quality Adjusted Life Years (QALYs) gained. Using NICE figures of £20,000 per QALY, there is a potential benefit of around £23,000 per critical medical event but this figure should be treated with caution as it is a theoretical extrapolation and the study was not designed to measure individual patient outcome.
Fire Medical Responding is a new development in the UK, having previously operated a strict demarcation between fire and ambulance services although it is well-established in some European countries and in other parts of the world, such as the USA. This study found FRS can frequently respond more rapidly to medical emergencies than the ambulance service and that they can be appropriately deployed to time critical conditions. This offers an opportunity to employ an underutilised, potentially life-saving resource more widely at low cost. There is a potential life-saving advantage in further developing and evaluating a Fire Medical Response capability.
12:00 - 12:10 #11971 - OP042 IMMIGRATION PROBLEM IN GREECE, The impact for Emergency Medical System in Attica Creece 2.
OP042 IMMIGRATION PROBLEM IN GREECE, The impact for Emergency Medical System in Attica Creece 2.
IMMIGRATION PROBLEM IN GREECE,
The impact for Emergency Medical System in Athens
Over 10000 refugees have lost their lives in the Mediterranean since 2016 in their endeavor to reach the EU
In the first half of 2016 there were 2809 recorded deaths
Immigration today is one of the most important problems in the world and at the same time a purely anthropocentric challenge for all stakeholders, especially the EMS in GREECE (National Centre for Emergency care) (First responder)
In 2015 Greece became the main point of entry into the EU for refugees and immigrants from Turkey. It is estimated that 850,000 people attempted the dangerous passage of the Aegean Sea
Of these, more than 53,000 refugees remained in Greece Most of them (about 90%) come from Syria, Iraq, and Afghanistan. Among them are small children, people with severe health problems, pregnant women, and infants
Disease-related diseases (refugees) are often unexpectedly severe and complex (extreme age groups - infants, children, and the elderly)
To describe & estimate the effect on EMS/NHS
Children make up 48% of the refugees, while for adults, 30% of them are men and 22% are women
- 10% of refugees in Greece are only 2 to 4 years old
- 14% are aged between 5 and 9 years
- 11% are aged 10 and 14 years old
There are camps that sheltered all these people in ATTICA
DATA for the present study are from the central Department of EMS & Na.H.O.C. archives
In the year 2016 they took place: more than 5000 records of emergency transportations from the above camps to Hospital through the Na.H.O.C. & EMS
- The effect of migration problem in our country runs through every activity
- EMS/NaHOC is responsible to manage the medical problems of the immigrants
- This require resources from our country in a very difficult period to be available
- Although our country overcomes the present problems & reacts in the best practice
12:10 - 12:20 #10977 - OP043 Intoxications with prescription drugs at Tampere University Emergency department in 2014.
OP043 Intoxications with prescription drugs at Tampere University Emergency department in 2014.
Background: Intoxications with prescription drugs are a common burden at emergency departments (EDs). Mortality associated with intoxication has been increasing. Intoxications are a common way to commit suicide, especially among women. Our study aimed to evaluate intoxication patients` psychiatric history and other clinical features.
Material and methods: We identified all patients with ICD10- code TX36 from year 2014 at Tampere University ED. We collected the data on age, gender, arrival time and date from hospital records. We also collected patient-specific data such as psychiatric diagnoses, previous psychiatric care and suicide attempts, alcohol and/or drug consumption, difficulties in life (with relationships, money, work or with own or relatives` health) and somatic symptoms.
Results: There were a total of 372 patients with a slight female predominance (51,6 %).The median age was 38 years (1-92 years). 40% of cases arrived to ED between 6 p.m-12 p.m. The most used prescription drug was benzodiazepam (34%). 13% of patients had also used some type of illegal drug, for example cocaine, LSD and cannabis. Activated charcoal was given to 71 % of the patients. According to our data, 53% of intoxications were intentional/suicidal and in 18% of cases the feature of self-harm was not registered. 10% of patients had had one previous intoxication in the database of Tampere University Hospital during the previous two years, and 2% had had more than one intoxication during the same time. The most common difficulties in life were associated with interpersonal relationships (43%). 54% of the patients received psychiatric consultation and 66% were guided to psychiatric after-care. The most common somatic complication of the intoxication was respiratory tract infection (7 %). Seven-day mortality was 0.8 % and one-year mortality 4.8 %.
Discussion: The results of our study were convergent with previous intoxication studies. Gastrointestinal decontamination was executed rarely but the number of complications, however, was low. This can be partly explained by effective and well-functioning treatment chains and settings. Understanding the associated features of intoxication patients is important for care guidance to these patients. As we could see in this study, many of the patients attempted suicide but only a minority of them were in danger of death. These cases should be recognized as a cry for help. It is important for health care workers to identify high-risk patients and to guide them to psychiatric care as soon as possible, in order to prevent recurrent intoxications. This study shows that if the intoxication patient reaches the hospital, the prognosis is good. The mortality rate in this patient group is low.
12:30 - 12:40 #11851 - OP045 Pediatric emergency department visits due to acute ethanol intoxication.
OP045 Pediatric emergency department visits due to acute ethanol intoxication.
Background: Alcohol is one of the most frequently abused drugs. Alcohol exposure of pediatric population is gradually increasing all over the world thus leading to acute alcohol intoxication and its consequences.
Objective: The aim of this study was to describe presentations and analyze demographic, clinical and laboratory characteristics of pediatric patients presented to the pediatric emergency department with acute ethanol intoxication.
Methods: We conducted a retrospective review of pediatric patients, who presented to a pediatric emergency department with any complaint and had serum ethanol level determined between January 2006 and December 2016. Patients with serum ethanol level below 50 mg/dL, patients with insufficient data and patients older than 18 year-old were excluded from analyses.
Results: Serum ethanol levels were determined for 917 patients. Among these, 229 patients were tested positive for alcohol abuse having serum ethanol levels >50 mg/dL. Nine patients were excluded because of having insufficient data so a total of 220 patients (Male 128; female 92) were included in the study. 53% patients were brought to the emergency department by emergency medical services. Mean age was 16.0±1.6 years. Most frequent complaints at presentation were decreased level of consciousness (29.5%, n=65), nausea/vomiting (21.8%, n=48) and trauma (14.1%, n=31). The median Glasgow Coma Score on admission to the emergency department was 15. Only 5 patients had GCS ≤8. Minor injuries were identified in vast majority of patients with trauma. Most common injury type was falls (5.5%, n=12). 11.8% (n=26) patients consumed alcohol as part of a suicidal attempt. Serum ethanol level ranged between 50.8-341.2 mg/dl (mean: 157.9±57.9 mg/dl). 63% (n=140) patients had blood gas analysis. Among these 68.6% (n=96) had hyperlactinemia. 207 patients had biochemical investigations, which revealed abnormal kidney functions in 20.8% (n=43). Likewise, 19% (n=39) had hypokalemia (<3.4 mEq/L) while 17.6% (n=36) had hypophosphatemia (<2.7 mEq/L). None of the patients had hypoglycemia. However, 51.9% (n=95) had mild hyperglycemia (100-200 mg/dL). Blood glucose level and pH were correlated with serum ethanol levels (p=0.007, R2=0.053 and p=0.008, R2= 0.038, respectively). Vast majority of the patients (94%) received treatment in the pediatric emergency department.
Discussion: Acute alcohol intoxication in pediatric population is a preventable emerging problem. It is important to recognize that hyperlactatemia, hypokalemia, hypophosphatemia, mild hyperglycemia and abnormal kidney functions are common biochemical findings in children with acute ethanol intoxication.
Free Papers Session 6
Moderators: Felix LORANG (Consultant) (Leipzig, GERMANY), Anastasia SFAKIOTAKI (Emergency Physician) (Melbourne, AUSTRALIA)
14:10 - 14:20 #10117 - OP046 Differences in the use of skull radiography in children with minor head trauma.
OP046 Differences in the use of skull radiography in children with minor head trauma.
Background: Minor head trauma is a major cause of emergency department visits. Head computed tomography (CT) is the reference standard for the emergency assessment of head trauma. A recent multicentre study of Research in European Pediatric Emergency Medicine (REPEM) network demonstrated that 30% of patients with a minor head trauma (MHT) underwent skull radiography (SR).
Objective: Describe the practice variation in the use of SR for MHT in a group of hospitals affiliated to REPEM.
Design/Methods: Subanalysis of a multicenter retrospective study, including 15 hospitals from 9 European countries. Patients up to 18 years with MHT, defined by Glasgow Coma Scale score (GCS) 14-15, evaluated in years 2012, 2013 and 2014 were included. Pediatric Emergency Care Associated Research Network (PECARN) rules were considered the standard to assess differences in management and to stratify the risk for clinically important Traumatic Brain Injury (ciTBI).
Results: In the main study 13.266 patients (GCS 13-15) were included and 10.109 (76.8%) patients had MHT. The prevalence of ciTBI was 79/10109 (0.77%). SR was performed in 2.762 (27.3%) patients. The rate of SR varied between centres from 0.42% to 92% (figure 1).
Fifty-four (1.96%) had a skull fracture in the SR. In 27 (50%) a head CT confirmed a skull fracture or documented an intracranial lesion. Thirteen (48.1%) patients with skull fracture had other intracranial findings while 14 (51.9%) children had an isolated displaced skull fractures.
Three (11.1%) patients required surgery, due to intracranial lesions.
In 27 (50%) patients, the head CT did not demonstrate any fracture or intracranial lesion.
Twenty-one (77.8%) true positive patients would be classified as intermediate or high risk for ciTBI according PECARN criteria.
Focusing on children determined as low risk for ciTBI according to PECARN rules, SR was performed in 1.933 (28.9%) patients, and demonstrated a fracture in 12 (0.62%) patients. Three (0.16%) patients had an associated intracranial lesion.
Factors associated with the use of SR were grouped as intermediate or high risk for ciTBI according to PECARN rules and isolated scalp hematoma.
Conclusion(s): Although the low diagnostic value does not justify its use, SR is frequently ordered in management of MHT patients in a representative group of pediatric emergency department of the REPEM. We demonstrated a wide variation in the use of SR. These differences are mainly to be due to local or national guidelines and consolidated practices more than lack of adherence to validated prediction rules.
14:20 - 14:30 #10905 - OP047 Cervical spine stabilisation in pediatric major trauma: a questionnaire of current practice.
OP047 Cervical spine stabilisation in pediatric major trauma: a questionnaire of current practice.
Cervical spine (C-spine) injuries in pediatric trauma are rare (0-2%)1, but can cause long-term morbidity. Recent Advanced Paediatric Life Support (APLS) guidance1 updated advice on management of suspected C-spine injury, not advocating routine use of hard collars. There are minor differences within existing national guidance on the same subject [National Institute for Health and Care Excellence (NICE)2, Joint Royal Colleges Ambulance Liaison Committee (JRCALC)3, Advanced Trauma Life Support (ATLS)4]. This study was undertaken to formally understand observed variations in C-spine stabilisation for pediatric trauma in the East of England (EoE) Trauma Network.
An online questionnaire was sent to members of the EoE Trauma Network. Respondents were presented with five hypothetical scenarios, reflecting changes in guidance, summarised as follows; 1) 4 year old (yr), high-speed motor vehicle collision, intubated, 2) 9 yr, 2 metre fall, GCS 14, chest pain, 3) 7 yr, bicycle collision, C-spine tenderness, for transfer to CT, 4) 6 yr, 4 step fall, GCS 13, combative, 5) 3 yr, rollover motor vehicle collision, asymptomatic.
Respondents chose whether C-spine protection was required followed by the type of protection required [‘Manual in-line stabilisation’ (MIS), ‘Collar’ or ‘Blocks and tape’ (B&T)] and ‘No protection required’.
A total of 163 responses were received from October 2016 to February 2017, mainly from paramedics (64%, 105/163) and 13% (21/163) from doctors.
- 77% (124/162) were unaware of recent changes in APLS guidance.
- The majority thought stabilisation was required in scenarios 1 to 4 [97% (161/166), 77% (130/168), 96% (158/164) and 82% (136/166) respectively]. However, opinion was divided in scenario 5 with 50% (81/162) choosing to stabilise, and 50% (81/162) otherwise.
- The chosen method of stabilisation also varied, notably in scenario 2 [MIS; 44% (57/130), collar; 20% (26/130), B&T; 36% (47/130)]. Few chose collar for a combative child [scenario 4; 8% (11/136)].
- Of 666 total responses, collars were chosen least often [18% (118/666)], and MIS and B&T were selected equally [41% (274/666)].
The results suggest varying practice in C-spine stabilisation in the region, possibly reflecting variation in national guidelines. Encouragingly, appropriate protection was used majority of the time. Despite the limitations of this survey, it provides preliminary evidence of inconsistent practice, and hence requirement for clearer guidance and education. More studies are needed to validate these findings, and ascertain whether they are representative of a national issue.
14:30 - 14:40 #10956 - OP048 How well do vital signs predict serious illness in children?
OP048 How well do vital signs predict serious illness in children?
Vital signs are commonly measured during the first clinical assessment at the emergency department (ED). Usually, healthcare workers judge these physiologic measurements based on existing reference ranges and values below or above the pre-specified cut-offs are interpreted as abnormal. Many different vital signs reference ranges exist for use in children, but their diagnostic value is uncertain. Therefore, the aim of this study is to determine the diagnostic value of commonly used heart rate and respiratory rate reference ranges for the recognition of serious illness in children at the ED.
We assessed commonly used paediatric reference ranges for heart rate and respiratory rate, including those from guidelines, textbooks, medical literature and those provided in triage systems or early warning scores. The analysis is based on a observational cohort of children under 16 years of age, presenting to the ED of a university hospital in the Netherlands (2009-2012). Nurses routinely recorded patient data, vital signs and patient destination in the electronic health record. Missing vital signs were imputed 10 times using a multiple imputation approach. In a descriptive analysis we explored differences between the age-classification and cut-off values of the different reference ranges. Moreover, we assessed the diagnostic accuracy of these reference ranges for serious illness in children, defined as the need for ICU admission or hospital admission immediately after the ED visit
In our cohort, 15,099 children attended the ED during the study period, of whom 314 (2.1%) were admitted to ICU and 2681 (17.8%) to hospital. We identified 11 commonly used paediatric reference ranges for heart rate, respiratory rate, or both. These showed a large variation in age classification and corresponding cut-off values. Application of the different reference ranges in our cohort classified 2.4% to 58.0% of heart rate and 1.0% to 61.4% of respiratory rate values as abnormal. None of the individual vital signs had both a high sensitivity and a high specificity to detect serious illness in children, but the trade-off was very different for each of the reference ranges. Abnormal heart rate had a sensitivity ranging from 0.13 to 0.76 and a specificity ranging from 0.42-0.98 for ICU admission. For hospital admission, sensitivity ranged from 0.06 to 0.72 and specificity from 0.45 to 0.98. The diagnostic accuracy of respiratory rate also had a wide range, with sensitivity 0.05 to 0.69 and specificity 0.39 to 0.99 for ICU admission and sensitivity 0.02 to 0.68 and specificity 0.39 to 0.99 for hospital admission.
Several vital sign reference ranges for children exist and differences are large. It is important to be aware whether a certain reference range is better at ruling-in or ruling-out serious illness. Future research should aim at optimizing the cut-off of individual vital signs to improve existing reference ranges for children at the ED.
14:40 - 14:50 #11026 - OP049 The value of routine blood pressure measurement in children at the emergency department: a prospective observational study.
OP049 The value of routine blood pressure measurement in children at the emergency department: a prospective observational study.
Blood pressure measurement is recommended in children at the emergency department (ED) because low blood pressure is considered a marker of serious illness. However, blood pressure measurement is time consuming and a burden for (young) children. Moreover, different reference values are available and little evidence exists about the diagnostic value of low blood pressure in children. This study aims to identify lower reference values for systolic blood pressure and to investigate the diagnostic value of routine blood pressure in addition to heart rate in children at the ED.
A systematic review was performed to define age-specific cut-off points for low blood pressure. Secondly, we used blood pressure cut-offs from two well-known international guidelines (APLS and PEWS) in a prospective cohort of children attending a university ED (2009-2013) in the Netherlands. To investigate the diagnostic value for these two blood pressure cut-offs, we performed multivariable logistic regression to assess the association of abnormal blood pressure with serious illness, adjusted for abnormal heart rate. Sensitivity and specificity for serious illness (hospital or ICU admission) according to abnormal blood pressure defined by the APLS and PEWS were calculated. To assess the additional value for heart rate, sensitivity and specificity were computed for tachycardia and for patients who had both tachycardia and abnormal blood pressure according to the two cut-offs.
18 articles and 11 guidelines reported reference ranges. Only one guideline cited literature references. There was a large variation between the different age-related cut-offs for hypotension (differences ranging from 15 to 30 mmHg in age groups). In the observational study, 5467 children had complete data of blood pressure and heart rate. Frequency of ICU- and hospital admission was 5.5% and 34.7%, respectively. Abnormal blood pressure was significantly associated with hospital admission when adjusted for heart rate based on APLS (OR 1.32 95%CI 1.17–1.48) or based on PEWS (OR 1.76 95%CI 1.57–1.98). Similar associations were found with ICU admission. Abnormal blood pressure according to the APLS showed moderate sensitivity (67%; 61%) and low specificity (43%;45%) for ICU- and hospital admission. The PEWS demonstrated low sensitivity (55%;44%) and moderate specificity (64%; 68%). Tachycardia had low sensitivity (37%;30%) and high specificity (81%;85%) for ICU- and hospital admission. When combining tachycardia and abnormal blood pressure, the APLS showed high specificity (88%; 90%) and low sensitivity (21%;14%). The PEWS showed similar results.
Clinical references for blood pressure show large differences and are mostly not evidence based. Abnormal blood pressure showed an association with serious illness at the ED, but its diagnostic value is uncertain. However, the combination of tachycardia and abnormal blood pressure appears to be good at ruling-in serious illness.
14:50 - 15:00 #11068 - OP050 Are procalcitonin, C-reactive protein and absolute neutrophil count useful for predicting invasive bacterial infection in neonates under 21 days old with fever without source?
OP050 Are procalcitonin, C-reactive protein and absolute neutrophil count useful for predicting invasive bacterial infection in neonates under 21 days old with fever without source?
Background: neonates with fever without source (FWS) present a higher prevalence of invasive bacterial infection (IBI) than older infants. For this reason, it has been universally recommended performing a lumbar puncture and the admission with antibiotic treatment for any febrile neonate, even for those who are well-appearing. The “Step-by-Step” approach uses the 21-days-old cut-off point to identify high-risk patients. Our objective was to analyze the performance of the procalcitonin (PCT), C-reactive protein (CRP) and absolute neutrophil count (ANC) to identify IBIs among well-appearing neonates ≤21 days old with FWS.
Methods: a prospective registry-based cohort study including all the infants ≤90 days old attended in the Pediatric Emergency Department of a tertiary teaching hospital between September 2008 and August 2016 with FWS. We compared the prevalence of IBI (isolation of a pathogen bacterium in blood or cerebrospinal fluid) between those well-appearing patients ≤21 days old and >21 days old without leukocyturia in two groups: those with altered blood tests (PCT ≥0.5 ng/mL, CRP >20 mg/L or ANC >10000/mcL) and those with normal blood tests. We excluded those patients in whom the value of any of the three blood tests, the urine dipstick result or the blood culture result was not available.
Results: we included 1,762 of the 1,970 infants ≤90 days old with FWS attended (89.4%). Of them, 1,358 (77.0%) infants were well-appearing and had no leukocyturia in the urine dipstick. PCT, CRP and ANC values were normal in 126 of the 178 infants ≤21 days old (76.7%) and in 956 of the 1,180 infants > 21 days old (81.0%).
Prevalence of IBI in infants ≤21 days old was 3.2% among those with normal blood tests (vs 0.1% in infants >21 days old; OR 31.31 [IC 95%: 3.28-741.52]) and 5.7% among those with any of the three blood tests altered (vs 4.9% in infants >21 days old; OR 1.19 [IC 95%: 0.25-4.83]). Two of the four well-appearing infants ≤21 days old with normal blood tests who had an IBI were diagnosed with a bacterial meningitis.
Sensitivity and specificity of the three blood tests for identifying IBIs were 42.9% (15.8-75.0%) and 71.3% (64.2-77.6%), respectively in infants ≤21 days old and 91.7% (64.6-98.5%) and 81.8% (79.4-83.9%), respectively in infants >21 days old.
Discussion: PCT, CRP and ANC do not have a good performance to identify febrile infants less than 21 days old at low risk for IBI. In contrast to older infants, these tests cannot be used to identify patients suitable for a less aggressive management. Accordingly, neonates under 21 days old with FWS must be admitted with empiric antibiotic treatment after performing a lumbar puncture, regardless the general appearance and the results of the blood tests.
15:00 - 15:10 #11306 - OP051 Antibiotic prescription in children with respiratory tract infections at EDs in The Netherlands.
OP051 Antibiotic prescription in children with respiratory tract infections at EDs in The Netherlands.
Fever is the main presenting symptom of children presenting at paediatric emergency departments (EDs) in Europe, with a majority related to respiratory tract infections (RTI’s). Despite a low rate of bacterial infections (5 – 10% of febrile children), we observe antibiotic prescription rates of 40-56% in children with RTI’s, with high variability among European EDs. This study aims to evaluate the association between clinical characteristics and antibiotic prescription rates in children under five with suspected lower respiratory tract infections at 6 Dutch EDs.
Prospective collected data of a multicentre study in 6 paediatric EDs in The Netherlands, both teaching and non-teaching. The population consisted of children aged 1 month to 5 years presenting at the ED with fever and cough or dyspnoea. We computed a risk profile for bacterial infection based on clinical characteristics, using a clinical prediction rule (Feverkidstool). Variation in risk profile and antibiotic prescription rate were assessed and associations tested.
Results are based on 206 patients, 63% male, median age 16 months (IQR 7 – 32m). Median predicted risk of a bacterial infection according to the Feverkidstool was 9% (IQR 9 – 17%), ranging between centres from 5 – 15%. Overall antibiotic prescription rate was 42% (range 24 – 60% between centres). Children with a higher risk profile had a significantly higher prescription rate (Nagelkerke’s R2=23%). There was no association between prescription rate and centre. When stratified by clinical profile, antibiotic prescription rate was 13% in low-risk patients (predicted risk 0-5%), 34% in medium-risk patients (predicted risk 5-10%) and 65% in high-risk patients (predicted risk >10%).
Antibiotic prescription rates are high among children with respiratory tract infections with variable rates among 6 Dutch EDs. Variability among centres is mainly explained by risk profile. Given the nature of lower respiratory tract infections, watchful waiting and follow-up in low and medium-risk patients could add to a reduction in antibiotic prescriptions.
15:10 - 15:20 #11489 - OP052 INTRANASAL KETAMINE FOR PERIPHERAL VENOUS ACCESS IN PEDIATRIC PATIENTS: A RANDOMIZED DOUBLE BLIND AND PLACEBO CONTROLLED STUDY.
OP052 INTRANASAL KETAMINE FOR PERIPHERAL VENOUS ACCESS IN PEDIATRIC PATIENTS: A RANDOMIZED DOUBLE BLIND AND PLACEBO CONTROLLED STUDY.
Objectives: To verify the efficacy of intranasal ketamine as sedative agent for venous access in children.
Method: Randomized, double blind, placebo controlled study conducted at ER Hospital de Clínicas de Porto Alegre (Brazil) between November 2015 and August 2016. Children needing venous access were randomized to receive intranasal ketamine (4mg/Kg) or normal saline solution (Placebo group). Groups were compared regarding the time for venous access, facility for performing the procedure, adverse events, disturbances in vital signs and perception of the accompanying adult. The study was approved by the Local Ethics Committee.
Results: 39 children (21 Ketamine; 18 Placebo) were included without differences regarding to age, sex, weight, reason for hospitalization and professional experience. The median age was similar (19.8 x 15.8 months), as well as the median weight (10.0 x 11.3Kg). Ketamine reduced the length for venous access (23.0 x 67.5 seconds; p=0.01), and facilitated the procedure (p=0.00009). Ketamine induced sleepiness 15 minutes after its administration (p=0.003) and reduced the number of people for the child’s restraint (p=0.025). No difference was verified between groups regarding adverse effects or vital signs disturbance ́s. Side effects were observed in 29% of the children in the Ketamine group and 17% in the Placebo group, irritability being the most common for both. The accompanying adult reported that 81% of children in ketamine group were calm and quiet (p=0.0003).
Conclusions: Intranasal ketamine (4mg/Kg) reduces the time for venous puncture, facilitates the procedure to the nurse, decreases the number of people involved and provides a tranquil environment with low risk.
15:20 - 15:30 #11541 - OP053 Optic nerve sheath diameter measurement: a means of detecting increased ICP in traumatic and non-traumatic pediatric patients.
OP053 Optic nerve sheath diameter measurement: a means of detecting increased ICP in traumatic and non-traumatic pediatric patients.
Introduction: Increased Intracranial Pressure (IIP) is a highly clinical mortality condition, which can be caused by various causes. It should be diagnosed rapidly, and its treatment should be done timely and correctly in emergency units. The procedures performed for the purpose of diagnosing and determination of etiology in patients with IIP are either invasive or cause radiation exposure. In this study, we aimed to determine the benefit of measurement of the optic nerve sheath diameter (ONSD) by ultrasonography (US) and power of the test in the evaluation of IIP.
Materials and Methods: After the primary treatment of the patient who was brought to our pediatric emergency department, transorbital ultrasonography was applied in the supine and neutral position as his/her eyes closed. Sonographic ONSD evaluation was performed using a SonoSite Edge ultrasound device with 6–13 MHz linear probe. The diameter of the optic nerve, which appeared as a hypoechoic two-sided line at a depth of 3 mm of globes which is determined as more sensitive to IIP alteration, was measured and recorded in both longitudinal and transverse sections.
Findings: Fifty-seven cases with IIP suspicion brought to our unit (31 males; 138 ±56 months old) and 35 controls (17 males; 151± 45 moths old) were included in the study between June 2015 and December 2016. Thirty-one cases (54%) were trauma cases with the high probability of clinical signs of IIP. Others had headache, vomiting, altered consciousness, seizures. Eight of our patients had GCS <= 8. One patient died and 16 children were admitted to our intensive care unit. 19 of our patients were treated with anti-edema treatment. The ONSD value of the 38 patients without brain edema on CT scan was 4.8 ± 0.05 mm (Processing time: 2.8 ± 1 min). The ONSD of those with brain edema was 5.5 ± 0.07 mm (Processing time: 2.0 ± 1 min). The mean ONSD of all patients (5.0 ± 0,07 mm) showed significantly increased compared with the controls (3,9 ± 0,02 mm) (p<0.01). The ideal cut-off value of ONSD was found to be 4.9 mm when the cerebral edema detected in the CT scan was accepted as a reference (Sensitivity 84.2% and specificity 63.2%). Six patients had optic disc elevation (The median ONSD was 6 mm). The CT scan of all of these patients was compatible with brain edema.
Conclusions: CT examination and fundoscopy for diagnosing IIP are useful methods for middle/late stages of the IIP syndrome. As ONSD begins to expand within minutes when intracranial pressure begins to increase, ONSD measurement may be more sensitive in the acute stage and guide patient management in case of clinical suspicion of IIP.
15:30 - 15:40 #11676 - OP054 EFFECTS OF A CLINICAL PATHWAY ON ANTIBIOTIC PRESCRIPTIONS FOR PEDIATRIC COMMUNITY-ACQUIRED PNEUMONIA.
OP054 EFFECTS OF A CLINICAL PATHWAY ON ANTIBIOTIC PRESCRIPTIONS FOR PEDIATRIC COMMUNITY-ACQUIRED PNEUMONIA.
Background and aims: Italian pediatric antimicrobial prescription rates are among the highest in Europe. It is essential to identify efficient measures to improve antimicrobial stewardship (AS) programs. Since Clinical Pathways (CPs) have proven a promising tool to reduce antibiotic prescriptions in primary care and in-hospital settings, we hypothesized that their implementation in the Padua University Hospital Pediatric Emergency Department (PED) would decrease overall prescription of antibiotics, especially broad-spectrum (BS), for common infectious diseases such as Community-acquired pneumonia (CAP).
Materials and methods: CP was implemented at the Department for Woman and Child Health of Padua on 01/10/2015. This is a pre-post quasi-experimental study comparing the 6-month period prior to CP implementation (baseline period: 15/10/2014-15/04/2015) and during the 6 months after intervention (post intervention: 15/10/2015-15/04/2016). We collected data from children aged 3 months -15 years diagnosed with CAP. We assessed differences in various measures of antibiotic prescription between pre and post periods including rates, breadth of spectrum, duration of therapy and, for inpatients, length of hospital stay. Chi-square, Fisher’s exact test and Wilcoxon rank sum test were used as appropriate.
Results: 120 pre and 86 post-intervention clinic visits were associated with CAP. In regards to outpatients, we observed a decrease of BS regimens (50% vs. 26.8%, p=0.0215), in particular macrolides, and an increase of narrow-spectrum ones (amoxicillin). Children received less antibiotics (median DOT from 10 to 8, p=0.0001) for fewer days (median LOT from 10 to 8, p=0.0001). Physicians prescribed a narrow- spectrum monotherapy more frequently than BS combination therapy (DOT/LOT ratio 1.157 vs. 1.065). No difference in treatment failure incidence was reported before and after the implementation (2.3% vs. 11.8%, p=0.2862). Among inpatients we also noted a decrease in BS regimens (100% vs. 66.7%, p=0.0238) and the introduction of narrow-spectrum regimens (0% vs. 33.3%, p=0.0238). Admitted patients received less antibiotics (median DOT from 18.5 to 10, p=0.004), while there was no statistical difference in LOT (median LOT from 11 to 10, p=0.0629). In particular, children received a notably lower amount of BS days of therapy (median bsDOT from 17 to 4.5, p <0.001). No difference in treatment failure was reported before and after CP implementation (16.7% vs. 15.4%, p >0.999).
Discussion: Our study showed sustained changes in physicians' prescribing behaviors for CAP after implementation of a clinical pathway. Prescribing changes for CAP included an immediate increase in amoxicillin prescriptions with a concomitant reduction of BS antibiotic prescriptions, use of combination therapy and duration of treatment for CAP indicates effectiveness of CP for AS in this setting.
Free Papers Session 7
Moderators: Agnès RICARD-HIBON (Pontoise, FRANCE), Anastasia SFAKIOTAKI (Emergency Physician) (Melbourne, AUSTRALIA)
16:10 - 16:20 #11005 - OP055 Abdominal sonographic evaluation as a screening test to reduce the CT scans in trauma patients.
OP055 Abdominal sonographic evaluation as a screening test to reduce the CT scans in trauma patients.
Computed tomography is the golden standard for evaluating haemodynamically stable blunt trauma patients. As a consequence, medical radiation induced cancers have been increasing exponentially. Ultrasound evaluation has been actively investigated as an alternative, but currently an ultrasound based algorithm for the investigation of blunt trauma patients cannot be supported. In this study instead of correlating ultrasound imaging findings to computed tomography imaging findings we correlate ultrasound imaging findings with patient clinical outcomes. This prospective clinical study took place in Nikaia general hospital Greece, between 6/2014 and 12/2014. We studied 60 (sixty) consecutive, haemodynamically stable, adult, blunt trauma patients, without injuries requiring immediate surgical intervention or hospitalisation, who met abdominal CT investigation criteria. All patients were initially investigated and treated according to current ATLS recommendations. An abdominal ultrasound evaluation was performed in all patients prior to the CT scanning. The ultrasound examination was performed by an ultrasound expert radiologist. We assessed the presence of free fluid as well as all solid abdominal organs for evidence of injury. Patients then underwent a formal trauma protocol abdominal CT. All patients were admitted to the surgical ward for a minimum of 48-hour observation, where they were closely monitored and investigated. If there was no deterioration patients were discharged. In any other case patients were treated accordingly. In 21/60 patients, the ultrasound was negative for fluid and solid organ injury. A further 21/60 despite the presence of free fluid no solid organ injury was detected. Of these patients 7/42 were found to have some degree of solid organ injury at CT. All 42 patients (100%) had an uneventful clinical course and were safely discharged. In 12/60 patients, ultrasound was positive for fluid and solid organ injury, all 12 patients had some degree of solid organ injury in the subsequent CT scan. Of these patients 25% were eventually treated surgically. In 6/60 patients, ultrasound was negative for free fluid but positive for solid organ injury. 5/6 of these patients had some degree of solid organ injury on CT. From this patient group 1/6 needed surgical intervention. This study provides evidence that abdominal ultrasonographic evaluation of trauma patients, when performed by an experienced professional can safely be used as a screening tool, since negative ultrasound findings correlate with 100% non-surgical clinical outcome and positive ultrasound findings correlate with a 100% positive CT findings and a 25% need for surgical intervention. Taking these results a step forward, it could be implied that blunt trauma patients can be safely discharged and followed up based on an ultrasound based algorithm.
16:20 - 16:30 #11300 - OP056 Discordance between Emergency Physicians (EP) and Radiologists (RA) interpretation of chest X ray: prospective observational study on 402 patients.
OP056 Discordance between Emergency Physicians (EP) and Radiologists (RA) interpretation of chest X ray: prospective observational study on 402 patients.
Chest X ray (CXR) is the most frequent imaging exam in the Emergency Department (ED). However, its interpretation is frequently difficult; thus, CXR based clinical decisions might be harmful. We investigate discordance (DI) between EP and RA on CXR interpretation prescribed for a non-traumatic indication.
Patients and methods
patients older than 15 years old
non traumatic indication
This observational study was conducted in the ED of a teaching hospital with an annual census of 75000 patients. During a 3-month period, EP and ED residents completed a reporting form for a convenience sample of patients with CXR. It included clinical features, a CXR systematic analysis and a conclusion. A similar form without clinical features was completed by RA being blind to the EP interpretation.
The main objective was DI between EP and RA. Secondary objectives were performance of EP interpretation, therapeutic and orientation impact induced by all CXR, therapeutic errors induced by a wrong interpretation and potentially serious illnesses missed by EP. RA interpretation was considered as the gold standard.
For a DI 0.1, with alpha risk 0.05 and beta 0.1, the required number of patients was 196. Qualitative data were expressed as percentage and 95% confidence intervals. They were compared by a Chi2 test, p < 0.05 being significant.
417 patients were included, 15 were excluded for lack of clinical informations. Age was 61 + 15 years old, sex ratio 1.09. CXR quality was assessed as good for 266 for EP and 136 for RA (p < 0.0001). DI was 23% [19-27%]. Sensitivity, specificity, negative predictive value, positive predictive value were 87% [82-86%], 64% [54-71%], 80% [72-85%] and 75% [69-80%] respectively. Therapeutic and orientation impacts of all CXR were 44% [39-49%] and 19% [15-23%], respectively. Due to wrong EP interpretation, 42 antibiotics and 31 diuretics were mistakenly prescribed. Eight suspect opacities were missed.
DI in our ED was comparable to other published studies. The main limit was a selection bias since only 20% of all prescribed CXR during the study period were included. Despite a rather bad quality and a DI affecting 23% of CXR, therapeutic impact of CXR remains high. Training of EP and ED residents to CXR interpretation has to be organized. However, intrinsic diagnosis qualities of this exam remain poor even with good realization and interpretation.
Implementation of lung Point-of-Care Ultrasound which has demonstrated far better performance might be interesting. This diagnosis procedure is inexpensive, radiation free, performed on the patient’s bedside and with immediate result.
16:30 - 16:40 #11565 - OP057 Assessment of left ventricular ejection fraction by the emergency physician versus the cardiologist: A concordance study about 52 cases.
OP057 Assessment of left ventricular ejection fraction by the emergency physician versus the cardiologist: A concordance study about 52 cases.
Transthoracic echocardiographic examination (TTE) that is performed at the patient’s bedside in emergency departments has several recognized important indications.
The purpose of our study is to evaluate the agreement of the estimates of left ventricular ejection fraction (LVEF) obtained by emergency physicians with the findings obtained by cardiologists in patients admitted to emergency departments.
Material and methods
This randomized prospective study was carried out in the emergency department of the military hospital of Tunis (Tunisia) over a period of 6 months going from September 2015 through February 2016, and involving patients aged > 16 years whose condition required an emergency TTE.
The patients included in the study had to undergo a double echocardiographic examination:
1-An initial investigation that was performed in the emergency department by an emergency physician who had previously received a three-month training in Doppler echocardiography.
2-A subsequent echocardiographic examination that was performed by an echo-Doppler proficient cardiologist.
Left ventricular ejection fraction was evaluated by both readers using the following methods:
1-the global visual estimation (GVE) method,
2-Teicholtz’s method in time movement mode (TM)
3-and Simpson Biplan method (SB).
We excluded from the study patients with:
1-segmental kinetic disorders
2-or with hearts out of alignment.
The findings thus obtained were compared using the inter-class concordance coefficient of Cronbach’s alpha.
Fifty-two patients were involved in the study. Mean age was 55 + 11 years; sex-ratio was 7 males/4 females.
-For the GVE method, the findings obtained by the emergency physician were similar to those obtained by the cardiologist: alpha = 0.72 (IC 95% = [0.68-0.78]; p<10-3).
-The findings obtained by both operators by Teicholtz’s method were as follows: alpha = 0.94 (IC 95% = [0.80-0.95]; p<10-3).
-The concordance of the findings obtained by the emergency physician and of those obtained by the cardiologist for their assessment of LVEF by SB method was shown by alpha=0.91 (IC95% = [0.80 – 0.98]; p<10-3).
Global visual estimation of LVEF can be performed similarly by an emergency physician or by a cardiologist provided they are sufficiently experienced. The results yielded by both other methods (Teicholtz’s method and SB method) were very similar indicating an excellent concordance independently of the degree of deterioration of the left ventricle contractility. Biplan Simpson’s method is, however, a time-consuming procedure.
16:40 - 16:50 #11825 - OP058 A systematic Review and Meta-analysis of the Management and Outcomes of Isolated Skull Fractures in Children.
OP058 A systematic Review and Meta-analysis of the Management and Outcomes of Isolated Skull Fractures in Children.
Objective: Most studies of children with isolated skull fractures have been relatively small, and rare adverse outcomes may have been missed. Our aim was to evaluate the short-term clinical outcomes of children with isolated skull fractures.
Methods: We performed a systematic review and meta-analysis of studies indexed in EMBASE, MEDLINE and Cochrane Library databases through August 2016 reporting on short-term outcomes of children ≤18 years with linear, non-displaced, isolated skull fractures (i.e. without intracranial injury on neuroimaging). Two reviewers independently reviewed identified articles for inclusion, assessed quality and extracted relevant data. Our primary outcome was emergent neurosurgery or death. Secondary outcomes were hospitalization and new intracranial hemorrhage on repeat neuroimaging. We calculated a pooled estimate of each outcome by fitting a random-effects model and then tested for heterogeneity across studies.
Results: Of the 385 studies screened, the 21 that met our inclusion criteria, included 6646 children with isolated skull fractures. One child needed emergent neurosurgery and no children died [pooled estimate: 0.0%, 95% confidence interval [0.0-0.0%]; I2 =0%]. Of the 6280 children with known emergency department disposition, 4914 (87%, 95% CI 78-95%; I2 = 98%) were hospitalized. Of the 644[SB1] children that underwent repeat neuroimaging, six had a non-operative intracranial hemorrhage (0.0%, 95% CI 0.0-0.1%; I2 = 79%).
Conclusion:Children with isolated skull fractures were at extremely low risk for emergent neurosurgery or death, but were frequently hospitalized. After careful consideration of non-accidental trauma, clinically stable children with an isolated skull fracture could safely be managed outpatient.
16:50 - 17:00 #11888 - OP059 THE IMPACT OF CLINICAL PATHWAYS ON ANTIBIOTIC PRESCRIBING IN THE EMERGENCY DEPARTMENT.
OP059 THE IMPACT OF CLINICAL PATHWAYS ON ANTIBIOTIC PRESCRIBING IN THE EMERGENCY DEPARTMENT.
Background and Objectives
Italian pediatric antimicrobial prescription rates are among the highest in Europe. To date it has not been paid adequate attention on how to implement and improve the antimicrobial prescriptions. As a first step for antimicrobial stewardship (AS) implementation, clinical pathways (CP) outlining standard of care for acute otitis media (AOM), and group A streptococcus (GAS) pharyngitis were developed and implemented on 1 October 2015 at the Pediatric Emergency Department in collaboration with Children’s Hospital of Philadelphia.
The primary aim of this study was to assess changes in antibiotic prescription before and after CP implementation for AOM e GAS pharyngitis; secondary aims were to compare treatment failure and to assess the change in the total antibiotics costs before and after CP implementation.
Pre-post quasi-experimental study comparing the 6-month period prior to CP implementation (baseline period: 15/10/2014-15/04/2015) and during the 6 months after intervention (post intervention: 15/10/2015-15/04/2016).
We assessed differences in various measures of antibiotic prescription appropriateness, including type and breadth of spectrum prescribed, using chi-square and t-tests as appropriate. We also assessed the total cost and the cost for each class of antibiotics comparing the two groups and relating it to 1000PD.
295 pre- and 278 post-intervention clinic visits were associated with AOM. After CP implementation there was an increase in “wait and see” (21.7%vs.33.1%,p<0.01) and a decrease from 53.2% to 32.4% (p<0.01) in overall prescription of broad-spectrum (BS) antibiotics. The total cost was significantly reduced (8.033,08€/1000PDvs. 5.878,30€/1000PD), with a decrease especially in BS antibiotics, above all cephalosporines, and a slight increase in the cost for amoxicillina. 151 pre- and 166 post-implementation clinic visits were associated with GAS pharyngitis, with decrease in BS prescriptions (46.4%vs.6.6%,p<0.01). The total cost was reduced (9.337,68€/1000PDvs. 6.247,23€/1000PD), with a sharp decline in the cost for BS antibiotics and an increase in the cost for narrow spectrum antibiotic contextually to the increase in its use.
Our study showed sustained changes in physicians' prescribing behaviors for AOM and GAS pharyngitis after implementation of a clinical pathway. Prescribing changes for AOM included an immediate increase in “observation with close follow-up” approach and amoxicillin prescriptions with a concomitant decrease in BS antibiotic prescriptions. Complying with the CP, a dramatic increase of amoxicillin prescriptions for GAS pharyngitis was documented with a concomitant decrease in BS antibiotic use. In summary, our data show that clinical pathways for AOM and GAS pharyngitis are associated with reduced rates of antimicrobial prescription and cost for antibiotics purchase with no significant change in treatment failure rates.
17:00 - 17:10 #10738 - OP060 An insight into the patient’s perspective of trauma care using point of view glasses.
OP060 An insight into the patient’s perspective of trauma care using point of view glasses.
Trauma patients are particularly vulnerable to negative experiences of healthcare. The psychological effects of trauma and restricted movement from cervical spine immobilisation combine to heighten a patient’s fear and anxiety. One factor identified to reduce anxiety amongst spinal immobilised patients is eye contact, however this has been neglected from communication tools used within emergency medicine. One explanation for this is the relative challenge of objectively assessing eye contact between doctor and patient using traditional methods.
New wearable technologies offer a way of addressing this blind spot in assessing doctor-patient communication. We subsequently set out to examine the use of point of view glasses as a method of objectively assessing the frequency and location of eye contact between a spinal immobilised patient and doctors in high fidelity trauma simulation.
This study was integrated into an emergency medicine module for clinical medical students. High fidelity trauma simulations requiring cervical spinal immobilisation were recorded using covert point of view glasses and ceiling mounted cameras. The simulation footage was analysed, examining the frequency of paired verbal communication and eye contact at five predefined locations around the patient (the foot of the bed, bellow the waist, above the waist, above the shoulders and at the head of the bed).
110 communication events and 29 eye contact events were observed during six high fidelity simulations. There was a significant difference in the number verbal communication events and eye contact events below the waist, above the waist and above the shoulders (p=0.0312, 0.0156 and 0.0312 respectively). Verbal communication at the head of the bed achieved the greatest eye contact on 95% of occasions (p=0.500).
Whilst methods for assessing communication skills have been validated for emergency medicine, they have neglected non-verbal communication that can only be assessed from the patient’s perspective.
Using new point of view technologies this study demonstrates an objective method for the identification of non-verbal doctor-patient communication and highlights the poor attainment of eye contact amongst medical students when managing trauma patients. Although this cannot be extrapolated to clinician’s, greater awareness of body position when communicating with spinal immobilised patients, especially in the absence of an anaesthetist, will help to improve eye contact with patients.
Whilst the priority for trauma patients will always be managing their medical condition it is important to give consideration to the patient’s experience, especially for vulnerable groups such as trauma patients. With this awareness and incorporation into current communication tools we aim to provide further feedback for learners during simulation, improving communication and thereby the patient’s experience of trauma care.
17:10 - 17:20 #11526 - OP061 Predictive factors for the failure of high flow nasal cannula therapy in children with bronchiolitis in pediatric emergency department.
OP061 Predictive factors for the failure of high flow nasal cannula therapy in children with bronchiolitis in pediatric emergency department.
Background: Bronchiolitis is a lower respiratory tract infection affecting principally the small airways. The disease is the most common cause of infant hospitalization during the winter months. High flow nasal cannula therapy is recommended in patients with severe disease. The aim of the study was to determine the parameters associated with high flow nasal cannula therapy failure in children with bronchiolitis in pediatric emergency department.
Methods: The patients were aged between 6 weeks and 24 months presenting to the pediatric emergency department of the Health Sciences University, Tepecik Teaching and Research Hospital with acute bronchiolitis between 01.01.2014 and 31.12.2015 were evaluated retrospectively. Vital signs and clinical findings were determined before interventions such as suctioning, antipyretic medication, oxygen support, and I.V. fluid. We included the patients with bronchiolitis treated with high flow nasal cannula therapy. Patients were divided in two groups: High flow nasal cannula therapy responders and non-responders. High flow nasal cannula therapy failure (non-responders) was defined as the need for escalation to another ventilation support: non-invasive ventilation or invasive mechanical ventilation.
Results: A total of 84 infants (median age: 5 month; 25-75 percentile: 2-10 month; minimum: 6 weeks – maximum: 19 months; female/male: 25/59) with bronchiolitis were treated with high flow nasal cannula therapy. 23 of them (27.4%) were in non-responders group; 19 of them were intubated and mechanically ventilated. Underlying chronic disease, prior hospitalization due to bronchiolitis, prior admission to the pediatric intensive care unit, significant tachycardia (0-12 months> 160 / min, 12-24 months: 150 / min), physical examination findings of significant dehydration (5% or more), pH <7.30 and high pCO2 level (>45 mm Hg) were found more frequently in non-responders group (p <0.05). In the logistic regression analysis, underlying chronic disease (p: 0.031; OR: 4.677; 95%CI: 1.148-19.062), significant tachycardia (p: 0.015; OR: 5.088; 95%CI: 1.369-18.910), and significant dehydration (p: 0.038; OR: 3.811; 95%CI: 1.079-13.459) were the most significant parameters.
Conclusion: The presence of underlying chronic disease, significant tachycardia, and significant dehydration were the most powerful predictors of high flow nasal cannula therapy failure in children with bronchiolitis.
17:20 - 17:30 #11716 - OP062 High flow nasal cannula therapy in the pediatric emergency department; a prospective pilot study.
OP062 High flow nasal cannula therapy in the pediatric emergency department; a prospective pilot study.
Background and Objectives: High-flow nasal cannula (HFNC) is a reliable method of respiratory support that has demonstrated large utility in the pediatric population. HFNC may be able to avoid intubations in patients with respiratory distress. There is limited data about its use in the pediatric emergency department (PED). The aim of this study was to evaluate whether the use of HFNC therapy is associated with reduced respiratory distress and a decreased need for intubation in patients presenting to the PED.
Methods: This was a single –center prospective observational study conducted over six months (October 2016 - March 2017) on children with severe respiratory distress (SRD) who commenced HFNC therapy in our PED. Baseline demographic and clinical data, as well as respiratory variables at baseline and various times after HFNC initiation during 24 h, were recorded. Therapy failure was defined as clinical deterioration in respiratory status after that requiring another form of non-invasive ventilation (nasal positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP)) or invasive ventilation (intubation) within 24 hours from the time of HFNC initiation. The rate of intubation, admisson to pediatric intensive care unit, therapy failure and predictors of therapy failure were also recorded.
Results: A total of 115 children commenced on HFNC therapy in PED during the study period. The median age was 12 months and 70% patients were male. The most common diagnosis was acute bronchiolitis (n=73, 63.5%) followed by pneumonia (n = 23, 20%) and asthma (n = 18, 15.7%). Seven-teen patients (14.8%) failed HFNC therapy;10 required secondary invasive mechanical ventilation and 7 BiPAP. Children who had higher initial respiratory score (RS) and comorbodity were more likely to fail the HFNC therapy (p=0.001, p=0.039). HFNC significantly reduced the respiratory rate, heart rate and (RS) at 2 hours of admission (p<0.05). These improvements were observed as early as 15 min after the beginning of HFNC for respiratory rate and heart rate.
Conclusion: HFNC has a beneficial effect on clinical signs and respiratory score in PED patients with acute severe respiratory distress. It also significantly reduced the respiratory rate and heart rate at the beginning.
17:30 - 17:40 #11757 - OP063 HACOR score to predict in-hospital mortality for patients with type I and type II acute respiratory failure treated with non-invasive ventilation.
OP063 HACOR score to predict in-hospital mortality for patients with type I and type II acute respiratory failure treated with non-invasive ventilation.
OBJECTIVES: In a group of patients with type I and type II acute respiratory failure (ARF), treated with noninvasive ventilation (NIV), we tested if an early evaluation through a validated scale, using variables easily obtained at the bedside, can identify patients at high risk of adverse outcome.
METHODS: This was a retrospective study including all patients with ARF requiring NIV over a two-year period (January, 2014-July, 2016), admitted in an Emergency Department High-Dependency Observation Unit (ED-HDU). Clinical data were collected at baseline, 1 hour, and 24 hours; HACOR score (previously employed only in patients with hypoxemic respiratory failure) was calculated before NIV and after 1 hour and 24 hours of treatment. For prognostic analysis, the score was evaluated as continuous value and as dichotomized value (≤5 or >5, as suggested in the validation study). The primary outcome was in-hospital mortality, need of ICU admission and NIV weaning in a 48-hour time interval.
RESULTS: The study population includes 348 patients, mean age 77±15 years, 53% male gender. Most frequent admission diagnosis were pneumonia in 59% of patients, congestive heart failure in 34% and sepsis in 20%, which overlapped in some patients. Ninety-eight patients presented a Type I ARF and 250 a Type II ARF. In-hospital mortality was 33% in Type I ARF patients and 19% in Type II patients (p=0.012). Compared with survivors, Type I non-survivors showed comparable HACOR score before NIV (7.3±5.5 vs 5.9±2.9, p=NS), but higher score after 1-hour (6.8±6.4 vs 3.4±3.3, p=0.025) and 24-hour (6.2±5.0 vs 3.0±2.6, p=0.022) NIV treatment; moreover, HACOR score reduction during the first hour of NIV treatment was significantly higher in survivors compared with non survivors (-2.7±3.2 vs -0.7±3.7, p=0.016). Analysis for repeated measures showed a significantly more marked score reduction in survivors compared with non-survivors (p=0.001). Compared with survivors, Type II non-survivors showed higher HACOR score before NIV (8.5±5.0 vs 6.3±4.2, p=0.005) and after 1-hour (6.7±4.7 vs 3.9±3.3, p<0.001) and 24-hour (3.8±4.3 vs 1.7±2.0, p=0.002) NIV treatment. Analysis for repeated measures showed a significantly more marked score reduction in survivors compared with non-survivors (p=0.001). Compared with patients with HACOR ≤5, Type II patients with HACOR score >5 showed a significantly higher mortality rate at every evaluation point (before NIV: 68 vs 48%, p=0.026; 1-hour: 55 vs 26%, p<0.001; 24-hour: 18 vs 5%, p=0.009); analysis with dichotomized values did not show significant differences among patients with Type I ARF.
CONCLUSIONS: among patients with Type II respiratory failure , a Hacor score value >5 was significantly associated with an increased mortality rate; among Type I ARF patients, patients with adverse outcome showed significantly worst score value compared with patients with a good prognosis.
Moderators: Tom BEATTIE (UK), Felix LORANG (Consultant) (Leipzig, GERMANY), Youri YORDANOV (Médecin) (Paris, FRANCE)
17:40 - 17:45 #11133 - OP121 Home treatment of patients with pulmonary embolism: comparison of the performance of three clinical rules in daily clinical practice.
OP121 Home treatment of patients with pulmonary embolism: comparison of the performance of three clinical rules in daily clinical practice.
Recent guidelines suggest home treatment for patients affected by pulmonary embolism (PE) judged to be at low risk of adverse clinical outcome. Several clinical rules have been proposed but studies aimed to compare their efficiency and safety in daily clinical practice are lacking.
We evaluated the efficiency and safety of PESI, sPESI scores and Hestia criteria in the identification of PE patients candidate to home treatment and compared them with clinical gestalt.
Consecutive adult patients with objectively diagnosed PE were prospectively included in the study. All data requested in PESI, sPESI and Hestia scores were collected prospectively. Patients were managed according to the clinical gestalt of the attending physician, independent of the results of clinical rules. The primary outcome was a composite of all-cause mortality, venous thromboembolic recurrence with or without hemodynamic collapse or major haemorrhage within 30 days from inclusion. Efficiency was the prevalence of low risk patients and safety the incidence of primary outcome in the low risk group according to each stratification model.
We included 277 patients with a median age of 75 years, 52.7% were females. After initial assessment, including right ventricular dysfunction evaluation, 123 (44.4%) patients were judged to be at low risk and discharged within 48 hours from presentation. Six (4.9%, 95% CI 1.8-10.3%) of these patients reached the primary outcome.
Similarly to clinical gestalt, Hestia criteria identified 121 (43.6%) low-risk patients, whereas both PESI and sPESI identified a significantly lower proportion of low-risk patients (24.9% and 19.1% respectively, p< 0.05 for both). Primary outcome incidence was 7.3% (95% CI 2.4%-16.1%), 7.6% (95% CI 2.1-18.2%) and 4.1% (95% CI 1.4-9.4%) in PESI, sPESI and Hestia low-risk groups respectively, without significant differences among prognostic models and in comparison to clinical gestalt.
In our cohort, Hestia criteria showed higher efficiency and similar safety in identifying low-risk patients when compared to PESI and sPESI scores. Clinical rules did not show better performance than clinical gestalt in identifying PE patients candidate to home-treatment.
Top scoring Abstract 1
17:45 - 17:50 #11370 - OP122 Impact of using the HEART score in chest pain patients at the emergency department: a stepped wedge, cluster randomized trial.
OP122 Impact of using the HEART score in chest pain patients at the emergency department: a stepped wedge, cluster randomized trial.
Background: The HEART score is a simple instrument to stratify chest pain patients according to their probability of having an acute coronary syndrome, but its impact in daily practice is unknown. The HEART-Impact trial was designed to measure the impact of its use on patient outcomes and use of health care resources.
Methods: In a stepped wedge, cluster randomized trial, chest pain patients presenting at emergency departments (ED) were included in nine hospitals in the Netherlands between 2013 and 2014. All hospitals started with “usual care” and over time hospitals consecutively switched to “HEART care”, during which treating physicians calculated the score for each patient to guide patient management. For safety, a non-inferiority margin for major adverse cardiac events (MACE) was set. Other outcomes included use of health care resources, quality of life, and cost effectiveness. Trial registration: ClinicalTrials.gov 80-82310-97-12154 (closed).
Results: A total of 3,648 patients were included, 1,827 receiving usual care and 1,821 HEART care. Six-week incidence of MACE during HEART care was 1.3% lower than during usual care (upper limit one sided 95% CI: +2.1%, not exceeding the non-inferiority margin of +3%). In low-risk HEART patients, incidence of MACE was 2.0% (95% CI: 1.2 to 3.3%). No statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits or visits to general practitioner were observed.
Conclusion: Using the HEART score during initial assessment of chest pain patients is safe but the impact on health care resources was limited possibly due to non-adherence to management recommendations. Physicians were hesitant to refrain from admission and diagnostics in patients classified as low-risk by the HEART score.
Top scoring Abstract 2
17:40 - 18:45 #11731 - OP123 Addition of magnesium sulphate to the femoral block: preliminary results.
Addition of magnesium sulphate to the femoral block: preliminary results.
Introduction: Due to its N-methyl-D-aspartic (NMDA) receptor antagonist effect in peripheral neurons, some studies suggest the potential analgesic effect of magnesium sulphate (Mg2+).On the other hand, according to our daily practices, the classic femoral block seems to have a short duration of action.The objective of our study is to show the potentiating effect of the addition of SMg to the xylocaine in the WINNI’s femoral block in traumatology. Methods: A prospective study including all patients aged> 16 years and suffering from a medio-diaphyseal femoral fracture or a knee wound. After patient consent, randomization was carried among 3 groups: A (15 ml xylocaine 2% + 5 ml SMg 10%), B (15 ml xylocaine + 5 ml S.Phy 0.9%), C (15ml SMg + 5ml S.Phy 0.9%). The severity of the pain was assessed using EVA at 0 min, 15 min, 30 min, 40 min, 50 min, 60 min and then every 60 min until the first six hours after the femoral block. If EVA> 5 after 15 min local anesthetic injection, titration of morphine as a rescue analgesic is recommended. Jujement criteria are the duration of the sensory block, the duration of tolerance of pain, the rate of failure of analgesia and the appearance of side effects. Results: We included 28 patients (39.3% are men) with a median age of 71.4 +/- 16 years. The most frequent occurrence of the fracture was the fall (68%). The average duration of the sensory block was 220 + /- 70 min, 125 +/ - 70 min, 14.5 +/ - 28.3 min respectively for group A (n =10), B (n =8) and C (n=10) with a significant difference. The average duration of tolerance of pain was 274 +/ - 103min, 148.74 +/ - 92 min and 18 +/ - 6.3 min respectively for group A, B and C with a significant difference. During the study we did not note any side effect. Conclusion: Mg sulphate appears to have a potentiating effect on the duration and efficacy of the WINNI’s femoral block without added side effect.
17:55 - 18:00 Introduction of Falck Foundation and Top scoring Pre-Hospital Abstract. Rune ANDERSEN (OTHER) (Arhus C, DENMARK)
18:00 - 18:05 Sophus FALCK Prize abstract presentation.
18:05 - 18:10 EUSEM YEMD Fellowship presentation. Riccardo LETO (Chief of ED) (Overpelt, BELGIUM)
18:10 - 18:15 YEMD Fellowship certificate hand-over.
18:15 - 18:20 EUSEM Best Abstract announcement and certificate hand over.
18:20 - 18:25 EMERGE EBEEM announcement. Ruth BROWN (Speaker) (London, UK)
18:25 - 18:30 European Board Examination of Emergency Medicine diplomates ceremony.
18:30 - 18:35 Best performance EBEEM Part A certificate.
18:35 - 18:40 Best performance EBEEM Part B certificate.
18:40 - 18:45 EMDM Diploma ceremony. Francesco DELLA CORTE (ITALY)
|Tuesday 26 September
Herman Delooz Lecture
Moderator: Rick BODY (UK)
08:30 - 09:00 Do we still need 'Tintinallis' in 2017? Judith TINTINALLI (Chapel hill, USA)
Disaster Medicine III (Cutting Edge)
European Response to Disaster
Moderators: Francesco DELLA CORTE (ITALY), Benoît VIVIEN (Paris, FRANCE)
Coordinator: Abdo KHOURY (Besançon, FRANCE)
09:10 - 09:40 French Reserve Corps. Sophie MONTAGNON (Rambouillet, FRANCE)
09:40 - 10:10 Turkish Response Team. Al BEHCET (faculty speaker) (Gaziantep, TURKEY)
10:10 - 10:40 Euro Corps: the European Response. Massimo AZZARETTO (Associate Researcher) (Novara, ITALY)
Cardiovascular (How To)
Moderators: Barbra BACKUS (dordrecht, THE NETHERLANDS), Rick BODY (UK)
Coordinator: Rick BODY (UK)
09:10 - 10:40 Panel discussion. Rick BODY (UK), Barbra BACKUS (dordrecht, THE NETHERLANDS), Ian STIELL (Physician) (Ottawa, CANADA), Martin THAN (NEW ZEALAND), Martin MOECKEL (Berlin, GERMANY)
Infectious Disease & Sepsis (Game Changers)
Moderators: Laura HOWARD (UK), Cao YU (emergency) (Chengdu, CHINA)
Coordinator: Christoph DODT (München, GERMANY)
09:10 - 09:40 Consensus Definitions for Sepsis and Septic Shock Advantages and Disadvantages. Luis GARCIA-CASTRILLO (Espagne, SPAIN)
09:40 - 10:10 Sepsis day and a National Registry of sepsis in Hungary. Peter KANIZSAI (HUNGARY)
10:10 - 10:40 Implementation of sepsis guidelines in the ED. Kurt ANSEEUW (Medical doctor) (ANTWERP, BELGIUM)
YEMD - Eye-opener Quiz
Moderators: Blair GRAHAM (Research Fellow) (Plymouth, UK), Riccardo LETO (Chief of ED) (Overpelt, BELGIUM)
Coordinator: Basak YILMAZ (Ankara, TURKEY)
09:10 - 09:30 Spot Diagnosis. Tony KAMBOURAKIS (Director Medical Services) (Melbourne, AUSTRALIA)
09:30 - 09:50 ECG Conundrum. Blair GRAHAM (Research Fellow) (Plymouth, UK)
09:50 - 10:10 Things you definitely should (not!) know. Basak YILMAZ (Ankara, TURKEY)
10:10 - 10:30 For the NERDS. Incifer KANBUR (Assistant doctor) (Istanbul, TURKEY)
Nursing session 1
Moderators: Marielle DEKKER (THE NETHERLANDS), Door LAUWAERT (BELGIUM)
09:10 - 09:40 The impact of medical specialist staffing on emergency department patient flow and satisfaction. Christien VAN DER LINDEN (THE NETHERLANDS)
09:40 - 10:10 Why we should implement a trauma protocol in ED. Georgios PAPAGEORGIOU (Nurse) (Nicosia, CYPRUS)
10:10 - 10:40 Nonfulfilled needs of the geriatric emergency patient -The role of GEM Nurse in the interprofessional team. Thomas DREHER-HUMMEL (Nurse) (Basel, SWITZERLAND)
Free Papers Session 8
Moderators: Anthony GERASKLIS (GREECE), Youri YORDANOV (Médecin) (Paris, FRANCE)
09:10 - 09:20 #11171 - OP064 Clinical characteristics of 2013 Haiyan typhoon victims presenting to the Belgian First Aid and Support Team.
OP064 Clinical characteristics of 2013 Haiyan typhoon victims presenting to the Belgian First Aid and Support Team.
On November 8, 2013, the central Philippines islands were struck by typhoon Haiyan (Yolanda), damaging many local hospitals and disrupting acute and regular healthcare. The Belgian First Aid and Support Team erected a type 1 field hospital and water purification unit in Palo (south of Tacloban) to temporarily replace the damaged local healthcare. This study aims to describe the diagnoses encountered, and treatment provided by the Belgian team. Hypothesis is that besides disaster-related trauma, medical problems emerge soon, emphasising the importance of an appropriate composition of Emergency Medical Teams and their supplies.
Using a descriptive observational study design, all patients presenting to the Belgian field hospital were retrospectively reviewed. Each patient had an individual paper medical record that included gender, age, triage chief complaint, all secondary complaints, diagnosis, management and possible referral information. These were compared with a control group of patients from the same area and season, but from another year.
All 1267 patients triaged, examined and treated in the field hospital, were included and analysed. Almost 28% suffered from injury, but the most important part of patients rather presented with medical diseases (64%), particularly respiratory (31%), dermatological (11%) and digestive (8%). The remaining 8% presented for follow-up, mental problems or pregnancy related issues. Most (53%) of the patients did not present with direct disaster-related acute pathology. More than 59% showed signs of infection within two weeks after the event. Most frequently used treatments were wound care (47%), pain relief (33%), vitamins and minerals (31%) and antibiotics (29% of all patients). Procedures were needed for 9%, fluid therapy for 8%, and psychological support for 5%. Logistic regression analysis indicates that children younger than 5 are more at risk for infectious diseases (OR 18.8 CI 10.6-33.3), and for injury (OR 10.3 CI 6.3-16.8), and males are twice more prone to be injured than females (OR 2.1 CI 1.6-2.6).
These results reveal that one week after the acute phase of a typhoon, respiratory, dermatological, and digestive problems emerge to the prejudice of trauma. Most patients did not present with direct disaster-related but with less acute diseases. Young children are more at risk for injury and infectious diseases. These facts should be anticipated when composing Emergency Medical Teams and supplies to be sent to the disaster site.
09:20 - 09:30 #11241 - OP065 Bystanders and volunteers in disasters, experience from the Brussels attacks.
OP065 Bystanders and volunteers in disasters, experience from the Brussels attacks.
Purpose: To examine what roles bystanders and volunteers can play during a disaster and to propose an action card for the (medical) incident commander to manage this often unutilised resource of manpower and knowledge.
Relevance: During the terrorist attacks in Brussels on March 22nd 2016 the advantages as well as the problems with bystanders and volunteers during disasters were encountered. Many lives were saved by bystanders by using simple bleeding control techniques and the application of tourniquets. Among the bystanders there were soldiers patrolling the national airport. Their knowledge of lifesaving first aid (e.g. the use of tourniquets), extrication and triage proved pivotal in the first aid rendered to the victims.
However there were also unsolicited medical volunteers arriving with unauthorised private ambulances who became more a liability than a fruitful resource. Drawn to the scene out of curiosity and desire to help, not only were they unfamiliar with the Incident Command System (ICS), but because of the fact they were not registered in the regular EMS system they didn’t have the appropriate means of communication and started freelancing in deciding what to do on site and where to take victims in unregistered ambulances.
An updated version of a national medical emergency plan was recently published. Being updated with the terrorist attacks in mind, it still fails to recognize bystanders as first aid providers.
Methods: Review of existing literature and unstructured interviews with medical personnel who volunteered during the aftermath of the Brussels Airport attack and the national EMS director.
Results: It is a certainty that (untrained) bystanders are the first providers of help during disasters. During the Brussels attacks we have seen the benefits of bystanders performing lifesaving bleeding control techniques, extrication of entrapped victims, transportation of casualties away from the blast sites and comforting victims.
All too often bystanders and volunteers at a disaster site remain unused and kept outside a perimeter upon arrival of EMS services and police and a clear guideline on how to integrate bystanders and volunteers was and still is lacking in any existing medical emergency plan. However, coordination of highly motivated bystanders and volunteers by professional EMS personnel had a positive effect on reducing morbidity and mortality in the Brussels attacks.
Conclusion: Because regular EMS is initially disrupted, bystanders and volunteers can aid in immediate search and rescue and first aid to victims. Instead of discouraging, their desire to help should be encouraged and planned for in emergency plans. To reduce the risk of untrained bystanders and volunteers disrupting the official organised response an action card to aid onsite incident managers is proposed.
09:30 - 09:40 #11504 - OP066 Training method in Personal Protective Equipment donning and doffing.
OP066 Training method in Personal Protective Equipment donning and doffing.
When working with infectious diseases of high consequences the simple act of donning/doffing Personal Protective Equipment (PPE) becomes a lifesaving procedure not only for the medical staff but for the thousands of people who depend on them. Previous studies have shown that donning and doffing skills may be insufficient even after training. That raises a question on how to properly train staff in PPE donning and doffing to maintain the long term competence of PPE donning and doffing?
This study assessed if there is a performance difference one month after training between a control group that received instructor training and a study group that had access to a video over the month to compare the traditional tutorial based teaching method in teaching PPE donning and doffing.
This was a randomized controlled trial pilot study of video versus instructor training. 21 medical students and junior doctors where divided into 2 groups by simple randomization. The control group received training with an instructor. This training involved a demonstration of donning and doffing of PPE. Students were then observed donning and doffing of PPE until satisfactory performance had been achieved. There was no other intervention until the day of the assessment. The video group watched a training video demonstrating proper donning and doffing. The video group was given the video to watch at home as many times as they wanted. The training video was made by the same nurse who conducted the instructor training, using the same equipment. After a 1month period, a doctor performed a blind evaluation of all control and study groups using an adjusted Donning and Doffing PPE Competency Validation Checklist 2014.
19 participants attended assessment session after a month with 9 in a control group and 10 in the study group. The mean donning score was 86,5/100. Mean score was 84,8 for the instructor group, and 88.0 for the video group.There was no statistically significant difference in the donning score between the video and instructor group (95% confidence interval for the effect: -7.7 to 9.5; p-value: 0.54). The mean doffing score was 76,4/100. The mean score for instructor group was 79.1 and 73,9 for the video group. There was no significant difference in the doffing score between the video and instructor group (95% confidence interval for effect: -7,6 to 18,0; p-value: 0.54).
The study results suggests that donning and doffing competencies are similar for those who were trained with an instructor to those who were trained with the video method.
09:40 - 09:50 #11653 - OP067 The use of table-top simulation for team training in disaster events.
OP067 The use of table-top simulation for team training in disaster events.
Objective: To find out if a table-top team training program would positively affect perception towards teamwork, and their ability to recognize the presence and quality of team skills in disaster events.
Background: Disaster training involves coordination and communication between various units, which necessitates involvement of the whole chain of response simultaneously. Due to the strict hierarchy culture in Korea, it is not easy to train healthcare providers in teamwork. Hospitals in Korea performs large-scale disaster exercise which takes a lot of preparation and resources. It is also difficult to assess teamwork and communication during a large-scale disaster exercise. Table-top simulation enables you to look at the whole process and the advantage of reflective, repetitive, and safe learning environment, where effective feedback can be provided. Since table-top simulation allows people to go through the thinking process, this could be a good module to train people improving on teamwork competency.
Methods: The educational intervention consisted of a half-day workshop for selected 24 emergency residents and 24 emergency nurses. Participants were given lectures on incident command system and surge capacity. They were randomly mixed into 6 groups (8 participants per group, 4 residents and 4 nurses). Participants were assessed as a group before and after the intervention, which consisted of debriefing session, focusing on the 5 components of teamwork (Team Structure, Communication, Leadership, Situation Monitoring, and Mutual Support). Discussions were focused on breaking the barrier of hierarchy in a crisis situation. The correct number of triage, treatment, and teamwork aspects were assessed. Assessment of teamwork was done in two parts. One was self-assessment of perception of teamwork, the Teamwork Perceptions Questionnaire (TPQ), and the other was assessment of the team performances, the Team Performance Observation Tool (TPOT). Both tools were derived from the TeamSTEPPS® Project (5-point Likert scale). They were modified to fit our culture and translated to Korean. Content validity index was performed (0.94). All pre-to-post differences within subjects were analyzed with paired t tests. The statistical level of significance was set at 0.05.
Results: Correct triaging and treatment improved after training with table-top simulation. Under triaging improved as well, but over triaging seemed to increase. Pre- and post-intervention differences for the 5 sections of the TPQ and TPOT improved. All results were statistically significant (p<0.05).
Conclusion: Teamwork and communication has cultural different aspects. Therefore, carefully planned curriculum tailored to the trainees, and debriefing session including discussion on cultural aspect is important when training for teamwork. Table-top exercise can positively affect perception toward teamwork, and their ability to recognize the presence and quality of team skills in disaster events.
09:50 - 10:00 #11779 - OP068 Evaluation of a training program to professionalize young doctors in humanitarian assistance.
OP068 Evaluation of a training program to professionalize young doctors in humanitarian assistance.
Well-prepared humanitarian workers are now more necessary than ever; simulation-based training and evaluation are essential for the preparation process. This study aimed to assess the efficacy of a training program developed by the Research Center in Emergency and Disaster Medicine (CRIMEDIM) in collaboration with the international organization Médecins Sans Frontières (MSF) to professionalize senior residents in humanitarian assitance.
The first three levels of the Kirkpatrick’s evaluation model (Reaction-Learning-Behaviour) were assessed.The 8 participants of the third course edition (4 residents in emergency medicine, 3 in anaesthesia and 1 in pediatrics) were enrolled in the study; the median age was 31. Residents participated in an introductory phase, completed a 3 month e-learning course, attended a residential week and were deployed with MSF in Pakistan (1), Afghanistan (2), Democratic Republic of Congo (1), South Sudan (1), Central African Republic (2) and Yemen (1). Reaction was assessed through a Likert scale questionnaire. The three dimensions of Learning were evaluated separately through a pre and post test as follows: a multiple-choice test was used to assess knowledge, a Likert scale questionnaire was used to evaluate attitudes, and simulation-based performance tests (using the Ottawa Global Rating Scale-GRS) were used to assess skills. Total multiple-choice scores and GRS overall performance scores were considered as primary and secondary outcomes, respectively. Differences were assessed using paired t-tests. P values of less than 0.05 were considered significant. Behaviour was assessed qualitatively at the end of students’ missions by their field supervisors through the MSF standard evaluation module. Supervisors were blind to the students’ participation in the training program.
Reaction: the delivery modality and residential course were highly appreciated. The average median score for the overall course was 5 (excellent). Knowledge: there was a significant improvement in the post-test multiple choice scores when compared to the pre-test scores (p = 0.0011). Skills: there was a significant improvement in the overall performance score (P = 0.000001). No differences were detected in attitudes scores. Behaviour: for most participants the following strengths were highlighted: compliance with MSF standards and principles, flexibility, good team working skills and cross-cultural sensitivity.Their professional competence was never questioned. All residents were recommended for future MSF missions.
Residents were highly satisfied with this training program and their knowledge and skills in low-resource simulated humanitarian environments improved after participation in the course. The implementation of this project represents a model of how academia can successfully partner with humanitarian aid organizations to increase professionalization within the humanitarian health sector.
10:00 - 10:10 #11824 - OP069 Stampede, or not a stampede – that is the question.
OP069 Stampede, or not a stampede – that is the question.
To quantify the frequency and intention with which “stampede” is used to describe types of mass gathering disasters
Hazard vulnerability analysis would identify “human stampedes” as high probability events at mass gatherings. Over 200 “stampedes” have occurred in the past 30 years. At the 2015 Hajj, at least 2000 pilgrims died in one of the deadliest mass gathering disasters in recent history. News and literature referenced the event as the “Hajj Stampede”, implying abruptly increased speed and mass panic. At the crux of many of these events, however, is a dense, immobile crowd – not the uncontrolled mindless mass implied.
The authors performed a systematic search of peer reviewed literature indexed in PubMed, EMBASE, and Web of Science. Studies were limited to human studies using the keyword stampede. Gray literature using “stampede” in the title or abstract in reference to mass gathering disasters were also reviewed.
Search strategy using the term “stampede” yielded 649 articles. After excluding those using the term 1) apropos computing, 2) as an acronym, or 3) colloquially, 61 remained which used the term in reference to mass gathering disasters. 29 of 61 articles describe a slow-moving, highly dense crowd. 12 articles cite sudden mass movement as the main trigger for the referenced disaster. The remaining 18 described both slow-moving crowds and sudden mass movement. Only three articles distinguished between crowd disasters caused by sudden movement and high density. Overall, “Stampede” was used in the same context as “crowd disaster”, “turbulence”, “quake”, “mass panic”, “crush”, and “trampling”.
It is important to distinguish between stampede and non-stampede events for the benefit of survivors and for mitigation strategies. Few articles describing stampedes actually involve speed anywhere in the description. The generic “stampede”, through suggesting a fast moving, irrational and culpable crowd, focuses on herding the masses rather than improving safe access or egress routes to the gathering site. We must stem the notion that these disasters are a whim of the crowd and work towards evidence-based engineered solutions.
10:10 - 10:20 #11965 - OP070 Disaster education in senior Flemish nursing students.
OP070 Disaster education in senior Flemish nursing students.
Introduction: Nurses can be confronted with disasters and the care for the patients resulting from these incidents, be it in - or prehospital or in their own environment. Are they educated to do so? Following worrisome results in a survey on this subject amongst medical students our study hypothesis is that nursing students aren’t educated at all.
Material and methods: To evaluate disaster education in Flemish nursing students an online survey on Disaster Medicine, training and knowledge and willingness to report was sent to students in the last year of basic nursing training. This reported knowledge was tested by a mixed set of 10 theoretical/practical questions. A similar survey was sent to students in the Bachelor-after-Bachelor (BAB) specialisation year of Emergency Medicine and Intensive Care.
Results: Preliminary results from the first responding educational basic training centers reveal a M/F ratio of 13/87 with 29% that state that they have had any disaster training what so ever. 25% state to have some knowledge on CBRN incidents. 42% are convinced that a basic training on disaster management should absolutely be included in the basic nursing curriculum. None of the respondents found it useless. Estimated knowledge on several disaster scenarios varied from 1.92/10 (dirty bomb) over 2.24/10 (nuclear) and 3.49/10 (Ebola) to 4.05/10 in highly contagious influenza pandemic. Self-estimated capability to deal with these incidents varied from 2.22/10 (dirty bomb) over 2.59/10 (nuclear) and 3.54/10 (Ebola) to 4.14/10 in mass shooting incidents. Willingness to report to work in these incidents was much higher and varied from 7.19/10 (dirty bomb) over 7.41/10 (Ebola) and 7.56/10 (nuclear) to 7.94/10 in mass shooting incidents. Some topics of the theoretical / practical case mix raise some concern. 64% directs potentially contaminated patients direct into the emergency department. 75% believes that iodine tablets protect against external radiation and 37% would use them as the first step in nuclear decontamination. 37% believes that chemical decontamination consists of a total body antidote spray in a civil defence cabin and only 20% would use a shower with water and soap. Up to 47% would rush unprotected into a traffic accident scene with active leakage from a tanker truck. Self-reported knowledge and capability in the BAB group did not differ from the basic students and also the willingness to report was similar. They had however a better score on the theoretical / practical case mix.
Conclusion: Our data support the hypothesis that Flemish nursing students are ill-educated in disaster management. Despite low estimated knowledge and capability there is a high willingness to report.
10:20 - 10:30 #10986 - OP071 Comparison of the quality of two speech translators in emergency settings : a case study with standardized Arabic speaking patients with abdominal pain.
OP071 Comparison of the quality of two speech translators in emergency settings : a case study with standardized Arabic speaking patients with abdominal pain.
In the context of the current European refugee crisis, at the Geneva University Hospitals (HUG) the languages which caused most problems were in 2016 Tigrinya, Arabic and Farsi. Several researchers pointed out serious problems of quality, security and equitability when no communication is possible between the doctor and his patient. BabelDr (http://babeldr.unige.ch/) is a common project of Geneva University's Faculty of Translation and Interpreting (FTI) and HUG which aims at facing this problem. The BabelDr application is a flexible speech-enabled phrase-book. The linguistic coverage is organised into domains, centered around body parts (abdomen, chest, head, kidney). Each domains has a limited semantic coverage consisting of 2000-2500 canonical sentences, but users can use a wide variety of surface forms when speaking to the system. The translation is not automatic; the canonical forms are translated into the target languages by translation experts from the FTI, which guarantees the quality of translation. At runtime, the system matches the spoken doctor’s utterance to a canonical sentence and echoes it back to the source-language user, only producing a translation if the source-language user approves.
We compared BabelDr with the statistical MT system Google Translate (GT) for the anamnesis in emergency settings. French speaking doctors were asked to use both systems to diagnose Arabic speaking patients with abdominal pain, based on two scenarios. For each scenario (appendicitis and cholecystitis), a patient was standardized by the HUG. Participants were four medical students and five doctors from HUG, who each performed two diagnoses, one with BabelDr and one with GT.
The translation quality was evaluated in terms of adequacy and comprehensibility by three Arabic advanced translation students. Adequacy was judged on a four point scale (nonsense/mistranslation/ambiguous/correct) and comprehensibility on a four point scale (incomprehensible/syntax errors/non idiomatic/fluent). For the BabelDr translations, 93% of doctor's interactions sent to translation were correct and 94% fluent at the majority judgements. For GT, we respectively obtained 38% and 38%. Inter-annotator agreement for both evaluations was moderate (Light's Kappa for adequacy: 0.483; for comprehensibility: 0.44). With Google Translate 5/9 doctors found the correct diagnosis, against 8/9 with BabelDr. The satisfaction of doctors was also higher with BabelDr than with Google Translate: doctors were more confident in the translation to the target language with BabelDr than Google Translate (1/9 negative opinion with BabelDr vs 8/9 in GT). They also think they could integrate BabelDr in their everyday practice in the emergency room, contrary to GT (1/9 negative opinion with BabelDr vs 5/9 with GT).These results tend to show that BabelDr is a promising tool for the task and that GT translations are insufficiently adequate, accurate and comprehensible for emergency settings.
10:30 - 10:40 #11056 - OP072 Predicting Hospital Admission at Emergency Department Triage: a comparison of natural language processing and neural network methodological techniques.
OP072 Predicting Hospital Admission at Emergency Department Triage: a comparison of natural language processing and neural network methodological techniques.
Emergency department (ED) crowding and increasing ED utilization are well-recognized problems for patient care in the United States. To what degree predictive analytic techniques can improve wait times and patient outcomes when employed early in the ED stay--specifically during the triage process--is not well described. We created predictive models to compare logistic regression (LR) and multilayer neural network (MLNN) techniques to predict hospital admission/transfer or discharge following initial presentation to ED triage with and without the addition of natural language processing (NLP) to analyze patient-reported free-text information.
Using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a cross-sectional probability sample of United States EDs from 2012 and 2013 survey years, we developed several models to predict patients’ disposition: hospital admission or transfer vs. discharge. We included patient characteristics which are immediately available after the patient presents to the ED following ED triage. We used this information to construct logistic regression and multilayer neural network models which included NLP and principal component analysis to incorporate the patient-reported reason for visit. Ten-fold cross validation was used to test the predictive capacity of each model and c-statistics / receiver operating curves (AUC) were calculated to compare these predictive models.
Of the 47,200 ED visits from 642 hospitals, 6,335 (13.4%) resulted in hospital admission (or transfer). A total of 48 principal components were extracted by NLP from patient’s reason for visit, which explained 75% of the overall variance for hospitalization. In the model excluding patient’s free-text reason for visit, the AUC was 0.824 (95% CI 0.818-0.830) for LR and 0.823 (95% CI 0.817-0.829) for MLNN. When patients’ free text reasons for visit were included, the AUC increased to 0.846 (95% CI 0.839-0.853) for LR and 0.844 (95% CI 0.836-0.852) for MLNN.
The predictive accuracy of hospital admission/transfer or discharge for patients who presented to ED triage improved with the inclusion of free text data from patients’ reason for visit regardless of modeling approach. The predictive ability of these models was generally quite good at predicting disposition with the limited information immediately available during the triage process. Natural language processing and multilayer neural networks provide ways to incorporate patient-reported free-text information when predicting various outcomes that are important in providers’ clinical decision-making.
Cardiovascular (Cutting Edge)
Moderators: Barbra BACKUS (dordrecht, THE NETHERLANDS), Szabolcs GAÁL-WEISINGER (resident) (Budapest, HUNGARY)
Coordinator: Rick BODY (UK)
11:10 - 11:40 What is the future of chest pain assessment? Moving beyond single biomarkers and dichotomous test results. Martin THAN (NEW ZEALAND)
11:40 - 12:10 Make Endocarditis Great Again. David CARR (Associate Professor of Emergency Medicine) (Toronto, CANADA)
12:10 - 12:40 Management of Recent-onset Atrial Fibrillation and Flutter (RAFF): Time for the ED to take Control. Ian STIELL (Physician) (Ottawa, CANADA)
SonoOlympics-Ultrasound in the cradle of civilization
The ultimative and interactive ultrasound competition
Moderators: James CONNOLLY (Newcastle upon Tyne, UK), Riccardo LETO (Chief of ED) (Overpelt, BELGIUM), Senad TABAKOVIC (Zürich, SWITZERLAND)
Coordinator: Senad TABAKOVIC (Zürich, SWITZERLAND)
Keynote Speaker: Hein LAMPRECHT (SOUTH AFRICA)
Neurological (How To)
Moderators: Vassilios GROSSOMANIDES (GREECE), Christian HOHENSTEIN (PHYSICIAN) (JENA, GERMANY)
Coordinator: Christian HOHENSTEIN (JENA, GERMANY)
11:10 - 11:40 Stroke. Carsten KLINGNER (GERMANY)
11:40 - 12:10 SAH. Jeff PERRY (CANADA)
12:10 - 12:40 Damned If you do, damned If you don’t – Malpractice in stroke care. Greg HENRY (USA)
YEMD - WLB
Health & Wellbeing
Moderators: Alice HUTIN (PARIS, FRANCE), Judith TINTINALLI (Chapel hill, USA)
Coordinator: Basak YILMAZ (Ankara, TURKEY)
11:10 - 11:30 Sleep deprivation and physical issues in emergency physicians. Laura HOWARD (UK)
11:30 - 11:50 Is Emergency Medicine a job good for a lifetime? Roberta PETRINO (Head of department) (Italie, ITALY)
11:50 - 12:10 How to make an ED attractive to young doctors. Judith TINTINALLI (Chapel hill, USA)
12:10 - 12:30 Can we get over the sadness in Emergency Medicine? Tatjana RAJKOVIC (NIS, SERBIA)
Nursing session 2
Detection of Family Maltreatment at the Emergency Department
Moderators: Thomas DREHER-HUMMEL (Nurse) (Basel, SWITZERLAND), Door LAUWAERT (BELGIUM)
11:10 - 11:30 Detection of child maltreatment: screening in the Emergency Departments. Henriette MOLL (paediatrician) (rotterdam, THE NETHERLANDS)
11:30 - 11:50 A new successful method for detecting child maltreatment based on parental characteristics. Hester DIDERICH-LOLKES DE BEER (policy officer family maltreatment) (THE HAGUE, THE NETHERLANDS)
11:50 - 12:10 Implementation with the help of mandated training and e-learning. Marielle DEKKER (THE NETHERLANDS)
12:10 - 12:30 Detection of Elderly maltreatment. Sivera BERBEN (research coordinator) (Nijmegen, THE NETHERLANDS)
Free Papers Session 9
Moderators: Anthony GERASKLIS (GREECE), Felix LORANG (Consultant) (Leipzig, GERMANY)
11:10 - 11:20 #10724 - OP073 Management of Coronary Artery Disease in Emergency Phase: Experiences of Iranian Patients.
OP073 Management of Coronary Artery Disease in Emergency Phase: Experiences of Iranian Patients.
Coronary Artery Disease (CAD) is one of the major causes of death. Evidence suggests that some preventive measures by patients in emergency phase can reduce the rate and risk of mortality. Thus, understanding the signs and risk factors of CAD from the patients’ perspective and their ways of dealing with this disease is of vital importance.
Objectives: This qualitative study aimed to explore the Iranian patients’ experiences about CAD and how they manage it in their first encounter.
Patients and Methods: This study was a grounded theory study conducted on 18 patients with CAD. The data were collected through semi-structured interviews. Initially, purposeful sampling was performed followed by maximum variety. Sampling continued until data saturation. Then, all the interviews were recorded and transcribed verbatim. After all, the data were analyzed by constant comparative analysis using MAXQUDA2010 software.
The themes manifested in this phase of disease included 1- "Invasion of Disease" with subthemes of "warning signs" and "risk factors", 2- "Patients’ Primary Challenges" with subthemes of "doubting primary diagnosis and treatment", and feeling of being different from others", 3- "Psychological Issues" with subthemes of "mental preoccupation", "fear of death and surgical intervention", "stress due to recurrence", and "anxiety and depression", 4- "Management Strategies" with subthemes of "seeking for information", "follow-up' , and "control measures".
Conclusions: Based on the results, physicians and nurses should focus on empowerment of patients by facilitating this process as well as by educating them with regards to dealing with CAD. Further, it is also essential for the mass media to educate the public on how to treat patients with CAD.
Key words: Management, Coronary Artery Disease, Emergency Phase, Grounded theory, Iran
11:20 - 11:30 #10853 - OP074 Positive feedback with Human Factors - Does it matter in an Emergency Department ?
OP074 Positive feedback with Human Factors - Does it matter in an Emergency Department ?
Background: Our Emergency department at New Queen Elizabeth Hospital in Birmingham is one of the busiest Major Trauma Centres in UK with around 250 staff with annual attendances of more than 100,000 patients. The issues of work load, space, staffing level and performance makes it a challenging environment. A multidisciplinary teams are more likely to perform better if they are made to feel appreciated and their good practices are acknowledged.
Learning from excellence is a new concept. The positive feedbacks are widely used in education for children and by corporate non- medical institutions. We wanted to explore its role in adult education and behaviour in the medical background. It’s very rare we recognise, celebrate and learn from good practice in the current working climate. The feedback had to timely, genuine, reflective, meaningful, specific and consistent. A template of a positive feedback along with specific local human factors framework (modification of NOTECHS II system) was developed based on the previous work on Favourable Event Reporting Form (FERF). The Human factors were analysed under the following topics- Leadership & management, Team building & cooperation, Problem solving and decision making, Situational awareness and environment.
The new initiative of positive feedback forms were introduced to the entire medical, Nursing and managerial staff in the emergency department. We organised few educational sessions for all the staff. The project went live three months ago in January 2017. We chose the option of hard copies rather than the online version to capture more data.
Analysis and results: We had sixty positive feedback forms form last three months. The returned forms were reviewed and analysed by Non-Emergency department staff to minimise the bias. The common theme was that the staff felt more appreciated and acknowledged. The newly appointed staff felt more welcome and seemed to understand the expectation of their new working environment. Interestingly we also found that the staff would highlight the issues such as staff shortages and process on a feedback form. This has enabled the senior management to respond immediately to appoint more staff and emphasise/encourage on process to improve performance. It also shared the exemplary practice of certain staff highlighting their leadership skills, situational awareness and decision making process in a high pressure environment. The forms also were beneficial for all the staff as a part of their yearly appraisal. The staff felt supported during difficult times regardless of role or grade.A short staff survey is also planned following the implementation. The feedbacks are now a regular part of clinical governance structure .
In summary, the positive feedback forms are a valuable tool in adult education, behaviour and performance of a multidisciplinary team. The positive feedback reinforces good practice and encourages positive self- esteem among the various members of the team.
11:30 - 11:40 #10891 - OP075 Fast Track in the Emergency Department: an effective measure?
OP075 Fast Track in the Emergency Department: an effective measure?
Introduction: The increase in attendance of Emergency Department is responsible of a real problem of flow management. The implementation of a Fast Track (FT) is one of the organizational measures to improve this flow and thus to reduce the length of stay of daily patients. The aim of this study was to evaluate the effectiveness of implementation of a non-traumatologic FT (a trauma FT already existing) in our ED, and also to evaluate the staff’s satisfaction with the establishment of this procedure and the number of orientation errors.
Methods: We present here a prospective and observationnal study over a period of three months (winter 2015-2016) in an academic French ED. A total of 258 patients who received in FT were included in the study. This cohort was compared with a control group that consulted a year previously during the same period and who could have been eligible for care in the FT.
Results: Our study showed a significant reduction of ED length of stay of patients referred to FT (95.5 min for the FT group versus 141 min for the control group, p<0.0001) and a significant decrease in patients left without care by 6,1% (1.1% for FT group versus 2.8% for the control group, p=0.01). The rate of errors of orientation in patients initially referred to FT who had to be reoriented to the standard care system was 3,3% (95%CI: [3.2-3.4]). The implantation of this Fast Track was a measure deemed satisfactory by the paramedical ED teams with a score of 3.65 ±0.57 out of a total of 4 and in a more nuanced way by the medical teams with a satisfaction noted at 2.58 ±1.24 out of 4. In spite of the relative satisfaction of both paramedical and medical teams, our study also highlights the problem of ED utilization by patients with minor complaints.
Conclusion: Establishing a Fast Track in the ED could be one of the answer to reduce the length of stay of patients present with minor complaints. Organizational measures such as adequacy between the working hours of the FT and those of the physician responsible for it or the improvement of the computer tool (DxCare®) would make it possible to improve its functioning. The establishment of a FT was a satisfactory measure by paramedical and medical ED teams and significantly reduced the time taken to manage patients with non-urgent complaints.
11:40 - 11:50 #11184 - OP076 Moderate to high complexity patients use the majority of resources in the emergency department - a modified TDABC analysis of ED utilization by RETTS category.
OP076 Moderate to high complexity patients use the majority of resources in the emergency department - a modified TDABC analysis of ED utilization by RETTS category.
Background Emergency department crowding and poor flow has been shown to lead to both poor clinical outcomes and poor patient experience. As such, improving ED care is usually important to policymakers, but which visits should be highest priority to address is often controversial. Many interventions to improve ED flow are focused on low-acuity, “fast-track” or primary care type patients, but it is not clear that these patients are the biggest drivers of ED crowding. Using a previously-developed Patient Encounter Costing (PEC) system, we show that simple triage level (RETTS in Sweden) can identify which patients drive ED utilization, and should be the key targets of improvement efforts.
Methods We used data from Region Halland, Sweden, a county of 300,000 people over 5,500 km2. We analyzed all 88,132 ED visits across 2 hospital-based ED sites in 2015. These visits incurred total costs of 255 million Swedish Crowns (SEK), or approximately 26 million EUR. Time spent per visit was determined from prospectively recorded ED records, and resource adjusted by published weighting factors for nursing care by triage acuity level. We used PEC methods to determine unit-time costs for ED care, which were then used to determine total ED patient-care costs for each visit. These data were aggregated at the triage (RETTS) level, showing the variation by triage score.
Results In 2015, Region Halland spent 255 million SEK on its emergency departments, incurring unit costs of 1,645 SEK per nursing hour. This represents approximately 4% of total healthcare expenses in the region. Patients were receiving care in a designated care space for a total of 262,705 hours. The average ED visit service cost 2,886 SEK (95%CI 2,264-2,299). Average costs by RETTS level were: 650 SEK for triage level 5, 1 696 SEK for level 4, 2 824 SEK for level 3, 4 551 SEK for level 2, and 4 534 SEK for level 1. In terms of total costs, 4% of total ED costs were spend on level 5 or uncoded visits, 9% on level 4, 47% on level 3, 34% on level 2, and 6% on level 1 patients. ED treatment space utilization followed a similar pattern.
Conclusion 81% of ED costs, and 80% of total treatment-space utilization time, is spent on RETTS level 2 and 3 patients. Interventions to improve ED throughput and resource utilization will be most effective if they focus on moderate to high-acuity and complexity patients, who often have multiple comorbidities and are at a higher risk of being admitted. Low acuity and primary care oriented interventions are likely to have a more limited effect potential.
11:50 - 12:00 #11270 - OP077 Nurse-led, physician-led or teamwork instead of triage: A longitudinal study of different triage processes and their impacts on patient flow at a busy emergency department.
OP077 Nurse-led, physician-led or teamwork instead of triage: A longitudinal study of different triage processes and their impacts on patient flow at a busy emergency department.
Objectives - To evaluate the impacts of two triage interventions compared to protocol-based comprehensive nurse-led triage on emergency department (ED) waiting times: senior physician-led triage and triage replaced by inter-professional teamwork in modules.
Design - A single center before-and-after study.
Setting – Conducted 2012.05.09 to 2015.11.11 at the adult ED of an urban county teaching hospital in Sweden, with 110 000 annual visits.
Participants – Registry data of patients arriving on weekdays 8 am to 9 pm during one year prior to the first intervention and one year immediately following each intervention.
Interventions - Senior physicians were reassigned to replace the triage nurses 8 am to 9 pm in the first intervention. In the second intervention, the triage section was abolished and replaced by inter-professional teamwork in modules.
Main outcome measures – Primary outcomes were the median total length-of-stay (LOS) and time to physician (TTP). Secondary outcome was the proportion of patients who left before treatment completed (LBTC).
Results – When senior physicians replaced the triage nurses, the median TTP plunged from 119 (95% CI; 117 to 120) to 57 min (95 % CI; 56 to 58). However, the median LOS increased from 236 (95% CI; 235 to 238) to 258 min (95 % CI; 256 to 260). When triage was abolished during teamwork in modules, the median LOS decreased to 229 min (95 % CI; 227 to 231). The median TTP was increased to 74 min (95 % CI; 73 to 76), yet 45 min shorter than during nurse-led triage. The LBTC rate increased over time: 2.5 % for nurse-led, 2.7 % for physician-led and 4.0 % for no triage during teamwork in modules. All differences in outcome measures were statistically significant with p-values < 0.001, except the non-significant difference in LBTC rate between nurse-led and physician-led triage.
Conclusions - Inter-professional teamwork in modules replacing triage performed the shortest LOS and may be an approach to cut waiting times in large busy EDs.
12:00 - 12:10 #11289 - OP078 "I am the Boss“ – Leading ad hoc teams in the shock room.
OP078 "I am the Boss“ – Leading ad hoc teams in the shock room.
Teams in the shock room (SR) usually are so-called „ad hoc teams”: They randomly convene to fulfill an ambitious task under time pressure with limited information and usually leave the scene as soon as this task is completed. What are the essential requirements to lead such a team? What can help to reach excellence as team leader in the SR?
We searched in the medical literature for the expressions team leading / team leader / team coordinator and emergency medicine. Moreover we conducted a survey with experienced consultants in our Emergency Department, who regularly work as team leaders, asking them to tell us their challenges, but also tips and tricks for reaching high performance in the SR.
Structure is often mentioned as important factor for high performance in the SR in the literature. This includes a briefing before the patient arrives, hands-off during handover, standards like the ABCDE and CRM (crisis research management) criteria or non-technical skills, and team debriefing after completion of the task. Additionally team resilience or high-performance teams can be found in the literature as important factors for high-quality teamwork. These terms primarily stem from other highly dynamic industries outside of healthcare like nuclear power plants or aviation.
In interviews with experienced emergency physicians who regularly work as team leaders in the shock rooms, they stressed the importance of pre-existing structures and standards, which should be implemented by an experienced emergency physician as team leader. As examples the “ABCDE” and CRM principles are mentioned. Many of the emergency physicians expressed being challenged by their colleagues from anaesthesiology or surgery. “Risk factors” for losing the lead in the SR are being inexperienced, junior, short or female, having a low voice or the wrong position in the room. In order to clarify their role and responsibility, ED consultants mention good visibility by wearing a coloured jacket defining them as team leader, using a footstool, developing a strong voice or knowing the names and functions of all involved team members. They emphasize the importance of Interdisciplinary and interprofessional in-situ simulation training for developing standards of collaboration and shared mental models.
Team leading in the shock room is extremely challenging: an ad-hoc team must collaborate in a highly dynamic situation with many uncertainties. Excellence as team leader not only depends on the team leader who must be highly competent in content, coordination and communication, but also on clear structures and standards. In order toe be prepared for often “unpreparable” situations, simulation training with all team members helps to reach excellence of care for patients whose survival often depends on high team performance.
12:10 - 12:20 #11968 - OP079 IMMIGRATION PROBLEM IN GREECE, Emergency Medical System Management.
OP079 IMMIGRATION PROBLEM IN GREECE, Emergency Medical System Management.
Over 10,000 refugees lost their lives in the Mediterranean since 2016 in their endeavor to reach the European Union (EU), first half of 2016 there were 2809 deaths
Immigration, most important problem in the world today & a purely human challenge for all stakeholders, especially the EMS in GREECE, as national first responder.
The large flow of refugees into our country, through the Aegean islands, has created great challenges, in the field of health.
In 2015, Greece, the main point of entry into the EU for refugees and immigrants from Turkey. It is estimated that 850,000 people attempted the dangerous passage of the Aegean Sea.
47,000 refs remained in Greece. Most of them (90%), originate from Syria, Iraq, Afghanistan. Among them people with severe health problems, pregnant women, infants.
The management of the severely ill amongst refugees based on a survival chain starting at the pre-hospital level, often at the site of arrival, and ends at the definitive care.
The role of EKAB, especially in the specific geographical relief of Greece, is particularly critical for the survival of people in distress.
Refugee-related diseases are unexpectedly severe, complex due to the difficulties of their situation: the extreme events of war; long-distance travel; lack of available medication for chronic pathologies; malnutrition; or the existence of past injuries. This vulnerable population, often consisting of infants and elderly, have reduced reserves in injury & sickness
Children, 48% of the refugee population; men 30% & 22% women. 10% of refugees in Greece are 2 to 4 years old, 14% are aged between 5 and 9 years, 11% are aged 10 to 14 years old
MD in small islands deal with an emergency patient among POPULATIONS ON THE MOVE in remote areas, in the absence of proper medical equipment in a small regional clinic on a border island and is able only to offer Initial stabilization and nothing more. Afterwards the EKAB system ensures the transfer of the patient to a definitive care Centre.
Aeromedical Department of EKAB archives:
2016: Emergency Transfers by the Aeromedical Department numbered 46, involving newly arrived seriously-ill refugees. Of these 46 patients, 17 were infants with res/ry distress; another 7 were children (1.5 to 12 ys ) suffering from various infections, burns, choking, swallowing of foreign bodies. 72% male & 28% female. Syrians comprised 64% of the pts; Afghans 20%; Iraqis 12%; and Kurds, Iranians etc. Athens was the destination for 34 patients; 5 were sent to Crete; 7 to peripheral hospitals. AIRBORNE TRANSPORT was carried out in cooperation with the Greek Air Force C27 and C130 planes H/Ps: Chinook, Super Puma. The choice was based on geographic distances, availability of appropriate landing facilities, and local meteorological conditions.
The experience of air transport provides the opportunity for prompt intervention and better management of vulnerable patients involved in a mass migration event.
12:20 - 12:30 #10980 - OP080 Non-specific abdominal pain and readmissions in a high-volume emergency department.
OP080 Non-specific abdominal pain and readmissions in a high-volume emergency department.
Acute abdominal pain is among the most common reasons for emergency department (ED) admissions. As abdominal symptoms are often vague, intermittent and non-specific, it may be difficult to distinguish non-specific conditions from specific and possibly severe conditions. Consequently, second admission to ED may be required to reach a diagnosis. As delay in diagnostics may lead to poor outcomes (including higher morbidity, mortality, prolonged hospitalization and higher costs of care), readmission rate has been one of the parameters used to evaluate the quality of care. While it has been well recorded and studied in elective surgery, the studies are few in the field of emergency medicine.
During the recent years in Finland, the emergency services have been reorganized and a new specialty of emergency medicine has been established. Emergency physicians have obtained a major role in EDs. Our aim was to evaluate the care, diagnostic accuracy and rate of readmissions in patients admitted to ED due to non-specific abdominal pain (NSAP) during the era of former and new ED organization.
Materials and Methods
All patients discharged with the diagnosis of NSAP during 2015 (former ED organization) and 2016 (new ED organization) in Tampere University Hospital were registered. Out of these, all patients readmitted to ED within 48 hours from the index admission with the diagnosis of NSAP or pelvic pain (ICD-10 codes R10.0, R10.1, R10.3 and R10.4) were included in the study. Planned readmissions were excluded. The number and reasons for readmissions, diagnostic accuracy and examinations performed were registered, and the findings between the two time periods were compared.
Out of a total of 173,630 ED admissions, 10,609 patients (6%) were discharged with the diagnosis of NSAP. Median age was 32 years (range 0-98) and 60% were female. 313 of these (1.2%; median age 32 years (range 0-98), 59.8% female) were readmitted to ED within 48 hours. The readmission rate was highest (4.1%) among patients aged 18 years or less. Non-specific diagnoses were significantly less common in 2016 than in 2015 (n=7.1% vs. 5.2%, p<0.001). However, the rate of readmissions remained similar (3.0% vs. 2.9%, p=0.975). Again, the rate of computed tomography and ultrasonography remained equal. An improvement in the diagnostic accuracy was noted especially in patients with acute cholecystitis, which was the single most important reason (n=16; 9.4%) for ED readmissions during 2015.
Readmission rate among patients discharged from ED with the diagnosis of NSAP was surprisingly low. After the ED organizational change in our hospital the diagnostic accuracy during the index admission has improved, but no reduction in the rate of readmissions has been observed. Better availability of radiological imaging may have reduced the misdiagnoses of some conditions, such as acute cholecystitis.
12:30 - 12:40 #11029 - OP081 What are the factors that affect the institution of ceilings of treatment in the emergency department?
OP081 What are the factors that affect the institution of ceilings of treatment in the emergency department?
BACKGROUND: Ceilings of treatment are crucial early decisions aimed at improving the quality of care for patients in whom they are deemed appropriate. Decision making concerning limitation of potentially life prolonging treatments is often challenging. Knowledge of end of life issues and decision making involved is lacking, and no research into ED ceiling of treatment decision making has been conducted in the UK. A qualitative approach is needed to expand the limited literature and validate transferability of research to current UK practice. AIMS: To determine the factors that influence the institution of ceilings of treatment for patients presenting critically ill to the Emergency Department. METHODS: This qualitative study used a phenomenological approach to explore attitudes and factors considered important in driving end-of-life decision making by ED consultants. Semi-structured interviews were conducted until data saturation was achieved (n=15). Participants were recruited via convenience sampling and represented 5 EDs in the West of Scotland. Interviews were audio recorded, transcribed verbatim, and thematic analysis was carried out using NVivo. A reflexive diary was kept throughout the data collection and analysis process, and emergent themes were returned to participants to validate findings. RESULTS: We present a model of factors that influence ceiling of treatment decisions making. It was found that acute clinical factors and patient specific factors lay the foundations of ceiling of treatment decisions. Such case-specific information is heavily contextualised by patient and family wishes, collateral information, anticipated outcome and whether the patient is accepted for higher care. This process flows through a ‘filter’ of cultural and environmental factors. The overarching nature of patient benefit was found to be of key importance, framing all aspects of ceiling of treatment institution. Ultimately, all decisions determining an appropriate ceiling of treatment for a given patient resulted in one of three common patient pathways: full escalation, ward-based care or palliative care initiation. CONCLUSIONS: To our knowledge, this is the first investigation of factors that affect ED ceiling-of-treatment decision making in the UK. Key factors identified included acute clinical factors, patient specific factors, patient and family wishes, anticipated outcome and eligibility for higher care. Together with cultural factors, environmental factors and collateral information factors, these key themes are framed by patient benefit to establish an appropriate level of treatment. This may have importance as an educational tool and can act as a guide for physicians making end-of-life decisions in the E.D. How different factors are combined, their weighting and influence on the decision to institute ceilings of treatment is variable. Clinicians should be cognizant of these factors and their associated biases when making these challenging decisions.
Infectious Disease & Sepsis (Cutting Edge)
Moderators: Kurt ANSEEUW (Medical doctor) (ANTWERP, BELGIUM), Christoph DODT (München, GERMANY)
Coordinator: Christoph DODT (München, GERMANY)
14:10 - 14:40 The septic patient with meningitis. Jeff PERRY (CANADA)
14:40 - 15:10 Most effective strategies to detect sepsis early. Lisa KURLAND (SWEDEN)
15:10 - 15:40 Septic arthritis and osteomyelitis in the ED. Tom BEATTIE (UK)
Leadership (The Boss' Office)
Moderators: Raed ARAFAT (ROMANIA), Robert LEACH (Head of Dept.) (Bruxelles, BELGIUM)
Coordinator: Christoph DODT (München, GERMANY)
14:10 - 14:40 The value of team work. Michael RADEOS (USA)
14:40 - 15:10 Effective & creative views of administrative power. Greg HENRY (USA)
15:10 - 15:40 How to make the big jump forward -Tips & Tricks. Jan STROOBANTS (Head of the Emergency Department) (Brecht, BELGIUM)
Cardiovascular (Game Changers)
Moderators: Basar CANDER (TURKEY), Martin MOECKEL (Berlin, GERMANY)
Coordinator: Rick BODY (UK)
14:10 - 14:40 Development of a national care system for cardiac syncope. Szabolcs GAÁL-WEISINGER (resident) (Budapest, HUNGARY)
14:40 - 15:10 Troponins and point of care troponins: what every emergency physician needs to know. Martin THAN (NEW ZEALAND)
15:10 - 15:40 Cardiovascular Killers: Aortic Dissection. David CARR (Associate Professor of Emergency Medicine) (Toronto, CANADA)
YEMD - Current Issues
Moderators: Dean DE MEIRSMAN (Emergency medicine resident) (Paal, BELGIUM), Basak YILMAZ (Ankara, TURKEY)
Coordinator: Basak YILMAZ (Ankara, TURKEY)
14:10 - 14:40 Working in the ED of a Small Hospital: A Survival Guide. Eleni SALAKIDOU (Rethymno, GREECE)
14:40 - 15:10 Working in the ED of a Large Hospital: A Survival Guide. Incifer KANBUR (Assistant doctor) (Istanbul, TURKEY)
15:10 - 15:40 Working in the ED of a Hospital in war settings: A Survival Guide. Alba RIPOLL GALLARDO (ITALY)
Nursing session 3
Moderators: Stamatina IORDANOPOULOU (GREECE), Door LAUWAERT (BELGIUM)
14:10 - 14:40 A patient with malaria at the emergency department: a practice story. Christien VAN DER LINDEN (THE NETHERLANDS)
14:40 - 15:10 Echoing away sepsis 2, welcoming sepsis 3. Georgios PAPAGEORGIOU (Nurse) (Nicosia, CYPRUS)
15:10 - 15:40 Hellenic Regulatory Body of Nurses: Project, "Health Education and Training in First Aids through the School, the Family, and the Community", 2014-2017. Tzannis POLYKANDRIOTIS (GREECE)
Free Papers Session 10
Moderators: Cem OKTAY (FACULTY) (ANTALYA, TURKEY), Riccardo PINI (Director, E.D. High Dependency Unit) (Florence, ITALY)
14:10 - 14:20 #10835 - OP082 Acute kidney injury and mortality among patients with rhabdomyolysis.
OP082 Acute kidney injury and mortality among patients with rhabdomyolysis.
Acute kidney injury and mortality among patients with rhabdomyolysis
Nielsen FE1,2, Cordtz J1,3, Rasmussen TB4, Christiansen CF4.
1Department of Emergency Medicine, Slagelse Hospital, Denmark. 2Institute of Regional Health Services Research, University of Southern Denmark. 3Department of Emergency Medicine, University Hospital of Zealand, Denmark. 4Department of Clinical Epidemiology, Aarhus University Hospital, Denmark.
Acute kidney injury (AKI) is a life-threatening complication of rhabdomyolysis (RM). There is controversy if the degree of the initial creatine phosphokinase (CK) elevation is associated with the risk of AKI and death.
To examine the risk of AKI, renal replacement therapy (RRT) and mortality among patients with RM and to evaluate the association between CK level and the risk of AKI, RRT and death.
Register-based study of adult patients admitted to hospitals in the region Zealand during November 1, 2011 to March 1, 2014 with CK levels higher than 1,000 U/L within 72 hours of admission. Information about CK and other laboratory data was obtained from a regional laboratory database. Data on medical history, medical treatment and survival were obtained from the Danish National Registry of Patients, the National Health Service Prescription Database and the Danish Civil Registration System. Patients with preexisting end-stage renal disease or acute myocardial infarction were excluded. AKI was defined according to Kidney Disease Improving Global Outcome. Logistic regression was used to compute odds-ratios (OR) with 95% confidence intervals (CI) comparing the risk of AKI, RRT and all-cause mortality according to CK-level adjusting for confounding.
The study included 1,024 patients with a median age of 72.9 years. Median CK was 2,226 U/L, 831 (81.2%) patients with CK 1,000-5,000 U/L, 154 (15.0%) with CK 5,001-15,000 U/L and 39 (3.8%) with CK 15,001+ U/L. A total of 442 (43.2%) patients developed AKI within 30 days, and 42 (4.1%) required RRT during the first year. A total of 170 (16.7%) patients had died within 30 days and 277 (27.1%) had died within 365 days. Twenty-seven (69.2%) patients with CK > 15,000 U/L developed AKI within 30 days compared to 62 patients (40.3%) patients with CK 5,000-15,000 U/L and 353 (42.5%) patients with CK < 5,000 U/L. Five (12.8%) patients with CK > 15,000 U/L required RRT within a year compared to 7 (4.6%) patients with CK 5,000-15,000 U/L and 30 (3.6%) patients with CK < 5,000 U/L. In multivariate analyses it was found that OR of AKI within 30 days was 2.6 (95% CI 0.9-7.3) and the OR of RRT within one year was 3.0 (95% CI 0.8-10.9) among patients with CK +15,000 U/L (CK < 5,000 U/L as reference). The CK level was not associated with the risk of death.
Our initial analyses showed that elevated initial CK values was not associated with death. However, elevated CK values was associated with increased risk of AKI and RRT, although estimates were statistically imprecise.
14:20 - 14:30 #10907 - OP083 Emergency Department Utilization among Kidney Transplant Recipients in the United States.
OP083 Emergency Department Utilization among Kidney Transplant Recipients in the United States.
Introduction: Patients with End Stage Renal Disease (ESRD) use the emergency department (ED) at a 6-fold higher rate than U.S. adults. No national studies have described ED utilization rates among kidney transplant (KTx) recipients, and the factors associated with higher ED utilization. A more definitive understanding of the trends, causes, and outcomes of ED utilization among KTx patients is necessary to identify the potentially modifiable factors and to identify opportunities for better care coordination, lower resource utilization, and improved quality of care.
Methods: We examined a cohort of 132,725 incident adult KTx recipients in the United States Renal Data System, a comprehensive national database of ESRD patients in the US, from 2005-2013. ED use, hospital admission, and diagnoses were obtained from the Medicare Physician/Supplier and Inpatient databases. Multivariable Poisson regression was conducted to assess the association of relevant patient variables with each of the primary and secondary endpoints where appropriate.
Results: Nearly half (46.1%) of KTx patients had at least one ED visit within the first post-transplant year (1.61 ED visits/patient year); 39.7% of ED utilizers were hospitalized in the first year post-transplant. ED visit rate was high in the first 30 days (5.26 visits/person year), but declined substantially thereafter (1.81 visits/person year (PY) in months 1-3; 1.13 visits/PY in months 3-12 post-transplant) (Figure 1). In multivariable analysis, factors associated with a lower ED utilization rate included preemptive transplantation (RR: 0.770, 95% CI: 0.751-0.790), peritoneal dialysis (RR: 0.859, 95% CI: 0.843-0.875), private insurance coverage, and transplant at high-volume centers (>200 transplants/year). Predictors of higher ED utilization rate included older age (RR: 1.010, 95% CI: 1.005-1.015 per 10 years), female sex (RR: 1.173, 95% CI: 1.159-1.187), comorbid medical conditions, Medicaid or Medicare insurance coverage, higher proportion of neighborhood poverty (RR: 1.002, 95% CI 1.001-1.002), longer dialysis vintage (RR: 1.302, 95% CI: 1.271-1.333 per 10 years), older donor age (RR: 1.002, 95% CI: 1.002-1.003, greater degree of HLA mismatch, longer index hospitalization (RR: 1.004, (%% CI: 1.004-1.004), delayed graft function (RR: 1.268, 95% CI: 1.251-1.285).
Conclusions: ED utilization for KTx patients is three-fold higher than the general population, but less than half the rate for ESRD patients on dialysis. Policies and strategies addressing preventable ED visits have high potential for improvement and savings
14:30 - 14:40 #11548 - OP084 Short-term exposure to breathable particulate matter and stroke incidence.
OP084 Short-term exposure to breathable particulate matter and stroke incidence.
Introduction and objective:
Particulate matter (PM) with particle sizes less than 10 microns, which are known as breathable suspended particulates, can get deep into the lungs and cause a broad range of health effects, respiratory and cardiovascular particularly. Studies confirmed a strong association between air concentrations of PM and cardiovascular disease. On the other hand, it is still unclear if exposure to breathable (size 10 microns or less) PM leads to stroke events and whether the timing of exposure is associated with stroke risk. In this study we examined the association between occurrence of stroke and respirable PM air concentration.
We retrospectively studied Emergency Department (ED) admission of acute stroke patients from Jan 2011 to Dec 2016. We registered occurrence of stroke compared to breathable PM (PM 10 and PM2.5) concentrations. Incidence of events was associated with PM levels on the day of onset and on the 3 days following PM elevation. PM concentrations were provided from local monitoring data from the Veneto Regional Agency for Prevention and Environmental Protection (ARPAV), classified accordingly with EU health based standards for pollutants in air (25 µg/m3 for PM2.5 and 50µg/m3 for PM10).
During the study period 2,590 stroke patients referred to our ED: 1,721 (66.4%) were ischemic and 869 (33.5%) were hemorrhagic. Gender (ischemic stroke: M: 49.3%; F: 51.7%; hemorrhagic stroke: M 51.6%; F: 48.4%) and age (ischemic stroke: 74 years, range: 18-102; hemorrhagic stroke: 68 years, range: 18-99) distribution were similar in the two groups. We did not observe any difference in stroke incidence with PM10 levels within or over the EU standards. PM2.5 air concentration over the EU standards revealed to be associated, acutely and on 3 following 3 days, with a higher incidence of ischemic stroke (+38.4%) and hemorrhagic stroke (+12.5%), compared to stroke events occurred on the within the EU standards PM2.5 levels days. Also in this case no age and gender differences were observed between the two study groups.
Medical researches show that the risk for various health impacts increases with air particulate matter exposure but there is little evidence to suggest a threshold below which no adverse health effects would be anticipated. It has also been shown that the health risks would be higher for those particles with particle sizes of 2.5 microns or less, which are commonly referred to as fine suspended particles or PM2.5. Our study suggests that short-term exposure to elevated PM 2.5 is associate with a higher incidence of ischemic stroke whereas the association with hemorrhagic stroke is less clear.
14:40 - 14:50 #11741 - OP085 Thrombolysis for Acute Ischemic Stroke in the Emergency Department(ED) is safe. comparative study : ED versus stroke unit.
OP085 Thrombolysis for Acute Ischemic Stroke in the Emergency Department(ED) is safe. comparative study : ED versus stroke unit.
Introduction : Stroke has a major impact on individual lives and the nation's health and economy. It is the third cause of death in the world, and a major cause of adult disability. The therapeutic revolution has completely changed the functional and vital prognosis of patients with stroke due to reperfusion, and particular intravenous stroke thrombolysis with rt-PA. Because « time is brain », thrombolysis should be performed as early as possible. Istablishing specific neurovascular units may improve the management of acute ischemic stroke. However, initiation of thrombolysis in the emergency room is still controversed.
Objective : The objective of this study is to compare the results of intravenous stroke thrombolysis performed in the ED versus that performed in the department of neurology in terms of delays, prognosis and complications .
Methods : we made a transversal analytical study in our ED during 2 years . In this study we analysed all the patients alerted for thrombolysis. We made two groups (group 1 = thrombolysis performed in the ED and group 2 = thrombolysis performed in the neurology department). All patients underwent brain CT in the ED. All delays were noted, in particular the delay "door to needle". The NIHSS score before thrombolysis, H1, H6 and H24 post thrombolysis and the occurrence of hemorrhagic transformation were noted too.
Results : 520 patients were included, only 188 patients were alerted for thrombolysis protocol. 60 patients underwent thrombolysis divided into 2 groups : group 1 in the ED and group 2 in the neurology department. The mean age was 64±12 years in group 1 vs 67±13 years in group 2. There wis no great gender predominance in the 2 groups.The time onset to needle was 2h50±30mn in group1 and 4h10±20mn in group2( p=0.007). There is a significant difference in the mean door-to-needle time between 2 groups : 80±33mn in groupe 1 vs 173±39 in group2 (p=0.0001). There is no significant difference between 2 groups in NIHSS score (at admission,at H1 and H6 post thrombolysis) and in good early outcome. The risk of intracerebral hemorrahge is more important in group 2than group 1 (10% vs 3% respectively with a significant difference p=0.004).
Conclusion : the beneficial effect of thrombolysis on mortality and functional outcome in patients with acute ischemic stroke may be improved when it is performed early and within the recommended delays.
14:50 - 15:00 #10975 - OP086 Oligoanalgesia in the emergency department waiting room: predictive factors.
OP086 Oligoanalgesia in the emergency department waiting room: predictive factors.
Pain is the leading symptom in emergency departments (ED). Due to overcrowding, some patients are oriented to the waiting room and their medical evaluation deferred. In order to ease analgesia in the waiting room, we have enforced a dedicated pain management protocol allowing nurses to administer analgesia when indicated. The objectives of this study were: (1) to measure treatment administration to patients with documented pain upon arrival; (2) to identify predictors of non administration of pain treatment (oligoanalgesia) ; (3) to evaluate pain protocol adherence by nurses.
Prospective observational study in the ED of a primary and tertiary urban teaching hospital with an annual census of 68‘000 patients. All patients with a pain score documented on arrival and oriented to the waiting room were eligible. Demographic characteristics, pain severity scores (0 to 10), time delays, triage complaint and emergency level as well as medication use were extracted from the electronic patient records. Univariate and multivariate analyses were performed to identify predictors of oligoanalgesia.
During a three months period, 2’371 patients were included. Their mean age was 49 years and the majority were male (51%). The leading triage complaint was abdominal pain (30.3%). Pain treatment was given to 734 patients (31%). Treatment was more frequently administered (43%) for pain severity scores > 5 than for lower acuity scores (16%, p <.0001). Time to treatment was 60 minutes (IQR 20-121) and 16 minutes (IQR 7-40) for pain scores < 5 and > 5 respectively (p =.01). Patients with an initial pain score < 5 were treated in accordance to the nurses’ protocol in 73.1% of the cases. This rate dropped to 32% in patients with initial pain scores ≥ 5.
In multivariate analyses, risk predictors for non treatment of pain in the waiting room were:
age > 80 y (OR 2.32 ; 95% CI 1.49-3.60), admission by ambulance (OR 1.50 ; 95% CI 1.12-2.01), higher triage severity level (OR 1.67 ; 95% CI 1.32-2.11), initial pain score < 5 (OR 3.78 ; 95% CI 2.99-4.76), waiting room LOS < 30 minutes (OR 2.79 ; 95% CI 2.06-3.78). When compared to pain suggestive of renal colic, pain associated with a neurological complaint (OR 6.54; 95% CI 2.88-14.84) was the most important predictor for oligoanalgesia. In the multivariate model neither waiting room occupancy nor ED’s patients’ load were significantly associated with non treatment.
In the waiting room of our ED, the proportion of patients receiving pain medication is low. Adherence to our pain protocol is insufficient. Older patients, patients with low intensity pain scores and presenting complaints other than renal colic are at higher risk of treatment abstention independently of emergency room workload. These patients should be targeted by specific interventions.
15:00 - 15:10 #11074 - OP087 Midazolam or haloperidol premedication in prevention of ketamine induced agitation in emergency department: A randomized double blind clinical trial.
OP087 Midazolam or haloperidol premedication in prevention of ketamine induced agitation in emergency department: A randomized double blind clinical trial.
Introduction: The effective and safe sedation for painful procedures in the emergency department is one of the principal concerns of emergency physicians. The sedative agent must be one with rapid onset, steady effects, quick recovery, and acceptable side-effects. Ketamine is an ideal sedative agent but emergency physicians are reluctant to use it due to fear of recovery agitation. It has been proposed to use other drugs specifically benzodiazepines as premedication to reduce the agitation.The goal of our study was to evaluate the effect of midazolam and haloperidol premedication on ketamine induced agitation, and also the emergency physician satisfaction with the procedure.
Method: This was a randomized double-blind placebo-controlled trial to assess the efficacy of ketamine premedication by midazolam or haloperidol, in reducing agitation incidence and severity. The study was approved by the university ethics committee. The samples were chosen from patients older than 18 of either sex who needed sedation in emergency department at Sina Hospital. Patients who had any contraindication to ketamine, midazolam or haloperidol were excluded.
Patients randomly allocated in 3 groups, Arm 1: patients received 2 intravenous injections of distilled water (1cc and 0.05 cc/kg) 5 minutes prior to receiving a sedative dose of 1 mg/kg IV ketamine. Arm 2: patients received 2 intravenous injections, 1cc of distilled water and 0.05 mg/kg midazolam, 5 minutes prior to ketamine. Arm 3: patients received 2 intravenous injections, 0.05 cc/kg of distilled water and 5mg of haloperidol, 5 minutes prior to ketamine.
Level of sedation and agitation were assessed using RASS score (after 5, 15 and 30 minutes of ketamine injection) and Pittsburgh Agitation Scale. Also, physician satisfaction with the sedation procedure was evaluated using Clinician Sedation Satisfaction Index(CSSI).
Results: 180 sample enrolled from July 2016 to March 2017.The incidence of Recovery Agitation, was 66% in the group that received no premedication and 20% in both groups that received premedication, whether midazolam or haloperidol (p<0.001). Also, agitation severity (mean PAS score of 3.37) in the group which only received ketamine was much higher in comparison to the other two groups (mean PAS score of 0.65 and .063) (p<0.001). The comparison between the two intervention groups (midazolam versus haloperidol) showed no significant difference in agitation severity (mean PAS score of 0.65 versus .063).The score of physician satisfaction was significantly higher in the field of reduced agitation in premedicated group (p<0.001).
Discussion: We found a significant reduction in recovery agitation of ketamine by using midazolam or haloperidol as premedication. Our results were similar to most previous studies about the effect of BZDs. However, few studies have been done about the effect of haloperidol on reducing ketamine induced agitation.
Trial registration: ClinicalTrials.gov NCT02909465
15:10 - 15:20 #11098 - OP088 Retrospective chart review exploring safety profile of ketamine-propofol in the pediatric emergency room.
OP088 Retrospective chart review exploring safety profile of ketamine-propofol in the pediatric emergency room.
Procedural sedation and analgesia (PSA) is routinely used in pediatric patients for painful procedures. The use of IV ketamine and propofol (‘ketofol’) for PSA is established in adult patients and has been shown to be safe and effective. The purpose of this study was to analyze the safety of ketofol in pediatric patients.
This was a single-center retrospective study at a Canadian pediatric tertiary care centre. Patients were included if they were less than 18 years old at time of PSA, and received ketofol within the period January 1, 2011 to December 31, 2016. Adverse events, interventions and recovery times were captured.
233 charts were analyzed, of which 163 met the inclusion criteria. 65% of the patients were male. 9% had an underlying medical condition, with 6% of all patients having asthma. The average age was 9.5 years (range 2 months to 18 years).
The indications for PSA using ketofol were usually fracture or joint reduction (63%) and laceration repair (18%). Other indications included plastics procedures (6%), lumbar puncture (4%), abscess incision and drainage (4%), burn/wound debridement (3%), and CT sedation (1%). The median procedure time was 13 minutes (interquartile range 8-22 minutes) and median time to recovery was 30 minutes (IQR 21-46 minutes).
The major adverse reaction experienced was hypoxia (10%) with resolution by conservative measures (stimulation, airway positioning and supplemental oxygen). Two cases with hypoxia required bag mask ventilation and none required intubation. Only one case had a severe adverse reaction (laryngospasm and hypotension), which resolved with supplemental oxygen, bag mask ventilation, and fluid bolus. 3% of cases had nausea or vomiting. No cases had hypersalivation, bradycardia, emergence reaction, or seizure. There was no relation to the dose of either ketamine or propofol to the observed adverse reactions. Three cases required re-sedation due to failure of previous sedation. Two of these cases failed intranasal sedation or local block and then received ketofol. Only one sedation failure was due to inadequate sedation from ketofol with repeat sedation requiring additional adjunct of midazolam.
Subgroup analysis on patients less than 24 months yielded no additional risk for adverse events or failed sedation.
This is the largest study to date analyzing the safety profile of ketofol in the pediatric population. Overall, ketofol is a safe and effective combination for pediatric PSA. Major adverse effects were lower than previous smaller studies. Additionally, mean recovery time was similar to published literature.
15:20 - 15:30 #11233 - OP089 Low-dose Ketamine in association with IV morpnine for acute pain in emergency department.
OP089 Low-dose Ketamine in association with IV morpnine for acute pain in emergency department.
Acute pain is the most frequent complaint in emergency department (ED), but its management is often complex, placing patients at risk of oligoanalgesia. Emergency physicians are considering alternative, complimentary medications, such as ketamine, combined with traditional drugs such as opioids to achieve multimodal analgesia in the acute setting.
The aim of this study was to determine the effectiveness of low-dose ketamine as an adjunct to morphine versus standard care with morphine alone for the treatment of acute moderate to severe pain among ED patients.
We conducted a double-blind, randomized, placebo-controlled trial at the ED, over a six-month period. Eligibility criteria were: age between 18 and 65, acute moderate or severe pain (the numerical pain rating scale (NRS)>5) who require morphine. Patients were randomized on three study groups: standard group receiving morphine and normal saline placebo; group1 receiving morphine and 0.15 mg/kg ketamine and group2 receiving morphine and 0.3 mg/kg ketamine. Pain was assessed at 30, 60 and 120 minutes after drug administration; rescue analgesia consisting on 0.5mg/kg morphine was prescribed if the reduction of pain was lower than 50%. The occurrence of adverse events was also measured.
One hundred twenty patients were enrolled: 41 patients in standard group, 42 patients in both groups 1 and 2. There were no difference between the three groups in baseline NRS, as well as in the demographic and clinical characteristics. The most common cause of pain was nephritic colic in 50.4% of patients. NRS improvement was more important and rapid in group 2 compared to the other groups with a statistically significant difference at 120 minutes. The SPID was higher in ketamine’s groups compared to standard group. Among patients receiving rescue analgesia, 28 were in standard group, 24 in group1 and 5 in group2 (p<0.001). The total dose of morphine was significantly greater in morphine group comparing to the ketamine groups. There was no difference in side effects between the three groups. More participants in the ketamine groups reported minor neuropsychiatric adverse effects such as dysphoria and dizziness. Patients from placebo group developed more digestive events such as nausea and vomiting.
Low doses of ketamine are well tolerated and present efficient analgesic effect in adjunction to morphine compared to morphine alone for pain management in ED. The dose of 0.3mg/kg seems more effective than 0.15 mg/kg but might cause more adverse neuropsychiatric events.
15:30 - 15:40 #11234 - OP090 Low-dose Ketamine in association with IV morpnine for acute pain in emergency department.
OP090 Low-dose Ketamine in association with IV morpnine for acute pain in emergency department.
Acute pain is the most frequent complaint in emergency department (ED), but its management is often complex, placing patients at risk of oligoanalgesia. Emergency physicians are considering alternative, complimentary medications, such as ketamine, combined with traditional drugs such as opioids to achieve multimodal analgesia in the acute setting.
The aim of this study was to determine the effectiveness of low-dose ketamine as an adjunct to morphine versus standard care with morphine alone for the treatment of acute moderate to severe pain among ED patients.
We conducted a double-blind, randomized, placebo-controlled trial at the ED, over a six-month period. Eligibility criteria were: age between 18 and 65, acute moderate or severe pain (the numerical pain rating scale (NRS)>5) who require morphine. Patients were randomized on three study groups: standard group receiving morphine and normal saline placebo; group1 receiving morphine and 0.15 mg/kg ketamine and group2 receiving morphine and 0.3 mg/kg ketamine. Pain was assessed at 30, 60 and 120 minutes after drug administration; rescue analgesia consisting on 0.5mg/kg morphine was prescribed if the reduction of pain was lower than 50%. The occurrence of adverse events was also measured.
One hundred twenty five patients were enrolled: 41 patients in standard group, 42 patients in both groups 1 and 2. There were no difference between the three groups in baseline NRS, as well as in the demographic and clinical characteristics. The most common cause of pain was nephritic colic in 50.4% of patients. NRS improvement was more important and rapid in group 2 compared to the other groups with a statistically significant difference at 120 minutes. The SPID was higher in ketamine’s groups compared to standard group. Among patients receiving rescue analgesia, 28 were in standard group, 24 in group1 and 5 in group2 (p<0.001). The total dose of morphine was significantly greater in morphine group comparing to the ketamine groups. There was no difference in side effects between the three groups. More participants in the ketamine groups reported minor neuropsychiatric adverse effects such as dysphoria and dizziness. Patients from placebo group developed more digestive events such as nausea and vomiting.
Low doses of ketamine are well tolerated and present efficient analgesic effect in adjunction to morphine compared to morphine alone for pain management in ED. The dose of 0.3mg/kg seems more effective than 0.15 mg/kg but might cause more adverse neuropsychiatric events.
Neurological (Cutting Edge)
Moderators: David CARR (Associate Professor of Emergency Medicine) (Toronto, CANADA), Jim DUCHARME (Mississauga, CANADA)
Coordinator: Christian HOHENSTEIN (JENA, GERMANY)
16:10 - 16:40 TIA. Jeff PERRY (CANADA)
16:40 - 17:10 Thunderclap headache - not just an SAH. Jim DUCHARME (Mississauga, CANADA)
17:10 - 17:40 Turning a zebra into a horse. David CARR (Associate Professor of Emergency Medicine) (Toronto, CANADA)
Infectious Disease & Sepsis (How To)
Moderators: Christoph DODT (München, GERMANY), Marc SABBE (Medical staff member) (Leuven, BELGIUM)
Coordinator: Christoph DODT (München, GERMANY)
16:10 - 16:40 Sepsis treatment: in the ED or ICU? Christoph DODT (München, GERMANY)
16:40 - 17:10 Evaluation of the effect of improved qSOFA score on the severity and prognosis of emergency adult sepsis patients. Cao YU (emergency) (Chengdu, CHINA)
17:10 - 17:40 Ultrasound in the ED in patients with sepsis. Cornelia HARTEL (Consultant in Emergency Medicine/ Director of Medical Education in Emergency Medicine) (Stockholm, SWEDEN)
Work-life balance (The Boss' Office)
Moderators: Pinchas HALPERN (department chair) (Tel Aviv, ISRAEL), Katrin HRUSKA (Farsta, SWEDEN)
Coordinator: Rick BODY (UK)
16:10 - 16:40 The myth of gender gaps in EM. Adela GOLEA (Associate Professor) (Cluj Napoca, ROMANIA)
16:40 - 17:10 Physician, Parent, Ironman: How to Have it All. Gayle GALLETTA (Emergency medicine physician) (USA/Norway, USA)
17:10 - 17:40 The challenge to be the man in the ED. Robert LEACH (Head of Dept.) (Bruxelles, BELGIUM)
YEMD - Simulation
Moderators: Anastasia SFAKIOTAKI (Emergency Physician) (Melbourne, AUSTRALIA), Jennifer TRUCHOT (Paris, FRANCE)
Coordinator: Basak YILMAZ (Ankara, TURKEY)
16:10 - 16:40 Building simulation "on the cheap": full scale simulation for less than 10.000€. Mohammed MOUHAOUI (TRAINEES/NURSES/PARAMEDICS) (CASABLANCA, MOROCCO)
16:40 - 17:10 Research in simulation: 2017 update. Luca CARENZO (SIMULATION COMPETITION ONLY) (NOVARA, ITALY)
17:10 - 17:40 Communication in a crisis: how to become a confident (young) team leader. Jennifer TRUCHOT (Paris, FRANCE)
Nursing session 4
Moderators: Sivera BERBEN (research coordinator) (Nijmegen, THE NETHERLANDS), Door LAUWAERT (BELGIUM)
16:10 - 16:40 BLS/AED training of deaf and hard-hearing citizens under the ERC guidelines. Tzannis POLYKANDRIOTIS (GREECE)
16:40 - 17:10 Managing delirium in the ED. Thomas DREHER-HUMMEL (Nurse) (Basel, SWITZERLAND)
17:10 - 17:40 EARLY WARNING SCORE-The need for inclusion in Greek hospitals. Stamatina IORDANOPOULOU (GREECE)
Free Papers Session 11
Moderators: Cem OKTAY (FACULTY) (ANTALYA, TURKEY), Riccardo PINI (Director, E.D. High Dependency Unit) (Florence, ITALY)
16:10 - 16:20 #10843 - OP091 Diagnostic Value of New Sepsis Criteria in the Emergency Department (DISC study).
Diagnostic Value of New Sepsis Criteria in the Emergency Department (DISC study).
In February 2016 a new definition of the sepsis was introduced, redefining sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection (.Sepsis-3). A shortened sequential Sepsis-related Organ Failure Assessment score (Q- SOFA score) is used to identify sepsis according to Sepsis-3 criteria. However, these new criteria have not yet been validated in a general emergency department (ED) patient population.
This is a multi-center, non-interventional observational pilotstudy. During this pilotstudy all adult patients who visit the ED with a suspected or proven systemic infection were included. In all included patients the SIRS criteria and the qSOFA criteria were collected. In addition to routine diagnostic tests such as blood cultures, the PCT levels will be determined.
Results from the first 100 inclusions
In this pilot of 100 patients 61 were male. Median age was 65.5 years (range 18 to 94). The q-SOFA was positive in 4 patients, while SIRS was positive in 44. The mortality in the total study population was 6%. 5 critically ill patients were not identified by qSOFA, while SIRS missed 2. 2 of the SIRS positive patients and none of the qSOFA positive patients were admitted to the intensive care unit.
This pilot study showed the implementation of q-SOFA as a screening tool in suspected systemic infection, did not identify all patients who needed intensive care or those with bad outcome after visiting an emergency department. More research needs to be done in a larger study to compare validity and usefulness of this scores in the ED population.
16:20 - 16:30 #11022 - OP092 Predictive factors of mortality in patients admitted to the emergency department for sepsis.
Predictive factors of mortality in patients admitted to the emergency department for sepsis.
Introduction: Despite major efforts to identify and treat sepsis early, this disease remains a major cause of mortality in hospitalized patients in the emergency department (ED).
Objective: To identify factors associated with intra-hospital mortality in patients admitted to ED for sepsis.
Methods: Prospective, observational, monocentric study, over 12 months in ED. Inclusion: patients (age ≥ 18 years) with a suspected infection associated with two or more criteria of the systemic inflammatory response syndrome (temperature ≥ 38 ° or ≤ 36 °C, heart rate> 90 bpm, respiratory rate> 20 / min, or Blood pressure in CO2 <32 mmHg or White blood cells> 12,000 cel / mm3, or <4,000 / mm3). Epidemiological, clinical, therapeutic and outcome criteria were collected. APACHE 2, SOFA and quickSOFA (qSOFA) scores were calculated. Prognosis was evaluated in intra-hospital mortality. Multivariate regression analysis to identify factors associated with mortality was performed.
Results: Inclusion of 185 patients (169 in sepsis and 16 in septic shock). Mean age = 61 ± 17 years. Sex ratio = 0.46. Comorbidities n (%): diabetes 88 (48), hypertension 87 (47), dyslipidemia 23 (12), chronic obstructive pulmonary disease 14 (7). Clinical manifestations (%): fever (76), altered general state (41), respiratory signs (39), digestive signs (35), neurological signs (9). Site of Infection (%): renal (39), pulmonary (30), cutaneous (15), digestive (12). Organ failure (%): renal (20), cardiac (15), respiratory (12), hepatic (8) and haematological (7) events. Median APACHE 2 score = 9. Median SOFA score = 6. Median qSOFA score = 1.Intra-hospital mortality = 5%.
In adjusted multiple regression models, age >75 years (adjusted OR = 2.8, 95% CI [1.72- 3,25], p<0.001), renal failure (adjusted OR = 4.6, 95% CI [1.4-14.6], p=0.009), septic shock (adjusted OR= 2.7, 95% CI [1.9 -8.32], p=0.05), and HCO3- level<18mmol/l (adjusted OR= 2.9, 95% CI [1.1-7.6], p=0.03) were independently associated with intra-hospital mortality.
Conclusion: In this study, age of 75 years, HCO3- level <18 mmol /, renal failure and septic shock were predictive factors for in-hospital mortality for patients admitted to ED for sepsis.
16:30 - 16:40 #11113 - OP093 Using Support Vector Machine to develop of a Mortality Prediction Model for Septic Patients in the Emergency Department.
Using Support Vector Machine to develop of a Mortality Prediction Model for Septic Patients in the Emergency Department.
Background: Many studies in the past have reported that sepsis is one of the leading causes of mortality in hospitalized patients. However, information regarding factors for early predictive mortality is limited.
Objective: The aim of this present study was to develop a 28-day mortality prediction model and assess the validity of it for the septic patient population in the emergency department by a machine-learning algorithm, Support Vector Machine and to compare with the Sequential Organ Failure Assessment (SOFA) Score.
Methods: This prospective observational study conducted in the emergency department in the Chang Gung Memorial Hospital in Linkou. Consecutive patients meeting the criteria for sepsis during the first 24 hours of ED admission were included. The 28-day mortality collected prospectively by inpatient database or telephone follow-up. We made use of the demographic and laboratory variables that used to diagnosis sepsis as the candidate variables, and applied the recursive feature elimination method to select the significant ones to build the prediction models. Data were divided into training (75%) and testing (25%) sets, and repeated 30 times to avoid selection bias. To assess the performance of the build prediction model, we calculated the area under the Receiver Operating Characteristic curve (AUC), sensitivity, specificity, and accuracy for either individual variable but also the combination of selected variables.
Results: 379 patients were prospectively recruited from the emergency department with sepsis (SIRS and infection, 42.22%), severe sepsis (or Sepsis 3.0, 56.2%), and septic shock (1.58%) with a 28-day mortality rate of 10.03%. The selected variables for prediction model were respiratory rate, albumin, C-reactive protein, D-dimer, and fibrin-degradation products. The analysis results summarized in Table illustrates that the method of Support Vector Machine had promising performance of accuracy, specificity, and AUC in training (0.842, 0.853, and 0.879, respectively) and testing (0.821, 0.890, and 0.754, respectively) sets where better than SOFA score (AUC: 0.711, accuracy: 0.835).
Conclusion: Our results revealed that using the combination of several laboratory variables is promising for early prediction of mortality in sepsis. However, further efforts still need to improve and increase the reliability of early predict mortality of sepsis such as the technique of machine learning.
16:40 - 16:50 #11147 - OP094 Eosinopenia: an interesting biological marker for the diagnosis of different infections in the ED.
Eosinopenia: an interesting biological marker for the diagnosis of different infections in the ED.
Introduction: The relevance of eosinopenia, as marker of infection, has been described in internal medicine, intensive care, and more recently in Emergency Departement (ED), for all infections combined. We aimed to specify the contribution of this biomarker in different common infections in ED, alone or in association with other inflammatory markers.
Methods: We present here a retrospective mono-centric study carried out in the Emergency Department of a teaching hospital in France for a 6 months period (September 2015-February 2016). All patients with one of the following diagnosis were eligible: appendicitis, cholecystitis, sigmoiditis, acute pyelonephritis, male urinary tract infection, pneumonia. Uninfected patients were randomly selected to form a control group of equivalent size to the cohort of infected patients collected for the study.
Results: We included a total of 466 infected patients and 466 controls. The sex-ratio in the infected group was 0.94, the mean age was 57.9 years (SD: 24.7 years). The eosinophil count in the infected patients was significantly reduced compared to controls (59/mm3 versus 129/ mm3, p <0.001). Deep eosinopenia (3) had a specificity of 94.4% for the diagnosis of infection (all combined) with a positive likelihood ratio (LR +) of 6.3 and an area under the curve (AUC ) of 75.9%. Eosinopenia was more effective in pyelonephritis, male urinary tract infections and acute cholecystitis (AUC > 80%), but had lower diagnostic performance in pneumonia (AUC =75%), appendicitis or sigmoiditis (AUC < 70%). The AUC of eosinopenia was higher than those of leucoccytosis in pyelonephritis and cholecystis. The association of eosinopenia with an increase of C-reactive Protein (> 40mg/l) or simply with the presence of fever (Temperature >38.5 ° C) showed a specificity greater than 99% and an LR + of 61 and 45 respectively.
Conclusion: Eosinopenia is an interesting biological marker to consider in the ED, alone or in combination with other clinical or biological parameters in order to diagnose an infection. It is particularly interesting in urinary or biliary infections in which it is a better marker than leukocytosis.
16:50 - 17:00 #11383 - OP095 Validation of qSOFA in the emergency department - a prospective study.
Validation of qSOFA in the emergency department - a prospective study.
Sepsis is the primary cause of death from infection worldwide. Recently, the 2016 Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” Together with the updated definition of sepsis, a new clinical concept termed ‘Quick Sepsis-Related Organ Failure Assessment’ (qSOFA) was introduced to identify high-risk patients with suspected infection outside of intensive care settings. The previous criteria- Systemic Inflammatory Response Syndrome (SIRS) - were removed from the current sepsis definition. qSOFA has not been validated in Hong Kong (HK). In the current study, we aimed to validate qSOFA in an emergency department in HK. Furthermore, we sought to compare the prognostic value of qSOFA and SIRS as well as another commonly used early warning score, the National Early Warning Score (NEWS).
This is a single-centre, prospective study conducted in the ED of Prince of Wales Hospital, HK between Jul 2016 and Feb 2017. 665 patients presenting to the ED triaged as category 2 (Emergency) and 3 (Urgent) were recruited. All variables for calculating qSOFA, SIRS and NEWS were collected. The outcome measure was 30-day mortality. Venous lactate was also measured to investigate whether lactate level provide additional value for the prediction of 30-day mortality. The prognostic value of qSOFA, SIRS and NEWS to predict 30-day mortality was studied. Receiver Operating Characteristic analysis were performed to determine the Area Under the Curve (AUC), sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio for qSOFA≥2, SIRS≥2 and NEWS>5.
Of 665 patients recruited, median age was 73 years (IQR: 58-84); 313 (47%) were male. Overall 30-day mortality was 4.8%. The prognostic value for prediction of 30-day mortality, with AUC of for qSOFA≥2, SIRS≥2 and NEWS>5 were 0.54 (95%CI 0.51-0.58), 0.65 (95%CI 0.61-0.69) and 0.65 (95%CI 0.61-0.68) respectively. Using pairwise comparison of ROC curves, the difference between NEWS>5 and qSOFA≥2 in predicting 30-day mortality in ED patients was significant (p=0.0168). The AUC of lactate level ≥ 2 mmol/l of predicting 30-day mortality was 0.66 (95%CI 0.62-0.69). The combination of lactate level ≥ 2 mmol/l with qSOFA≥2, SIRS≥2 and NEWS>5, AUC were 0.53 (95%CI 0.49-0.57), 0.65 (95%CI 0.61-0.69) and 0.60 (95%CI 0.56 to 0.64) respectively. In addition, positive likelihood ratio of qSOFA≥2, SIRS≥2 and NEWS>5 to predict 30-day mortality were 19.69 (95%CI 4.14-93.73), 2.53 (95%CI 1.73-3.70) and 3.55 (95%CI 2.22-5.70).
Among emergency and urgent patients presenting to the ED, the prognostic value for using NEWS was greater than qSOFA, while there was no difference between qSOFA and SIRS. Combinations of lactate level with qSOFA, SIRS or NEWS did not improve the prognostic value in predicting 30-day mortality for ED patients.
17:00 - 17:10 #11486 - OP096 Early lactate clearance and short-term mortality in severe sepsis and septic shock patients.
Early lactate clearance and short-term mortality in severe sepsis and septic shock patients.
Introduction: The sensitivity and specificity of single lactate concentrations as markers of tissue hypoperfusion in sepsis have been debated. However, serial measurements or lactate clearance over time may be better prognosticators of organ failure and mortality.
Objective: Examine the clinical utility of the lactate clearance (or the percent decrease in lactate) as early as after 6 hours as an indicator of outcome in severe sepsis and septic shock.
Methods: Prospective observational study over one year. Inclusion of adult patients presenting to the emergency department (ED) with severe sepsis or septic shock. Inclusion criteria consisted of a suspected sepsis source and the following: a) two or more criteria of the systemic inflammatory response syndrome (SIRS) (temperature ≥38 ° C or ≤36 ° C, heart rate> 90 beats/min, respiratory rate > 20 / min or PaCO2 <32 mm Hg or WBC > 12,000 cel / mm3 or <4,000 / mm3) associated with organ failure (defining severe sepsis) or b) two of the SIRS criteria and a persistent hypotension (SBP <90 mmHg) despite fluid resuscitation or signs of hypoperfusion (lactate ≥4 mmol / l) (defining septic shock). Serial lactate levels in ED admission and 6 hours (h) later were measured. Lactate clearance, percent decrease in lactate level in 6 h ((lactate admission – lactate 6 h) x 100/lactate admission) was calculated. The main outcome measure was 7-day mortality.
Results: Inclusion of 253 patients. Mean age was 61 ± 17 years. Sex-ratio = 0.84. The overall mortality at the seven day was 10%. Baseline APACHE II score was 12 ± 78 and the median admission lactate was 1.1 mmol/L [0.6, 2.27]. Survivors compared with nonsurvivors had a median lactate clearance of 25 vs. 19, respectively (p=0.05). Based on Area Under the Curve in receiver operating characteristic analysis, lactate clearance have a significant inverse relationship with short-term mortality (0.63, 95% CI [0.45 to 0.80]), with a cut-off at 25%. The sensitivity, specificity, positive predictive value and negative predictive value of this cut-off were 56, 47, 25 and 81% respectively.
Conclusions: Lactate clearance in the most proximal presentation of severe sepsis and septic shock is associated with improved mortality rates. This is consistent with current efforts that emphasize the importance of identifying and treating tissue hypoperfusion during the first 6 hours of resuscitation.
17:10 - 17:20 #11543 - OP097 An e-learning program to attempt to decrease the use of Third-generation cephalosporin for pneumonia in the Emergency Department.
An e-learning program to attempt to decrease the use of Third-generation cephalosporin for pneumonia in the Emergency Department.
Background: Third-generation cephalosporins are particularly prone to promote bacterial resistance. Their use for pneumonia increased between 2002 and 2012 in our Emergency Department, and 80% of these prescriptions may have been avoided, i.e. third-generation cephalosporin may have been replaced by a penicillin. In 2013, we implemented an e-learning program that encouraged treating pneumonia with a penicillin rather than a Third-generation cephalosporin, when possible. The e-learning was completed by 65% of physicians in 2013 and by every Emergency Department resident since 2013.
Objectives: to assess if the e-learning implementation was associated with a decreased proportion of patients treated with a Third-generation cephalosporin and with a decreased proportion of avoidable Third-generation cephalosporin prescriptions.
Methods: Retrospective study of a random sample of patients treated for community-acquired pneumonia in an emergency department between 2002 and 2015, and subsequently hospitalized in non-Intensive Care Units. Third-generation cephalosporin prescriptions were presumed unavoidable if they met both criteria: (i) age ≥ 65 year’s old or a comorbid condition; and (ii) allergy or intolerance to penicillin, or failure of penicillin first-line therapy, or treatment with penicillin in three previous months. Prescriptions were otherwise deemed avoidable. Percentages are shown with 95% confidence interval.
Results: 956 patients were included. The proportion of patients treated with a Third-generation cephalosporin increased significantly from 14% [7%–24%] in 2002 to 30% [20% – 42%] in 2012 (Chi-scare for trend, P=0,02). This proportion was stable between 2013 (26% [18%-36%]) and 2015 (29% [19%-40%]; Chi-scare for trend, P=0,78). Treatment with a Third-generation cephalosporin was avoidable in 165 out of 212 patients (78% [72% – 84%]) during the whole study period. The proportion of avoidable prescriptions tended to decrease after the e-learning implementation, but the difference was not statistically significant (before e-learning, 79% [72%– 85%]; after e-learning, 74 % [62% – 84%]; P=0,6).
Conclusion: The implementation of an e-learning program seemed to stop the yearly increase of the proportion of patients treated with a Third-generation cephalosporin for pneumonia in the Emergency Department, but it failed to decrease the proportion of avoidable prescriptions of Third-generation cephalosporin. Other interventions are necessary to decrease the use of Third-generation cephalosporin for pneumonia in the Emergency Department.
17:20 - 17:30 #11576 - OP098 QuickSOFA is an independent predictor of 30-day mortality among patients admitted to an emergency department with suspected or documented infection.
QuickSOFA is an independent predictor of 30-day mortality among patients admitted to an emergency department with suspected or documented infection.
QuickSOFA is an independent predictor of 30-day mortality among patients admitted to an emergency department with suspected or documented infection
Osama Bin Abdullah1, Johannes Grand1, Astha Sijapati1, Petrine Nimskov1 , Finn Erland Nielsen1,2
1. Department of Emergency Medicine, Slagelse Hospital, Slagelse, DENMARK
2. Institute of Regional Health Services Research, University of Southern Denmark, DENMARK.
Background. Definitions and clinical criteria for sepsis have been revised in 2016.A simple bedside score (‘qSOFA’, for quick Sequential [Sepsis-Related] Organ Failure Assessment) has been proposed, which incorporates hypotension (systolic blood pressure ≤100mmHg), altered mental status and respiratory rate ≥ 22/min: the presence of at least two of these criteria has been associated with poor outcomes typical of sepsis.
Purpose. To evaluate qSOFA as a predictor of 30-day mortality in a model with other predictors of death among patients admitted to a single-centre emergency department (ED) with either suspected or documented infection on admission.
Methods. A historical cohort study among prospectively registered patients with suspected or documented infection. The patients were having at least two Systemic Inflammatory Response Syndrome (SIRS) criteria on admission and all the patients were treated with intravenous antibiotics in the ED. The admission period was from 1 November 2013 to 31 October 2014. Baseline clinical data and data for survival were obtained from a standard sepsis admission form, the patient records and The Danish Civil Registration System. Logistic regression analysis was used to adjust for potential confounders and to determine whether the predictive factors for death in the crude analyses were independently associated with 30-day mortality.
Results. A total of 434 patients with a median age of 70 years were included in the study, 246 (56.7%) were men. Fifty seven (13.1%; 95% confidence interval [CI] 9.9-16.3%) patients died during the first 30 days. Among several potential confounders tested in the model we found that age (odds ratio [OR] 1.29; 95% CI 1.03-1.61), Charlson Comorbidity Score ≥ 3 (OR 3.83; 95% CI 1.41-10.37), qSOFA score ≥2 (OR 4.78; 95% CI 2.09-10.91) and lactate values (lactate values < 2.0 as reference) in the interval 2.00-3.99 (OR 2.21; 95% CI 1.06-4.62) and lactate values ≥ 4.0 (OR 3.97; 95% CI 1.44-2,92) were associated with 30-day mortality.
Conclusion. This study shows that a new simple clinical bedside index, qSOFA, can be helpful to identify infectious patients in an ED with an increased risk of 30-day mortality.
17:30 - 17:40 #11719 - OP099 A predictive score of acute appendicitis for practice in emergency department.
A predictive score of acute appendicitis for practice in emergency department.
Acute appendicitis is the most surgical emergency. Its diagnosis is not already evident. So we need a predictive score as simple and effective to avoid unnecessary investigations.Objective :To establish a predictive score of acute appendicitis more adapted to our population and more practical.Methods : A prospective study carried out in our emergency department) over a period of 2 years, involving patients presenting with acute abdominal pain in the right iliac fossa (FID). Datas interesting medical caracteristics , biologic and imaging were collected at baseline. diagnosis of acute appendicitis is confirmed by positive histological exam. Results :400 patients were enrolled and completed follow-up .the mean age of the study population was 33 +/-7 years. The sex ratio was 1.4 . Among these patients , for only 240 ( 60%) the diagnosis of appendicitis was comfirmed histologically . The most common reason for consultation in this series is FID pain,this sign is present in 77.5% in the confirmed group group with p = 0.016. Univariate analysis identified other signs as significantly predictifs ( p = 0.001 ) : radiation of pain from epigastrum to the umbilicus , positive rovsing sign and sensitive abdomen in palpation.In multivariate analysis, our score was estabished, containing 7 variables : Vomiting>=2 épisode =1 point) , pain project From the epigastrium to the umbilicus = 2 point , positive Rovsing sign =1 point , positive Blumberg sign = 1 point, sensitive abdomen =2 point , défense de la FID= 2 point and White blood cells >10000 (hyperleucocytosis) =2 point .
The descrimination power is represented by the ROC curve. Area under the ROC curve of the appendicitis score was 0.874.This score can have a sensitivity of 99% and a specifity of 80%.
Conclusion : many scores have been developed (Alvarado, Andersson, François, ...), but are not common practice. A model based on variables easily available at ED, like our appendicitis score , can help ED physicians to diagnosis the acute appendicitis.
EUSEM Annual General Assembly
for Members only
|Wednesday 27 September
Keynote Lecture 3
Moderator: Christian HOHENSTEIN (PHYSICIAN) (JENA, GERMANY)
08:30 - 09:00 Constructive alignment: Curriculum, examination, training & beyond. Eric DRYVER (Consultant) (Lund, SWEDEN)
Moderators: Barbara HOGAN (Past President of the European Society for Emergency Medicine, EuSEM) (HAMBURG, GERMANY), Jan STROOBANTS (Head of the Emergency Department) (Brecht, BELGIUM)
Coordinator: Christoph DODT (München, GERMANY)
09:10 - 09:40 Resilience in emergency response systems. Raed ARAFAT (ROMANIA)
09:40 - 10:10 Burnout in Emergency Medicine. Pinchas HALPERN (department chair) (Tel Aviv, ISRAEL)
10:10 - 10:40 Management instruments in the ED: tools for creating ED resilience. Barbara HOGAN (Past President of the European Society for Emergency Medicine, EuSEM) (HAMBURG, GERMANY)
Falck Foundation - Paramedic-led research
Moderators: Demetrios PYRROS (GREECE), Nagi SOUAIBY (Chief Editor) (Byblos, LEBANON)
Coordinator: Christoph DODT (München, GERMANY)
09:10 - 09:40 Creating a research supportive EMS organisation. Karen SMITH (MELBOURNE, AUSTRALIA)
09:40 - 10:10 Doing research as a paramedic. Veronica LINDSTRÖM (Researcher, Lecture) (Stockholm, SWEDEN)
10:10 - 10:40 Best paramedic-led research papers 2011-2016. Marc SABBE (Medical staff member) (Leuven, BELGIUM)
Mountain Medicine (Game Changers)
Moderators: Steffen HERDTLE (MD) (Jena, GERMANY), Peter PAAL (Head of Department) (Salzburg, AUSTRIA)
Coordinator: Christian HOHENSTEIN (JENA, GERMANY)
09:10 - 09:40 "high-level CPR": BLS with AED in Mountain Medicine. Peter PAAL (Head of Department) (Salzburg, AUSTRIA)
09:40 - 10:10 "high-level science": the EURAC simulation center. Hermann BRUGGER (Head of Institute) (Bolzano/Bozen, ITALY)
10:10 - 10:40 "high-level HAP(P)ENESS": New strategies in management of HAPE. Philip SCOTT (UK)
YEMD - Research
Moderators: Alice HUTIN (PARIS, FRANCE), Jennifer TRUCHOT (Paris, FRANCE)
Coordinator: Basak YILMAZ (Ankara, TURKEY)
09:10 - 09:25 Tips to write a really good abstract and present it at EUSEM. Yonathan FREUND (Paris, FRANCE)
09:25 - 09:40 From the abstract to the article. Colin GRAHAM (Hong Kong, HONG KONG)
09:40 - 09:55 3 best YEMD articles. Youri YORDANOV (Médecin) (Paris, FRANCE)
09:55 - 10:10 #11057 - OP118 Predicting Utilization of Advanced Medical Imaging at Emergency Department Triage Using Patient-reported Reason for Visit and Immediately Available Medical Information.
OP118 Predicting Utilization of Advanced Medical Imaging at Emergency Department Triage Using Patient-reported Reason for Visit and Immediately Available Medical Information.
Background Emergency department (ED) crowding is associated with negative health outcomes, patient dissatisfaction, and longer length of stay (LOS) during the ED visit. Advanced imaging procedures are major contributors to increased ED LOS; earlier and improved prediction of patients’ need for advanced imaging may improve overall ED efficiency. We used information immediately available at ED triage including free text data regarding a patient’s reason for visit to predict utilization of advanced medical imaging (AMI): CT, Ultrasound (US), and MRI. Methods We used the 2012 and 2013 US National Hospital Ambulatory Medical Care Survey data to examine factors associated with the utilization of CT, US, MRI, and multiple AMI during a patient’s ED stay. We incorporated natural language processing (NLP) in multivariable logistic regression models to examine whether patient-reported reasons for visit available at time of ED triage improved prediction for AMI use.
Results: Among the 50,976 ED visits from 642 hospitals, 9,488 (18.6%) resulted in advanced medical imaging use including 7,240 CTs (14.2%), 1,585 ultrasounds (3.1%), 178 MRIs (0.35%) and 485 (0.95%) multiple types of AMI. Black patients had lower odds for all AMI use compared to whites (OR 0.64; 0.59-0.68). Odds of AMI use increased for patients with history of dementia (OR 4.0; 3.4-4.7), cerebrovascular disease (OR 3.1; 2.7-3.5), and diabetes (OR 1.7; 1.6-1.9). The predictive accuracy of the multivariable logistic models for all types of AMI use improved with the inclusion of patient-reported information using NLP: c-statistic increased from 0.74 to 0.82 for CT use, 0.76 to 0.83 for US use, 0.70 to 0.78 for MRI use, and 0.73 to 0.79 for multiple AMI use.
Conclusions: Patient-reported information available during ED triage can be used to predict the use eventual use of advanced medical imaging. Models such as this which employ immediately available data and patient reported reasons for visit may help to identify patients earlier who will require various types of imaging during their ED stay. These findings the potential to impact radiology and ED workflow.
10:10 - 10:25 #11616 - OP119 An Analytical Approach to the Risk Stratification Screening of Sepsis utilizing The Systemic Inflammatory Response Criteria (SIRS) versus the Quick Sepsis Organ Failure Assessment (QSofa) in Portiuncula University Hospital, Ireland.
OP119 An Analytical Approach to the Risk Stratification Screening of Sepsis utilizing The Systemic Inflammatory Response Criteria (SIRS) versus the Quick Sepsis Organ Failure Assessment (QSofa) in Portiuncula University Hospital, Ireland.
In February 2016, the 3rd International Consensus for Sepsis Definitions were revised. A major change in the approach to sepsis was replacing the widely used SIRS criteria with the new qSofa Score. As the new Sepsis Guidelines replace existing medical practices, we can expect considerable impacts in terms of identification, management, and treatment of sepsis.
The objective of this paper was to analyze and compare the sensitivity and specificity between the SIRS criteria and the 2016 new qSofa Score in the detection and recognition of sepsis.
A retrospective study was carried out between the period of July 2015 to November 2015 where patients that were admitted due to sepsis (n=79). These patients were studied in terms of recognition in triage based on the SIRS criteria and the new qSofa Score which comprises of hypotension, altered mental status, and tachypnea. This study includes: the elements of recognition at triage, patient demographics (age and sex), common qsofa criteria, prevalence of type of sepsis that is captured most by the qSofa Score, a termed “Evolving qsofa” for patients whom at triage were qsofa negative but Developed qsofa Positive whist in the Emergency Department.
The total number of patients studied that were SIRS positive and admitted for sepsis were 79 (n=79). The mean age was 67, 35 males and 44 females. 28 had a respiratory source and 29 urinary tract infection. 43 sepsis cases were recognized using the qSofa (54.4% CI,43:79). Patients that developed a positive qsofa Score (whom were previously negative) were termed “Evolving qsofa” and were numbered at 10 (12.6% CI, 10:79). This brings the total to 53 positive qsofa in the time of study (67.08% CI, 53:79) (P>0.01). The mean time taken for a septic patient to be seen recorded at 39.17minutes. ICU admissions were 23 in total (29.11%, 23:79). All ICU admissions were patients with a positive qsofa (100% CI, 53:23). Positive Cultures numbered at 62 (78.4%, 62:79). The breakdown of positive qsofa criteria was as follows: Tachypnea numbered 34 (64.15% CI 34:53), Hypotension numbered 38 (71.69%, 38:53), Altered mental status numbered 26 (49.05%, 26:53). There were no mortalities resulting from sepsis in the ED during the term of the study.
Conclusively, this study stresses the consideration for the continuum of sepsis and proves that the qsofa has an extremely high specificity and overall accuracy in identifying septic debilitated patients whom will require ICU, and therefore superior to SIRS. However, the SIRS Criteria with its lowered Receiver operating Characteristics [ROC], possesses high sensitivity, enabling a wider cohort of patients presenting with infection to be triaged as likely sepsis and ensure robust Sepsis Screening.
10:25 - 10:40 #11751 - OP120 High-Dependency Observation Units: which parameters to identify patients at high risk of ICU transfer?
OP120 High-Dependency Observation Units: which parameters to identify patients at high risk of ICU transfer?
Aims: To evaluate independent predictors of ICU (Intensive care Unit) transfer in a multicentre population of patients admitted in two Emergency Department High Dependency Units (ED-HDU).
Methods: From June, 2014, to July, 2016, we recorded all patients admitted in the ED-HDU of University Hospital Careggi and in the ED-HDU in the Azienda Ospedaliero - Universitaria Policlinico - Vittorio Emanuele in a standardized database;; after 25 months, we analyzed the database in order to identify predictive parameters of an adverse outcome. To standardize comorbidity, Charlson index was calculated; SOFA score calculation was employed to evaluate organ dysfunction. The primary end-point was ICU admission.
Results: During the period June 2014-July 2016, 3311 patients were admitted in the two Units, 1822 in Florence and 1489 in Catania, mean age 72±16 years; overall HDU mortality rate was 5% (n=171). The most frequent admission diagnosis were COPD exacerbations (9%), ischemic (11%) and congestive (19%) heart disease, trauma (7%) and cardiac arrhythmias (18%). Overall 18% of patients presented a respiratory failure requiring non-invasive ventilation and 7% had a shock requiring vasoactive medications.
At HDU admission, 32% of patients presented an infections; respectively 4 and 8% of patients showed a respiratory (pH <7.3 with pCO2 >45 mmHg) or metabolic acidosis (Base excess ≥ -5 or lactate level 1.5 time the reference level); mean SOFA score, calculated on the basis of the worst values in the first 24 hours, was 3.8±3.3. Overall 208 (7% of HDU survivors) patients were transferred to an Intensive Care Unit (ICU): compared with patients with a good prognosis, age was comparable between patients transferred to ICU and the others (71±15 vs 72±16, p=NS), while comorbidity burden (Charlson index 3.1±2.5 vs 2.8±2.6, p=0.046) was only slightly higher in patients admitted to ICU . Presence and number of organ insufficiency actually differentiated patients’ disposition: compared with patients transferred to an ordinary ward, number of organ failure was significantly higher in patients transferred to ICU (1.0±0.9 vs 0.6±0.7, p<0.001) as well as the presence of respiratory (41 vs 15%), renal (39 vs 32%) and cardiovascular (18 vs 7%) failure. A sepsis (23 vs 10%), as well as a septic shock (11 vs 4%), was more frequent among patients transferred to an ICU.
In a multivariable analysis which included all variables significantly different according to ICU transfer (SOFA score, Charlson index, presence of acidosis and presence of infection at admission) SOFA score was independently associated with a untoward prognosis in the whole study population (RR 1.23; 95%CI 1.16-1.29, p<0.001); the result was confirmed among patients admitted in Catania Center (RR 1.39; 95%CI 1.26-1.52, p<0.001) and Florence center (RR 1.23; 95%CI 1.15-1.32, p<0.001).
Conclusions: a higher SOFA score was the only independent predictor of ICU admission in an unselected population of HDU patients.
EM development: The International ways
Moderators: Panos AGOURIDAKIS (GREECE), Bernard FOEX (Manchester, UK)
09:10 - 09:40 The Development Tendency of Emergency Medicine in China. Wang ZHONG (CHINA)
09:40 - 10:10 Cultural contamination for a better European EM. The exchange program for young doctors. Roberta PETRINO (Head of department) (Italie, ITALY), Riccardo PINI (Director, E.D. High Dependency Unit) (Florence, ITALY)
10:10 - 10:40 Development of EUSEM Research Network. Said LARIBI (PU-PH, chef de service) (Tours, FRANCE)
Free Papers Session 12
Moderators: George NOTAS (GREECE), Anastasia ZIGOURA (GREECE)
09:10 - 09:20 #11104 - OP100 How often does a routine urinalysis help with emergency department clinical decision making ?
OP100 How often does a routine urinalysis help with emergency department clinical decision making ?
Objective: to determine how often the urinalysis (UA) contributes to clinical decision making and/or disposition decisions in the emergency department (ED).
During 12 consecutive days, the records of all adult patients presenting to our ED were reviewed to see whether or not they a UA was ordered during their ED visit. In addition to this variable, patient demographics, and whether it influenced clinical decision-making (based on the medical decision-making section of the physician chart) or disposition decision were abstracted.
A total of 559 patients presented during the study period, of which 66% were female. The median age was 51, with an interquartile range of 35 to 68 years. 294 (38%) presented on a weekend, defined as Friday 7pm to Monday 7 am.101 (35%) presented during the night shift, defined as arriving between the hours of 7pm-7am.
265 (65%) were first seen by a physician assistant (PA) and then seen by an MD. 138 (25%) were seen by a PA alone. A total of 232 patients (42%) were admitted. 287 patients (51%) had a UA ordered in the ED.
193 (35%) had a UA ordered by the PA. 94 (17%) had a UA ordered by the physician. The UA was cancelled in 50 patients.
Patient disposition decision was made prior to UA resulting in 60 cases (25%).
Of these, 36 (60%) were women, and the median age was 65, with an interquartile range of 49 to 73 years.
29 (48%) were seen on the weekend. 20 (33%) were seen on the night shift. 56 (93%) not seen by PA.18 (30%) ordered by PA. 42 (70%) ordered by MD. 100% UA cancelled
The UA was used in clinical decision making in 118 (66%). Univariable correlates included:
Being female (P=0.0050, 95% CI 0.0068 - 0.378)
Being older (P<0.0001, 95% CI -0.010 to -0.004)
Being first seen by a PA then a physician (P=0.0486, 95% CI= 0.0048 - 0.1555)
More often in discharged patients (P<0.0001 95% CI -0.6749 to -0.4487)
Conclusion: Our results suggest that a routine UA may not impact clinical decision making up to 33% of the time, nor alter or disposition decision one out of four times. Unnecessary tests place additional burden on the patient, and the ED personnel, and perhaps should be reconsidered.
09:20 - 09:30 #10850 - OP101 Impaired cognition is highly prevalent and independently associated with adverse outcomes in older patients presenting to the emergency department; the APOP study.
OP101 Impaired cognition is highly prevalent and independently associated with adverse outcomes in older patients presenting to the emergency department; the APOP study.
We investigated whether impaired cognition is associated with adverse outcomes in older emergency department (ED) patients, because this association could have large implications for ED management and follow-up after disposition.
A prospective multi-center cohort study was performed in all acutely presenting older patients visiting the ED (APOP study). Demographic data, disease severity and geriatric characteristics were collected during the first hour of the ED visit. Cognition was measured using the 6 Item Cognitive Impairment Test (6CIT). Cognitive impairment was defined as a 6CIT ≥11, self-reported dementia or the inability to perform the cognition test. Adverse outcome after three and twelve months was defined as a 1 point decrease in Katz-ADL, new institutionalization or mortality. Multivariable regression analysis was used to assess whether impaired cognition independently associates with adverse outcome.
Of the 2131 included patients 588 (27.6%) had cognitive impairment. A total of 375 (24.5%) patients with normal cognition suffered from adverse outcomes after three months, compared to 280 (47.8%) patients with impaired cognition. The association remained after correction for baseline functional status, disease severity and comorbidities (OR 1.71, 95%CI 1.36-2.15). After twelve months 332 (27.9%) patients with normal cognition suffered from adverse outcome, compared to 240 (54.5%) patients with impaired cognition (adjusted OR 1.89, 95%CI 1.46-2.46).
Cognitive impairment is highly prevalent in older ED patients and is associated with adverse outcome after three and twelve months, independent of baseline functional status, disease severity and comorbidities. This emphasizes the importance for ED physicians to assess cognition and possibly intervene.
09:30 - 09:40 #10952 - OP102 Determinants of Self-Rated Health in older adults before and three months after an emergency department visit; a prospective study.
OP102 Determinants of Self-Rated Health in older adults before and three months after an emergency department visit; a prospective study.
Older patients often experience adverse health outcomes after an Emergency Department (ED) visit, which potentially affects quality of life (QOL). Self-rated health (SRH) is a way of exploring QOL and is an important outcome of interest in older adults. There are only a few reports on SRH and its determinants in older patients visiting the ED. The aim of this study was to identify the determinants of decline in SRH in older patients three months after visiting the ED.
This study is an analysis of the data from the Acutely Presenting Older Patient (APOP) study in which all patients aged ≥ 70 years, attending the EDs of the Leiden University Medical Center (LUMC) and Alrijne Hospital in the Netherlands were included. At presentation and after three months, patients were asked to score their general health during the last month excluding the reason of their visit to the ED, with zero being the worst and ten being the best imaginable situation. The main outcome was a decline in SRH defined as a transition of a SRH ≥6 at baseline to a SRH
At baseline there were 1219 (81.2%) patients with a sufficient SRH (SRH ≥6) and 283 (18.8%) patients had an insufficient SRH (SRH <6). Three months after the ED visit 870 patients had a stable SRH (71.4%), 209 patients declined in their SRH (11.5%) and 142 patients died or there was no follow-up SRH available (17.1%). Independent factors associated with a decline in SRH were: male gender (OR 1.84, 95 % CI 1.19-2.85), living alone (OR 1.58, 95 % CI 1.01-2.47), living in residential care or nursing home (OR 2.76, 95 % CI 1.21-6.27), number of different medications (OR 1.08, 95 % CI 1.03-1.13), using a walking device (OR 1.73, 95 % CI 1.05-2.82) and the Katz-ADL score (OR 1.23, 95 % CI 1.02-1.48). Patients who experienced functional decline three months after an ED visit, show a steeper decline in mean SRH (0.68 points) compared to patients who did not experienced functional decline (0.12 points, p<0.001).
Decline in SRH after an ED visit in older patients is mainly dependent on factors of functional capacity and functional decline. Preventive interventions to maintain functional status could be the solution to maintain SRH.
09:40 - 09:50 #10982 - OP103 Emergency admissions in older patients: a population-based survey.
OP103 Emergency admissions in older patients: a population-based survey.
Background: Older patients comprise a major proportion of all emergency admissions and associated costs. As this population grows, there will be a mounting demand for health care services and emergency services in particular. In this study, we investigated the burden and costs related to older patients’ emergency department (ED) use.
Methods: Consecutive patients aged 80 years or over admitted to a high-volume, collaborative ED during a two-year study period (January 2015 to December 2016) were included. The hospital provided primary and tertiary care emergency services to a population of 226,696 inhabitants (10,991 aged 80 years or over). Patient demographics, diagnoses, costs of ED care were retrieved from hospital records. Only in-hospital costs of ED care and examinations were included. The key factors under analysis were the incidence of emergencies and the associated costs of ED care.
Results: A total of 12,177 patients (median age 85 years, range 80-114 years; 65% female) had 24,441 ED admissions (14% of all ED admissions) during the two-year study period. The incidence of emergencies increased from 387/1,000/year (133/1,000 inhabitants of this age group required emergency services) in patients aged 80-89 year to 511/1,000/year (147/1,000) in those aged 90 years or over (p<0.001). High-frequency users (≥5 admissions/year, n=621, range 5-46 admissions) covered 6% of all ED admissions in patients aged ≥80 years.
Older patients were most often diagnosed to suffer from different types of non-specific symptoms (24%), cardiovascular diseases (18%), injuries (17%), respiratory diseases (8%), genitourinary diseases (8%) and gastrointestinal diseases (5%). Typical specific diagnosis included pneumonia (5%), femoral fracture (3.1%), cerebral infarction (2.3%), acute pyelonephritis (2.1%) and acute myocardial infarction (1.4%).
Twenty-two per cent of patients required tertiary care in our hospital, 38% were discharged home and the rest (40%) to other hospitals, to primary care centres or to nursing homes. Only 0.2% was admitted to intensive care unit. There was a steady increase in the costs according to age; population-size adjusted costs of ED care in inhabitants aged 90 years or more were over 1.3-fold (430 euros/same aged inhabitant) compared to that of those aged less than 90 years (324 euros). The mean costs of a single admission in high-frequency users did not differ significantly from those of requiring emergency evaluation only once. Patients requiring multiple admissions covered 88% of all costs of ED care in older patients.
Conclusions: A large share of older people needs ED services annually and many have repeated visits. Despite high use of ED resources and consequent costs, no specific diagnosis could be made in one-fourth of cases. Potentially avoidable ED admissions and repeat admissions could be a target for cost-reductive initiatives.
09:50 - 10:00 #11823 - OP104 End-of-Life decisions rate in the prehospital field for fragile patients.
OP104 End-of-Life decisions rate in the prehospital field for fragile patients.
The management of the elderly or patients with severe conditions has increased in emergency field. In the prehospital setting, teams are often confronted with the absence of data allowing to rule on therapeutic limitations. Emergency physicians must therefore discuss and apply therapeutic limitations, i.e. End-of-Life (EoL) decisions. These decisions should be recorded in the medical transport sheet (MTS). The aim of our study is to assess the EoL decisions rate on the Emergency Medical Service (EMS) MTS of patients considered as fragile.
We performed a monocentric, 1.5-month retrospective analysis of the medical records of patients managed in a mobile intensive care unit of an EMS located in an urban zone.
The inclusion criteria were: patient age > 85 years with a lost of autonomy and patients with an incurable disease.
The primary interest criterion was the reported EoL decisions rate, i.e. decided by the EMS and indicated on the MTS.
Secondary criteria were patients’ characteristics: the pathology concerned, the EoL decisions rate taken before the team’s arrival, the destination service when transported, and the rate of contact with the family to participate in decision-making recorded in the MTS.
From mid-October to late November 2016, 63 patients met the inclusion criteria. Thirty-five (56%) were men; median age was 88 [IQR: 81-91] years. The management took place at home, at a nursing home or at a rehabilitation care service in respectively 45 (71%), 12 (19%) and 6 (10%). Pathology concerned were cardiac arrest, neurology, respiratory, cardiology, metabolic and others in respectively 18 (29%), 16 (25%), 15 (24%), 5 (8%), 3 (5%) and 4 (6%) cases.
EoL decisions were known before EMS intervention in three cases. For the others, EoL decisions were written on the MTS for 15 patients. The reported EoL decisions rate was 24% (95% CI: 14% - 36%). After medical evaluation, three (5%) were left alive at home, 20 (32%) died on scene and 40 (63%) were sent to hospital. On those, 38 (60%) patients were sent to an emergency room and two (3%) were sent to an intensive care unit with a massive haemorrhagic stroke. Family was contacted in 17 (27%) cases to participate in decision-making.
Reported EoL decisions rate for elderly patients without autonomy or patients deemed incurable was low. Furthermore, transports’ rate to emergency department was high and the number of patients left alive on scene was low. This could be considered as a gap in the ethical care of very fragile patients. A service procedure will be implemented to improve practices.
10:00 - 10:10 #11925 - OP105 Loss of autonomy and home carers in elderly patients visiting the Emergency Department.
OP105 Loss of autonomy and home carers in elderly patients visiting the Emergency Department.
In emergency departments (ED), elderly patients are an increasing part of visiting patients. Their admission rate is higher than young patients and their lenght of stay is longer partially because admission can lead to loss of autonomy. Assessing autonomy level and home carers presence is not always done through ED visit. However it could help anticipate their care pathway after ED visit. We want to assess what do elderly patients visiting ED become depending on their autonomy level and the presence of carers at home before the event. We also want to draw the epidemiological portray of elderly patients and assess their mortality rate.
Method : Prospective multicenter cohort study with inclusions done on a given day in 147 Emergency Departments. Patients ≥ 80 years old have been included and questionnaire filled in by the doctor in charge. It was dealing with patient characteristics, emergency situation, medical care, autonomy, home carers, and situation on day 30. Our main aim was to assess their mortality rate. Secondary objectives were to analyse patients characteristics and especially in terms of autonomy and home assistance. We also wanted to evaluate what do these patients become through hospitalization and institutionalization rate at day 30. We completed statistical analysis through descriptive statistics and a second part of this work will be to perform logistic regressions in order to assess association between mortality, hospitalization, institutionalization and existence of home assistance. This last part has not been done yet. Regression will adjust for age, sexe, comorbidities, severity, loss of autonomy, socioeconomic category.
Results : n= 1659 patients were included. Mean age was 86,9 ±4,7 years old. 60,7% were women. 72% were living at home (among which 79,5% with general home carers and 44,8% with professional carers). Only 2,2% had no medical history, 62,9% had more than 3 daily treatments and 36,6 % had cognitive impairment. Among patients living at home, 60,1% had mild impairment in Activity of Daily Living and 2,5% had extreme loss of autonomy. 13,7% of visiting patients had severe conditions and 3,7% were admitted in intensive care. 64,7% have been admitted after ED visit. On day 30, mortality rate was 8,3% and 30,3% of admitted patients were still hospitalized or had been institutionalized. Among patients living at home : 29,8% of patients with home carers were still admitted or had been institutionalized on day 30 vs 24,2% of patients without home carers, p<0,05.
Conclusion : Elderly patients are mainly living at home, most of them have at least mild loss of autonomy and 44,8% have professional carers to help them deal with their dependance. Admission and mortality rate are high. On day 30, a third of elderly patients are still hospitalized. Logistic regressions are needed to go further and to analyze association between the existence of home carers in dependent patients and hospitalization rate after visiting ED.
10:10 - 10:20 #11263 - OP106 Improving ED working conditions, employee well-being, and patient satisfaction: An intervention study.
OP106 Improving ED working conditions, employee well-being, and patient satisfaction: An intervention study.
ED work systems encompass a multitude of work stressors that impact ED professionals’ well-being and delivery of patient care. Little is known about effective interventions to improve the psychosocial ED work environment with positive effects on professionals’ mental health and quality of care. The aim of this intervention study was to analyze the prospective effects of an employee-centered intervention (“health circles”) with regard to psychosocial work stressors, mental well-being, and patient satisfaction.
This study established a two-wave interrupted time series design with a time lag of one year. The study setting comprised a multidisciplinary German ED with an annual volume of approx. 84000 patients. All ED employees (nurses, physicians, and administrative staff) were invited to participate in a survey. Validated and standardized instruments were used to measure psychosocial work stressors and mental well-being. Additionally, patients were surveyed on-site with a short questionnaire about their satisfaction with quality of care on 40 randomized days at both waves. Between baseline and follow-up, ten interdisciplinary moderated “health circles” with ED nurses and physicians were conducted on different topics of ED work organization and ED leadership. Differences over time and associations between study variables were calculated with SPSS 23.0.
Overall, N = 149 surveys were completed. 40 ED employees responded at both waves. A total of 1418 patients was surveyed. Employees reported high levels of interruptions, time pressure, and low participation opportunities throughout both waves. However, improvements after one year were reported in autonomy (p=.014), while employees’ perceptions of staffing levels (p=.046) and social support (p=.002) deteriorated. Concerning mental well-being, general job satisfaction declined (p=.013) and depersonalization increased (p=.027). Psychosocial work stressors and ED professionals’ mental well-being were strongly associated at both waves. There was evidence on divergent trends in the evaluation of psychosocial work stressors and mental well-being between nurses, physicians, and administrative staff. However, patient satisfaction with organization of care, with interactions and information from care providers, and with waiting times significantly improved from baseline to follow-up (all scales p<.001).
Discussion and Implications
To our knowledge, this is the first systematic study of a participative intervention in an ED which evaluates longitudinal effects on psychosocial work stressors, mental well-being, and patient satisfaction. We observed significant changes in autonomy, staffing, and social support of ED employees, their job satisfaction and depersonalization, and finally, significant improvements in patient satisfaction with quality of care. Our results suggest that employee-centered interventions that target the psychosocial work environment in EDs might improve quality of care.
10:20 - 10:30 #11364 - OP107 Capillary lactate vs POCT venous lactate in the emergency department.
OP107 Capillary lactate vs POCT venous lactate in the emergency department.
An elevated blood lactate level (hyperlactatemia) is a sensitive marker that may be used to identify critically ill patients. Capillary lactate measurement using handheld devices may allow for rapid determination of test results and these devices can be used in the pre-hospital setting. The present study aimed to investigate the agreement of capillary lactate measured using handheld lactate analyzer compared to the reference- venous blood lactate level assessed using a point of care test (POCT) blood gas analyzer in the Emergency Department (ED).
Prospective observational study of patients presenting to the ED in Hong Kong. Patients triaged as ‘urgent’ (Category 3 of the 5 category triage scale), aged 18 years or above, who presented to the ED during 2016 were recruited. Venous and capillary blood samples were collected for lactate analysis. Venous lactate levels measured by blood gas analyzer were used as a reference (VL-Ref). Capillary lactate levels were measured using two handheld analyzers (Nova StatStrip Xpress Lactate Meter and Lactate Scout+ Analyzer) (CL-Nova and CL-Scout+). Venous lactate measurements were also performed using two handheld analyzers (VL-Nova and VL-Scout+). Agreement of lactate levels from handheld analyzers with the reference blood gas analyzer was determined using Bland-Altman agreement analysis.
Two hundred and forty patients (mean age 69.9 years; 54.2% males) were recruited between March and July 2016. The result of VL-Ref ranged from 0.70 to 5.38 mmol/L, with a mean of 1.96 mmol/L. 63.75% and 36.25% showed lactate level (VL-Ref)
An overall low systemic bias were observed in CL-Scout+ (bias: -6.2%) and VL-Scout+ (bias: 13.0%), suggesting the potential clinical utility of Scout+ handheld analyzer for screening patients who should or should not have further formal lactate measurement using a POCT blood gas analyzer or analysis in the central laboratory. In addition, POCT lactate may not be available in all EDs, or in the pre-hospital setting. Screening lactate levels using a handheld analyzer could provide information to hasten the identification of patients at risk, to make early decisions for further treatment.
10:30 - 10:40 #11770 - OP108 Agreement of emergency department and hospital diagnosis of septic shock.
OP108 Agreement of emergency department and hospital diagnosis of septic shock.
Title: Agreement of emergency department and hospital diagnosis of septic shock.
Background: Sepsis is the leading cause of shock in the emergency department (ED). Clinical suspicion of infection is crucial to early identification of septic shock. No studies of agreement between real-time emergency physician (EP) impression and hospital diagnosis of septic shock have been identified in the literature.
Objectives: The primary objective was to evaluate agreement between real-time EP impression and hospital diagnosis of septic and non-septic shock.
Methods: This was an observational cohort study on patients presenting with shock in an academic tertiary ED from January 2015 to January 2017. Subjects were identified through an interactive shock alert tool that alerts EPs instantaneously when a patient has either a systolic blood pressure < 90mmHg or lactate ≥ 4mmol/L. The alert requires the EP to click their impression. Two-by-two tables for ED impression at the time of alert against hospital diagnosis were computed. Agreement of real-time EP impression was evaluated by calculating sensitivity, specificity, predictive values and likelihood ratios with 95% confidence intervals (CIs).
Results: A total of 2208 ED visits met inclusion criteria. After applying exclusion criteria, 1520 remained and were included in the study. The mean age was 61.1 (SD 18.2) years, and 56.7% were men. There was a good hospital agreement with the EP impression of septic shock, with the following performance: sensitivity 77.3% (95% CI 73.7-80.5), specificity 89.2% (95% CI 87.0-91.0), positive predictive value (PPV) 81.7% (95% CI 78.3-84.7), negative predictive value (NPV) 86.2% (95%CI 83.9-88.3), positive likelihood ratio 7.153 (95% CI 5.919-8.644) and negative likelihood ratio 0.255 (95% CI 0.219-0.296). Dehydration was most common EP impression of non-septic shock, among those who turned out to have hospital diagnosis of septic shock.
Conclusion: Good agreement between real-time EP impression of septic and non-septic shock and hospital diagnoses was shown by PPV of 81.7% (95% CI 78.3-84.7), and NPV of 86.2% (95%CI 83.9-88.3). This outperforms available lab testing in diagnosing sepsis.
Moderators: Kurt ANSEEUW (Medical doctor) (ANTWERP, BELGIUM), Bruno MEGARBANE (Professor, head of the department) (Paris, FRANCE)
Coordinator: Senad TABAKOVIC (Zürich, SWITZERLAND)
11:10 - 11:40 Paracetamol poisoning: basics for EP, novel techniques and upcoming research. Davide LONATI (MD, Clinical Toxicologist, Invited speaker) (Pavia, ITALY)
11:40 - 12:10 Novel phycho-active substances in the ED. Kurt ANSEEUW (Medical doctor) (ANTWERP, BELGIUM)
12:10 - 12:40 ECMO for treatment of cardiotoxic intoxications. Bruno MEGARBANE (Professor, head of the department) (Paris, FRANCE)
EUSEM journal club
Moderators: Rick BODY (UK), Senad TABAKOVIC (Zürich, SWITZERLAND)
Coordinator: Senad TABAKOVIC (Zürich, SWITZERLAND)
Speakers: Rick BODY (UK), Colin GRAHAM (Hong Kong, HONG KONG), Youri YORDANOV (Médecin) (Paris, FRANCE)
11:10 - 11:40 - Nine papers that question current practice.
11:40 - 12:10 - The top 3 papers in Emergency Medicine, 2016-17.
12:10 - 12:40 - How to bring science to the people.
Ethical and legal issues in EM (How To)
Ethical dilemmas in the ED
Moderators: Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, GREECE), Robert LEACH (Head of Dept.) (Bruxelles, BELGIUM)
Coordinator: Rick BODY (UK)
11:10 - 11:40 We can do almost everything, but should we do it? Marc SABBE (Medical staff member) (Leuven, BELGIUM)
11:40 - 12:10 Family-witnessed resuscitation in the Emergency Department. Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, GREECE)
12:10 - 12:40 Withholding and withdrawing life sustaining treatments in the ED. Bernard FOEX (Manchester, UK)
Choosing wisely in the ED
Moderators: George NOTAS (GREECE), Michael RADEOS (USA)
11:10 - 11:40 Laboratory tests in the ED: Sometimes ‘Less is More’. George NOTAS (GREECE)
11:40 - 12:10 How can we reduce unnecessary radiology tests? Tony KAMBOURAKIS (Director Medical Services) (Melbourne, AUSTRALIA)
12:10 - 12:40 Focusing on the front door: Streaming strategies and pitfalls. Nikolas SBYRAKIS (GREECE)
General Emergency Medicine
Moderators: Raed ARAFAT (ROMANIA), Said LARIBI (PU-PH, chef de service) (Tours, FRANCE)
11:10 - 11:40 Advances in the technologies and processes of care in emergency care. Tiziana MARGARIA STEFFEN (IRELAND)
11:40 - 12:10 Post traumatic stress disorder in the ED. Togay EVRIN (Speaker) (Ankara, TURKEY)
12:10 - 12:40 ARDS: The challenge for early intensive care in the ED. Juliusz JAKUBASZKO (POLAND)
Free Papers Session 13
Moderators: Youri YORDANOV (Médecin) (Paris, FRANCE), Anastasia ZIGOURA (GREECE)
11:10 - 11:20 #10860 - OP109 Risk factors helping to decide for whom to isolate, when suffering from acute gastroenteritis.
OP109 Risk factors helping to decide for whom to isolate, when suffering from acute gastroenteritis.
Title: Risk factors helping to decide for whom to isolate, when suffering from acute gastroenteritis.
Isolation of contagious patients with gastroenteritis requires more caregiver time and delays the examination, start of treatment and reduces the level of care. But isolation is, especially in an emergency department (ED) with high patient flow, necessary to prevent spreading of communicable diseases.
The aim of the study was to identify risk factors helping to identify patients with acute gastroenteritis infected with Norovirus or toxic Clostridium difficile requiring isolation, in order to choose the right room before or at the patients’ arrival.
At four regional hospitals all patients, acutely admitted due to acute gastroenteritis, were interviewed and stool samples analyzed for Norovirus, toxic Clostridium difficile and pathogenic gut bacteria. Vital parameter at admission and anamnestic factors (gastrointestinal symptoms before admission, travel history, previous and recent treatment with antibiotics) were obtained.
191 patients were included, 54 patients were not able to deliver any fecal sample. 81 samples were negative, 22 samples were positive for pathogenic gut bacteria, 32 were positive for infectious gastroenteritis (Norovirus or toxic Clostridium difficile) and 2 were positive for infectious gastroenteritis and pathogenic gut bacteria (Campylobacter one combined with norovirus, once combined with toxic Clostridium difficile).
The following risk factors were found significant for Norovirus: a sub febrile temperature (37.5 -38.5 Celsius OR 3.5; 95% CI 1.1 -11.6), length of diarrhea (more than three days OR 0.3; 95% CI 0.01- 0.3), length of vomiting (one day OR 4; 95% CI 1.2 – 13.2), number of vomiting’s (more than 10 on the day of symptom debut OR 6.9; 95% CI 1.7 – 28.1) and appearance of another patient infected with Norovirus with in the previous week (OR 4.3; 95% CI 1.4 - 12.7).
Mucus in stools was significant for toxic Clostridium difficile (OR 3.5; 95% CI 1.02 – 12.3) as well as previous treatment with antibiotics (completed cure one month before admission OR 15.5; 95% CI 3.4 – 71.2) and low pulse (<60/minute OR 7.8; 95% CI 1.5 – 40.2) as well as length of diarrhea (more than three days OR 4.9; 95% CI 1.1- 23.0).
An algorithm to identify patient with infectious gastroenteritis will be developed by using the identified risk factors. As Norovirus and toxic Clostridium difficile can be significant in the same factor but with opposite meaning (length of diarrhea for Noro OR 0.3 and toxic Clostridium difficile OR 4.9) both factors may not be combined to one algorithm for infectious gastroenteritis.
11:20 - 11:30 #11603 - OP110 Socio-economic determinants of general practitioner consultation after emergencies visit.
OP110 Socio-economic determinants of general practitioner consultation after emergencies visit.
Introduction: Recent studies have demonstrated the existence of social inequalities in health and healthcare access worldwide. Having a general practitioner (GP) and a greater continuity of care is associated with decreased emergency department (ED) use at any age of life. Some studies have demonstrated that interventions aiming to enhance follow-up after ED visit are associated with a better healthcare continuity and a reduction of ulterior ED visits. But no data is available concerning quality of continuity of care after an ED visit.
Objectives: To identify the determinants of GP visit after an ED visit.
Method: We included all adult patients that have presented in an ED during a 7 days period. Patients admitted to the hospital were excluded. Collected data included socio-economic and medical characteristics of patients as well as GP visit in the month following ED visit. A mutivariate logistic regression has been used to identify the determinants of GP consultation.
Results: The study included 243 patients among which, 122 (50%) consulted their GP in the month following ED visit. Among all GPs, 75 (31%) were located in an area of less than 2km from the ED. Older age (p=0,001), poor self-reported health status (p=0,001), self-reported functional limitation (p=0,020), good perceived accessibility of GP (p=0,001) and prescription of work stoppage (p=0,029) were associated with an increased frequency of GP visit. In multivariate analysis, only age (aOR=1.03), poor self-reported health status (aOR=2.95) and prescription of work stoppage (aOR=2.95) were associated with increased likelihood of GP consult. Only 57 patients who had consulted their GP brought the medical report from ED visit.
Conclusion: Our study showed that half of patients consulted their GP after an ED visit and about 30% of GPs were located in a 2km area. Primary care use was partly explained by age, poor reported health status and prescription of work stoppage.
11:30 - 11:40 #10964 - OP111 TTUHSC EP Intubation Results from the National Emergency Airway Registry (NEAR).
OP111 TTUHSC EP Intubation Results from the National Emergency Airway Registry (NEAR).
We have joined the National Emergency Airway Registry (NEAR) which is a multicenter registry that has compiled data about intubations conducted at academic teaching institutions since the 1990s. Between 2002 and 2012 the registry recorded 17,583 intubations at 13 facilities. A new data collection cycle began in January 2016 and our institution joined in February 2016.
The goal of this study was to analyze the data for our institution and compare it to the published national registry data for 2002-2012.
Materials & Methods
We analyzed the data in the NEAR registry for our institution for February 2016 to February 2017. Using descriptive statistics we examined the indications for intubation, operators, success rate, and adverse event rates for emergency department intubations at our facility and compared them to published NEAR data.
Over 12 months we reported 380 intubations to NEAR. About 2/3rds of intubations were indicated for medical emergencies with the remaining 1/3 being done in trauma cases. Our overall first pass success rate was 84% which is on par with the published national rate. Resident physicians performed 95% of intubations while attendings performed the remaining 5%. Adverse events occurred in ~11% of intubation patients at our institution and events included vomiting, cardiac dysrhythmias, laryngospasm, hypoxia, and misplacement of the tube. This percentage is also similar to the published national average. Small differences were seen in the induction agents used at our facility compared to national rates: etomidate 83%, ketamine 13%, propofol 3%, midazolam 1% vs 91%, 1%, 3.2 %, 1.4 % respectively. A more significant difference was found in the use of paralytic agents: we used rocuronium in 66% and succinylcholine in 34% of intubations requiring paralytics compared to the national rates of 23% for rocuronium and 75 % for succinylcholine.
Our data so far shows similar rates of first pass intubation success and adverse event rates when compared to the previous cycle NEAR data. The preference of paralytic agents at our institution appears to be the reverse of the national trends. Continued monitoring will help us identify deficiencies in practice and opportunities for improving training and patient care.
1) Brown CA, Bair AE, Pallin DJ, et al. Techniques, success, and adverse events of emergency department adult intubations. Annals of Emergency Medicine. 2015. 65:363-370
11:40 - 11:50 #11906 - OP112 Trauma setting ‘can’t intubate, can’t oxygenate’ emergencies: European Trauma Course Austria instructors' perspective.
OP112 Trauma setting ‘can’t intubate, can’t oxygenate’ emergencies: European Trauma Course Austria instructors' perspective.
Purpose of the study: In trauma setting, difficult airway (DA) emergencies require prompt intervention, and may result in significant morbidity and mortality. Direct airway trauma, accompanied with cervical immobility, and tenuous haemodynamics further complicate decision-making proccess. An unanticipated DA often results in an adverse outcome if the concerned trauma physician is either not abreast with current guidelines or is not familiar with the use of variety of airway adjuncts. The Difficult Airway Society (DAS) guidelines provide framework for the management of the unanticipated DA, ending with the emergency ‘front-of-neck access’ (FONA) algorithm in the ‘can't intubate, can't oxygenate’ (CICO) scenario. In the 2015 DAS guidelines, ‘scalpel-bougie’ (SB) technique has been advocated, because it requires equipment readily available to most clinicians regardless of clinical setting. In addition, other techniques, such as needle cricothyroidotomy (CCT), are proposed, depending on individual experience, training, comfort of use, and case specifics. Recent scientific evidence regarding the technical and human factors superiority of one technique over another remains largely speculative. In our study we aimed to investigate European Trauma Course (ETC) instructors’ management preferences during CICO emergencies. Materials and methods: A total of 44 (69%) instructors, actively teaching on ETC in Austria throughout 2016, completed an online survey. The survey consisted of demographic data, and 13 open questions regarding DA management in CICO scenarios. Results: There were 29 (66%) male instructors, aged from 30 to 71 years (median 42). The majority of instructors were anesthetists (57%), followed by emergency physicians, and trauma surgeons in descending order. Nearly two thirds (73%) of responders were aware of protocolled FONA algorithms for the CICO scenarios, instituted in place of their own operating rooms. However, only half of them would consider these proposed institutional algorithms in real life CICO emergencies. Despite the 2015 DAS FONA algorithm guidelines, promoting SB technique, nearly half of our instructors are still in favor of a CCT technique. Our instructors expressed the strongest agreement with the statement that cannula techniques, when compared to surgical ones, potentially offer advantages from a human factors perspective, if supported by appropriate educational programs. Conclusions: Our results suggest our instructors have a strategy of utilizing well-practiced algorithms at a moment’s notice when faced with a critical trauma patient during the CICO scenarios. However, using a scalpel still remains a rare intervention for most of them. Directing resources towards demystification and better training in the scalpel techniques, may improve our instructors’ willingness of performing SB interventions.
11:50 - 12:00 #11422 - OP113 The correlation and prognostic value of high sTWEAK protein levels and ischemic area volume detected by diffusion weighted imaging in acute ischemic stroke patients.
OP113 The correlation and prognostic value of high sTWEAK protein levels and ischemic area volume detected by diffusion weighted imaging in acute ischemic stroke patients.
Background& Aim: Stroke is a leading cause of mortality and has a subsequent serious long-term disability among survivors. This study evaluated the relationship between sTWEAK (soluble Tumor necrosis factor-like weak inducer of apoptosis) protein levels and the lesion area measured in diffusion-weighted imaging (DWI) in acute ischemic stroke patients.
Patients and Methods: Forty-one patients with acute ischemic stroke and 41 control cases were included in the study. The age, sex, chronic illnesses, emergency department admission times, emergency department examinations, GCS and 7-day prognostic status of the patients were evaluated.
Results: The symptoms of stroke started within the first 3 hours in 32 (78%), between 4-6 hours in 6 (14.7%) and between 7-12 hours in 3 of the patients (7.3%). There was no difference between onset time of complaints, age, regular medication usage, medications, evaluation findings in emergency department, number of findings and GCS (p>0.05). However there were statistically significant differences between the number of findings noted during the emergency evaluation of patients, GCS and the ischemic area volumes measured in magnetic resonance imaging (MRI) (p=0.001, p=0.022, respectively). There was also a statistically significant difference in blood urea nitrogen, creatinine and the volume of ischemic area measured in MRI among the patients who died (19.5%) within the first 7 days and alive group (p=0.011, p=0.029, p=0.004, respectively). A statistically strong negative correlation between the ischemic area volume measured in the DWI and the GCS (r=-0.61), and intermediate positive correlation between BUN (r=0.40) and creatinine (r=0.36) were detected (p<0.05). There was a statistically significant difference in sTWEAK levels between stroke patients and healthy controls included into the study (p<0.001). sTWEAK levels of stroke patients were significantly higher than the healthy controls [AUC:0.86 (0.77-0.94); p<0.001] and the cut-off value was determined as 995.5pg/ml. This cut-off value for sTWEAK had a sensitivity of 80.5% and specificity of 82.5% with a positive predictive value of 82.5% and negative predictive value of 80.5%.
Conclusion: sTWEAK is a valuable marker for the diagnosis of acute stroke but is not significant in predicting early prognosis.
12:00 - 12:10 #11532 - OP114 C - reactive protein as a prognosticator in non ST elevated myocardial infarction.
OP114 C - reactive protein as a prognosticator in non ST elevated myocardial infarction.
The inflammation is well known in the initiation and propagation of acute coronary syndrome. The aim of study was to assess the ability of C - reactive protein (CRP) to predict in hospital morbidity of patients with non ST elevated myocardial infarction (NSTEMI).
It was an observational prospective study conducted in an emergency department (ED) during six months (July-December 2015). We included patients who met criteria of NSTEMI aged more than18 years. The prognosis was evaluated on the occurrence of myocardial infarction (MI) and hospitalization in cardiac intensive care unit (CICU) within 30 days.
We enrolled 89 patients. The mean age was 59 years. Sixty eight were males. Sixty seven percent of patients were smokers, 47% had hypertension, 33% diabetes, 13% dyslipidemia and 25% had coronary disease. A depressed ST segment was found in 11.2% of cases, inversed T wave in 10.1%, and left bundle bloc in 5%. The mean CRP of patients admitted to CICU was significantly higner than CRP of others (not admitted to CICU) with 35.54 ± 33.18 vs 13.36 ± 20.2 (p˂0.000). The mean CRP of patients with MI was significantly higner than CRP of others with 39.55 ± 27.39 vs 16.9 ± 29.38 (p˂0.000).
CRP can be used as an indepedent factor to predict morbidity in patients with NSTEMI in emergency department.
12:10 - 12:20 #11582 - OP115 suPAR improves risk prediction with national early warning score in acute medical patients.
OP115 suPAR improves risk prediction with national early warning score in acute medical patients.
The national early warning score (NEWS) is a combined measure of vital signs and is used for triage in the ED. The NEWS is a strong short-term outcome predictor. However, patients with normal vital signs (low NEWS) may also be at risk of a negative outcome and thus have need for clinical attention. Soluble urokinase plasminogen activator receptor (suPAR) is an inflammatory biomarker that has been shown to be a strong marker of patient prognosis. Here, we aimed to investigate whether suPAR in combination with NEWS can improve risk prediction.
This study includes 17,312 patients admitted to the acute medical department, Copenhagen University Hospital Amager and Hvidovre, between 18 November 2013 and 30 September 2015. Patients were followed for 90 days via national registries. suPAR measurements and data on vital signs, admission NEWS, diagnoses, and vital status were combined for the index admission. Endpoints were in-hospital-, 30-day-, and 90-day mortality. Statistical analysis was carried out with Kruskal-Wallis test, multivariate Poisson regression analysis, and receiver operating characteristics (ROC) curve analysis.
NEWS was available for 16,244 patients (93.8%) and ranged from 0-16. The majority of patients (59.7%) had a NEWS of 0-1. Median suPAR increased with NEWS (P<0.0001), and suPAR and NEWS were weakly positively correlated (Kendall’s tau-b 0.23, P<0.0001).
The frequency of patients who died increased with NEWS score (P<0.0001) for in-hospital-, 30-day-, and 90-day mortality. Furthermore, mortality rates for all endpoints increased with increasing NEWS group compared with patients with NEWS 0-1 in Poisson regression adjusted for age and sex.
The median suPAR level at the index admission was significantly higher in patients who died compared with patients who survived at all three endpoints (P<0.0001). High suPAR was significantly associated with increased mortality rates in all NEWS groups and for all endpoints, except for in-hospital mortality for patients with a NEWS of 6. The mortality rate ratio for a doubling in suPAR was highest for patients with NEWS 0-1.
ROC curve analyses were carried out for predicting in-hospital-, 30-day-, and 90-day mortality. The AUCs for all three endpoints were markedly improved when adding age and sex to the NEWS. The addition of suPAR further improved the prediction (P<0.0001). For in-hospital mortality, the AUC for NEWS alone was improved from 0.87 (95% CI, 0.85-0.88) to 0.92 (95% CI 0.91-0.92) after adding age, sex, and suPAR.
In this study of acute medical patients, we found that NEWS and suPAR were both strongly associated with risk of in-hospital-, 30-day-, and 90-day mortality and suPAR improved the predictive value of the NEWS. The suPAR level increased with increasing NEWS and there was a strong association between suPAR and mortality across NEWS scores; suPAR was a stronger predictor of mortality in patients with low NEWS scores.
12:20 - 12:30 #10903 - OP116 Comparison of point-of-care testing to conventional laboratory process in urban emergency department.
OP116 Comparison of point-of-care testing to conventional laboratory process in urban emergency department.
Background. The laboratory turn-around time for results from central laboratories (CL) can take over 60min compared to 10-15min with point-of-care bedside testing (POCT). However, many studies on POCT, focused on selected tests and limited patient populations, have suggested reduced length of stay (LOS). Many have also reported, where POCT strategy alone has not necessarily improved LOS or had effect on only certain group of patients.
In this study, we hypothesized that POCT would reduce LOS in emergency department (ED) when compared to central laboratory testing and be a factor in patient discharge destination, home or hospital.
Methods. Single centre observational study was performed in random ED patients, excluding ambulatory and fast-track, at Jorvi, Helsinki University Central Hospital, Finland. Blood testing was performed either with POC instruments iSTAT (Abbott) for blood gases and chemistry panel, and PocH-100i (Roche) for full blood count, and Afinion (Alere) for CRP or at central laboratory or combination of both. Blood draw and POCTs were performed by experienced nurses. Time to blood draw, results availability, and disposition of patients either to home or hospital were captured and analysed by Mann-Whitney U test and a p value less than 0.05 considered as statistically significant. Patients with any missing data were eliminated from the analysis. This study was approved by local institutional ethics committee.
Results. During the four-week study period, 2618 patients underwent sample testing (POCT: n=726, central lab: n=1669; both n=726). The average time for blood draw after registration ranged from 1:12±0:56 to 1:30±1:16 hours and it did not depend on the method of laboratory testing. POCT provided results significantly faster than the other two methods of testing (mean±SD for POC 1:02±1:56, CL 2:31±3:18, Combined 3:18±3:36 hours, p<0.0001). The overall ED LOS was also reduced (POC 6:40±3:36, CL 8:05±4:59, Combined 8:13±5:17 hours, p<0.0001). The mean ED LOSs were not statistically significant when the patients were discharged to hospital/care unit (POC 7:33±2:10, CL 8:32±1:07, Combined 8:47±1:05 hours, p=ns), whereas the patients with POCT were discharged home at least 2 hours earlier than those who had testing done by other two methods (POC 5:58±1:18, CL 7:48±1:58, Combined 7:22±1:32 hours, p<0.0001). The percentages of patients discharged were: to home POC 16%, CL 50%, Combined 34% and to hospital: POC 10%, CL 56%, Combined 34%.
Conclusion. POCT shortened laboratory process significantly and made results available significantly faster than the central lab or combined testing, resulting in overall LOS reduction in ED. This also provides options to discharge patients home quicker than to hospital/care unit that may be delayed due to the need for additional diagnosis, or availability of hospital beds. Thus, with proper training and education to the ED care team, POCT can be used as an effective tool for managing patient flow in ED.
12:30 - 12:40 #11036 - OP117 Evaluation of the accuracy of a clinical decision rule to rule out acute coronary syndrome and adequacy of coronary CT requests in emergency department.
OP117 Evaluation of the accuracy of a clinical decision rule to rule out acute coronary syndrome and adequacy of coronary CT requests in emergency department.
BACGROUND: Non-traumatic chest pain is a common presenting complaint among patients seeking care in the Emergency Department (ED). A substantial proportion of patients with chest pain are admitted for inpatient care in order to rule-out acute coronary syndrome (ACS) and only a small proportion had abnormal tests and lead to a change in management. These admissions and investigations in patients without ACS cause a substantial health care burden. At the same time, 2-4% of patients with ACS are erroneously discharged from the ED. The aim of this study is to assess the accuracy of the Diamond Forest clinical decision rule (CDR) to select candidates for coronary CT in patients with non-traumatic chest pain and suspicious of ACS and the adequacy of coronary CT requests in emergency department.
METHODS: We prospectively enrolled adults (age ≥18 years) who presented with chest pain at emergency department of Cruces University Hospital (a tertiary hospital with a cover population of 320,000 people) over 12 months. Physicians completed standardized data collection forms before diagnostic testing. The primary adjudicated outcome was acute myocardial infarction, revascularization, or death of cardiac or unknown cause within 3 months. To include patients in the study we stablish three premises: normal/no diagnosis of ACS in EKG, chest radiograph performed without an alternative diagnosis of ischemic heart disease (IHD) and negative troponin. To stablish the pretest probability (PTP) of IHD the Diamond-Forrest scale (DFS) was calculated according to the characteristics of the pain (typical/atypical/non-anginal), age and sex. If the PTP was from 15-65% a coronary CT was performed. Significant stenosis was considered if the decrease in vessel size in one or more vessels was >50%.
RESULTS: We included 232 patients (mean age 51.7 years, 74.1% male, 12.3% admitted to hospital). 48.1% presented typical angina, 12.3% atypical angina and 39.6% non-anginal pain according to the DFS. We calculate diagnostic accuracy of the Diamond Forest clinical decision rule (CDR) to select candidates for coronary CT, with the following characteristics: sensitivity 87.5% (95% confidence interval [CI] 69.0–95.7%), specificity 51.9% (95%CI 45.2–58.6%), positive predictive value 17.4% (95%CI 11.6–25.1%) and negative predictive value 97.3% (95%CI 92.4–99.1%). 46.1% had PTP <15% for IHD, 3 with significant coronary stenosis (SCE)> 50%. 43.1% had PTP 15-65%, 13 (13%) had SCE > 50%. 8.2% had PTP 66-85%, 31.6% had SCE > 50% and from 6 cases with PTP > 85%, 33.3% had IHD. In 4 cases cardiac catheterization was performed and it was not possible in 2 cases.
DISCUSSION: Coronary CT has been increasing its importance in the management of ACS being a fast, safe and efficient diagnostic tool for patients with low-intermediate risk of ACS in the ED. The DFS is not an adequate CDR to select candidates for coronary CT in patients with non-traumatic chest pain at the ED.
EUSEM 2017 Closing Ceremony