| Sunday 11 October |
| Time |
Auditorium Agnelli |
Room 500 |
Room Londra |
Room Istanbul |
Room Madrid |
Room Parigi |
Room Roma |
Room Atene |
Room Dublino |
Room Lisbona |
| 13:00 |
13:00-14:30
 
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State of the Art
Airway Emergencies
Moderators: Rick BODY (UK), Sabine MERZ (senior consultant) (Villingen-Schwenningen, GERMANY)
13:00 - 13:30 Extreme Airways. Rich LEVITAN (USA)
13:30 - 14:00 Preparing for the challenging airway. Chris NICKSON (South Yarra, AUSTRALIA)
14:00 - 14:30 Decision time: Owning the airway in the ED. Reuben STRAYER (USA)
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Italy invites
Trauma
Moderators: Corrado CASULA (ITALY), Paolo CREMONESI (ITALY)
13:00 - 13:20 I percorsi diagnostico-terapeutici in DEA. Marco BAROZZI (Cesena, ITALY)
13:20 - 13:40 The STOP the bleeding campaign: a che punto siamo? Giuseppe NARDI (Roma, ITALY)
13:40 - 14:00 Il trauma cranico nel paziente in terapia con farmaci anticoagulanti / antipiastrinici. Andrea FABBRI (Chief of Emergency Unit) (Forli, ITALY)
14:00 - 14:20 Il trauma toracico nella prima ora. Elvio DE BLASIO (Salerno, ITALY)
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13:00-14:30
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Clinical Questions: Controversies
Pre-hospital EM
Moderators: Maaret CASTREN (HELSINKI, FINLAND), Stefan TRENKLER (Košice, SLOVAKIA)
13:00 - 13:30 Use of Point of Care in the prehospital EMS MICU ambulances. Eric REVUE (Head of the ED and prehospital EMS) (Paris, FRANCE)
13:30 - 14:00 All about gasping – from pathophysiology to ethics. Jana SEBLOVA (Emergency Physician) (PRAGUE, CZECH REPUBLIC)
14:00 - 14:30 The DNR order in pre-hospital emergency intervention: possible or impossible. Carmen Diana CIMPOESU (Prof univ. Head of ED) (IASI, ROMANIA)
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Administration / Management
Managing Cost Effectiveness
Moderators: Wilhelm BEHRINGER (Director) (Jena, GERMANY), Michael DUERR SPECHT (GERMANY)
13:00 - 13:30 The principle of cost effectiveness. Wilhelm BEHRINGER (Director) (Jena, GERMANY)
13:30 - 14:00 National AED programs, are they worth the money? Patrick Stephen MORAN (IRELAND)
14:00 - 14:30 Can cost control and appropriateness get along in today’s emergency medicine? Roberta PETRINO (Head of department) (Italie, ITALY)
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Research
Pulmonary Emergencies
Moderators: Luis GARCIA-CASTRILLO (Espagne, SPAIN), Said LARIBI (PU-PH, chef de service) (Tours, FRANCE)
13:00 - 13:30 Observational studies in Emergency Medicine. Luis GARCIA-CASTRILLO (Espagne, SPAIN)
13:30 - 14:00 EuroDEM study: results and perspectives. Said LARIBI (PU-PH, chef de service) (Tours, FRANCE)
14:00 - 14:30 Australian study on dyspnea in Emergency Medicine. Anne-Maree KELLY (PHYSICIAN) (ESSENDON, AUSTRALIA)
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YEMD
Sim Session #1
Moderators: Jennifer TRUCHOT (Paris, FRANCE), Youri YORDANOV (Médecin) (Paris, FRANCE)
13:00 - 13:30 From Zero to Sim. Thomas PLAPPERT (Fulda, GERMANY)
13:30 - 14:00 Engaging Resident Education trough Simulation Competitions. Pier Luigi INGRASSIA (Novara, ITALY)
14:00 - 14:30 SESAM @ EuSEM. Rainer GAUPP (SWITZERLAND)
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UK Patient Safety Forum
Making emergency care safe: what is our role?
Moderator: Ruth BROWN (Speaker) (London, UK)
13:00 - 13:30 UK incidents and audience vote on actions. Ruth BROWN (Speaker) (London, UK)
13:00 - 14:00 Second victim. Mary DAWOOD (UK)
14:00 - 14:30 Panel discussion.
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Oral Paper 1
Cardiovascular Emergencies I
Moderators: Al BEHCET (faculty speaker) (Gaziantep, TURKEY), Cristian BOERIU (Assoc.Professor) (Targu Mures, ROMANIA)
13:00 - 14:30 #1002 - #1002 - Cluster analysis of emergency department acute heart failure patients based on their presenting hemodynamic measurements. Implications for therpay.
#1002 - Cluster analysis of emergency department acute heart failure patients based on their presenting hemodynamic measurements. Implications for therpay.
Background: Hemodynamic (HD) phenotyping of patients with acute heart failure (AHF) using cluster analysis may help to define potential targets for specific therapeutic interventions. Blood pressure (BP) and pulse do not accurately identify the underlying HD profiles of acutely ill patients in general. Objectives: To derive distinct clusters of Emergency Department (ED) patients with AHF based on their presenting noninvasive HD measurements and to identify any potential distinguishing clinical characteristics among patients within each cluster. Methods: Presenting, pre-treatment noninvasive HD parameters (n=23) were compiled using the Nexfin device (Bmeye/Edwards LifeSciences) from 127 ED patients with confirmed AHF. Based on these parameters, k-means clustering was performed to identify a set of variables that provided the greatest level of inter-cluster discrimination and intra-cluster cohesion. The parameter k, representing the number of clusters, was identified iteratively by maximizing the ratio of inter (discrimination) and intra cluster error (cohesion), with smaller values of k being preferred. Principal components analysis validates the choice of small k as appropriate for the data. Our final model included 3 groups with clustering based on the following mean parameters: stroke volume index [(SVI), ml/M²], systemic vascular resistance index [(SVRI), dynes/sec/cm/M²] and finger mean arterial pressure [(fMAP), mmHg]. Group comparisons were then performed. Results: Cluster 1 had normal cardiac function and vascular resistance (SVI 38.7 ± 9.7; SVRI 2065.4 ± 305.7; fMAP 66.7 ± 21.2); cluster 2 slightly low cardiac function (SVI 31.0 ± 6.2) with increased vascular tone (SVRI 3109.4 ± 379.3, fMAP 81.0 ± 20.0); and cluster 3 very decreased cardiac function (SVI 22.4 ± 7.5) with markedly elevated vascular resistance (SVRI 4696.8 ± 795.3, fMAP 89.8 ±26.5). All p values for the cluster HD parameters were <0.0001. Presenting diastolic BP differed among the clusters. However the systolic BP and other baseline variables (including age, gender, heart rate, history of coronary artery disease and creatinine, BNP and recent ejection fraction values) were statistically equivalent. Conclusions: Among ED patients with AHF, distinct clusters can be defined based on presenting non-invasively derived HD measures of cardiac function, systemic vascular resistance and finger mean arterial BP. This approach may help identify distinct patient subtypes that would benefit from target-specific treatment, providing granularity that cannot be achieved using more traditional ED variables.
Richard NOWAK (GROSSE POINTE PARK, MICHIGAN, USA), Brian REED, Salvatore DISOMMA, Prabath NANAYAKKARA, Michele MOYER, Scott MILLIS, Robert SHERWIN, Phil LEVY
13:00 - 14:30 #1215 - #1215 - The utility of a modified heart score in chest pain patients with normal troponins in predicting need for further observation and /or provocative cardiac testing.
#1215 - The utility of a modified heart score in chest pain patients with normal troponins in predicting need for further observation and /or provocative cardiac testing.
Background: The TRAPID-AMI study was a multicenter international trial evaluating the high sensitivity cardiac troponin (hs-cTnT) assay in a rapid "rule-out" acute myocardial infarction (AMI) strategy in the Emergency Department (ED). We evaluated a modified HEART Score (MHS) using historical features (clinical suspicion), ECG, age and cardiac risk factors and a normal hs-cTnT to identify a low-risk patient population that might not require further observation and/or provocative cardiac testing. Each of the elements of the MHS is assigned a 0,1 or 2 with the composite score ranging from 0-8. Methods: There were 1,282 patienst studied in the ED for possible AMI from 10 European, 2 USA and 1 Australian Centers from August 2011 through June 2013. Patients were enrolled if the onset of their chest pain (or equivalent) was less than 6 hours from presentation and hs-cTnT (99%, 14 pg/L) was measured at baseline, 1,2 and 6 hours later. All patients were followed for 30 day adverse events (AEs) which included death and MI. Patients were considered low risk if they had hs-cTnT less than or equal to 14 pg/L at baseline and 6 hours and had a MHS less than or equal to 3. Results: There were 17% (217/1282) of patients that suffered an AE at 30 days overall: 8 deaths (0.6%) and 215 AMIs (17%). There were 40% of patients (514/1282) with normal hs-cTnT values and a MHS less than or equal to 3. The AE (all AMIs) rate in the patients with a MHS less than or equal to 3 was 0.2% (1/514) amd those with a MNS 4 or greater 1.8% (5/285) (p = 0.024) .Conclusions: Serial testing of hs-cTnT along with application of a MHS may identify a very low risk ED chest pain population that might be able to be directly discharged from the ED without further observation and/or provocative testing with outpatient follow up within 30 days. Further prospective trials are needed to verify these results.
Richard NOWAK (GROSSE POINTE PARK, MICHIGAN, USA), James MCCORD, Richard BODY, Evangelos GIANNITSIS, Peter DILBA, Michael CHRIST, Bertil LINDAHL, John FRENCH, Tomas JERNBERG, Christopher DEFILIPPI, Robert CHRISTENSON, Franck VERSCHUREN, Gordon JACOBSEN, Garnet BENDIG, Christian MUELLER
13:00 - 14:30 #1364 - #1364 - Development of a simplified risk score to assess the pre-test probability of acute aortic syndrome in the Emergency Department.
#1364 - Development of a simplified risk score to assess the pre-test probability of acute aortic syndrome in the Emergency Department.
Background. The diagnosis of acute aortic syndromes (AAS) is a challenge for Emergency Physicians due to lack of sensitive and specific signs and symptoms. Patient stratification according to pre-test probability of AAS is suggested to standardize both evaluation and diagnostic decisions on aortic imaging. The Aortic Dissection Detection (ADD) risk score, indicated by the 2010 American Heart Association and 2014 European Society of Cardiology guidelines, can be used to evaluate the pre-test probability of AAS according to the presence/absence of 12 risk factors. Accordingly, three risk categories of patients can be defined: low, medium, and high-risk of AAS. However, the ADD risk score is relatively complex and is not easy to routinely implement in the Emergency Department (ED). Aim of this study was to compare the predictive value of several risk factors for AAS and to develop a simplified score allowing more straightforward risk-stratification for AAS in the ED.
Methods. Consecutive patients admitted to the ED with a clinical suspicion of AAS were enrolled in two EDs between 2008 and 2013. Patients were included in a registry if the following criteria were satisfied: (1) presence of chest pain, back pain, abdominal pain, syncope or signs/symptoms of perfusion deficit; (2) unclear diagnosis after initial medical evaluation; (3) order of an urgent aortic imaging exam by the attending physician to identify/exclude AAS. Trauma patients were excluded. The final diagnosis was based on computed tomography angiography results. For each patient, we retrospectively reviewed ED charts to calculate both the ADD risk score and a simplified score. Risk factors for the simplified score were identified based on their potential predictability, calculated using the modified Rho2 Spearman’s rank correlation coefficient. We assessed the discriminatory ability of both scores using the c-index.
Results. 1,328 patients with suspected AAS were enrolled in the registry, and 291 (21.9%) had a final diagnosis of AAS. The ADD risk score was 0 (low-risk) in 439 (33.1%) patients, 1 (intermiediate-risk) in 646 (48.6%) patients and >1 (high-risk) in 243 (18.3%) patients. Based on Rho2 coefficient, we identified 5 highly predictive variables for AAS to be used in the simplified score: severe pain, abrupt onset of pain, pulse deficit, hypotension and focal neurologic deficit. Both the ADD risk score and the simplified score had a high c-index (0.73 and 0.72 respectively). Using the 5-variable model, we also built a nomogram for rapid evaluation of AAS risk in the ED. The agreement between expected and predicted scores for the simplified model was assessed by calibration analysis. The performance of the simplified model was similar to that of the ADD risk score, and the simplified score in particular showed a good predictive capacity amongst non-high risk patients.
Conclusion. This is first attempt to simplify a published scoring system for suspected AAS. Our 5-variable simplified risk score showed a discrimination power similar to the 12-variable ADD risk score. External validation of the simplified score is needed, and a new prospective study is currently recruiting.
Emanuele PIVETTA (Torino, ITALY), Peiman NAZERIAN, Francesca GIACHINO, Simone VANNI, Corrado MOIRAGHI, Matteo CASTELLI, Milena MAULE, Stefano GRIFONI, Enrico LUPIA, Fulvio MORELLO
13:00 - 14:30 #1429 - #1429 - Hypothesis of correlation between hemoconcentration and paroxysms of supraventricular arrhythmias: prospective study in emergency department.
#1429 - Hypothesis of correlation between hemoconcentration and paroxysms of supraventricular arrhythmias: prospective study in emergency department.
Background. During a previous study performed in our emergency department (ED), about comparison between electrical and pharmacological cardioversion of paroxysmal Atrial Fibrillation (AF), higher values of hematocrit were observed in patients with AF. A positive correlation between higher hematocrit and incidences of paroxysmal AF have already been reported in a small number of patients and in some studies of the 90s - early 2000s. It is still to be clarified if hemoconcentration itself is the cause of the arrhythmia, or, alternatively, is caused by Atrial Natriuretic Peptide (ANP) hypersecretion during the paroxysms of AF.
Objectives. The aim of our study was to investigate the possible proarrhythmic role, mostly for the AF, of the hemorheological abnormalities due to increased hematocrit.
Materials and methods. Between December 2014 and March 2015, a control case-control study was carried out on patients presenting to the ED complaining of “palpitations”. For all these patients, we asked all physicians of our ED to fill in a form reporting: medical history, medications, vital signs and ultrasound measurement of dynamic changes of inferior cava vein (IVC) diameter.
The patients with paroxysms of AF or supraventricular tachycardia (SVT) were reviewed after a month, in order to complete the same form, perform the ECG, and collect the same blood samples.
Results. We enrolled 167 patients: 98 patients were analyzed, 59 had sinus rhythm and 39 had supraventricular arrythmia (33 AF and 6 SVT); 69 patients were excluded. Incidence of recent profuse sweating (p=0.085) and polyuria (p=0.083), and assumption of antiarrhythmic agents (p=0.0003) or drugs that induce a decrease of hematocrit (p=0.015) were higher in patients with arrythmia. Mean + standard deviation values of hemoglobin (Hb) [151.20+12.55 vs 141.42+13.23 g/L (p=0.0004)], red blood cells (RBC) [8.29+1.97 vs 7.34+2.40 x10.12/L (p=0.01)] and white blood cell count (WBC) [5.14+0.46 vs 4.88+0.57 x10.9/L (p=0.01)], hematocrit (HCT) [0.465+0.034 vs 0.433+0.039 (p<0.0001)], urea [6.34+2.32 vs 5.22+1.55 mmol/L (p=0.003)], creatinine [88.71+21.53 vs 79.10+5.99 umol/L (p=0.007)], sodium [140.48+1.81 vs 139.72+1.73 mmol/L (p=0.04)], osmolality [292.05+4.48 vs 285.88+5.14 mOsm/Kg (p<0.0001)], Prohormone Brain Natriuretic Peptide (NT-proBNP) [604.56+1143.45 vs 87.45+160.41 ng/L (p<0.0001)] and Erythropoietin (EPO) [13.11+7.36 vs 10.53+5.51 IU/L (p=0.015)], were higher among patients with arrhythmia. No difference was found between the two groups regarding platelets count, MCV, calcium, magnesium, TSH levels, blood pressure values and IVC diameter changes.
After 1 month, patients with arrythmia showed lower values of WBC (p<0.0001), RBC (p<0.0001), Hb (p<0.0001), HCT (p<0.0001) urea (p=0.02), creatinine (p=0.002), osmolality (p<0.0001) and NT-pro BNP (p=0.0009), while EPO slightly decreased (p=0.036) and IVC values did not change.
No difference were found between the lab values of the group with sinus rhythm and with supraventricular arrhythmias after 1 month, except lower values in calcium, potassium, osmolality, TSH and NT-proBNP.
Conclusion. Our study shows that hemoconcentration is common in patients presenting with paroxysms of supraventricular arrhythmias. These patients shows chronically higher EPO and NT-proBNP values. The hemorheological abnormalities in combination with fluid loss, apparently only in part induced by BNP hypersecretion on an atrium already mechanically stressed, can promote the occurrence of arrhythmias.
Sara GREGORI (PADOVA, ITALY), Chiara SANDONA', Roberta VOLPIN, Samuela BARTOLACCI, Monica MION, Francesco BORRELLI, Gianna VETTORE, Martina ZANINOTTO, Franco TOSATO, Mario PLEBANI
13:00 - 14:30 #1525 - #1525 - Patients with NSTEMI treated with non invasive procedures in an emergency department: a review of a case study.
#1525 - Patients with NSTEMI treated with non invasive procedures in an emergency department: a review of a case study.
Introduction
The use of invasive therapeutic treatments is still controversial and under debate for selective elderly patients presenting with UA/NSTEMI. Age and several comorbidities lead to a difficult management of this kind of patients.
Objectives
Elderly patients are often underrepresented in clinical trials. The aim of this study is to analyze the treatment protocol, the mortality risk factors, the one-year mortality rate and the recurrence rate of MI in elderly patients presenting with UA/NSTEMI and treated in our Unit.
Methods
This is a review of case study. From 2013 to 2014, 137 patients have been admitted in the Department of Medicina Interna Area Critica of Policlinico in Modena for the management of acute myocardial infarction. For each patient we analyzed clinical presentation, past medical history (focusing on previous cardiac diseases, renal failure, advance tumour), therapeutic approach and outcomes (one year mortality, recurrence of myocardial infarction). We proceded with a univariated and multivariated analysis of the mortality risk factors and of the one-year overall survival, assessed with Cox regression analysis.
Results
The mean age was 84.2 ± 10.3 y.o. The therapeutic approach was conservative in 117 patients (85%) and invasive (PCI) in 20 patients (15%). The average follow up was 292 days. The overall mortality rate was 43.1% (59 patients). 21 of them (3.6%) died during hospitalization: they were considered “critical patients” since admission.
The population was divided in two groups: patients dead at the time of the analysis and patients still alive. We compared the two groups considering all the data collected. Concerning the survival, the univariated analysis pointed out as prognostic factors: age (p=0.001), urea (p=0.001), creatinine (p=0.003), glycemic decompensation (p=0.029), troponine risen (p=0.048), symptomatic heart failure (p=0.048), conservative approach indication (p=0.020), acute administration of Ace-inhibitors/Sartans (p=0.004), Statins (p=0.004), B-blockers (p=0.012) e Aspirin (p=0.039).
The multivariated analysis showed as independent mortality risk factors: age (Hazard Ratio 1.055, Confidence Interval at 95% 1.014-1.098, p=0.009), troponine risen (HR 1.026, CI95% 1.011-1.043, p=0.001), urea (HR 1.012, CI 95% 1.004-1.020, p=0.004), symptomatic heart failure (HR 1.76, CI 95% 1.01-3.06, p=0.046), glycemic decompensation (HR 1.004, CI 95% 1-1.007, p=0.054), acute administration of Statins (HR 0.43, CI 95%, p=0.015) and Aspirin (HR 0.43, CI 95% 0.22-0.85, p=0.015).
Conclusions
Elderly patients with MI are high mortality risk patients.
One-year mortality is higher in patients conservatively treated, compared to those receiving reperfusion therapies. The mortality is higher in patients presenting with risen troponine, renal failure, heart failure and glycemic decompensation.
In patients not suitable for invasive treatments, acute administration of selected medications (Aspirin, Statin, Ace-inhibitor/Sartan and B-blocker) is the therapeutic approach to reduce mortality risk at one year
Brugioni LUCIO (Modena, ITALY), Gozzi CRISTINA, Vivoli DANIELA, Cameli ANNAMARIA, Rossi ROSARIO
13:00 - 14:30 #1531 - #1531 - Anticoagulation therapy for patients with non valvular atrial fibrillation: evaluation of the oral anticoagulants prescription by emergency physicians.
#1531 - Anticoagulation therapy for patients with non valvular atrial fibrillation: evaluation of the oral anticoagulants prescription by emergency physicians.
Background: Atrial fibrillation (AF) is the most frequently arrhythmia represented in Emergency department (ED). The risk of thromboembolic events is five times higher in patients with AF than those in sinus rhythm. The vitamin K antagonists (VKAs) are currently the most effective therapeutic class for the prevention of these events.
Objectives: To study the epidemiology of non-valvular AF (NVAF) in ED, assess VKAs prescription in eligible patients and to determine criteria associated with an under-prescription of this therapy.
Methods: Prospective, observational, over two years study. Inclusion criteria: age> 18 years, patients with NVAF eligible for anticoagulation. Non-inclusion criteria: AF treated by VKAs, contra-indications to VKAs. Collection of epidemiological and clinical parameters, classification of NVAF, calculation of ischemic risk (CHADS2 [Congestive heart failure (CHF), Hypertension (HTA), Age75 years, Diabetes(D), Stroke (S)] or CHA2DS2-VASc [CHF, HTA, Age75 years, DM, Stroke, Vascular disease, Age 65 -74 years, Sex category] and bleeding risk (HAS-BLED [HTA ,Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly, Drugs/alcohol concomitantly]) scores. Patients divided into two groups: VKAs+ Group: patients received VKAs and VKAs- Group. An analytic study was done in order to know the parameters significantly and independently associated with under prescription of the VKAs.
Results: During study, 176 patients were enrolled. Mean age: 67±13 years. Sex-ratio=0.5. Cardiovascular comorbidities were present in 68% cases. FA classification: paroxysmal n=114, permanent n=47 and persistent n=15. The mean CHADS2 score was 1.5 ± 1.2, the mean CHA2DS2VASc score was 2.88 ± 1.55 and the mean HASBLED score was 1.52 ± 1.05. VKA prescription rate was 36%. In multivariate analysis, age >70 years (OR=1.59, 95%CI[1.11-2,21];p<0.001), creatinine level ≥110 µmol/l(OR=2,54;95%CI[1,20–5,37];p=0,01) and aspirine use (OR =1,7;95%CI[1,08-2,67];p=0,02) were independently associated with non-prescription VKAs. The main causes of VKAs underuse reported by the emergency physicians were: factors related to patient characteristics n=38, factors related to emergency physician n=62, factors related to the patient environment n=20 and factors related to the drug n=22.
Conclusions: The prescription rate of VKAs was 36%. To optimize this rate, the prescription of VKAs must be in a socio-medical perspective taking account the socio-economic conditions of each patient. The goal is to aim for appropriate and rational management to improve the prognosis of this disease.
Hanen GHAZALI, Jihen ESSID (TUNISIE), Houssem AOUNI, Anware YAHMADI , Moez MOUGAIDA, Mahbouba CHKIR, Mohamed MGUIDICH, Sami SOUISSI
13:00 - 14:30 #837 - #837 - CLINICAL AND LABORATORY CHARACTERISTICS OF PATIENTS PRESENTING TO THE EMERGENCY DEPARTMENT WITH HYPERTENSIVE URGENCY.
#837 - CLINICAL AND LABORATORY CHARACTERISTICS OF PATIENTS PRESENTING TO THE EMERGENCY DEPARTMENT WITH HYPERTENSIVE URGENCY.
Background: Clinical and laboratory characteristics of individuals presenting to the emergency department (ED) with hypertensive urgency (HU) are not well characterized.
Methods: In a retrospective chart review study, 150 consecutive patients admitted to a tertiary care center ED with HU (systolic blood pressure values >180 mmHg or diastolic blood pressure values > 110 mmHg without evidence of end organ involvement) were compared with 150 patients with normal blood pressure evaluated in the surgical ward of the same emergency room. Demographic variables, co-morbidities and laboratory values were compared between the two groups.
Results: HU patients were older (66±16.1 years vs. 61.7±19 years, p=0.04), had a greater prevalence of hypertension 90% vs. 64%, p=0.001), were treated with more anti-hypertensive medications (1.9±1.4 vs. 1±1.3, p=0.001) and had a higher prevalence of chronic kidney disease (10.6% vs. 4% p=0.044). Laboratory findings were similar in HU and normotensive individuals.
Conclusions: HU in an ED setting is more prevalent among elderly, hypertensive individuals, particularly among those with chronic kidney disease
Shachaf SHIBER (tel aviv, ISRAEL), Alon GROSSMAN
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Oral Paper 2
Geriatric Emergencies
Moderators: Gautam BODIWALA (UK), Mehmet Akif KARAMERCAN (ANKARA, TURKEY)
13:00 - 14:30 #1161 - #1161 - Treatment of acutely admitted elderly patients in a short stay unit vs. standard care. A randomised trial.
#1161 - Treatment of acutely admitted elderly patients in a short stay unit vs. standard care. A randomised trial.
Background: Short stay units (SSU) in conjunction to emergency departments (ED) are increasingly being implemented to provide accelerated care and shorter hospitalisation. However, it is not well studied, whether short stay hospitalisation is appropriate for elderly medical patients. In an audit, we have found that treatment of elderly patients in our SSU vs. standard treatment in a department of internal medicine (DIM) was associated with lower mortality (7 vs. 22 %, p=0.05), shorter length of stay (2.8 ± 2.0 days vs. 7.7 ± 7.5, p<0.001), fewer adverse events (5 % vs. 19 %, p=0.04), and lower re-admission rate (2 % vs. 23 %, p=0.001)[1]. These findings are promising, but we have now decided to conduct a randomised trial to examine this more rigorously.
Methods: The ELDER trial is a randomised trial with 1:1 allocation between hospitalisation in a SSU (intervention) vs. a DIM (standard care). The study is conducted at Holbaek Hospital, a regional hospital and part of University of Copenhagen. Eligible participants are patients with age ≥ 75 years; in need of in-hospital treatment of an acute internal medical condition; which are stable on admission indicated by green tag triage in the ED. Patients are randomised by computer-generated block sequence with varying block size. Blinding participants or services to the allocation is not possible, but all outcome measures will be blinded for investigators until analyses are complete. The primary outcome is 90-day all cause mortality. Secondary outcomes are: length of stay in-hospital, the incidence of complications during hospitalisation, in-hospital mortality, number of ward transfers during hospitalisation, rate of readmission, change in instrumental activities of daily living, and change of living facility after hospitalisation. We aim at recruiting 430 patients. All outcome measures will be assessed in an intention-to-treat analysis.
Results: Recruitment started in January 5th, 2015. An interim analysis will be performed after inclusion of 215 patients. By April 17th 2015, we have enrolled 78 patients (average inclusion rate: 0.76 participants/day). Therefore, we expect to complete inclusion by July 2016.
Conclusion: In the present study, we explore benefits and harms related to treatment in a short stay unit for elderly medical patients compared to standard hospitalisation.
[1] Strøm C, Rasmussen LS, Rasmussen SR, Schmidt TA. Fast track medical treatment of elderly patients (≥75 years) may be related to lower mortality. Abstract. Eusem 2014.
Camilla STRØM (Copenhagen S, DENMARK), Lars Simon RASMUSSEN, Thomas Andersen SCHMIDT
13:00 - 14:30 #1513 - #1513 - The Identification of seniors at risk (ISAR) score to predict frequent returns in elderly discharged from emergency department.
#1513 - The Identification of seniors at risk (ISAR) score to predict frequent returns in elderly discharged from emergency department.
Introduction: At the emergency department (ED), tools are required to identify older people at high-risk of frequent returns so that appropriate services can be directed towards them. The Identification of Seniors at Risk (ISAR) score is a short self-report questionnaire that can quickly identify older patients in the ED at increased risk of several adverse health outcomes and those with current disability during the 6 months after the ED visit.
Objective: In this study, we investigated whether the ISAR tool can also predict frequent returns to ED in patients aged more than 65 years old.
Methods: Prospective and observational study. Inclusion of all patients aged more than 65 years who were discharged from the ED on the index consultation (IC) from October 1st to October 31st. ISAR score calculation. Follow-up of 3 months. Frequent returns were defined as patients who consulted at any ED more than 2 times during the 90 days after the IC. The cut-off value of the ISAR score was determined by using the receiver-operator curve analysis to compare baseline ISAR to frequent returns at 90 days.
Results: Inclusion of 137 patients. Mean age 76 ± 7 years. Sex-: 0, 92. Co-morbidities: Hypertension 65%, Diabetes 37%, Coronaropathy 21%. Mean ISAR score: 2,66±1, 5. Frequent returns was observed in 29% (n=41) of patients. A score≥ 2 on the ISAR tool predicted frequent returns to the ED (area under the curve (AUC) = 0, 65, p=0, 02; 95% IC [0,46-0,59]). The sensitivity, specificity, PPV and NPV of this cut-off were 84%, 32%, 44% and 86% respectively.
Conclusion: In elderly, frequent returns to the ED are common. The ISAR score, a simple tool, has a good predictive value to determine senior at high-need of care.
Ines CHERMITI, Hanen GHAZALI, Najla EL HENI , Sami SOUISSI, Rania JABRI (Ben Arous, TUNISIA), Mohamed MGUIDICH, Anware YAHMADI , Sami KOOLI
13:00 - 14:30 #1530 - #1530 - Comparison of emergency risk scoring systems in geriatric ED patients: results of a national study-TEDGES.
#1530 - Comparison of emergency risk scoring systems in geriatric ED patients: results of a national study-TEDGES.
Objective: We aimed to evaluate the prognostic value of the Modified Early Warning Score (MEWS), VitalPac Early Warning Score (VIEWS), and Rapid Emergency Medicine Score (REMS) score in predicting hospitalization and in-hospital mortality in geriatric emergency department (ED) patients.
Methods: This prospective, multi-centered observational study was conducted over one week at the EDs of 13 hospitals in patients 65 years old and older presented to ED. The following vital parameters of the patients measured on admission to ED were recorded. The scores were calculated using the recorded physiological parameters of the patients. Hospitalization and in-hospital mortality were used as the primary outcomes.
Results: A total of 1299 patients was included in this study.The mean age of the patients was 74.8±7.3 years and 619 (47.7%) were male. While 877 patients (67.5%) had been discharged from ED and 140 (10.8%) were admitted to intensive care unit. Overall in-hospital mortality rate was 5.8%. The MEWS is effective for discriminating patient groups that have been discharged from ED, admitted to a ward and admitted to ICU (1[1-2] vs. 2[1-3] vs. 2[1-4], respectively, p<0.001). The VIEWS is also effective for discriminating patient groups that have been discharged from ED, admitted to a ward and admitted to ICU (2[1-3] vs. 3[1-5] vs. 6[2-9], respectively, p<0.001). The REMS is also effective for discriminating patient groups that have been discharged from ED, admitted to a ward and admitted to ICU (6[5-8] vs. 7[6-9] vs. 8[7-11], respectively, p<0.001). The median MEWS of the non-survivors were statistically significantly higher than those of the survivors (3[2-5] vs. 1[1-2], p<0.001). The median VIEWS of the non-survivors were statistically significantly higher than those of the survivors (6[4-10] vs. 2[1-4], p<0.001). The median REMS of the non-survivors were statistically significantly higher than those of the survivors (8[6-11] vs. 6[5-8], p<0.001).The AUCs of MEWS, VIEWS, and REMS were 0.656, 0.668, and 0.627 in predicting hospitalization, respectively. The AUCs of MEWS, VIEWS, and REMS were 0.797, 0.802, and 0.711 in predicting in-hospital mortality, respectively.
Conclusions: The MEWS, VIEWS, and REMS are easy-to-use and less time consuming for predicting the hospitalization and in-hospital mortality of geriatric ED patients.
Zerrin Defne DUNDAR, Mehmet ERGIN, Mehmet AYRANCI, Yucel YAVUZ, Ozcan YAVASI, Mustafa SERINKEN, Tarik ACAR, Mucahit AVCIL, Behcet AL, Atif BAYRAMOGLU, Hasan Mansur DURGUN, Yalcin GOLCUK, Ibrahim ARZIMAN, Mehmet Akif KARAMERCAN (ANKARA, TURKEY)
13:00 - 14:30 #1565 - #1565 - Validation of the Identification Seniors at Risk tool (ISAR) in acutely presenting older adults; the APOP study.
#1565 - Validation of the Identification Seniors at Risk tool (ISAR) in acutely presenting older adults; the APOP study.
Introduction: Acute medical illness in older adults is a major contributor to deterioration. Even a minor medical problem can result in a permanent change in daily life. Early identification of high-risk patients could be the first step to decrease adverse health outcomes. The Identification of Seniors At Risk (ISAR) tool has specifically been developed for older Emergency Department patients to predict negative outcomes. However, clinical usefulness is debated because of lack of accuracy and efficiency. In the present study we externally validated the ISAR tool with regard to mortality and functional decline.
Methods: We initiated the prospective Acutely Presenting Older Patient (APOP) study, in which we included all consecutive patients aged 70 and over 24h/7d presenting to the Emergency Department of an university teaching hospital (LUMC) in the Netherlands. The traditionally used ISAR cut-off score of 2 or higher (range 0-6) was used to analyse predictive performance for 90 day mortality and 90 day functional decline, which was defined as a 1 point increase in Katz ADL score and/or new institutionalisation.
Results: 757 patients were included from September 2014 until November 2014 with a mean age of 78.7 years. During the ninety day follow-up 72 patients (9.5%) deceased and 163 patients (21.5%) declined in functional status. A ISAR score of 2 or higher had a hazard ratio of 3.38 (95% CI 1.82-6.29) on mortality and an odds ratio of 4.18 (2.83-6.18) on functional decline. Predictive performance on mortality showed a sensitivity of 0.83, a specificity of 0.41, a positive predicting value (PPV) of 0.13, a negative predicting value (NPV) of 0.96 and an area under receiver operating curve (AUROC) of 0.67 (95% CI 0.61-0.73) and on functional decline a sensitivity of 0.79, a specificity of 0.48, a PPV of 0.35 , NPV of 0.87 and an AUROC of 0.68 (95% CI 0.63-0.72).
Conclusion: In our study, the ISAR was able to stratify patients at risk for adverse outcomes with moderate accuracy. Positive predictive value was low, whereas negative predictive value was high, suggesting that ISAR more accurately identifies patients NOT at risk for negative outcomes.
J. DE GELDER (LEIDEN, THE NETHERLANDS), J.a. LUCKE, B. DE GROOT, C. HERINGHAUS, A.j. FOGTELOO, G.j. BLAUW, S.p. MOOIJAART
13:00 - 14:30 #1595 - #1595 - Independent predictors of hospital admission in emergency department patients younger and older than 70 years of age.
#1595 - Independent predictors of hospital admission in emergency department patients younger and older than 70 years of age.
Background: Independent predictors of hospital admission have been investigated in patients on the Emergency Department, but it hasn’t been researched whether these predictors are different for patients above and below 70 years old. Therefore, the aim of the present study was to compare readily available patient characteristics between patients younger and older than 70 years and to investigate if independent predictors of hospital admission are different in ED patients younger and older than 70 years of age.
Material and methods: In this retrospective cohort study all ED visits in a tertiary hospital in 2012 were stratified in ED patients younger and older than 70 years of age. Readily available patient characteristics at ED presentation including way of arrival, presenting complaint and urgency of the complaint were analysed. Multivariable logistic regression was used to identify independent predictors of hospital admission. Discriminative performance of the models was quantified by receiver operator characteristics with area under the curve (AUC) analysis. Goodness of fit was tested with the Hosmer and Lemeshow test.
Results: 4255 patients older than 70 years and 17319 patients younger than 70 years of age were included. 45 % of the older patients were hospitalized as opposed to 25% of the younger patients. In the patients younger and older than 70 years of age exactly the same independent predictors were found, most of them reflecting illness severity. Only gender was not an independent predictor in the model of patients above 70 years. However the fit of the model was different in both groups. The prediction model for hospitalisation had had a higher discriminative performance in the young patients with an AUC of 0.85 (0.84-0.85), whereas the AUC of the prediction model in old patients had an AUC of 0.76 (0.75-0.78) with both models having good predicting capabilities.
Conclusion: Independent predictors of hospital admission are similar in patients younger and older than 70 years of age. However the discriminative performance of the prediction model for hospitalisation was higher in the younger patients, indicating that besides patient characteristics reflecting illness severity, other factors, such as cognitive and functional status, multimorbidity and polypharmacy, may play role in prediction of hospitalisation in older patients. In future studies these factors should be investigated.
Jacinta LUCKE (LEIDEN, THE NETHERLANDS), Jelle DE GELDER, Fleur CLARIJS, Bas DE GROOT, Christian HERINGHAUS, Jaap FOGTELOO, Gerard-Jan BLAUW, Simon MOOIJAART
13:00 - 14:30 #1624 - #1624 - Early recognition of cognitive impairment in the ED.
#1624 - Early recognition of cognitive impairment in the ED.
Introduction:
Cognitive Impairment (CI) is present in up to 40% of older adults who use the services of the Emergency Department (ED), with acute delirium comprising a significant proportion of the spectrum of CI seen in the ED. Despite reports that acute delirium confers the same mortality rates as acute coronary syndromes, is still missed in up to 80% of cases by emergency physicians. Two main reasons for this have been hypothesized; a lack of adequate training for Emergency physicians and of validated screening tools which can be completed quickly and with minimal training in the ED. Failing to diagnose delirium delays diagnosis and timely management of underlying, potentially life-threatening conditions. In previous audit at our trust, we found that only 54% of adults over 75 had cognitive screening and we sought a means to improve rate of screening across and to introduce a more simple screening tool to our department.
Methods:
We performed a prospective, point prevalence study of cognitive impairment in the ED of a London major trauma center. All patients over the age of 16 were eligible for inclusion over a 24 period in the department. Screening was completed by all present emergency nurses, trainees and consultants, supported by allocated dementia nurses, using the 4AT screening tool. If an AMT10 had already been completed, this was accepted instead of the 4AT. We included all patients including those with a history of severe dementia or substance abuse. Patients either too ill to be interrogated or unable to speak a language for which we had a reliable interpreter were excluded.
Results:
Of the 147 patients who visited our ED during the 24 hour study period who were eligible for inclusion 62(43%) had a cognitive assessment. The male/female ratio was 65/82 and the average age was 56.6 years. Out of the 51 patients who were assessed with the 4AT, 7 (14%) had cognitive impairment (cutoff ≥1). Of the 11 patients who had a AMT10 done 9(81.8%) had CI (cutoff <8). Overall we found that 16/147 (10.8%) patients who visited our department during the audit had signs of cognitive impairment in the first screening while only 6/147 (4%) had known previous dementia.
Conclusion:
Although adding Cognitive screening to usual clinical assessment in the ED may be seen as an additional burden to the assessment process in the ED, we found it to be a ‘high yield’ step with 10% of all those screened found to have impairment. Our main purpose in conducting this study was to raise awareness about the prevalence of CI within our ED and encourage screening prior to our next audit cycle.
Acute cognitive impairment is a medical emergency and should have protocolled risk stratification and management, as is the case with other diseases with similar mortality rates, such as acute coronary syndrome and sepsis.
Serena ROVIDA (London, UK), Sarah DARCIS, Jonathan RITSON, Hannah DUNLOP, Rosa MCNAMARA
13:00 - 14:30 #1738 - #1738 - Population ageing in Verona district and its impacts on the Emergency and Hospital activities.
#1738 - Population ageing in Verona district and its impacts on the Emergency and Hospital activities.
Objective and Methods: We report presentation and outcome patterns of aged patients treated at the Accident and Emergency Department (AED) of Verona (Italy) during the period Jan 2002 - Dec 2014. Data are discussed in the framework of population demographics in the District of Verona and NHS acute hospital bed stocks trends. RESULTS: In the study period total of AED presentations decreased from 82,797 (2002) to 69,568 (2014) patients/year but aged patients admissions increased from 20,274 to 24,368. When dividing the patients in different groups of age the increase is more evident in the elder group: +74.1% with a mean yearly increase of 4.83% in the >85 years old population and +27.33% (2.08% of mean yearly increase) in the 76-85 years old group. Over two thirds of patients self-presented to AED without medical consultation (66-75 years old: 82.9% (Q1: 82%; Q2: 84%; IQ range: 2%); 76-85 years old: 79.4% (Q1: 78%; Q2: 82%; IQ range: 4%); >85 years old; 74.9% (Q1: 72%; Q2: 77%; IQ range: 5%). According to our triage criteria, we observed an increase of patients tagged at higher disease acuity: 66-75 years old: from 21.7% to 31.6%; 76-85 years old: from 27.1% to 32.3%; >85 years old: from 36% to 48.4%). Ward admissions dramatically increased in the eldest group (>85 years old: +48.57%) with a slight decrease in the 66-75 years old (-7.72%) and in the 76-85 years old (-2.99%) groups. Verona District demographics in the study period showed an increase of general population (from 827,328 to 921,717 inhabitants) and aged people in terms of figures (66-75 years old: +17.58% (mean year increase: 1.37%); 76-85 years old: +34.69% (mean year increase: 2.54); >85 years old: +49.03% (mean year increase: 3.48%) and of indexes (ageing index: +5.54%; old aged dependency ratio: +18.74%). Despite those figures mean bed stock availability in our hospital decreased from 899 in 2006 to765 in 2014 (medical department: -27.2%; surgery: -20.5%). On the other hand the ratio urgent/planned admissions increased from 0.5 to 1.52 (medical department: +327%; surgery:+176%). DISCUSSION: Accident and Emergency departments overcrowding have been widely reported. One of the causes of patients' long staying in the emergency departments seems to be related to a lack of available beds in the hospital wards. In this study we report the impact of Verona District population ageing on AED activity during the last years. There has been an increase of aged AED and ward admissions. On the other hand Healthcare policy imposes reduction of bed stocks in NHS acute hospitals. First consequence is the heavy impact on planned hospital admissions to be delayed. Therefore an accurate gate control in terms of better targeted admissions is required to the emergency physician in order to avoid the risk of AED but also hospital paralysis.
Massimo ZANNONI (VERONA, ITALY), Lucia ANTOLINI, Laura CRESTANI, Giulia BISOFFI, Giorgio RICCI
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State of the Art
Cardiovascular Emergencies
Moderators: Rick BODY (UK), Louise CULLEN (Brisbane, AUSTRALIA)
15:00 - 15:30 The burden of chest pain assessment: Is it time for change? Louise CULLEN (Brisbane, AUSTRALIA)
15:30 - 16:00 Six years of the HEART score. Barbra BACKUS (dordrecht, THE NETHERLANDS)
16:00 - 16:30 Coronary CTA: Who, What and When? Judd HOLLANDER (USA)
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Malattie infettive e BPCO
Moderators: Giorgio CARBONE (ITALY), Paolo GROFF (ITALY)
15:00 - 15:25 Vecchi batteri e nuove resistenze. La terapia empirica più appropriata. Silvio BORRE (Vercelli, ITALY)
15:25 - 15:50 Tubercolosi e micobatteri atipici. Guido CALLERI (TORINO, ITALY)
15:50 - 16:15 BPCO: nuovi farmaci, vecchi pazienti? Rodolfo FERRARI (Bologna, ITALY)
16:15 - 16:30 Polmoniti: guida ragionata alla diagnosi e terapia in PS. Giovanni PINELLI (Modena, ITALY)
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Clinical Questions: Controversies
Hot Controversies in EM
Moderators: Janos BAOMBE (manchester, UK), Mehmet Akif KARAMERCAN (ANKARA, TURKEY)
15:00 - 16:30 Unstable pelvic trauma: contemporary management. Marco BAROZZI (Cesena, ITALY)
15:30 - 16:00 How To Use Ketamine Fearlessly, For All Its Indications. Reuben STRAYER (USA)
16:00 - 16:30 High flow oxygen in hypoxemic lung failure. To difficult to apply in the Emergency Department? Abdo KHOURY (PH) (Besançon, FRANCE)
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Clinical Questions: Controversies
Thrombosis
Moderators: Luis GARCIA-CASTRILLO (Espagne, SPAIN), Anne-Maree KELLY (PHYSICIAN) (ESSENDON, AUSTRALIA)
15:00 - 15:30 Should patients with superficial vein thrombosis receive anticoagulation? Giuseppe CAMPORESE (ITALY)
15:30 - 16:00 Is warfarin an outdated treatment? Jecko THACHIL (UK)
16:00 - 16:30 Should we give thrombolysis to patients with submassive pulmonary embolism? Franck VERSCHUREN (Bruxelles, BELGIUM)
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Research
Pre-hospital EM
Moderators: Patrick PLAISANCE (Paris, FRANCE), Gregor PROSEN (MARIBOR, SLOVENIA)
15:00 - 15:30 Rescuer fatigue and energy expenditure during basic life support. Roman SKULEC (KLADNO, CZECH REPUBLIC)
15:30 - 16:00 Helium in acute asthma patients. Patrick PLAISANCE (Paris, FRANCE)
16:00 - 16:30 Cerebral saturation pre-hospital during cardiac arrest. Cathy DE DEYNE (BELGIUM)
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YEMD
Joining the FOAM-party
Moderators: Riccardo LETO (Chief of ED) (Overpelt, BELGIUM), Chris NICKSON (South Yarra, AUSTRALIA)
15:00 - 15:30 Social Media For Today's Learners: Medical Education on Steroids. Rob ROGERS (USA)
15:30 - 16:00 Social Media changed my life! Natalie MAY (Oxford, UK)
16:00 - 16:30 Data science for health: social media analytics, surveillance and interventions. Ciro CATTUTO (ITALY)
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UK Patient Safety Forum
Making emergency care safe: what is our role?
Moderator: Ruth BROWN (Speaker) (London, UK)
15:00 - 15:30 Crowding and exit block. Sally-Anne WILSON (LEEDS, UK)
15:30 - 16:00 Designing departments for safety. Susan ROBINSON (Doctor) (Cambridge, UK)
16:00 - 16:30 Panel discussion.
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Oral Paper 1
Paediatric Emergencies I
Moderators: Nikolas SBYRAKIS (GREECE), Itay SHAVIT (ISRAEL)
15:00 - 16:30 #1005 - #1005 - Development of a risk map in a pediatric emergency department of a teaching hospital.
#1005 - Development of a risk map in a pediatric emergency department of a teaching hospital.
BACKGROUND
Patient safety is an topic of particular concern in pediatrics. Developing a risk map in a Pediatric Emergency Department (PED) using proactive strategies (PS) and reactive strategies (RS) can help to identify risks and promote an improvement of health quality. However, to the best of our knowledge, no risk map has been developed in the Emergency setting combining these two strategies.
OBJECTIVE
To develop a risk map in a PED of a tertiary teaching hospital combining PS and RS.
METHODS
PS: After several meetings, a document identifying several risks was written and reviewed by external consultants.
RS: the incidents reported by professionals and caregivers of the children admitted in the PED from Nov´04-Dec´13 were analyzed.
Results obtained from both strategies were classified using the International Classification for Patient Safety from the World Health Organization and the degree of the risks was classified according to the official classification system of the Spanish Ministry of Health.
Finally, the map was created combining both strategies.
RESULTS
PS: 49 failures, 60 effects and 252 causes were identified. Most common failures were related with the discharge of the patient (mainly identification of the patient and delay of the process). Most common effects were related with complaints of the caregivers, prolonged length of stay in the PED, delay in diagnosis/treatment and unnecessary treatment. Most frequent causes were due to: not including the family in the process, shift change, incorrect identification of the patient and computer error.
RS: 1795 incidents were notified by nurses (33%), caregivers (25%), PED pediatricians (14%), director of the ED (13%), quality manager (9%) and others (6%). Most of them were related with medical equipment (38%), resources/organization of staff (17%), clinical process (15%), facilities (12%) and medication errors (5%).
PS identified risks in several phases of the clinical process: complementary tests, treatment and discharge. RS added risks about prehospitalary transportation, triage, medical care, complementary tests, treatment and discharge.
CONCLUSSION
The combination of PS and RS improves the quality of the risk map in a PED. The involvement of different professionals and caregivers enables the risk map to accurately reflect the real situation of the PED.
Elisa MOJICA, Estibaliz IZARZUGAZA, Maria GONZALEZ, Eider ASTOBIZA, Javier BENITO, Santiago MINTEGI (Barakaldo, SPAIN)
15:00 - 16:30 #1189 - #1189 - Non-inferiority monocentric retrospective observational study about the efficacy of paracetamol in different pharmaceutical forms in reducing pain in children belonging to the Regina Margherita Children's Hospital Emergency Department.
#1189 - Non-inferiority monocentric retrospective observational study about the efficacy of paracetamol in different pharmaceutical forms in reducing pain in children belonging to the Regina Margherita Children's Hospital Emergency Department.
Background: Pain is a physical and psychological negative experience, often linked to suffering. It is therefore important to alleviate it as soon as possible using the most appropriate and pleasant medication for the patient.
Objective: To test the non-inferiority in terms of efficacy of buccal paracetamolvs syrup or tablet paracetamol in reducing pain in pediatric patients referred to the Emergency Department for headache, earache, nonspecific abdominal pain (NSAP).
Materials and Methods: we conducted a non-inferiority monocentric retrospective observational studyon children between 3 and 14 years, in which pain was assessed by Wong-Baker scale at entrance and 60 minutes after administration of analgesic therapy in triage. The data were collected using special data collection and processed by statistical analysis.
Results: We analyzed 200 patients (70 buccal vs 130 tablet or syrup), with mean entrance pain level of 4.77/10. Buccal paracetamol was found to be more effective to reduce pain (mean reduction: 2.37/10) vs tablet or syrup paracetamol(mean reduction: 1.95/10) (p<0.05), in particular for earache (2.32/10 vs 1.90/10, p<0.05) and NSAP (2.43/10 vs 1.93/10, p<0.05). In addition, there were statistically significant differences (p<0.05) depending on the intensity of pain, age, gender and nationality.
Conclusions: Buccal paracetamol was found to be more effective in reducing pain in certain conditions. It is therefore a specific pediatric nurse task to take into account the peculiarities of each patient in administration of paracetamol. Further similar studies are desirable on other painkillers.
Marta Lucia Celestina GOGLIO (Rivarolo Canavese (TO), ITALY), Pierpaolo CHIALVO, Liliana VAGLIANO, Emanuele CASTAGNO, Fulvio RICCERI, Fulvio RICCERI, Antonio Francesco URBINO
15:00 - 16:30 #1355 - #1355 - Feverkidstool to reduce prescription of antibiotics in children suspected of community-acquired-pneumonia.
#1355 - Feverkidstool to reduce prescription of antibiotics in children suspected of community-acquired-pneumonia.
Background
Community acquired Pneumonia (CAP) is the most frequent serious infection among children with fever. The rate of antibiotic prescribing amongst children suspected of CAP is high, contributing to antibiotic resistance in the community. Diagnostic tools for guiding antibiotic prescribing in children with fever are needed.
Aim: To evaluate the diagnostic value of the Feverkidstool, a validated decision rule using clinical features and CRP, to safely identify children suspected of CAP who do not need antibiotics.
Methods
Patients: previously healthy children aged 1 – 60 months, with fever and cough at risk of CAP, visiting the emergency department of ErasmusMC in 2013.
Outcome: children suspected of CAP recovering without antibiotics.
Prospective observational study with standardised data collection. Risk of CAP was calculated using the Feverkidstool, a validated prediction model for febrile children (www.erasmusmc.nl/feverkidstool).
Results:
In a population of 248 children (median age 14 mo (IQR 7-27), 51 children received antibiotic treatment (21%), of whom 53% received amoxicillin; 55 (22%) were hospitalized. For both the frequency of antibiotic prescription and the predicted risk for CAP by the Feverkidstool, we observed a high association with the doctors decision to perform chest radiographs, but not for the result of the chest radiograph. The risk for CAP predicted by the Feverkidstool was significantly associated with increased antibiotic prescription, even after correcting for age, gender and performing a chest radiograph. The discriminative value of the Feverkidstool was 0.67 (0.60-0.74) to identify children suspected of CAP not needing antibiotics. In a population with low antibiotic prescription rate, the Feverkidstool cutoff of 10% had specificity of 73% to correct identify children suspected of CAP not needing antibiotics; specificity increased to 89% using a 20% cutoff. In children with predicted risks below these thresholds, a follow-up strategy to detect deterioration and to start delayed antibiotic treatment if necessary, was safe.
Conclusion:
The Feverkidstool safely identifies children suspected of CAP who do not need antibiotics. This adds to reducing unnecessary antibiotic prescription in febrile children.
Michelle HORSTEN, Ruud NIJMAN, Yvonne VERGOUWE, Rianne OOSTENBRINK (rotterdam, THE NETHERLANDS)
15:00 - 16:30 #1500 - #1500 - Management of febrile young infants with altered urine dipstick. A Spanish Pediatric Emergency Research Network’s (RISeuP-SPERG) substudy.
#1500 - Management of febrile young infants with altered urine dipstick. A Spanish Pediatric Emergency Research Network’s (RISeuP-SPERG) substudy.
Background
Urinary tract infection (UTI) is the most common serious bacterial infection (SBI) in febrile infants. A primary diagnosis can be made in the emergency department if an altered urine dipstick test is obtained. Spanish guidelines recommend inpatient treatment in patients less than 90 days old with UTI suspected.
Objective
To describe the management of febrile young infants with in a urine disptick and analyze factors associated with an outpatient management.
Patients and methods
Subanalysis of a prospective multicentric study developed in 19 Spanish Pediatric Emergency Departments (PED) included in the Spanish Pediatric Emergency Research Network (RISEUP-SPERG), including febrile infants less or equal than 90 days old with fever without source (FWS) attended at the PED between October-2011 and September-2013.
An urine dipstick was considered altered whien either a leukocyte esterase test or nitrite test were positive.
Results
A total of 3,401 infants were included. Of them, 765 (22.5%) had an altered urine dipstick and 72 (9.4%) were managed as outpatient, 30 after an observation period shorter than 24 hours. After a multivariate analysis, variables that remained as independent factors for an outpatient management were: being well-appearing, being older than 60 days old and presenting a C-reactive protein (CRP) less than 20 mg/L and a procalcitonin (PCT) less than 0.5 ng/mL.
Among the 72 patients managed as outpatients, 51 received antibiotic treatment (70.8%; via oral in 27 and parenteral in 24). Overall, urine culture grew >50,000 cfu/ml in 36 (50%) of them, and 10000-50000 cfu/ml in other 3 (4.2%). None of them was admitted after receiving the results of the urine culture. Two patients had bacteremia, both of them received one dose of parenteral antibiotic in the emergency department prior to discharge. Both patients were afebrile when blood culture result was received.
Conclusions
A significant proportion of febrile young infants with a suspected UTI are managed as outpatients. Well appearing patients older than 60 days old with normal CRP and PCT values are more frequently managed as outpatients.
Roberto VELASCO (Laguna de Duero, SPAIN), Helvia BENITO, Rebeca MOZUN, Borja GOMEZ, Mercedes DE LA TORRE, Santiago MINTEGI, Of The Riseup-Sperg Network GROUP FOR THE STUDY OF THE FEBRILE INFANT
15:00 - 16:30 #1806 - #1806 - Presentation and investigation of paediatric bone and joint infections in the paediatric emergency department.
#1806 - Presentation and investigation of paediatric bone and joint infections in the paediatric emergency department.
Bone and joint infections present a major diagnostic challenge in the paediatric emergency department (PED). The presenting features of osteomyelitis and septic arthritis in children can vary greatly and can be difficult to distinguish from other conditions.
Method
We performed a retrospective review of the medical notes and electronic patient records of children diagnosed with osteoarticular infections over a 12-year period at a Paediatric Emergency Department (PED) serving a diverse urban population. We compared the presenting features and investigations to the literature and current trends in practice.
Results
A total of 88 cases of osteomyelitis and/or septic arthritis presented to the PED and were managed at the same hospital during the study period. Fever, pain, impaired function and localised changes were commonly reported at presentation but overall there was inconsistency in the incidence of these features among patients with osteoarticular infections.
Inflammatory makers were sensitive tools in identifying bone and joint infections, particularly when used in combination. When CRP, total white cell count and ESR were all abnormal, 98% of bone and joint infections were identified.
A positive microbiological diagnosis was only obtained in 38% of cases, the largest proportion being from cultures of synovial fluid and bone tissue. Streptococcal organisms were significantly more likely to be isolated in children under 5 years than in children over 5 years (p = <0.001). Conversely staphylococcal organisms were significantly more likely to be isolated in children over 5 years than in children under 5 years (p = <0.001).
It is of concern that virulent organisms such as PVL staphylococcus aureus and MRSA were identified in some of our cases. This should prompt review of antibiotic choices and broaden diagnostic techniques.
Overall, children under 5 years of age were significantly more likely to be diagnosed with septic arthritis than osteomyelitis (p = 0.006). Children over 12 years of age were significantly more likely to be diagnosed with osteomyelitis than septic arthritis (p = 0.019).
Conclusion
Our experience highlights the difficulty of differentiating osteoarticular infections from other conditions using clinical features alone. Diagnosis of bone and joint infections requires a combination of clinical suspicion and investigations. However, the differences we identified between the incidence of osteomyelitis and septic arthritis and the variation of causative organisms across age groups may be useful to consider at presentation and in cases of diagnostic uncertainty.
Olugbenga AKINKUGBE (London, UK), Charles STEWART, Caoimhe MCKENNA
15:00 - 16:30 #1963 - #1963 - Are healthcare professionals comfortable with parental presence during paediatric resuscitation?
#1963 - Are healthcare professionals comfortable with parental presence during paediatric resuscitation?
Introduction
The practice of family centred care within paediatric hospitals has continuously evolved over the past number of decades, with parents now considered essential participants in their child’s care. Parents are now routinely present during situations where they previously would have been asked to leave e.g. intravenous cannulation, lumbar puncture and cardiopulmonary resuscitation (CPR). However controversy remains around the presence of parents in the paediatric resuscitation room. There is a paucity of evidence to support the practice, few policies/guidelines and few established programmes which provide specific training.
Outcome Measures
The primary outcome measure was to identify healthcare professionals’ attitudes towards parental presence in the resuscitation room during paediatric resuscitation. Secondary outcome measures included:
1. Identification of barriers towards parental presence during paediatric resuscitation
2. Identification of methods to facilitate parental presence
3. Identification of methods of training suitable for clinicians involved
Methods
An anonymous questionnaire was created and distributed among healthcare professionals involved in paediatric resuscitation. The purpose of the audit was to gain perspective into the thoughts of the healthcare professionals involved in paediatric CPR and discover their views on what the best methods of training in dealing with parental presence are.
Results
There were 36 respondents to the questionnaire: 24 doctors and 12 nurses. Of the doctors, 12 were emergency physicians, 10 were paediatricians and 2 were anaesthetists. The majority of respondents (n=22, 61%) stated they were happy for parents to remain during a procedure/resuscitation. The majority of respondents (n=26, 72%) felt that parents/family members should be present in the resuscitation room during the resuscitation process. However they did not feel that they had adequate training in how to deal with family members during paediatric resuscitation (n=32, 89%). The majority of participants did not agree that their training had prepared them for any difficulties that could arise with having parents/family members present in the room during a resuscitation (n=29, 81%). Respondents were asked if their APLS or NRP training had dealt with the situation where relatives are present in the room during paediatric resuscitation. Of the 27 participants who were eligible to answer this question, the majority did not agree (n=19, 70%). All of the respondents said that they would welcome additional training in running a resuscitation with relatives present.
When asked to rank types of training a lecture followed by simulation of distressed relatives was the most popular method with 22 (61%) participants ranking it highest. The second most popular was training with simulation alone (n=14, 39%). No other method of training was given a highest ranking. The least popular method of training was a booklet with 26 respondents (72%) ranking it lowest. It was followed by computer/e-learning with 6 participants (17%) ranking it lowest.
Conclusions
Parental presence during paediatric resuscitation is increasing and guidelines should be developed to facilitate it. This small audit demonstrates that clinicians welcome relatives being present, but would welcome education in on how to facilitate parental presence during paediatric resuscitation. Simulated scenarios together wih formal instruction would be the preferred ecucation methods.
Nuala QUINN, Eimhear QUINN, Gavin STONE (Cork, IRELAND), Paula MIDGLEY, Tom BEATTIE
15:00 - 16:30 #982 - #982 - PILOT CLINICAL TRIAL OF THE USE OF OXYGEN AT HIGH FLOW IN CHILDREN WITH ASTHMA IN THE PEDIATRIC EMERGENCY DEPARTMENT.
#982 - PILOT CLINICAL TRIAL OF THE USE OF OXYGEN AT HIGH FLOW IN CHILDREN WITH ASTHMA IN THE PEDIATRIC EMERGENCY DEPARTMENT.
Background:
High-flow oxygen (HFO) therapy has been shown to be efficacious and safe treatment in pediatric populations with acute respiratory processes. There are, however a lack of studies about its application in the ED.
Objective:
The aim of our study is to assess the feasibility of HFO treatment and assess its efficacy and safety given to children with asthma and moderate respiratory failure attended in the emergency department (ED).
Patients and method:
This was a prospective randomized trial of children (1 – 16 years) who presented to the ED with acute asthma. Patients with a Pulmonary Score (PS) ³ 6 or oxygen saturation < 90% with FiO2 40, despite initial treatment with nebulized salbutamol every 20 minutes during the first hour (at least 3 doses) were randomly assigned to one of two treatment groups. The experimental group received HFO therapy and the control group conventional oxygen therapy. Along with oxygen therapy the pharmacological treatment of acute asthma was left to the discretion of the attending physician.
The PS, oxygen saturation, respiratory rate and heart rate were recorded at 30 minutes, 1 hour 2 hours and then every 2 hours after initiation of therapy.
At the end of the study a satisfaction questionnaire was distributed among the PED staff.
Results: Duringa period of 24 months (Oct 2012 – Oct 2014), 52 patients met the inclusion criteria and 36 patients were studied (18 in each study group). Characteristics of patients at baseline did not showed differences except in the mean PS that was higher in HFO group (6.5 (1.29) in the HFO group vs. 6.05 (0.23) in control group; p<0.001). At two hours after initiation of therapy Pulmonary Score decreased more than 2 points in 11 patients (61.1%) in HFO group vs. 5 (27.8%) in control group (mean PS scores 4.77 (1.16) and 5.05 (1.05) respectively); p<0.05). No differences were found in oxygen saturation mean values at this time, 95.77 (1.76) and 97.81 (2.04) respectively. Eleven patients (51.1%) in HFO group were finally admitted in ward versus 7 (38.9%) in control group. The satisfaction questionnaire was answered by 42 professionals and 36 (85%) considered HFO treatment as a positive experience. No adverse effects were reported.
Conclusions: HFO treatment is feasible and safe when given in the ED. HFO improves the overall respiratory status of children with acute asthma and moderate respiratory failure. Further studies are needed to prove its overall effectiveness in the management of patients with asthma and respiratory failure in the emergency department.
Yolanda BALLESTERO, Jimena DE PEDRO, Otilia MARTINEZ-MUJICA, Elisa MOJICA, Eunate ARANA, Javier BENITO (Getxo - Vizcaya, SPAIN)
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Oral Paper 2
Disasters and Psychosocial emergencies
Moderators: Anna SPITERI (Consultant) (Malta, MALTA), Robert WUNDERLICH (Scientific Assistant) (Tübingen, GERMANY)
15:00 - 16:30 #1018 - #1018 - Demographic Characteristics of the Patients Suffering from Mushroom Poisoning in Bolu.
#1018 - Demographic Characteristics of the Patients Suffering from Mushroom Poisoning in Bolu.
OBJECTIVE: City of Bolu has a lot of greenery places and it gets frequent rains. This frequent rains give rise to an increase in the diversity of mushrooms in a year. It can not be neglegted that this diversity is essential commercially. In this study, we aimed to evaluate the demographic characteristics of poisoning cases due to highly preferred mushrooms.
MATERIALS-METHODS: We evaluated the patients who had admitted to Bolu Abant Izzet Baysal University Izzet Baysal Research and Education Hospital Emergency Department in the time period of 01/01/2007-31/12/2014. Patient characteristics such as age, gender, length of stay in hospital and the way of discharge from hospital were evaluated statistically.
RESULTS: There was 648 patients who were applied to Bolu AIBU Izzet Baysal Research and Education Hospital Emergency Department in the time period of 01/01/2007-31/12/2014 with mushroom poisoning. 257 (39.7%) of the patients were male (mean age 41,32 ± 19,44), and 391 (60.3%) of them were female (mean age 39,6854 ± 18,7). Most of the patients are in the age range below 40 (351 patients, 53.4%). The most common application complaint was abdominal pain (288 patients, 44.4%), and the remaining ones are diarrhea (198 patients, 30.6%), nausea (60 patients, 9.3%), lack of apetite (60 patients, 9.3%), severe vomiting (36 patients, 5.6%) and weakness (6 patients, 0.9%) respectively. Most common applications were in the evening hours (16-24 time interveal: 53.7%) and in the months of November (15.6%) and June (14.8%). In the season of autumn (51.4%) and in the years of 2014 (29.3%) and 2010 (25.3%), registrations in the emergency department are higher than the remaining time periods. Most discharges were from the observation room of emergency department (64%), and the remaining part from the intensive care units (51 patients, 7.9%) and inpatient clinics (182 patients, 28.1%). 26 of the patients in intensive care units were sent to other medical centers.
CONCLUSION: It is obviously seen that poisoning from the mushrooms are increasing in the seasons of high mushroom growing. Most of the patients require hospitalization. If the intensive care unit observation is not enough and there is a necessity of liver transplantation, patients are sent to other medical centers.
Arif DURAN, Mansur Kürşad ERKURAN, Bülent YILMAZ (Bolu, TURKEY), Tarık OCAK, Musab Medeni ZORLU
15:00 - 16:30 #1029 - #1029 - Impact of 2012 Olympic and Paralympic games on a Large Central London Emergency Department.
#1029 - Impact of 2012 Olympic and Paralympic games on a Large Central London Emergency Department.
Background
In 2012, London hosted the International Olympic and Paralympic games. To date, there has been minimal research on the impact of the games on local hospitals.
Methodology:
This was a retrospective analysis comparing Emergency Department (ED) attendances during the Olympic (OG) and Paralympic Games (POG) to a corresponding period in the previous year.
Results:
Over the Olympic and Paralympic period, there was no significant change in attendances, gender or age.
(Attendances: OG:2012=6069 2011=6558. POG 2012=4716 2011=4710)
(Females: OG:2012=46.5%,2011=53.5%.p=0.114. POG:2012=50.6%,2011=49.4%p=0.146)
(Age: OG: (I.Q.R):2012=36.04,(23-49),2011=36.59,(22-50),p=0.149. POG: (I.Q.R):2012=34,(23-51),2011=33,(23-49),p=0.065).
There were reduced numbers of patients from our catchment area with slight increase in patients from London/UK. There was no significant change in number of British nationals compared to overseas patients.
(Catchment area: OG: 2012=83.08%, 2011=84.96% p=0.001. POG 2012=59.2% 2011=69.5% p=0.001)
(Non EU; OG: 2012=2.59%, 2011=2.82%, p=0.407. POG: 2012=1.3%, 2011=0.9% p=0.112)
Admission rates were similar between both years.
(Admissions: OG: 2012=25.97%, 2011=28.07, p=0.008%. POG: 2012=29.3%, 2011=29.3%, p=0.982)
Despite minor differences in patient demographics, there were changes in presentations. During the games, there were increases in chest, respiratory, and abdominal problems.
(OG p=0.001, POG p=0.016; OG p=0.093, POG p=0.003; OG p=0.020, POG p=0.029)
There were fewer presentations of alcohol intoxication, assault and trauma.
(OG p=0.863 POG p=0.042, OG p=0.172 POG p=0.795, OG p=0.321 POG p=0.671)
Conclusion:
In our study more people presented with chest, respiratory, and abdominal problems. This conflicts other studies which suggest there may not be a difference in pathology during sporting events. However; these studies reviewed a definitive diagnosis (ie acute myocardial infarction) rather than a patients’ presenting complaint (ie. chest pain). Our study population is large (22,053 patients) and despite our results showing there is no increase in admissions, there may need to be extra provision for outpatient investigations. Furthermore, the data shows a decrease in the number of patients presenting with alcohol intoxication, assault and trauma.
This project has shown there were minimal changes in the number of attendances and patient demographics. In addition; the rates of hospital admission were not affected. Such information is exceptionally useful for future workforce and event planning. It is the first of its kind to solely review a large tertiary non-designated hospital for two major international sporting events. Furthermore, by reviewing patients’ presentations rather than diagnosis, it gives a focus for where future service provision may need to be directed.
Sarah EL-SHEIKHA, Sarah EL-SHEIKHA (Liverpool, UK), Tony BOLTON, Joseph EL-SHEIKHA, Rebecca SAMUELS, Yusuf BEEBEEJAUN, Francesca GARNHAM
15:00 - 16:30 #1166 - #1166 - Homeless patients in the emergency department: a multicenter case-control prospective study in France.
#1166 - Homeless patients in the emergency department: a multicenter case-control prospective study in France.
Study objectives
Homeless people represent a vulnerable population. Their access to health care is limited and they have a higher mortality rate. Public hospitals and their emergency departments (EDs) are known to be used frequently by these patients. They can be seen as difficult to treat, and have an increased incidence of substance abuse and risk of violence in the ED. We tested the hypothesis that homeless patients experience suboptimal care by the provision of fewer healthcare resources.
Methods: We conducted a prospective multicenter case-control study in 31 EDs in France. Our Institutional Review Board authorized the study without the need for signed informed consent. We defined a homeless patient as a patient that currently lives on the street or in a shelter. During 72 hours from March 3th 2015, all homeless patients that visited the participating EDs were included in the study. One control patient was prospectively recruited after each case was included: the next patient that visited the ED with similar severity triage level (on a one to four scale), similar age (+/- ten years) and same sex. The primary outcome measures were length of stay, number of investigations per patient and treatment in the ED.
Results:
A total of 212 homeless patients and 212 control patients were included in the study. Mean age was 44 (standard deviation SD 13) years in both groups, and 87% were male. Homeless patients were more likely to have visited the ED in the past 28 days than other patients (47% vs 10%, p<0.001). They presented with similar rates and types of comorbidities than control patients, except for a more frequent history of substance abuse.
Heart rate, blood pressure, temperature, capillary blood glucose and Glasgow Coma Scale score were similar in both groups. Chief complaint was “housing demand” for 30 (14%) homeless patients. After excluding them, we found no difference in the type of chief complaint except for alcohol abuse, more frequent in homeless patients (20% vs 4%, p<0.001). We found a similar median waiting time to physician assessment in the two groups (58 min for both), although mean length of stay was longer for homeless patients than for control patients (6.2 vs 3.9 hours, p<0.001). We found no significant difference in the rate of radiological or biological investigations between the two groups. Similarly, we found no significant difference for the rate of oral or parenteral treatment administration, and admission rate was similar in the two groups (9% vs 7%, p=0.6)
Amongst the 182 analyzed homeless patients that visit the ED beside a housing demand, 53 (29%) were uninsured.
Conclusion:
We did not find a difference in the level of medical care delivered in French ED to homeless patients when compared to matched control. Resource consumption was similar for both groups, as was the admission rate. Nevertheless, homeless patients visit ED more often for an alcohol related complaint, are often uninsured and have higher rates of return visit.
Anne-Laure FERAL (, ), Adeline AUBRY, Jennifer TRUCHOT, Pierre-Alexis RAYNAL, Alice HUTIN, Geraud DEBRUYNE, Luc-Marie JOLY, Juvin PHILIPPE, Agathe LELEU, Bruno RIOU, Yonathan FREUND
15:00 - 16:30 #1196 - #1196 - Weapon related injuries in cairo during a turn of civilian violence in 2013: an overview.
#1196 - Weapon related injuries in cairo during a turn of civilian violence in 2013: an overview.
Background: Violence in Egypt during the recent years of political turmoil has involved civilians. The use of armed weapons among opposing groups (armed demonstrators, extremists and security forces) has resulted in extensive injuries causing pain, disabilities and when severe, death.
Methods: During an episode of civilian violence (3 months in 2013) a total of 841 hospital files of firearm - wounded victims were analyzed. The hospitals were near Tahrir Square and Cairo City Center where chaos was at a maximum. Some of the victims were clinically examined. Emphasis on medical neutrality, the rights of the wounded and the need for social and psychiatric support to the victims is implied.
Results: Seventy two percent of the wounded victims were young males (mean age 30.54 ± 10.22 years). Wounds were mostly inflicted by locally made crude arms having low-energy clout and involved the lower extremity in 29.8 %, upper extremity in 22.6%, eye zone in 19.0% and trunk in 4.4%. All shootings were from a short distance, but a minority , probably by snipers, were from a long distance. In some cases of gunshot wounds (13.08%) affected more than one anatomical region of the body: 4 regions in 2.38%, 3 in 3.92 % and 2 in 6.78%.
Conclusion: Handguns were the most common weapons inflicting civilian injuries in Cairo during armed demonstrations. Young males were injured the most, having wounds distributed randomly over their body, but significantly focused on the extremities causing severe morbidity. Social and psychotraumatic support to the injured were inadequate, but positive steps are being taken and improvement is anticipated.
Gamal SAIED (Cairo, EGYPT), Karim MOUSTAFA
15:00 - 16:30 #1395 - #1395 - Effects of large public outdoor events on attendances in an Emergency Department.
#1395 - Effects of large public outdoor events on attendances in an Emergency Department.
Introduction:
Brighton & Hove is a large cosmopolitan city with a population of nearly 300,000. It is the most populous sea side resort in England. Its economy has a strong emphasis on creative, electronic and digital technology. There are two large universities in the city (University of Brighton and Sussex University) with over 35,000 students in total. Brighton & Hove is unusual in that large proportion of its population (42%) is aged between 20-44.
Emergency Department at Royal Sussex County Hospital is the only department in the 14 mile radius and is a Level 1 trauma centre. It has annual attendances in excess of 110,000. There is a separate Children's Emergency Department with an annual attendance of 36,000. As Brighton & Hove is a seaside resort, there is also a large transit population of tourist coming on holidays, who would not necessarily have knowledge of how to access primary care services in the city.
There are several large outdoor public events that take place in the city (all take places on a Sunday). These include:
•Half Marathon
•Brighton Marathon
•London to Brighton Bike Ride
•Pride
•Shakedown
•5th November Bonfire Night
•Ney year’s Eve
We wanted to see whether these events increase number of attendances to our Emergency Department.
Methods:
Data from Emergency Department (Symphony) was used. Attendances for Sunday one week prior and one week post event were used to compare to those on the day of the event. Both Adults and Children Emergency Department attendances were included.
Results:
Out of all events mentioned above, the only two that clearly impacted on the Emergency Department were the Pride (August) and New Year’s Eve (December). Both increased attendances by 10-14% when compared to the attendances same day a week before and a week after.
Other events mentioned have a well-established medical management team which organises and runs prehospital support for the participants and the audience. The medical team consists of Emergency Medicine Consultants, Emergency Medicine Nurses and other advanced health care practitioners. They are able to treat multitude of presentations on scene thereby preventing unnecessary attendances in the Emergency Department. They operate to clear clinical protocols and have an open line of communication with the Department in relation to the patients they feel need transfer to the hospital.
Conclusion:
Emergency Departments should be aware of the large events that take place in the region and which can increase their attendances. Staffing should be increased to allow for a busy department. Also, there should be a real drive to have medical cover of these events prehospitally as it has been shown that having a medical team at events decreases attendances.
Natasza LENTNER, Maria FINN (Hove, UK)
15:00 - 16:30 #1978 - #1978 - Emergency Department physician’s perceptions of difficulties during the treatment of psychological/psychiatric emergencies: a pilot study.
#1978 - Emergency Department physician’s perceptions of difficulties during the treatment of psychological/psychiatric emergencies: a pilot study.
Background: Psychological andpsychiatric diseases in acute phases largely access to the hospital emergency department (ED). Knowledge about ED physician’s perceptions of difficulties during the treatment of psychological/psychiatric emergencies is limited. A pilot study was used to assess factors associated to the perception of difficulties of medical staff working in two EDs.
Methods: Two EDs (Santa Croce and Carle Hospital in Cuneo and Regina Montis Regalis Hospital in Mondovì in Northwestern Italy), approximately 80,000 and 30,000 patients per year respectively, were selected as convenience samples. A semi-structured questionnaire was conducted with closed and open-ended questions. The survey was conducted using questionnaire having: (i) background and demographic data of the physicians; (ii) physician’s perception of difficulties in the treatment of psychological/psychiatric patients was evaluated by a 10-point numerical rating scale (0 = no difficulties, 10 = extreme difficulties). A cut-off ≥ 7 was used to determine a high level of difficulty. (iii) Personal satisfaction in treating psychological/psychiatric emergencies with respect to other types emergencies; (iv) prescribing behaviour; (v) physicians’ emotions mostly associated to psychological/psychiatric patients (considering positive feelings like empathy and wonder, anxious emotions like anxiety, alarm, concern, discomfort, or depressive emotions like boredom, impotence, anger, frustration; (vi) physicians’ perception about the principal causes of difficulties with psychological/psychiatric patients; (vii) physicians’ perception about factors that could ameliorate the treatment of psychological/psychiatric emergencies.
Descriptive statistics of percentages, means, standard deviations and correlations were used to analyse the data.
Results: Forty-eight out of fifty-four eligible emergency doctors (89%) gave their consent to participate. Twenty-eight males and twenty women had completed the questionnaires. Participants’ mean age was 40,3 years (SD = 8,5). Psychological/psychiatric emergencies showed physicians’ lower degree of preference with respect to other hospital emergencies (like cardiovascular, neurological, respiratory, toxicological, trauma, infectious, hematologic and gastroenterology emergencies). Physicians’ perception of difficulties with psychological/psychiatric patients had a mean level of 6,5 (SD = 1,8). Thirty-one physicians evaluated their difficulties with a numerical rate ≥ 7.
Univariate analysis indicated that the lack of specific psychological/psychiatric training (84.3% vs 15,7%, OR=5,7 CI 95% 1,3-23,9; p=0.01) was significantly associated with physicians’ perceived difficulties with those patients. Physicians’ difficulties resulted not significantly associated with a specific emotional cluster (positive, anxious or depressive cluster), but a trend was noticed between difficulty perception and anxious emotions.
Conclusions: Several factors potentially involved in the physicians’ perception of difficulties in the treatment of psychological/psychiatric patients have been analysed, but the sole significant values were associated to the lack of specific psychological/psychiatric training for the ED medical staff. Data collection was arduous and a larger study will require strategies to improve recruitment. On the whole this pilot study indicated that a deeper knowledge of physicians’ perceptions and emotions is useful both to identify and act on the principal causes of their difficulties with psychological/psychiatric patients, in order to ameliorate assessment procedures and clinical treatment.
Attilio ALLIONE, Ketty LETO (Cuneo, ITALY), Bartolomeo LORENZATI, Emanuele BERNARDI, Letizia BARUTTA, Elisa PIZZOLATO, Elena MAGGIO, Luca DUTTO, Giuseppe LAURIA, Bruno Maria TARTAGLINO
15:00 - 16:30 #2010 - #2010 - INTERCONNECTION BETWEEN HOSPITAL EMERGENCY DEPARTMENT AND HOME CARE IN THE UNIVERSITY HOSPITAL MARQUÉS DE VALDECILLA.
#2010 - INTERCONNECTION BETWEEN HOSPITAL EMERGENCY DEPARTMENT AND HOME CARE IN THE UNIVERSITY HOSPITAL MARQUÉS DE VALDECILLA.
Introduction: Hospital emergency departments (ED) are overwhelmed by the high workload and the inability of the hospital to reduce waiting times for the transfer of patients already hospitalized from the emergency to inpatient facilities. An alternative to conventional hospitalization is the Hospitalization at Home (HaH), in which patients would enter under some criteria, thus avoiding hospitalization and reducing the collapse of emergency departments.
Objective: To evaluate the healthcare model of HaH, on the basis of cost-effectiveness in patients with infectious diseases who are admitted from the emergency room.
Patients-Methods: A descriptive study of 654 incidents of patients receiving OPAT (Outpatient Parenteral Antibiotic Therapy) between April 2013 and April 2014, sent from the ED. Each patient was diagnosed in the emergency department before being included in the HaH programme. Demographic details, comorbidity, location of infection, isolated microorganisms and HIAT duration were recorded. The effectiveness through cure / recovery rate, deaths and readmissions (during OPAT and within 30 days). We evaluate the cost of stay in the HaH and in conventional hospital and the average stay in both.
Results: Average age: 66.39 years. Women: 49%. Average Charlson index: 2.21. Most frequent types of infection: respiratory (42%), urinary (34%), skin and soft tissue (11%). Causal microorganism known in 30% of cases. Most frequent germs: Escherichia Coli: 35%, Pseudomonas aeruginosa: 17%, Klebsiella spp: 9%, Staphylococcus spp: 7%. OPAT average duration: 8.3 days. Cure / recovery rate: 94%. Deaths: 1%. Readmissions during OPAT: 5%. Readmissions within 30 days: 7%. The estimated cost per HaH stay was €166 per day, and the average cost in hospital was €630 per day.
Discussion: Thanks to the use of this healthcare model, some serious infections have been treated at the patient’s home, thus avoiding hospital admission and the consequent vacancy of boxes in the ED. Comparing the cost of staying one day in the HaH (166 euros) and in hospital (630 euros), we can state that this model is linked to significant cost savings to the National Health Service.
Giusi SGARAMELLA (santander, SPAIN), Maria LARA, Zuany SONEIRA, Maria ANDRES, Ana AGUILERA, Luis Gerardo GARCIA-CASTRILLO, Emilio PARIENTE, Pedro SANROMA
15:00 - 16:30 #2068 - #2068 - The demographics and clinical data for domestic violence patients in the emergency department.
#2068 - The demographics and clinical data for domestic violence patients in the emergency department.
Introduction:
Victims of domestic violence (DV) appeal to the health care system through emergency room visits for injuries related to violent episodes. Health professionals must acknowledge DV as a possible cause of injuries and other health disorders in emergency patients. Knowing the demographics, epidemiological and clinical data of DV patients can enhance the quality of care for these victims.
Objective:
To identify demographic, epidemiological and clinical characteristics of victims of DV in emergency department and to deduce the possible deleterious consequences of DV.
Methods:
A prospective observational study was conducted over one year. Patients were eligible for inclusion if they reported being a victim of DV. A domestic violence questionnaire was used. The demographics, co-morbidities, clinical data and in-hospital procedures were collected. Gravity was estimated according to the clinical classification of patients in emergency department (CCMU, Rea Urg 1994)
Results:
Inclusion of 169 patients. 2 men and 167 women. The average age of abused women was 35 +/ - 9 years and the average age of the abuser was 40 + - 9 years. The emergency visit was the same day (64%) and the second day (25%). The frequency of DV was daily in 60% cases. Women have filed a complaint in 45% of cases and sanctioned partner became more aggressive in 33% of cases. The topics of quarrel were (%): money and leisure (74%), alcohol (48%), children's education (47%), jealousy and infidelity (40%), family relationship (38%), sex (15% ) Friends relationship (11%), related to work (8%). The nature of the abuse was physical in 100% cases, psychological (99%), economic (65%) and sexual (29%). The abusers had a history of alcohol use in 48% of cases, 47% had completed primary education and 64% were unemployed.
The damage was generally mild, class 1 of CCMU classification was found in 75% of cases. One hundred forty eight patients were discharged home, 21 victims of VC were addressed to a specialized service: 7 cases in orthopedics, 2 in ophthalmology, 2 in neurology and 10 in gynecology.
Conclusion:
Domestic violence affects female victims and has the characteristics of a gender-based violence. It is occurring at an alarming rate, is under-reported, and often not recognized by physicians and nurses. Screening of DV in emergency department can enhance the quality of care for these victims.
Rania JEBRI (Ben Arous, TUNISIA), Sami SOUISSI, Najla HENI, Mohamed MGUIDICH, Wifek BEN HMIDA, Soumaya MAHDHAOUI , Wided BOUSSLIMI, Hanane GHAZALI
15:00 - 16:30 #2082 - #2082 - How does countertransference (CT) affect medical decision-making? A resident survey.
#2082 - How does countertransference (CT) affect medical decision-making? A resident survey.
Background: Medical decision-making is not an objective process, despite the presence of medical algorithms for work-up and diagnosis of most conditions. Bias in medical decision making can cause costly mistakes in treatment, and has been linked to race, gender, socio-economic status. However, the real reasons for bias are not well understood, nor are the mechanisms by which bias affects decision-making. Countertransference, the psychodynamic concept representing feelings of providers towards patients, has been reported anecdotally to affect decision-making, but never formally studied in this setting. Modern countertransference representations have operationalized those feelings into eight dimensions: overwhelmed/disorganized, helpless/inadequate, positive, special/overinvolved, sexualized, disengaged, parental/protective, and criticized/mistreated. In this study, we explore how countertransference affects medical decision making in typical patient encounters, with the overarching hypothesis that CT feelings impact decision-making in everyday patient encounters, not exclusively in psychiatric settings.
Methods: Five patient encounters eliciting one to two CT dimensions each were filmed. The vignettes were as follows: 1- a likeable nurse presenting with chest pain, 2- young man with a history of drug addiction and chest pain, inability to walk more than a few steps, patient is covered win tattoos and marginally cooperative 3- young woman with borderline, histrionic personality c/o chest pain and palpitations (has pulmonary embolism), 4-Entitled patient with acute cholecystitis who repeatedly belittles, refuses to talk to housestaff & 5- young man presenting with sleepiness- has an overbearing, overly controlling mother- patient has a knife in his belt buckle; presents very differently when interviewed with his mother versus alone.
Residents in emergency medicine were shown the vignettes, asked what workup they would order for the patient, their top three differential diagnoses, then asked to fill out the therapist response questionnaire, a countertransference questionnaire. Participants were given 5-6 minutes per questionnaire, aiming at instinctive, rapid answers.
Results: Twenty-eight residents in emergency medicine participated in the survey. CT Feelings elicited by patient vignettes were similar across levels of training, and consistent with projected hypotheses. CT influenced medical decision making in cases combining psychiatric and medical components. Two kinds of effects were detected: patients eliciting positive CT were less likely to get tested for drug use, whereas patients eliciting negative CT were more likely to be dismissed with minimal workup, more likely to get tested for drug use (even when drug use is reported in already available history) and be subject to a higher suspicion of malingering.
Conclusions: To our knowledge, this is the first study linking countertransference to how resident providers in emergency medicine made decisions to order tests: CT seems to affect adherence to ACEP-recommended algorithms. The effect is most prominent when the criticized/mistreated, helpless/inadequate dimensions are activated. The effect is less pronounced when a diagnostic dilemma is absent, as in the case of the patient with gastrointestinal symptoms. When providers had positive CT for a patient, less testing for substance use was performed. Lack of awareness of one’s own feelings towards patients could cause significant changes in treatment, potentially missing serious conditions.
Nidal MOUKADDAM (Houston, USA), Asim SHAH, Larry LAUFMAN, Jim LOMAX, Veronica TUCCI
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State of the Art
Pre-hospital EM
Moderators: Eric REVUE (Head of the ED and prehospital EMS) (Paris, FRANCE), Jana SEBLOVA (Emergency Physician) (PRAGUE, CZECH REPUBLIC)
16:40 - 17:10 Difficult airways in prehospital care – up-to-date. Stefan TRENKLER (Košice, SLOVAKIA)
17:10 - 17:40 Sonography during cardiac arrest – state of the art and new opportunities. Roman SKULEC (KLADNO, CZECH REPUBLIC)
17:40 - 18:10 LEAN way of thinking in the process of acute care. Maaret CASTREN (HELSINKI, FINLAND)
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Italy invites
Organizzazione dei Dipartimenti d'Emergenza
Moderators: Salvatore MANCA (ITALY), Francesco PUGLIESE (Rome, ITALY)
16:40 - 17:00 L'architettura ideale per una buona organizzazione. Annamaria FERRARI (Reggio Emilia, ITALY)
17:00 - 17:20 Gestione delle risorse e percorsi appropriati per garantire il diritto alle 6 ore. Bruno TARTAGLINO (Cuneo, ITALY)
17:20 - 17:40 Responsabilità nelle disfunzioni organizzative in area d'emergenza. Michele ZAGRA (Messina, ITALY)
17:40 - 18:00 Il punto di vista del cittadino sulle strategie organizzative. Alessio TERZI (ITALY)
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Clinical Questions: Controversies
Cardiovascular Emergencies
Moderators: Rick BODY (UK), Polat DURUKAN (TURKEY)
16:40 - 17:10 High sensitivity troponin: friend or foe? Louise CULLEN (Brisbane, AUSTRALIA), Rick BODY (UK)
17:10 - 17:40 Is there any point in taking a history from a patient with chest pain? Edd CARLTON (UK), Barbra BACKUS (dordrecht, THE NETHERLANDS)
17:40 - 18:10 Ruling out ACS: Getting It Done. Judd HOLLANDER (USA)
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Administration / Management
Patient Safety & Risk Management
Moderators: Janos BAOMBE (manchester, UK), Christian HOHENSTEIN (PHYSICIAN) (JENA, GERMANY)
16:40 - 17:10 You can't fix what you don't measure: Improving care in the ED and beyond. Susan ROBINSON (Doctor) (Cambridge, UK)
17:10 - 17:40 Pitfalls in behaviour that can take you to court - soft skills that satisfy patients and make them your friend. Christian HOHENSTEIN (PHYSICIAN) (JENA, GERMANY)
17:40 - 18:10 The IFEM Quality and Safety Framework for Emergency Medicine. Fiona LECKY (Professor of Emergency Medicine) (Sheffield, UK)
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16:40-18:10
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Research
Education
Moderators: Katrin HRUSKA (Farsta, SWEDEN), Cem OKTAY (FACULTY) (ANTALYA, TURKEY)
16:40 - 17:10 The iTeachEM approach to medical education. Rob ROGERS (USA)
17:10 - 17:40 The European Board Examination in Emergency Medicine (EBEEM). Cornelia HARTEL (Consultant in Emergency Medicine/ Director of Medical Education in Emergency Medicine) (Stockholm, SWEDEN)
17:40 - 18:10 Medical Education in 2015: the Swedish perspective. Katrin HRUSKA (Farsta, SWEDEN)
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YEMD
Sim Session #2
Moderators: Luca CARENZO (SIMULATION COMPETITION ONLY) (NOVARA, ITALY), Roberta PETRINO (Head of department) (Italie, ITALY)
16:40 - 17:10 Simulation Clinical Case 1. Luca CARENZO (SIMULATION COMPETITION ONLY) (NOVARA, ITALY), Roberto COSENTINI (Milano, ITALY)
17:10 - 17:40 Simulation Clinical Case 2. Chris NICKSON (South Yarra, AUSTRALIA)
17:40 - 18:10 Simulation Clinical Case 3. Riccardo LETO (Chief of ED) (Overpelt, BELGIUM), Mikkel MALBY SCHOOS (Copenhagen, DENMARK)
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EuSEM meets
China
Moderators: Giorgio CARBONE (ITALY), Gian CIBINEL (Torino, ITALY)
16:40 - 17:10 The Developing Trend of Chinese Emergency Medicine. Zhong Qiu LU (CHINA)
17:10 - 17:40 The Professional Quality Control Indicator of Chinese Emergency Medicine. Wei JIE (CHINA)
17:40 - 18:10 The Standardized Training of Emergency Medicine Residency in China. Wei JIE (CHINA)
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Oral Paper 1
Imaging and Ultrasound I
Moderators: Ammar ALANI (UK), Paolo PRINETTO (ITALY)
16:40 - 18:10 #1033 - #1033 - REAL-TIME ULTRASOUND-GUIDED THORACENTESIS USING A LONGITUDINAL AXIS APPROACH IN THE EMERGENCY DEPARTMENT.
#1033 - REAL-TIME ULTRASOUND-GUIDED THORACENTESIS USING A LONGITUDINAL AXIS APPROACH IN THE EMERGENCY DEPARTMENT.
BACKGROUND: Real-time ultrasound guidance has demonstrated to improve the success and to reduce the incidence of adverse events during medical procedures. Ultrasound-guidance during thoracentesis has decreased the likelihood of pneumothorax by 19% --thereby improving the overall outcomes. Since the needle orientation in a longitudinal axis provides better precision and decreases the rate of adverse events during ultrasound-guided vascular access, we hypothesized that ultrasound-guided thoracentesis performed with a longitudinal axis approach could also have better outcomes. To our knowledge, this technique and its potential benefits have not been yet reported in the literature. We aimed to describe the real-time ultrasound-guided thoracentesis using longitudinal axis approach.
OBJECTIVE: To describe the outcomes of ultrasound-guided thoracentesis using a longitudinal axis approach in an Emergency Department in Bogotá-Colombia.
METHODOLOGY: We described two different techniques of ultrasound-guided thoracentesis: 1) the conventional (out of plane) and 2) the longitudinal axis (in-plane), in the Emergency Department of Fundación Cardioinfantil - Instituto de Cardiología, from October 1, 2013 to September 10, 2014. The measured variables were: difference between pleural effusion depth at the puncture site, success rate in pleural fluid removal, and adverse events.
RESULTS: We performed 47 ultrasound-guided thoracentesis using the conventional approach and 26 ultrasound-guided thoracentesis using the longitudinal axis approach. Pleural effusion depth median at the puncture site was 32.5 mm in the longitudinal axis group, compared to 47 mm in the conventional technique group (p = 0.0225), with a lowest pleural effusion depth of 15 mm and 20 mm respectively. Success rate in fluid removal was 100% in thoracentesis performed with longitudinal axis approach, compared to 93% (44 out of 47 procedures) with the conventional approach. One pneumothorax occurred in the conventional technique group. Thoracentesis was performed in the first attempt in all cases when longitudinal axis was used. Six thoracentesis required more than one attempt of puncture in the conventional technique group.
CONCLUSION: Longitudinal axis approach during ultrasound-guided thoracentesis is a feasible and safe technique that could potentially improve the success rate in pleural fluid removal while reducing the likelihood of adverse events. Additional clinical studies are needed to support our findings.
Luis Arcadio CORTES-PUENTES (BOGOTA, COLOMBIA), Gustavo Andres CORTES-PUENTES, Gerardo LINARES-MENDOZA
16:40 - 18:10 #1209 - #1209 - THROMBUS (THROMbosis detection by Bedside UltraSound). A prospective, multicentre study: Diagnostic concordance of emergency doctor-performed bedside US vs radiologist echo-doppler US in the diagnosis of deep venous thrombosis of lower limbs.
#1209 - THROMBUS (THROMbosis detection by Bedside UltraSound). A prospective, multicentre study: Diagnostic concordance of emergency doctor-performed bedside US vs radiologist echo-doppler US in the diagnosis of deep venous thrombosis of lower limbs.
INTRODUCTION:
Deep venous thrombosis (DVT) is an increasing major cause of mortality and morbidity. There is a need for quick, easy, inexpensive, convenient, and reliable diagnostic tools.
OBJECTIVES:
To ascertain the diagnostic concordance of emergency doctor-performed ultrasound (EDUS) of the lower extremities with specialist doctor-performed echo doppler (SDED) in the diagnosis of DVT.
METHODS:
In this prospective, multicenter study, adult patients (>18 years old) with clinical suspicion of DVT, with high or moderate risk (on Wells scoring) or low risk with increased D-dimer levels, were eligible.
From September 2013 to September 2014, 328 patients were enrolled. Fifty-one investigators from seven hospitals performed the EDUS. Each patient had the EDUS and SDED both in femoral and popliteal areas.
The final result was considered non-concordant if one or both of the EDUS did not match with the SDED. For inter-rater agreement analysis, we used the Kappa statistic,12 and confidence intervals (CIs) of 95% were computed using a jack-knife re-sampling procedure.
RESULTS:
Of 328 pairs of US studies, 37 were non-concordant between EDUS and SDED. Two EDUS were incomplete; therefore, the concordance analysis was performed with 326 ultrasound studies, with 35 discordant.
The percentage of agreement between EDUS and SDED was 89%. The kappa index was 0.76 (95% CI = 0.69–0.84), which means a “substantial agreement.”
CONCLUSIONS:
There is substantial agreement between the EDUS and SDED in the diagnosis of DVT in routine clinical practice.
WHAT THIS STUDY ADDS:
What is already known on this subject
Current available evidence suggest that emergency doctors can perform bedside ultrasonography to diagnose or to rule out DVT, in a quick, inexpensive, and accurate way in comparison with “gold standard” studies by the Radiology department.
Nonetheless, important concerns have been raised about the interpretation of the data: small sample sizes and methodological issues (very different experience of the emergency doctors performing bedside ultrasound, lack of details involving patient enrollment)
Section 2: What this study adds
There is a “substantial agreement” between bedside ultrasound performed by a homogeneous sample of novice in bedside ultrasound management emergency doctors, and Doppler ultrasound performed by the Registrar radiologist in the diagnosis of DVT of lower limbs.
The diagnostic concordance will escalate from 89% to 95% if the emergency doctor is shadowed in the first five performances, when the most mistakes are made.
Roberto PENEDO ALONSO, Mario SÁNCHEZ PEREZ, Fernando ROLDAN MOLL, Domingo LY-PEN (Westcliff on Sea, UK), Miguel ZAMORANO SERRANO, Luis DÍAZ VIDAL, Soledad JUSTO
16:40 - 18:10 #1238 - #1238 - Implementing the national institute for health and clinical excellence head injury 2014 guidelines in a children’s major trauma centre.
#1238 - Implementing the national institute for health and clinical excellence head injury 2014 guidelines in a children’s major trauma centre.
Background/Introduction
Head injury is a common paediatric Emergency Department presentation1. The National Institute for Health and Clinical Excellence (NICE) updated its guidance in January 2014 regarding imaging required for adults and children following a head injury1. This study looked at compliance rates pre-guideline and post-guideline implementation.
Participants and methods
A single-centre, retrospective cohort study was carried out, examining imaging practice in children with head injuries pre-guideline and post-guideline implementation. Extraction was from patients’ records and radiology department imaging registers. The new guidelines were implemented formally in August 2014 to the new trainee doctors. The pre-implementation data collection consisted of a 2-month period between and including November 2013 to December 2013 and the post-implementation stage consisted of 2-month period between and including September 2014 to October 2014. The primary outcome measured was compliance with the 2014 NICE guidelines. As the data was binary, 95% confidence intervals were used for comparison.
Results
1797 patients were identified as having a head injury, of which 62.7% were male. There was a positive skew of ages with a median of 50 months. Pre-guideline implementation, 4.8% (95% CI 3.3% and 6.2%) had a CT head scan performed. Post-guideline implementation, there was a reduction to 2.4% (95% CI 1.4% and 3.4%). Implementation at The Sheffield’s Children NHS Foundation Trust (SCFT) resulted in a statistically significant increase in guideline compliance from 79.2% (95% CI 76.4% and 81.9%) to 85.0% (95% CI 82.8% and 87.3%). The greatest increase in compliance was found in CT head scans, from 95.8% (95% CI 94.5% and 97.2%) to 97.7% (95% CI 96.7% and 98.6%). The compliance for CT C-spine scanning was hard to assess due to few patients having clinical indications for this.
Discussion/Conclusion
The implementation at the SCFT was successful in satisfying the aim of the NICE Head Injury 2014 guidelines by increasing compliance and decreasing CT head scans1. The increase in compliance is contrary to previous studies, indicating a former reluctance to adhere to NICE guidelines for imaging children2.
References
- National Institute for health and care excellence. Head Injury: Triage, assessment, investigation and early management of head injury in children, young people and adults. Methods, evidence and recommendations. CG176. 2014.
- Mooney JS, Yates A, Sellar L, Shipway T, Roberts C, Parris R, et al. Emergency head injury imaging: implementing NICE 2007 in a tertiary neurosciences centre and a busy district general hospital. Emergency medicine journal. 2011;28(9):778-82.
Acknowledgements
Thank you to the Sheffield Children’s Foundation Trust for data access.
Natalie RAMJEEAWON (London, UK), Fiona LECKY, Derek BURKE, Shammi RAMLAKHAN
16:40 - 18:10 #1299 - #1299 - Pre-hospital Vscan® echoscopy : influence on orientation and management. A prospective pilot study (SMURSCOPE).
#1299 - Pre-hospital Vscan® echoscopy : influence on orientation and management. A prospective pilot study (SMURSCOPE).
Introduction
The ultrasound-guided management in pre-hospital emergency medicine has come out as an emerging subject of clinical research and publication over the last decade. But it does not seem to have become common practice amongst SMUR (mobile intensive care units) yet [1]. Nonetheless it remains a tool that has proven its efficiency for diagnostic certitude improvement [2] and that could also modify pre-hospital medical management [3].
The use of a compact, light, hand-held ultrasound device with an optimized ergonomy such as the V-Scan ® seems to be the best option in our practice.
Prospective studies are lacking. We wish to assess the influence of the use of echoscopy in the pre-hospital setting: diagnostic certitude, length of intervention, patient’s treatment and orientation.
Material and methods
- Prospective mono-centric interventional pilot study in current care setting.
- Inclusion criteria: any patient over 18 years old, that are managed in the pre-hospital setting, for one targeted motive amongst a few (related to traumatology, haemodynamic failures, cardio-respiratory distress…).
- Medical management is completed with a VScan® echoscopy, according to a procedural sequence. Non-experienced physicians are given a 16-hour training in emergency ultrasound examination before participating to the study.
- We mainly assess modifications of orientation that are attributable to echoscopy. Secondary judgement criteria are: modifications of diagnosis, diagnostic certitude before and after echoscopy (according to a numeric auto-assessment on a scale from 0 to 10), therapeutic changes that are attributable to echoscopy, and stratification of those results according to the doctor’s experience (experienced versus minimal training).
Results
- 114 patients are included over 8 months by 14 physicians: 8 junior doctors who received the minimal training (60% of investigated patients), and 6 doctors who are experienced (specific training and qualification in ultrasound scan with over 3 years of experience). Main motives of intervention are chest pain (54%), shortness of breath (15%), or severe traumatology (10%).
- The mean duration of echoscopy is 5.7 minutes and is not influenced by the experience of the investigator.
- A change of orientation occurs in 17% (CI95%; 11-25%), with a trend toward superiority of experienced doctors (23 versus 13%; no significant difference).
- After echoscopy, main diagnostic hypothesis does change in 21% of cases, and therapeutic management in 15%.
- Diagnostic certitude is mostly increased when it is initially scored between 3 and 7 over 10.
Discussion:
This pilot study already shows the usefulness of ultrasound examination with an ultraportable device in the pre-hospital setting. It seems to have an influence on orientation decision and therapeutic management. This improvement does not have a significant duration cost. A targeted training over 2 days is enough to show positive results, and advanced training improves even more those results. A minimal training should particularly target focused echocardiography skills. A study on a larger scale is currently being conducted.
References:
[1] Ann Fr Anesth Reanim. 2014 ; 33(3):29-33
[2] Am J Em Med 2006; 24, 237–242
[3] Congrès Urgences 2012; CP 158
Adeline CHARDIN (le kremlin bicetre), Sylvain BENENATI, François-Xavier LABORNE, Roger KADJI, Joël CHENAL, David SAPIR, Karim TAZAROURTE, Jacques DURANTEAU, Nicolas BRIOLE
16:40 - 18:10 #1728 - #1728 - CAN SPLANCHNIC ARTERY DUPLEX ULTRASOUND PREDICT ACUTE MESENTERIC ISCHEMIA? A LONGITUDNAL MULTICENTRIC STUDY.
#1728 - CAN SPLANCHNIC ARTERY DUPLEX ULTRASOUND PREDICT ACUTE MESENTERIC ISCHEMIA? A LONGITUDNAL MULTICENTRIC STUDY.
INTRODUCTION: Acute mesenteric ischemia (AMI) is considered a vascular emergency and mortality is time dependent. Early diagnose is challenging as presenting symptoms are non-specific. The aim of this study was to evaluate the performance of duplex ultrasound (DUS) of the splanchnic vessels to detect AMI against the reference standard of multi-detector computer tomography (MDCT) abdomen scan in patients presenting to the Emergency Department with abdominal pain and no clear diagnosis after early standard assessment.METHODS: This observational prospective study was performed in two hospitals between October 2012 and April 2014. All patients underwent to MDCT of the abdomen using arterial, venous and portal acquisition. A single operator recruited and performed the DUS blind to MDCT reports. Inclusion criteria were: age >18; acute abdominal pain with onset <24h and/or altered bowel habit; history of atrial fibrillation and/or atherosclerosis in any vascular territory; no diagnosis after standard tests. Duplex assessment was performed of the coeliac arthery (CA) and superior mesenteric artery (SMA) taking a sample of the peak systolic velocity (PSV). We considered normal PSV values between 90-190 cm/sec for the CA and between 80-200 cm/sec for the SMA. Statistical analysis was performed using Student t test, χ2 test, Fisher exact test, whenever appropriate, to assess differences among AMI and non-AMI groups.RESULTS:49 patients were eligible for the study: two withdrew consent and DUS not feasible in two patients leaving 45 for analysis, among this MDCT diagnosed 15 AMI cases. DUS revealed a median SMA PSV of 276.3cm/sec (SD:149,6) and of 188,3 (SD:140,5) in AMI and non-AMI groups respectively (p=0.01). The median CA PSV values were 241,7cm/sec (SD:191,5) and 196,7cm/sec (SD:155,3) in AMI and non-AMI groups respectively (p>0,05). Considering both SMA and CA, abnormal PVS values were found in 27 patients, 12 of them had AMI. Of the remaining 18 patients with normal values, just three had AMI. PSV reached a 80% (95%CI:51.91-95.43) sensitivity, 50% (95% CI: 31.31-68.69) specificity, 44,44%(95%CI: 25.50-64.66) PPV, 83,33%(95%CI: 58.56-96.23) NPV.CONCLUSION:The investigator achieved PSV readings of the SMA in 45/47 (96%) and of the CA in 44/47 (94%) of patients. A normal PSV has a high NPV for AMI (83,33%) suggesting the diagnosis is unlikely. However the PPV of an abnormal PSV is 44% and so suggests but does not confirm the diagnosis. MDCT angiography remains the gold standard for the diagnosis of AMI, although DUS PSV values could be a feasible and reliable tool that can reasonably rule it out in high risk population. REFERENCES: 1)AbuRahma AF et al. Mesenteric/celiac duplex ultrasound interpretation criteria revisited, J Vasc Surg 2012; 55(2): 428–436; 2)Reginelli EA Genovese EA,et al. Intestinal Ischemia: US-CT findings correlations, Critical Ultrasound Journal 2013; 5(1):S7. Acknowledgements: No funding or conflict of interest.
Stefano SARTINI, Marcello PASTORELLI, Carolina GRANAI, Guido CALOSI, Tim HARRIS, Fulvio BRUNI, Stefano SARTINI (Genova, ITALY)
16:40 - 18:10 #1987 - #1987 - Role of bedside videocapillaroscopy in the study of microcirculatory alterations in septic patients in the emergency department: a preliminary study.
#1987 - Role of bedside videocapillaroscopy in the study of microcirculatory alterations in septic patients in the emergency department: a preliminary study.
Introduction: Videocapillaroscopy (VCS) is a non-invasive diagnostic tool used to assess structure and haemodynamic of microcirculation. VCS is an important tool in the diagnostic management of rheumatologic diseases, but nowadays this technique is also being used in critical care to evaluate microcirculatory changes in sick patients: the rationale beyond this idea is that the primum movens of a number of diseases could be found in microcirculation and studying its alterations could identify early signs and this could help to prevent the progression of the disease. For example, macrocirculatory alterations in sepsis are tardive and often related with a poor prognosis: having the chance to find early signs of microcirculatory failure could help to identify those patients at risk for a worse outcome.
Scope of the study: primary endpoint was to assess quantitative and qualitative microcirculatory alterations in septic patients in the Emergency Department; secondary endpoint was to assess correlations between videocapillaroscopic quantitative parameters and laboratory tests (CRP, lactates, procalcitonin).
Materials and methods: we enrolled 26 non consecutive patients (80 ± 12 years old) with positive SIRS criteria + clinical suspicion of sepsis while 30 healthy individuals were enrolled in the control group. As per our standard diagnostic workup, all patients underwent vital signs evaluation (heart rate, blood pressure, respiratory rate, body temperature) and blood samples were taken for lab tests (procalcitonin, c reactive protein, lactates, blood gas analysis, full blood count, u&e, mioglobin and ck). All the enrolled patients were assessed with VCS by an expert indipendent operator: periungual bed and bulbar conjunctiva were the anatomical sites chosen for videocapillaroscopic evaluation. All the images were recorded and analyzed for qualitative (flow velocity, hyperemia, background paleness, loop orientation, wall abnormalities, tortuosity, transparency, visibility, capillary distrophy) and quantitative (lenght and diameter of the afferent, middle and efferent loop) parameters. The final diagnosis was made by the emergency physician after the full work up and compared with capillaroscopic findings.
Results: septic patients had significative qualitative and quantitative alterations if compared to healthy subjects (ANOVA with Bonferroni post-hoc test). Statistical signifitivity was found for flow alterations, hyperemia, background paleness, loop orientation, wall abnormalities, tortuosity, trasparency, visibility and capillary distrophy; also, we found that middle loop is stretched in septic patients if compared with controls. To assess the secondary endpoint we used Pearson's score to correlate quantitative parameters to procalcitonin, c reactive protein and lactates: we found that the lenght of the afferent and efferent loop were related to all these three parameters.
Conclusions: VCS is a reliable tool for an early diagnosis of sepsis and its use in an Emergency Department is feasible. This is still a preliminary study and the enrollment is still ongoing to increase the statistical power of the study. A further step will be made comparing clinical scoring systems with serial VCS recordings to assess prognostic value of this methodic.
Matteo CAPECCHI, Matteo BORSELLI, Savino MINERVA, Fulvio BRUNI, Veronica GIALLI, Marcello PASTORELLI (Asciano, ITALY)
16:40 - 18:10 #2032 - #2032 - Ultrasound guided chest compressions during Cardiopulmonary Resuscitation.
#2032 - Ultrasound guided chest compressions during Cardiopulmonary Resuscitation.
Ultrasound guided chest compressions during cardiopulmonary resuscitation (CPR)
P. Benato MD; M. Zanatta MD; A. Barchitta MD; C. Pirozzi MD; V. Cianci MD.
Early and effective chest compressions have a well known pivot role in cardiopulmunary resuscitation (CPR) and 2010 International Consensus on Cardiopulmonary Resuscitation (CPR) have strongly reinforced its importance.
The efficacy of chest compressions depends on hands position and on compression technique (frequency and depth).
Medical education and training can easily improve chest compression technique, while the choice of thoracic landmark is always blind even if 2010 consensus indicated that it is reasonable to place the hands in the lower half of the sternum.
Critical care ultrasound (CCUS) has changed the approach of critical ill patient, transforming blind medicine into visual medicine and can identify potential reversible causes of cardiac arrest during CPR.
Our challenge is to use CCUS to locate the most appropriate site for chest compressions.
We planned a pilot study (in progress) to evaluate the capability of critical echocardiography to improve the quality of chest compressions with a subcostal view while CPR is taking place.
We presented data of a small case series from 6 non traumatic cardiac arrests who had been treated both in-hospital and in pre-hospital settings.
In 3 out of 6 patients compressions were correctly performed and passive left ventricle contractility was guarantied. In the other 3 cases partials left ventricle compression or the narrowing of the base of the heart and aorta was observed. Ultrasound guided changes in hands position improved passive left ventricle contractility in the 3 incorrect CPR.
Our study doesn’t permit to estimate if the changes made in hands position would have affected the outcome of CPR.
Anyway we think that the possibility to focus the power of the hands over the real position of left ventricle certainly improves the quality of our chest compressions.
Piero BENATO (arzignano, ITALY), Mirko ZANATTA, Agata BARCHITTA, Concetta PIROZZI, Vito CIANCI
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Oral Paper 2
CPR / Resuscitation
Moderators: M Ashraf BUTT (CAVAN, IRELAND), Timothy Hudson RAINER (UK)
16:40 - 18:10 #1021 - #1021 - Bispectral index EEG monitoring reliably detects epileptic activity in post-cardiac arrest patients.
#1021 - Bispectral index EEG monitoring reliably detects epileptic activity in post-cardiac arrest patients.
Bispectral index EEG monitoring reliably detects epileptic activity in post-cardiac arrest patients.
J. Vundelinckx2; J. Haesen 1,2; L. Desteghe 1,2; I. Meex 1,2; C. Genbrugge 1,2; J. Demeestere 2;
L. Ernon 2; J. Dens 1,2; C. De Deyne 1,2
1 Hasselt University, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium
2 Ziekenhuis Oost-Limburg, Genk, Belgium
Introduction: Assessment of prognosis in post–cardiac arrest (CA) patients became challenging since the introduction of therapeutic hypothermia (TH). Continuous EEG monitoring has been proposed to improve prognostication; however, its use is limited due to difficulties in readily interpretation. This emerges the need for a simple EEG montage. The bispectral index (BIS) monitor is a simplified EEG system, mainly calculating an index ranging from 0 (isoelectric EEG) to 100 (full consciousness) to provide information on hypnotic depth of anaesthesia. The aim of the study was to validate the accuracy of simplified EEG monitoring in a CA - setting.
Methods: BIS monitoring (BIS VISTATM) was applied to collect frontotemporal data in TH-treated CA patients. A standard 19 – channel EEG was performed after return to normothermia. Afterwards, small EEG frames coincident with the time of full EEG registration were extracted from the BIS monitor. We asked 2 neurophysiologists to indicate the presence of status epilepticus (SE), cerebral inactivity (CI), burst suppression (BS), Periodic epileptiformic discharges (PED) or a diffuse slowing pattern (DS). In addition, these samples were analyzed by 2 inexperienced physicians, who were asked to indicate the presence of SE.
Results: Thirty-four simplified EEG samples were analyzed. According to standard EEG, 11 patients showed a DS pattern, 3 had CI, 6 showed BS, 4 showed PEDs and 10 had an SE. Neurophysiologists interpreted all samples with a high accuracy (table 1). Only 1 SE was missed by 1 neurophysiologist. Unfortunately, only 1 PED was confirmed by both neurophysiologists. Interobserver reliability was high (kappa=0.843). High correlations were found for the comparison of full and simplified EEG for both neurophysiologists (r=0.809). Further, the 2 inexperienced physicians identified SE with a sensitivity of 85% and specificity of 98%.
Conclusion: Simplified EEG monitoring, using BIS, resulted in high accuracy of a simple classification system in post – CA patients. Not only neurophysiologists, but also treating physicians were capable to identify SE, which may play an important role in the early detection of SE. We suggest using BIS as a screening tool in post – CA patients to save valuable time in the detection of SE, without replacing the need of full EEG monitoring for confirmation.
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Table I: Validation of simplified EEG
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Full EEG
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Simplified EEG
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|
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I
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II
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Consensus
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Slow diffuse (n)
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11
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10
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11
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11
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Burst suppression (n)
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6
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6
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4
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5
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Cerebral inactivity (n)
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3
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3
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3
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3
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PEDs (n)
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4
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1
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1
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1
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Status epilepticus (n)
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10
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10
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9
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10
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Total
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34
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30
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28
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30
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Statistics
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Sensitivity (%)
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86.96
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77.27
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86.96
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Specificity (%)
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90.00
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93.75
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100.00
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Sensitivity disregarding PED (%)
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100.00
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89.47
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100.00
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Specificity disregarding PED (%)
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90.00
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93.75
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100.00
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Interobserver variability (kappa)
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0.843
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0.843
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Abbreviations: EEG: Electroencephalogram; PED: periodic epileptiform discharges; Sensitivity – PED: sensitivity calculated disregarding PEDs; Specificity – PEDs: sensitivity calculated disregarding PEDs;
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Joris VUNDELINCKX (Genk, BELGIUM), Jolien HAESEN, Lien DESTEGHE, Ingrid MEEX, Cornelia GENBRUGGE, Luc ERNON, Jo DENS, Cathy DEDEYNE
16:40 - 18:10 #1411 - #1411 - Association between Proportions of Highly Educated Neighborhood with Provision of Bystander Cardiopulmonary Resuscitation.
#1411 - Association between Proportions of Highly Educated Neighborhood with Provision of Bystander Cardiopulmonary Resuscitation.
Background
Bystander cardiopulmonary resuscitation (BCPR) is one of crucial community factor for out-of-hospital cardiac arrest (OHCA). We studied the association between the education level of neighborhood and provision of BCPR.
Methods
Emergency medical service (EMS)-treated OHCA with presumed cardiac etiology in Korea were enrolled from January 2012 through December 2013, excluding cases that were witnessed by EMS providers or have unknown outcome. Exposure was proportion of highly educated (more than bachelor) neighborhood in community, categorized in four groups from Q1 (low) to Q4 (high). Endpoints were provision of BCPR for study population and short time interval (
Results
Total of 26,073 OHCAs were included, 41.0% were witnessed and 36.9% had BCPR. BCPR was provided for 31.3% in Q1, 33.6% in Q2, 35.6% in Q3, and 41.8% in Q4 group. Among witnessed patients, 24.4% had short AIC in Q1, 29.3% in Q2, 29.9% in Q3, and 35.8% in Q4 (p<0.01). The AORs (95% CIs) compared with Q1 for BCPR were 1.01 (0.91-1.12) in Q2, 1.08 (0.98-1.18) in Q3, and 1.29 (1.17-1.43) in Q4. For short AIC, the AORs were 1.19 (0.99-1.44) in Q2, 1.21 (1.01-1.45) in Q3, and 1.45 (1.20-1.75) in Q4 for witnessed OHCA.
Conclusion
Proportion of highly educated neighborhood in incident site of OHCA is associated with receiving BCPR and short AIC. Targeted public intervention may be needed for community with relatively low education level.
Sun Young LEE (seoul, KOREA), Young Sun RO, Sang Do SHIN, Kyoung Jun SONG
16:40 - 18:10 #1770 - #1770 - Mechanical Positive Pressure Ventilation during Resuscitation: Influence of Chest Compression Synchronized Ventilation (CCSV) and Intermitted Positive Pressure Ventilation (IPPV) on Cerebral Oxygenation in a Pig Model.
#1770 - Mechanical Positive Pressure Ventilation during Resuscitation: Influence of Chest Compression Synchronized Ventilation (CCSV) and Intermitted Positive Pressure Ventilation (IPPV) on Cerebral Oxygenation in a Pig Model.
Objective:
A major goal of resuscitation is the oxygenation of the brain to prevent hypoxic damage. The ILCOR-Guidelines recommend mechanical ventilation with pure oxygen and Intermitted Positive Pressure Ventilation during resuscitation [1]. We investigated the influence of the novel resuscitation ventilation mode Chest Compression Synchronized Ventilation (CCSV) compared with Intermitted Positive Pressure Ventilation (IPPV) on cerebral tissue oxygenation in a pig model [2].
Methods:
After approval by local authorities 32 pigs underwent anaesthesia with intubation. The probes for the micro-lightguide spectrophotometer O2C were implanted in the cortex via two burr holes with a distance of 15mm at a depth of 10 mm for white light tissue spectrometry. Ventricular fibrillation was induced and after 3 min continuous chest compressions followed. Pigs were mechanical ventilated with IPPV in a volume controlled mode (FiO2 1.0, tidalvolumes 7ml/kgKG, respiratory rate 10/min, PEEP=0mbar) or Chest Compression Synchronized Ventilation (CCSV), a pressure-controlled and with each chest compression synchronized breathing pattern (FiO2 1.0, Pinsp=60mbar, inspiratory time 205ms). CCSV is designed to insufflate a very short oxygen flow in time with the start of each chest compression, each inspiration is stopped before decompression begins to allow expiration and unhampered venous blood flow into the right heart. Interventions: Epinephrine 1mg iv at t=7min, vasopressin 0.8IU/kg at t=11min. Cerebral tissue oxygen saturation (ScO2[%]) was recorded, analysis was performed using U-test, results are presented as median (25%/75%percentiles).
Results:
ScO2 baseline before cardiac arrest (FiO2 0.21): IPPV 49% (47/53), CCSV 50% (47/54), p=0.8. ScO2 during CPR at t=6min: IPPV 38% (30/45), CCSV 46% (36/49), p=0.037; at t=10min: IPPV 43% (36/50), CCSV 51% (37/62), p=0.28; at t=12min: IPPV 54% (43/60), CCSV 59% (36/74), p=0.4.
Conclusions:
The cerebral tissue oxygen saturation does not reach baseline values during resuscitation even when mechanical ventilation was performed with pure oxygen. Chest Compression Synchronized Ventilation (CCSV) improves tissue oxygenation compared to IPPV. Once vasopressors were given, the cerebral tissue oxygenation increases slightly above baseline values.
References:
[1] Deakin CD et al.:Resuscitation 2010; 81:1319
[2] Kill C et al Care Med. 2014; 42(2):e89-95.
Clemens KILL (Marburg, GERMANY), Rebecca THONKE, Oliver HAHN, Pascal WALLOT, Karl KESPER, Hinnerk WULF, Wolfgang DERSCH
16:40 - 18:10 #1813 - #1813 - Comparison of Quality of Cardiopulmonary Resuscitation between Conventional versus Dispatch-assisted Basic Life Support Training Program; a Randomized Simulation Study.
#1813 - Comparison of Quality of Cardiopulmonary Resuscitation between Conventional versus Dispatch-assisted Basic Life Support Training Program; a Randomized Simulation Study.
Comparison of Quality of Cardiopulmonary Resuscitation between Conventional versus Dispatch-assisted Basic Life Support Training Program; a Randomized Simulation Study Tae Han Kim*, Sang Do Shin*, Yu Jin Lee*, Hanga Park**, Eui Jung Lee*, Dayea Beatrice Jang**, Hyeona Lee**, Kyoung Jun Song*, Young Sun Ro** *Department of emergency medicine, Seoul National University College of Emergency Medicine **Laboratory of Emergency Medical Services Seoul National University Hospital Biomedical Research Institute Background: Home bystanders such as elderly or women who have lesser chance of cardiopulmonary resuscitation (CPR) training and less competency nor retention of skill and knowledge. We developed the dispatch-assisted-basic life support(DA-BLS) training program to improve the quality of CPR performed by home bystanders. Objectives: We compared the quality of CPR of bystanders educated with new DA-BLS training program to conventional BLS training program. Methods: This is a randomized simulation study. 24 elderly or housewives without previous CPR education were enrolled. Participants were randomized into 2 groups of BLS training programs(Conventional vs. DA-BLS). The DA-BLS, video-based 60-min. training program, included current dispatch-assisted BLS protocols, dispatcher instructions, BLS skill session and debriefing session. The conventional BLS training was the American Heart Association BLS provider course. After completing each education program, participants performed 5 minutes of CPR as bystanders in a simulated environment. Quality of CPR was measured and recorded by simulation manikins . Primary outcome was no flow time in 5 minutes of CPR. Results: Among 24 participants, 2 participants(8.3%) with mechanical failure of simulation manikin and 1 participant(4.2%) with simulation protocol violation were excluded. Mean no flow time was 83.2±19.5 seconds for DA-CPR program group and 148.7±38.1 seconds for conventional education group (p<0.01). Mean percentages of adequate rate of chest compression and adequate depth of chest compressions for each groups(DA-BLS vs. conventional) were 70.0±20.7% vs 56.0±30.5%(p=0.23) and 12.1±23.8% vs 23.7±38.6%(p=0.41) respectively. Conclusion: Bystanders educated with the new DA-BLS training program were shown to perform better bystander CPR in simulated OHCA.
Tae Han KIM (Seoul, KOREA), Sang Do SHIN, Yu Jin LEE, Hang A PARK, Eui Jung LEE, Dayea Beatrice JANG, Hyeona LEE, Kyoung Jun SONG
16:40 - 18:10 #1897 - #1897 - The Effect of Resuscitation Position on Cerebral and Coronary Perfusion Pressure during Mechanical Cardiopulmonary Resuscitation in Porcine Cardiac Arrest Model.
#1897 - The Effect of Resuscitation Position on Cerebral and Coronary Perfusion Pressure during Mechanical Cardiopulmonary Resuscitation in Porcine Cardiac Arrest Model.
Background: Mechanical compression devices can allow us to select a positon during transport with cardiopulmonary resuscitation (CPR) in a small space (like elevator) to reduce the length of stretcher cart.
Objective: To evaluate whether resuscitation position is associated with cerebral perfusion pressure (CePP) or coronary perfusion pressure (CoPP).
Methods: This is a randomized crossover experimental trial using female farm pigs (n=12) (42 ± 3kg) sedated, intubated, and paralyzed on a tilt table. After surgical preparation, 6 minutes of untreated ventricular fibrillation was induced followed by 3 minutes in 0° supine position as a stabilization period with mechanical CPR device, Lucas-2 (L) and an impedance threshold device (ITD). Then, 5 minutes of L-CPR+ITD was performed in a position randomly assigned to either head-up tilt at 30°, 45°, or 60° or head-down tilt at 30°, 45°, or 60° followed by 5 minutes of L-CPR+ITD in crossover position to the other. We measured and compared the CePPs and CoPPs at the positions using ANOVA with Duncan post-hoc test.
Results: Baseline hemodynamic parameters among pigs were not different. From head-down to head-up by elevation of angle, mean aortic pressures slightly decreased and intracranial pressure significantly decreased. With 60°, 45°, 30° head-down, 0°(supine), and 30°, 45°, 60° head-up positioning, CePPs increased linearly as follows: 2.4± 3.1, 9.3±3.9, 16.5±5.0, 27.0±2.3, 35.1±1.2, 39.4±12, 39.9±1.5mmHg respectively (p<0.001 by ANOVA and all significant for post-hoc test). CoPPs was peak in head-up 30 °: 12.9± 4.2, 13.3±5.0, 12.8±2.9, 18.1±2.0, 30.3±1.5, 24.1±1.7, 26.5±1.9 mmHg respectively (p<0.001 by ANOVA post-hoc test except between head-down -30° and -65°).
Conclusion: Mechanical CPR position was associated with different cerebral perfusion pressure by head-up angles. The head-up 30° showed the peak coronary perfusion pressure.
Yongjoo PARK (Seoul, KOREA), Taeyum KIM, Sand Do SHIN, Kyoung Jun SONG, Dayea Beatrice JANG, Hwansun MOON, Jihyun KIM, Sung Wook SONG, Soo Jin KIM
16:40 - 18:10 #1992 - #1992 - The rate and types of complications on performing extracorporeal cardiopulmonary resuscitation (ECPR).
#1992 - The rate and types of complications on performing extracorporeal cardiopulmonary resuscitation (ECPR).
Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) using extracorporeal membrane oxygenation (ECMO) is now becoming to be more widely implemented as an option for resuscitating cardiopulmonary arrest (CPA). However, there are very scarce data reporting its complication rate.
Purpose: To report the rate and types of complication on performing ECPR and discuss tips to prevent such events.
Methods: Retrospective search was done on ECPR database in single tertiary hospital between April 2010 and March 2015. Inclusion criteria for the search were out of hospital cardiac arrest and age greater than 18 years old. An exclusion criterion was traumatic arrest. Extensive chart review was done after extracting eligible cases and the rate and types of hazardous events complicated by ECPR was analyzed.
Result: Eighty-two cases were identified during the study period. There were 3 cases (3.7%) of cannulation failure in which two were failure to insert cannulas and one was misplacement of cannulas, veno-venous instead of veno-arterial. There was 1 case (1.2%) of liver injury, and 2 cases (2.4%) of vessel injury in which one lead to iatrogenic aortic dissection. There were 3 cases (3.7%) of uncontrollable hemorrhage requiring surgical intervention. There were 2 cases (2.4%) of lower extremity compartment syndrome. There was no thromboembolic event.
Discussion: Although ECPR yields better survival rate compared to that of conventional CPR, there are several hazardous events that can occur during and after the procedure. Every effort should be made to prevent hazardous event, even in knowing the fact that in this population there is minimal chance of recovery if not for ECPR. The safest way to prevent mechanical complication during insertion of cannulas is to perform it under fluoroscopic guidance. Ultrasound guided puncture and cannulation is also recommended to prevent posterior wall injury of the vessels and ease of hitting the vessels in the first attempt. Uncontrollable hemorrhage is usually caused by the leak from the slit between cannula and heavily calcified vessel and need to be repaired surgically. Lower extremity compartment syndrome can be avoided by placing a bypass line to superficial femoral artery distal to the cannula insertion site via arterial ECMO circuit. Full anticoagulation is necessary to prevent thromboembolic event.
Conclusion: The overall complication rate of ECPR was approximately 10%. Some of these complications can be avoided by knowing tips on performing ECPR.
Ryusuke MIKI, Ryusuke MIKI (Kobe, JAPAN), Nobuaki IGARASHI, Haruki NAKAYAMA, Akihiko INOUE, Shigenari MATSUYAMA, Tetsunori KAWASE, Satoshi ISHIHARA, Shinichi NAKAYAMA
16:40 - 18:10 #938 - #938 - Impact of early chest compression on heart rate detected by semi-automatic defibrillator during out-of-hospital cardiac arrest.
#938 - Impact of early chest compression on heart rate detected by semi-automatic defibrillator during out-of-hospital cardiac arrest.
Introduction: Out-of-hospital cardiac arrest remains a public health problem worldwide. Prognosis depends on a real chain of survival. This study aimed to test the hypothesis that early chest compression (CC) by a non professional bystander could increase the rate of ventricular fibrillation (VF) when pre-hospital emergency team turn on the semi-automatic defibrillator (SAED), which is necessary for a return of spontaneous circulation (ROSC).
Method: Prospective cohort observational study. Inclusion criteria were: patient over than 18 with non traumatic out-of-hospital cardiac arrest. Epidemiological and electrocardiographic data were collected (first heart rate at SAED, post-shock rhythm at 5 and 60 seconds).
The primary endpoint was having a first VF when turning on the SAED used by emergency medical service personnel. The secondary endpoints were: heart rhythm observed at 5 and 60 seconds after SAED shock, secondary FV rate, ROSC rate, rate of transport to hospital with a beating heart.
Results: The analysis involved 280 SAED traces over two 15-day periods respectively in 2012 and 2013. Median age was 69.5 [55-83] years with a predominance of males (n = 151, 53.9%). In 2012 nearly three-quarters (73.1%) of victims had a bystander, who, in one of three cases performed CC, while in 2013, half of the victims had a bystander (57.3%), who, in of two cases, performed CC. The rate of first VF was significantly higher when the bystander had previously performed CC compared to the absence of CC (OR = 8.9 [1.2-60.4], p = 0.029). This CC had no effect on immediate post SAED shock rhythm, and rather tended to develop a secondary VF (p = 0.07), and transportation with a beating heart (OR = 2.5 [0.71-8.84]. Nevertheless, CC shows a disadvantage for ROSC before arrival of the pre-hospital medical team (OR = 0.04 [0.003-0.46], p = 0.01).
Discussion: Early CC seems to maintain myocardial excitability, increasing the rate of first VF at SAED. The reduction of ROSC reported in patients undergoing CC could be explained by a less frequent search for palpable pulse due to performing chest compressions.
Conclusion: The positive effect of a bystander should boost efforts to train the general population on CC.
Mylene DESROZIERS, Benoit FRATTINI, Laurence SZTULMAN (PARIS), Daniel JOST, Pascal DANG MINH, * GT CPR, Michel BIGNAND, Jean Pierre TOURTIER
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08:30-09:00
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Keynote Session 1
Moderator: Rick BODY (UK)
08:30 - 09:00 Goal directed medical education - creativity meets discipline. Victoria BRAZIL (AUSTRALIA)
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State of the Art
Neurological Emergencies
Moderators: Stefano GRIFONI (Firenze, ITALY), Andy JAGODA (USA)
09:10 - 09:40 Dizziness : a new evidence-based approach I. Jonathan EDLOW (USA)
09:40 - 10:10 Dizziness : a new evidence-based approach II. Jonathan EDLOW (USA)
10:10 - 10:40 Reversal of novel oral anticoagulants: what are the current options? Giancarlo AGNELLI (Perugia, ITALY)
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Italy invites
Competenze del team dell'urgenza
Moderators: Marilena CELANO (MILAN, ITALY), Juricich ZORA (ITALY)
09:10 - 09:30 Nuove strategie per la gestione dell'attesa. Luca GELATI (Modena, ITALY)
09:30 - 09:50 Le competenze infermieristiche in area critica. Elena MANA (Pinerolo, ITALY)
09:50 - 10:10 Le emergenze sociali in pronto Soccorso. Paolo MOSCATELLI (Genova, ITALY)
10:10 - 10:30 Metodologie mediche non convenzionali nell'urgenza. Mario RAVAGLIA (Lugo, ITALY)
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Clinical Questions: Controversies
Disaster Medicine & Biohazards
Moderators: Francesco DELLA CORTE (ITALY), Abdo KHOURY (PH) (Besançon, FRANCE)
09:10 - 09:40 Are we prepared to face emerging diseases: The Ebola case. Laurie MAZURIK (TORONTO, CANADA)
09:40 - 10:10 A multitude of volunteers in disaster response: Resource or problem? Patrick DREWS (research associate) (Stuttgart, GERMANY)
10:10 - 10:40 Hospital triage in mass casualty incidents: A gain or loss of time? Pinchas HALPERN (department chair) (Tel Aviv, ISRAEL)
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EuSEM meets
ERC
Moderators: Maaret CASTREN (HELSINKI, FINLAND), Marc SABBE (Medical staff member) (Leuven, BELGIUM)
09:10 - 10:40 What is ERC? Maaret CASTREN (HELSINKI, FINLAND)
09:10 - 10:40 Resuscitation academy. Maaret CASTREN (HELSINKI, FINLAND)
09:10 - 10:40 Resuscitation registries. Ian MACONOCHIE (UK)
09:10 - 10:40 How long should we resuscitate? Marc SABBE (Medical staff member) (Leuven, BELGIUM)
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Administration / Management
Women in Emergency Medicine
Moderators: Adela GOLEA (Associate Professor) (Cluj Napoca, ROMANIA), Barbara HOGAN (Past President of the European Society for Emergency Medicine, EuSEM) (HAMBURG, GERMANY)
09:10 - 09:20 Introduction. Barbara HOGAN (Past President of the European Society for Emergency Medicine, EuSEM) (HAMBURG, GERMANY)
09:20 - 09:45 Women leaders in EM. Judith TINTINALLI (Chapel hill, USA)
09:45 - 10:15 Computer-aided female intuition. Tiziana MARGARIA STEFFEN (IRELAND)
10:15 - 10:40 The politics of managing emergency departments. Clara WU (N.T., HONG KONG)
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YEDM
Sim Wars
Moderators: Pier Luigi INGRASSIA (Novara, ITALY), François LECOMTE (Paris, FRANCE)
Coordinators: Abdo KHOURY (PH) (Besançon, FRANCE), Youri YORDANOV (Médecin) (Paris, FRANCE)
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Paediatric Track
Paediatric Biomarkers and Vital Signs
Moderators: Ian MACONOCHIE (UK), Yehezkel WAISMAN (ISRAEL)
09:10 - 09:40 Are biomarkers useful in the management in children with fever at the ED? Alain GERVAIX (SWITZERLAND)
09:40 - 10:10 The value of routine vital signs in children at the Emergency Department. Henriette MOLL (ROTTERDAM, THE NETHERLANDS)
10:10 - 10:40 Panel discussion.
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Oral Paper 1
Cardiovascular Emergencies II
Moderators: Veli Pekka HARJOLA (Head of Department) (Helsinki, FINLAND), Timothy Hudson RAINER (UK)
09:10 - 10:40 #1081 - #1081 - Revascularization strategy for acute coronary syndrome with ST-segment elevation: accessibility to angiography room and mortality.
#1081 - Revascularization strategy for acute coronary syndrome with ST-segment elevation: accessibility to angiography room and mortality.
Introduction: European Society of Cardiology advocate the period and management of coronary reperfusion, primary percutaneous coronary intervention (pPCI) or thrombolysis, according to the interval between the beginning of chest pain (symptoms onset) and the first medical contact (CP-FMC) and the availability of pPCI. The objective of the study was to investigate the mortality of acute coronary syndromes with ST-segment elevation (STEMI) according to the recommended time and availability of pPCI.
Materials and methods: Data collected on a regional level through a retrospective study managed by 8 out-of-hospital emergency medical services (EMS) and 40 mobile intensive care units (MICU). Inclusion criteria: data collected from 2003 to 2013, all uncomplicated STEMI with symptom onset < 12h, with a pre-hospital decision taken for direct pPCI, arriving alive at the hospital. The area was divided into three concentric zones: city, inner and outer suburb. Availability of PCI was defined as the concentration of cath lab per 100 km2. Time intervals were defined in three categories according to the guidelines: target time (pPCI < 60min if CP-FMC < 2h or < 90min if CP-FMC between 2h-12h), reasonable time (pPCI between 60 and 120 min if CP-FMC < 2h or between 90 and 120 min if CP-FMC between 2h-12h) and out of time in the other cases. Chi-2 test was used for testing the trends, statistical significance p < 0.05.
Results: Data on 10,210 patients were recorded in 10 years, 2,454 (24%) received thrombolysis and 7,756 (76%) pPCI. Availability of PCI was 9.5 per 100km² in city, 2 in inner suburb and 0.1 in outer suburb. A significant increase of out of time PCI was found when access to PCI decreased (city 6% < inner suburb 9% < outer suburb 14%). Time delay to PCI were in target time for 16% (n=1,619), in reasonable time for 49% (n=5,026) and out of time for 11% (n=1,111). Mortality was significantly (p<0.0001) related to increased reperfusion period: in “target time” mortality was 1.8% (n=28), in “reasonable time” 1.9% (n=94) and in “out of time” 4.3% (n=46). Data were missing or uninterpretable in 3% of cases.
Discussion: Management of STEMI reperfusion is in target time for 16% of patients and 65% within acceptable time. PPCI-related “out of time” delay increased when availability of pPCI decreased. The clinical impact of non-compliance with time intervals is a major significant increase in mortality. These objectives legitimized by international guidelines must be implemented and respected.
Laurent REBILLARD, Alexandre ALLONNEAU, Hugues LEFORT (Metz), Lionel LAMHAUT, Aurélie LOYEAU, Sophie BATAILLE, François-Xavier LABORNE, Amandine ABRIAT, Yves LAMBERT, Jean-Michel JULIARD, Frédéric LAPOSTOLLE
09:10 - 10:40 #1116 - #1116 - Is the management of ST–segment elevation myocardial infarction in patient aged over 80 optimal?
#1116 - Is the management of ST–segment elevation myocardial infarction in patient aged over 80 optimal?
Introduction : The Acute Coronary Syndrome with ST- segment elevation (STEMI) is a priority in emergency medicine. Do patients >= 80 years benefit from a management comparable to that of younger patients?
Objectives: Compare the characteristics of management of STEMI patients >= 80 years and
Methods: Data are derived from a prospective registry that lists all STEMI managed within 24 hours by 8 out-of-hospital emergency medical services (SAMU) and 40 mobile intensive care units (MICU) in a region of France. Secondary transfers were excluded from the analysis. Statistical analysis: Chi-2 test and Wilcoxon test were used. Multivariate analysis with reference group patients over 80 years old.
Results: 18,093 STEMI were included from 2003 to 2013 with 2,502 (14%) being >= 80 years. The proportion of elderly patients is stable since 2003. There was a majority of women (51% were over 80 years). The call to SAMU is delayed after the beginning of pain, since this call is made on average after 93 minutes for those aged over 80 as opposed to 57 minutes. Given these delays, the occurrence of at least one criterion of gravity was more common in those aged more than 80 years (29% against 18% in those aged less than 80 years). During the treatment, the decision of an unclogging was less frequent in patients >= 80 years of age 83% against 97% in patients aged less than 80 years, but when the decision was taken to unclog, primary angioplasty was carried out similarly in both groups. After adjusting for sex, age < 80 years remains an independent criterion for decision-making of an unclogging (OR = 3.5 [3.1 to 4.0], p <0.0001). Pre-hospital mortality was therefore greater for those above 80 years (1.3% against 0.5%), similarly, in-hospital mortality (15.7% against 3.8% in those under 80 years).
Discussion: The management of STEMI patients >= 80 years was associated with less reperfusion decisions than in younger people. However, to call to SAMU allowed to take the decision of unclogging in 83% of cases. The lack of decision-making certainly contributes to the excess mortality among those aged >= 80 years.
Julian MORO, Isabelle KLEIN, Hugues LEFORT (Metz), Sophie BATAILLE, Aurélie LOYEAU, François-Xavier LABORNE, Yann-Laurent VIOLIN, François DUPAS, Yves LAMBERT, Thévy BOCHE, Jean-Michel JULIARD
09:10 - 10:40 #1148 - #1148 - Pulmonary and venous ultrasonography improve the diagnostic accuracy of the Wells score in patients with pulmonary embolism.
#1148 - Pulmonary and venous ultrasonography improve the diagnostic accuracy of the Wells score in patients with pulmonary embolism.
Objective
Pulmonary embolism (PE) has a heterogeneous clinical presentation and international guidelines recommend the use of validated clinical scores to estimate the pre-test probability of PE. Recently, point-of-care ultrasonography has been widely used, proving to be accurate and useful in the diagnosis of deep venous thrombosis (DVT) and of many acute pulmonary pathologies. The aim of this multicentric prospective study is to compare the diagnostic accuracy of a clinical-ultrasonographic score (US-WS) with a clinical score as Wells score (WS).
Methods
We calculated the dichotomized WS (“PE likely” if >4 points, “PE unlikely” if ≤4) in consecutive adult patients suspected of PE presenting to four italian hospitals. In each patient lung and venous ultrasonography were performed by a physician blinded to clinical data. The US-WS differs from traditional WS in the following items: “signs and symptoms of DVT”, replaced by “evidence of DVT at venous lower limbs ultrasonography” and ”alternative diagnosis less likely than PE” replaced by ”alternative diagnosis less likely than PE after lung ultrasonography”. The last item was considered positive in presence of at least one subpleural infarct; in absence of lung infarcts and in case of an alternative echographic diagnosis such as pneumonia, pleural effusion or diffuse interstitial syndrome, the item was considered negative. Finally, in case of a normal lung US examination, the item had the same point assigned to the same item in the WS. Final diagnosis of was obtained by multidetector CT pulmonary angiography or when not feasible by lung scintigraphy and a 30 days clinical follow-up.
Results
Among the 339 enrolled patients, PE was finally diagnosed in 96 (28.3%). Two-hundred (59%) patients had a WS ≤4, and among them PE was present in 41 (20.5%). In the 139 patients (41%) with WS >4, PE was diagnosed in 55 (39.6%). Lung and venous ultrasonography was performed in 7±3 minutes. US-WS was ≤4 in 247 patients (72.9%, p<0.05 vs WS), of which 30 (12.1%) had PE as final diagnosis. In the 92 patients with US-WS >4 (27.1%, p<0.05 vs WS), 66 (71.7%, p<0.05 vs WS) had PE as final diagnosis. US-WS reallocated 85 patient (25.1%), moving 66 patients from PE likely to PE unlikely (only 7 had PE) and 19 patients from PE unlikely to PE likely (18 had PE). Sensitivity (68.8%, 95% CI 58.5-77.8) and specificity (89.3%, 95%CI 84.7-92.9) of US-WS where significantly superior to sensitivity (57.3%, 95%CI 46.8-67.3) and specificity (65.4%, 95%CI 59.1-71.4) of Wells score (p<0.05 for both). The area under the curve of US-WS (86.6%, 95% CI 81.9-91.4) was significantly superior to that of WS (64.5%, 95% CI 57.7-71.2) (p<0.05).
Conclusion
The US-WS is rapidly feasible at the bedside, increases the proportion of low-risk patients with a better global accuracy compared to traditional WS.
Peiman NAZERIAN, Marco VITTORINI (Firenze, ITALY), Chiara GIGLI, Emanuela GAMBETTA, Francesco Giuseppe SFERLAZZA, Baioni MICHELE, Valentina SALVATORI, Andrea NENCIONI, Simone VANNI, Stefano GRIFONI
09:10 - 10:40 #1260 - #1260 - Impact of off-hour presentation on process performances and outcomes in patients with ST-elevation myocardial infarction.
#1260 - Impact of off-hour presentation on process performances and outcomes in patients with ST-elevation myocardial infarction.
Background: Several studies examined the impact of off-hour presentation (cath lab staff available on call) on both the processing time of patients with ST-elevation myocardial infarction (STEMI) and the resulting outcomes. There is general agreement in the literature with regard to the importance of the processing timing of the patients, although data regarding increase in mortality as a function of processing timing are conflicting.
Objective: To evaluate the association between off-hour presentation, door-to-balloon time (D2B), first medical contact-to-device (FMC2D), total ischemic time (TIT) and in-hospital and 30 day mortality in patients with STEMI.
Methods and results: Through a retrospective analysis, we examined the medical records of patients admitted for STEMI documented within 12 hours from symptoms onset, who underwent an emergency PCI in a hub hospital in the period spanning from 01/01/11 to 12/31/14.
A total of 525 patients were included in the study; 352 of them (67%) reached to hospital in a moment of inactivity of the cath-lab (off-hour) with all or part of the staff not physically present, while 173 (33%) presented themselves during the hours of service of the cath-lab (on -hour).
The two groups were homogeneous for sex, age ≥75 years, cardiogenic shock, and bradycardia. The delay in seeking relief was similar in the two groups, significant differences emerged with regard to D2B, FMC2D and TIT; patients who arrived during off-hours showed longer D2B (median 65 'vs. 49', p<0.001), FMC2D (median 95.5 'vs 84 ', p<0.001): reperfusion was achieved less frequently in a time interval consistent with guidelines (≤ 90% FMC2D': 45.5% vs 56.2%, p=0.036, OR 0.65, 95 % CI 0.43 to 0.97); TIT was similar in the two groups (median 200 'vs 185', p=0.348).
These differences in time of reperfusion are confirmed after adjustment for age, sex, and access modality (emergency service vs self-presentation).
The in-hospital mortality was higher in patients presenting during off-hours (7.1% vs 2.3%, p=0.024, OR 3.24, 95% CI 1.11 to 9.46): 30 day mortality was also different although it did not reach the statistical significance (7.7% vs 3.4%, p=0.06, OR 2.33, 95% CI 0.94 to 5.74).
Conclusions: In our working setting patients with STEMI presenting during off-hours had revascularization times significantly higher: this data are associated with a significantly higher in-hospital mortality. These data highlight the need of improving the cath-labs organization as well as rationalize the allocation of resources in order to ensure adequate revascularization times to all patients with STEMI to improve significantly both clinical outcomes and survival.
Giovanni PERALTA (QUARTU SANT ELENA, ITALY), Nicola GLORIOSO, Fabrizio POLO, Umberto PISANO, Maurizio PORCU
09:10 - 10:40 #1269 - #1269 - Initial elevated blood glucose in acute heart failure syndrome: a prognostic factor.
#1269 - Initial elevated blood glucose in acute heart failure syndrome: a prognostic factor.
Background: Several biological prognostic indicators were analyzed in the acute heart failure syndrome (SICA) such as: hemoglobin, serum sodium, troponin levels…Initial hyperglycemia appears among these prognostic indicators (1).
Purpose: The objective of this work was to investigate the prognostic impact of the initial elevated blood glucose on mortality among patients with SICA admitted to the emergency department.
Participants and methods: We conducted a single- center, prospective, observational study. Inclusion of patients with SICA. Standardization of treatment according to clinical scenario (CS). Hyperglycemia was defined as:
- Diabetic known patient or unknown but with HbA1C ≥ 6.5%: hyperglycemia if glucose level ≥ 11mmol /L.
- No diabetes with HbA1C < 6.5%: hyperglycemia if glucose level ≥ 7mmol /L.
Results: One hundred eighty patients were included. Mean age= 66 ± 11 years [22-94]. Sex ratio= 1.27. Clinical history N (%): Hypertension 147 (81.7), known diabetes 124 (68.9). The distribution by clinical scenario N (%) : CS1: 121 (67.2), CS2: 14 (7.8), CS4: 44 (24.4), and CS5: 1 (0.6). Twenty three patients had an HbA1C test which allowed tracking 8 unrecognized diabetes (HbA1C ≥ 6.5%). Average blood glucose concentration at admission was 15.65± 8.4 mmol/L [3.3 - 44]. The initial hyperglycemia was noted in 128 patients (71. 1%): 96 diabetic, 32 without diabetes. Overall 21 patients (11, 7%) died during 30 days of follow-up, 24 patients (13, 3%) died during 90 days of follow up. Mortality at one month was significantly elevated in patients with initial hyperglycemia [14, 8% (n= 19) vs 3, 8% (n=2); p = 0,041]. The same difference was demonstrated at 90 days follow –up [17,1% (n=22) vs 3,8 % (n =2 ); p = 0,016).
Conclusion: Elevated blood glucose concentrations at presentation are associated with one month and three months mortality in acute heart failure syndrome admitted in emergency department.
(1): Mebazaa and al . J Am Coll Cardiol 2013; xx: 1-10
Hela MANAI (Tunis, TUNISIA), Sarra JOUINI, Kehna BOUZID GHOZZI, Dorra CHTOUROU, Rym HAMED, Imene BOUKHALFA, Khaled SAIDI, Bechir BOUHAJJA
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Oral Paper 2
Pain Management I
Moderators: Andrea FABBRI (Chief of Emergency Unit) (Forli, ITALY), Sabine LEMOYNE (Senior Staff Member) (Edegem, BELGIUM)
09:10 - 10:40 #1150 - #1150 - Femoral block with dexmedtomidine reduces postoperative opioid requirement in femoral shaft fracture.
#1150 - Femoral block with dexmedtomidine reduces postoperative opioid requirement in femoral shaft fracture.
Dexmedetomidin is a novel selective α-2 adrenoreceptor agonist with anxiolytic, sedative and analgesic properties that prolongs analgesia and decreases opioid related side effects when used in perineural as a local anesthetics adjuvant. The goal of this study was to test whether it has any effect on pain intensity and opioid requirements when injected perineurally alone.This prospective and double-blind study was conducted in 60 American Society of Anesthesiologist (ASA) class I–II patients undergoing femoral fracture shafts surgery. Based on block permuted randomization, the patients were randomly divided into two groups: D and C, with and without PNB respectively.In the group D ,dexmedtomidine 100 µg, was injected to surround the femoral nerve completely using US guidance. In both groups total postoperative opioid consumption,visual analogue score (VAS) for pain were compared. There was a significant different in postoperative narcotic required in the group D in comparison to the group C. No significant adverse effects were encountered among groups. The mean VAS scores showed a significant different immediately postoperatively and at6,12and 24 hours postoperatively in the group D in comparison to the group C (P < 0.05)For overall patient satisfaction, patients in the group D reported significantly higher mean satisfaction scores than those in the group C .In conclusion perineural administration of dexmedtomidine significantly decreased postoperative pain intensity in the patients undergoing femoral surgery.
Elham MEMARY (Tehran, IRAN, ISLAMIC REPUBLIC), Alireza MIRKHESHTI, Sadegh SHIRIAN , Ali ARHAMI, Aida KHADEMPOUR
09:10 - 10:40 #1283 - #1283 - Acute renal colic: appropriate clinical management in the emergency department ?
#1283 - Acute renal colic: appropriate clinical management in the emergency department ?
INTRODUCTION: acute renal colic (ARC) represents one of the most common causes of abdominal-lumbar pains (2.9%), and nontraumatic diagnosis (1.5 %) of emergency medical conditions. But ARC heterogenic management and inadequate analgesia are frequents. The goals of this study were (1) to evaluate emergency department (ED) practices concerning the use of analgesic drugs for optimal pain control or relief, urine diagnostic tests, and medical imaging techniques in patients with ARC; and (2) to compare this clinical assessment with national recommendations. METHODS: we performed a retrospective study of patients admitted in the ED from January 2012 to December 2013 with a final diagnosis of acute renal colic. RESULTS: during this period 440 ARC in 317patients were enrolled, of whom 213 men (71%), with an average age of 39 years. Sixty-five patients (20.5%) developed ARC recurrence (a total of 123 times) during this period. Concerning the pain intensity, 83% of patients had a score ≥ 5 on admission, using the Visual Analog Scale (VAS: 0-10) or the Numeric Rating Scale (NRS: 0-10). The meantime to pain acute care was 1 hour; but it was < 45 minutes if pain score ≥ 6. Paracetamol was the most commonly used drug for pain relief. Nonsteroidal anti-inflammatory drugs (NSAIDs), especially ketoprofen, were prescribed in 49.5% of patients. Morphine as the first choice of strong painkillers was used in only 18% of patients with pain score ≥ 8 on admission, but in 27% of them with score= 10. A NSAIDs-morphine combination therapy was prescribed as first-line drugs of choice in only 11 patients. A urine dipstick test for hematuria was negative in 20.5% of cases. A urine culture was performed in 89% of cases with positive urine dipstick test for white blood cells and/or nitrites: only 16% of them were positives. In spite of the absence of severity criteria, 73% of patients with first-episode ARC had at least one ED imaging test: sonography (42% of patients; ureteric calculi detection: 22%); noncontrast abdominal computed tomography (47%; ureteric calculi detection: 73%). Hospitalization was indicated for 74% of patients with ARC severity criteria. DISCUSSION: the application rate of ARC national recommendations was superior to 80% for almost of them. On the contrary, this rate was inferior to 70% concerning the prescription of NSAIDs (54%) and morphine (36%), and imaging indication in young people. CONCLUSION: The first priority in ARC is to ensure quick and effective relief of pain, but progress still has to be made on this matter. The respect of recommendations would improve the ARC management and diagnosis, and reduce costs and ED stay delay, critical challenges in emergency medicine.
Paul GAYOL (STRASBOURG CEDEX), Samuel OUDINECHE, Eric BAYLE, Fadi KHALIL, Manana POTOCNIK, Cecile ROUSSEAU, Ruxandra COJOCARU, Benjamin LEHR, Pascal BILBAULT
09:10 - 10:40 #1408 - #1408 - Effect of local Ketamine added to Lidocaine gel on perceived pain of men during urethral catheterization.
#1408 - Effect of local Ketamine added to Lidocaine gel on perceived pain of men during urethral catheterization.
Background and Objectives
Inserting foley catheter in male urethra is one of most annoying procedures in the emergency departments. Although most of the physicians use Lidocaine gel for alleviating pain and discomfort of this procedure, there are numerous of patients who need foley catheter complaining of its pain and discomfort
This study was conducted to examine the efficacy of local ketamine along with Lidocaine gel for instillation in the male urethra for easiness of urethral catheterization, as compared with using Lidocaine gel alone.
Method
A total of seventy four male patients who were scheduled to undergo urethral catheterization were randomly assigned to receive either 10mL of 2% Lidocaine gel mixed with 1mL normal saline (Lidocaine only group), or 10mL of 2% Lidocaine gel combined with 1mL Ketamine (50mg) (Lidocaine plus Ketamine group). Up to 8 mL of prepared mixture instilled directly into the urethra. Three minutes later by using sterile and standard technique and lubricating the appropriate catheter with whatever remained from the mixture, procedure was done
Baseline characteristics and hemodynamic variables of all patients including pulse rate, respiratory rate and blood pressure were measured before and after insertion of Foley catheter. Level of pain perception of patients at the baseline and after every procedure in both groups was recorded by using the numeric rating scale (from Zero to 10).
Result
There were no significant differences in baseline characteristics and hemodynamic changes between two groups of the patients, before and after the procedure. Although pain of urethral catheterization of “Lidocaine only” group were at tolerable level (NRS= 3.8), it was significantly decreased in “Lidocaine plus Ketamine” group (NRS=1.4)
Conclusion
Instillation of Lidocaine gel in conjunction with Ketamine locally in the urethra could decrease perceived pain and would make men undergoing urethral catheterization more comfortable during the procedure.
Amir NEJATI, Pegah LOTFABADI (Tehran, IRAN, ISLAMIC REPUBLIC), Behtash KHANIABAD
09:10 - 10:40 #1413 - #1413 - Evaluation of pain management for adult sickle cell patients in a emergency department.
#1413 - Evaluation of pain management for adult sickle cell patients in a emergency department.
Background: Pain is the main cause of presentation in an emergency department (ED) for patients with sickle cell disease. Due to the atypical presentation of those patients and the high doses of opioids needed to treat them, they are often misunderstood, under evaluated and under treated by the staff. For all those reasons we have written, in collaboration with the hematology department, a protocol including hyper-hydration and high dose of morphine.
Aims: The primary objectives were to evaluate the management of those patients and the adequacy of this treatment with the written protocol and the pain score defined by the use of an analogic visual scale(AVS) by the patients and by the nurses. The secondary endpoints were an evaluation of the satisfaction of the patients with a questionnaire, measuring an estimated time by the patients between the first contact and the administration of the first dose of analgesic drugs and finally the total dose of opioid given.
Methods: In partnership with the department of hematology, we realized an observational prospective monocentric study, after submission to the ethical committee, concerning the treatment of adult sickle cell disease patients in our ED. This study was performed during two years (from February 2013 until February 2015) . Informed consent was obtained previously during routine visit or in the emergency department when the patients were admitted for vaso-occlusive crisis. Both nurses and patients realized a pain evaluation on admission, with AVS, and the treatment was started using the written protocol. Before leaving the ED, patients received a satisfaction questionnaire to evaluate their degree of satisfaction. The questionnaire was graded from 1 (very bad) to 5 (very good).
Results: During this period, we registered 70679 consultations in our ED, where we recruited 104 observations (0.15%), reparsed on 51 patients. Mean waiting time was 18,6 minutes between first contact and first dose of analgesic drugs, but the received doses of morphine were significantly lower than those recommend on our protocol. The mean satisfaction score of patient was 3,8.
Discussion: Due to the presence of a protocol, we have noticed that the ED staff was more attentive and reactive to sickle cell disease patients, with a quick evaluation of the pain and a short delay between the first contact and the first dose of analgesic drugs. We also noticed a respect of the hydration program, but an underutilization of opioids, despite the presence of a specific protocol. However, we obtained a good global satisfaction of the patients concerning their management.
Conclusion: Despite the presence of a specific protocol, we can observe that the management of vaso-occlusive crisis is quite difficult and depends on the partiality of the staff in pain evaluation and the fear to entertain a opioid addiction by those patients. The presence of a written protocol is nevertheless a good point to sensibilize the team about this quite rare affection and formations given to the staff about this rare pathology help to improve the satisfaction of the patients.
My Quyen TRAN THI, Marie Agnes AZERAD, Sana BELHAJ, Coralie CHAN, Blanche DOHET, Thierry PRESEAU (Brussels, BELGIUM)
09:10 - 10:40 #1830 - #1830 - How to improve documentation of pain management.
#1830 - How to improve documentation of pain management.
RN Helle Ipsen, RN Christina Ørsted Rasmussen, RN Marianne Barylak. Emergency Department the Hospital of Nykobing Falster,
Introduction and purpose
Pain is a frequent cause leading to admission in the Emergency Department (ED,) and pain relief has importance for patient satisfaction. Surveys have shown that patient satisfaction is high, but audits in patient’s journals didn´t reflect this. Therefore, we have studied the gap between patient satisfaction, staff performance and documentation of pain management, to find the basic reason for the disagreement, which have led us to develop and implement a local guideline. The hypothesis was that the documentation only described a minor part of the efforts to treat the patient`s pain, and an altered approach to documentation of pain management would embrace the clinical efforts, and be shown in the patient files.
Materials and methodology
A validated semi structured questionnaire of ED nurses experience and attitude to pain management and their documentation is compared to patient satisfaction. A regional standard demands that all patients with a score > 3 on a Visual Analog Scale (VAS) have a documented plan and follow up of the effectiveness of treatment. Baseline data are results from the national investigation of patient satisfaction and standardized audit on the use of VAS in 77 cases. In the study, 20 nurses from the ED working 2 consecutive days had a questionnaire with 11 questions about how they document and perform pain treatment, and their experience of the barriers to follow the regional standards. In parallel, 20 acute patients were interviewed, and afterwards the documentation of their pain treatment was analyzed. After implementing a local guideline for pain management a follow up audit was carried out. Results are analysed with a mixed qualitative and quantitative analysis and presented as tables.
Results
Baseline data: 82-87% of the patients in the ED are satisfied with the pain management, and audit shows that 85% of all patients (n=77) have been asked about pain at arrival to the ED. Of 20 patients with a VAS > 3, audit showed less than 15% of the files contained a plan and follow up procedures for pain treatment. The nurses express a holistic approach to pain treatment using medication as well as non-pharmaceutical skills, but they experience lack of time, uncertainty about their skills in pain management and weak IT support as the main course of their insufficient documentation. Giving the nurses new opportunities to manage the patient’s pain at arrival, and instructions to use the available IT system in an easier way, the quality of documentation of pain management and follow up of the effectiveness of treatment are improved from 15% to 90%.
Conclusion
The study shows that the procedures nurses use to give pain relief might have importance for the patient satisfaction, although it is not demonstrated in their documentation. Giving the nurses policy options for pain management and demonstrating how to use the IT system in a simple way, can reduce the gap between documentation and the performed clinical skills.
Helle IPSEN (Nykøbing F., DENMARK), Christina ØRSTED RASMUSSEN, Marianne BARYLAK
09:10 - 10:40 #1990 - #1990 - Comparison of topical lidocaine and ketamine in reducing nasogastric tube insertion pain: a double blinded randomized clinical trial.
#1990 - Comparison of topical lidocaine and ketamine in reducing nasogastric tube insertion pain: a double blinded randomized clinical trial.
Introduction: Nasogastric tube insertion is one of the routine and painful procedures in emergency department. Lidocaine gel is routinely used for analgesia before nasogastric tube insertion. There are growing evidences on local effect of sub anesthesia doses of ketamine in reducing procedures pain without developing systemic effects. This study was designed and performed for comparison of routine nasogastric tube insertion with lidocaine and nasogastric tube insertion using ketamine.
Methods: This prospective double blinded randomized clinical trial was performed on emergency department's patients who were above 18 and without serious concurrent disease. Patients were divided into two groups. We administered 3ml (50mg) intranasal ketamine 5minutes before nasogastric tube insertion in one group and other group patients just received 3ml of distilled water in the same way. Nasogastric tube insertion was done by using lubricant gel in former and lidocaine 2% gel in latter group.
Results: Seventy four patients were enrolled in the study (equally distributed). There were not any significant differences between demographic data in two groups. Pain was significantly lower in ketamine group (visual analogue scale: 38.162 ± 8.398 vs. 57.417 ± 11.193); however there was not any significant difference on difficulty of tube insertion (mean 5 point Likert scale: 2.879 ± 0.451 vs. 2.680 ± 0.500). Complications were nearly same in two groups.
Conclusion: Nasogastric tube insertion using intranasal ketamine produces less pain than using intranasal lidocaine. Ketamine is a safe drug for nasogastric tube insertion in patients without serious concurrent illness. However, nasogastric tube insertion using ketamine is no way easier than insertion using lidocaine.
Arash SAFAIE (Tehran, IRAN, ISLAMIC REPUBLIC), Amir NEJATI, Reza SHARIAT MOHARARI, Ali ARDALAN, Seyedeh Roghieh LARIMI
09:10 - 10:40 #914 - #914 - Oral ketamine versus oral midazolam for sedation of children during laceration repair.
#914 - Oral ketamine versus oral midazolam for sedation of children during laceration repair.
Background: Children referred to the pediatric emergency department for suturing a laceration often require sedation in order to lower anxiety and pain and to induce amnesia.
Objective: To assess the efficacy of oral Ketamine vs oral Midazolam for sedation in laceration repair at the pediatric emergency department
Methods: Children aged 1-10 years with laceration requiring suturing were recruited at the pediatric emergency department. After obtaining consent from the legal guardian, children were randomly assigned using a computer-generated sequence to one of two groups. One group was treated with oral ketamine 5 mg/kg (maximal dose 70 mg) and the other was treated with oral midazolam 0.7mg/kg (maximal dose 20 mg). Parents and investigators were blinded to randomization until statistical analysis of the study was completed.
Main outcome measures were level of pain during local anesthesia, as assessed by VAS (visual analog scale) by the parent, and the number of children who failed oral sedation. Secondary outcomes were VAS by investigator, level of sedation using the UMSS (University of Michigan Sedation Scale), parents and physician satisfaction, length of stay and adverse effects.
The analysis of the data was done by intention to treat and per protocol. Groups were compared by t-test or Mann Whitney for continuous variables and by Fisher exact test for categorical variables. The estimated sample size was 26 children in each group.
Results: Eighty six eligible patients were approached and 68 children were recruited. Thirty seven children were allocated for treatment with Ketamine and 31 for Midazolam. Mean age was 5.6 + 2.1 years in children treated with ketamine and 4.5 + 2.1 years in children treated with midazolam (mean difference 1.1, 95% CI 0.05 to 2.1).There were no other differences between groups in the demographic characteristics. Failure to achieve adequate sedation was more common among children treated with ketamine. Twelve (32% ) of the children treated with ketamine required IV sedation compared with only two children (6%) of the children treated with midazolam (p=0.014). Twenty five children treated with ketamine and 29 children treated with midazolam completed the study. VAS by a parent during local anesthesia was 4.8 +3.3 in children treated with ketamine and 3.8 +3 in children treated with midazolam (mean difference 0.96, 95% CI -0.74 to 2.67). Average UMSS in children treated with ketamine and midazolam was 1.6+0.84 and 1.7+0.65 respectively. Average recovery time was 105.08+29.09 minutes in children treated with midazolam and 98.78+30.63 in children treated with ketamine. There was no significant difference between groups in the physician satisfaction from the procedure as assessed on VAS. No serious adverse effects were noted.
Conclusions: In children requiring sedation for laceration repair treatment with 5mg/kg of oral ketamine compared with 0.7mg/kg of oral midazolam resulted in higher proportion of sedation failure. In the doses tested, oral midazolam provide better sedation.
Orit RUBINSTEIN, Shiri BARKAN , Rachel BRITEBRAT , Sofi BERKOVITCH , Michal TOLEDANO , Natali KARADI , Anat NASSI , Eran KOZER (Zerifin, ISRAEL)
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State of the Art
Pulmonary Emergencies
Moderators: Barbra BACKUS (dordrecht, THE NETHERLANDS), Said LARIBI (PU-PH, chef de service) (Tours, FRANCE)
11:10 - 11:40 Assessment of suspected venous thromboembolism in 2015. Franck VERSCHUREN (Bruxelles, BELGIUM)
11:40 - 12:10 V&A in the ED: A blood gas masterclass. Anne-Maree KELLY (PHYSICIAN) (ESSENDON, AUSTRALIA)
12:10 - 12:40 Non-invasive ventilation in the ED. Roberto COSENTINI (Milano, ITALY)
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Italy invites
La Sofferenza in pronto Soccorso
Moderators: Agostino GERACI (ITALY), Mario GUARINO (NAPLES, ITALY)
11:10 - 11:30 Il dolore acuto in pronto Soccorso: riusciremo a gestirlo adeguatamente? Fabio DE IACO (Chief) (Imperia, ITALY)
11:30 - 11:50 Il dolore nel fine vita: progetto SIMEU per le cure palliative. Alessio BERTINI (Pisa, ITALY)
11:50 - 12:10 Comunicare le cattive notizie: il contenimento della sofferenza. Roberto RECUPERO (Cirie, ITALY)
12:10 - 12:30 La cura del "dolore" : quali ripercussioni sull' equipe di PS ? Carla OLIVETTI (ITALY)
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Clinical Questions: Controversies
Neurological Emergencies
Moderators: Giancarlo AGNELLI (Perugia, ITALY), Martin WIESE (UK)
11:10 - 11:40 How and where should TIA patients be evaluated? Andy JAGODA (USA)
838:5 - 12:10 Which patients with acute headache should be imaged? Vincent BOUNES (Toulouse, FRANCE)
12:10 - 12:40 Which patients with back pain need emergent MRI? Jonathan EDLOW (USA)
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Research
Cardiovascular Emergencies
Moderators: Rick BODY (UK), Eric REVUE (Head of the ED and prehospital EMS) (Paris, FRANCE)
11:10 - 11:40 Do we need another hero? Tomorrow's cardiac biomarkers. Rick BODY (UK)
11:40 - 12:10 Aortic Catastrophes. Rob ROGERS (USA)
12:10 - 12:40 Advances in the pre-hospital diagnosis of acute coronary syndromes. Jacob SORENSEN (DENMARK)
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YEDM
Sim Wars
Moderators: Pier Luigi INGRASSIA (Novara, ITALY), François LECOMTE (Paris, FRANCE)
Coordinators: Abdo KHOURY (PH) (Besançon, FRANCE), Youri YORDANOV (Médecin) (Paris, FRANCE)
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Paediatric Track
Paediatric Infectious Disease
Moderators: Ian MACONOCHIE (UK), Yehezkel WAISMAN (ISRAEL)
11:10 - 11:40 Paediatric Infectious Disease. Javier BENITO FERNANDEZ (Getxo - Vizcaya, SPAIN)
11:40 - 12:10 Sport and Exercise Medicine in the Paediatric ED. Tom BEATTIE (UK)
12:10 - 12:40 Panel discussion.
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Oral Paper 1
Management / ED Organisation I
Moderators: Lars Petter BJORNSEN (Emergency Physician) (Trondheim, NORWAY), Susan ROBINSON (Doctor) (Cambridge, UK)
11:10 - 12:40 #1107 - #1107 - An experienced nurse as Flow Processing Manager in the Emergency Department to overcome overcrowding-related risks.
#1107 - An experienced nurse as Flow Processing Manager in the Emergency Department to overcome overcrowding-related risks.
INTRODUCTION / BACKGROUND
Emergency Departments (EDs) are struggling with crowding and its associated morbidity, mortality, and decreased patient and health-care worker satisfaction
In an era of ED overcrowding, an efficient triage system is essential because it allows the emergency team to treat patients according to the urgency of their condition
AIMS, MATERIALS / METHODS
A triage liaison provider may be a way to improve ED throughput, when additional staff resources are available, in an effort to improve patient satisfaction, decrease waiting time (WT), improve clinical care and decrease lost revenue from patients leaving without treatment.
A senior experienced nurse, with known both technical and non-technical skills, was added in the ED, during daily shifts (h 8-14 and 14-20) in working days, acting after the usual nurse triage protocol, and before the Medical Doctor (MD) taking charge of the patient.
His tasks, as a Flow Processing Manager (FPM), were:
- to upgrade triage evaluation process and improve throughput efficiency in a timely manner,
- to early identify time-dependent situations (by clinical or welfare conditions) and outliers,
- to redirect and address (according to the instant picture of the ED) the specific patient (according to his acuteness, frailty and complexity), to a specific route (according to the need for less or more intensive care), and to a specific MD (according to his expertise, and being more or less busy).
We performed a prospective “before and after” cohort study, in the ED of a University Teaching Hospital, from 08/4/2012 to 07/4/2013, and from 08/4/2013 to 7/4/2014, to assess the impact of FPM in terms of WT, rate of outliers, patients Left Without being Seen (LWS), and MD performances.
RESULTS
We compared “before” (control group) and “after” (intervention group) data (respectively):
the number of triaged patients augmented (67400 “before” versus 70922 “after”);
waiting times (media; in minutes.seconds) slightly changed depending on “triage code” (red 7.04 versus 7.02; yellow 15.32 vs 21.25, green 84.10 vs 88.07, white 88.55 vs 78.04);
total time spent in the ED (media; in minutes) dramatically changed depending on “triage code” (red 221 versus 940; yellow 988 vs 1159, green 218 vs 699, white 161 vs 177);
the number of patients admitted slightly increased (24687 versus 24759);
LWS rate decreased (1135 versus 741).
CONCLUSIONS
In the ED the introduction of an additional experienced nurse provider as FPM showed the ability to ameliorate patient throughput, waiting times and LWS rates, improving both safety and quality of care, even coping with the dramatic increase in length of staying due to overcrowding and shortage of beds.
ED waiting rooms are high liability areas for hospitals: opposite to trends towards overall increasing risks, the addiction of a FPM can actually reduce risks in individual patients
Chiara LANZARINI, Rodolfo FERRARI (Bologna, ITALY), Sauro CANOVI, Gianni VITALE, Mario CAVAZZA
11:10 - 12:40 #1134 - #1134 - Critically ill patients in the shock room: We must improve !
#1134 - Critically ill patients in the shock room: We must improve !
Introduction: patients in the resuscitate room (or shock room) are considered the most critically ill patients and correspond to 4-5% of vital distresses in an ED according to literature. Our main objective is to optimize its use and thus provide a better quality of care.
Materials and Methods: A retrospective comparative analysis of patients treated in the shock room during 3 years (2012-2014) in a General Hospital ED since the implementation of a 24 hours/day dedicated resuscitate Team composed by the prehospital EMT (senior Emergency Physician, nurse and nurse aide). Patients’ demographic data, diagnoses and outcomes were accessed. Comparison of patients chief complaints to Nurse and Physician Triage, analyze of Waiting Time (WT), Length of Stay (LOS).
Results: In the last 3 years among 41000 visits / year in the ED, the absolute rates of emergency room utilization rose, the rate of unstable patients demanding urgent intensive care regularly increase with a mean number of 445 patients / year (4% of all admissions) in 2014. Sex Ratio 60 Male /40 % Female. Average age 62.7 years. Most important activity on Monday 16.5% vs 11.5% on Saturday, hourly peak 11-12 AM 7.1% vs 3% 9 / 10am activity increased in winter 34.6% vs 27.5% in summer. Neuro-vascular disorders (18%) multiple trauma (15.6%) and respiratory distress 12.4% . Before their admission in the ED, 39 % of patients were managed by prehospital EMS . A majority of these patients had severe Triage level (1-2) but 52% of patients were initially in the general ED ward and not in the shock room. The LOS in the resuscitate room is 2 hours for 66% of patients and remains stable despite the increasing activity of ED visits. Patients were oriented to the intensive care unit (31%), Observation Unit (26%) or transferred (10%) in other centers.
Discussion: our study highlights essential points for the initial triage and the impact of a LOS on morbidity /mortality for critically ill patients .Optimal management of the shock room with regular training of multidisciplinary medical team to determine whether subjects need immediate admission to the shock room. Risk management precautions dictate that under no circumstances would an unstable patient remain in the open triage section of the emergency room under inferior surveillance and need to stay immediately in the shock room. A new protocol with the Triage Team is in progress to evaluate the impact on the management of the shock room.
Conclusion: management of the shock room is an important part of the treatment chain of the severely injured patients in the Emergency Department. Successful management in the resuscitate room requires a reliable and effective tailored guidelines for evaluation and decision protocol of Triage and regular evaluation of patients in the ED.
Eric REVUE, Alexandre HENNIART (PARIS), Akim SADDAR, Perrine MEGRET, Delphine CASENAVE, Melinda PERCHERON
11:10 - 12:40 #1444 - #1444 - A New Model of Urgent Care Centre in the Emergency Department of the United Kingdom.
#1444 - A New Model of Urgent Care Centre in the Emergency Department of the United Kingdom.
A New Model of Urgent Care Centre in the
Emergency Departments of the United Kingdom
Abstract
Introduction: Primary Care patients in the accident and emergency departments have been the topic of discussion since 1998 in the United Kingdom. Numerous studies have analysed attendances retrospectively and suggest that at least one third to two thirds of patients attending the emergency department with problems which could be managed appropriately in General Practice. The pattern of emergency department usage seems to be international. Outside the United Kingdom in Australia and many departments in the United States include walk in facilities. Staffed by Physicians on family practice residency programme. It clearly appears in the United Kingdom that emergency departments have to accept that such patients with primary care problems will attend the emergency department and facilities will have to be provided to provided services to these patients.
Urgent care centres were developed near the accident and emergency departments to reduce the pressure on the emergency departments. Unfortunately this has not happened. It has been noticed that when more patients are seen in Urgent Care Centres the number of attendances in emergency departments increase as well.
Objective: We started a new model of Urgent care centres where the urgent care centre was located in the emergency department and is staffed by a General Practitioner and a Senior Doctor in the department.
Method: We studied the number of patients, type of patients and the time it took for the patients to be seen in the Urgent Care Centre.
Results: Our Urgent Care Centre has been running for the last six months and we have seen a gradual increase in the number of patients being seen from 6.89% to 46.85% now. Most of these patients were in the category 4 and 5 according to the Manchester Triage System.
Discussion: It has been recognised that primary care patients in the Emergency Department are a major part of attendances of the Department and unless the patients are seen in Urgent Care Centres, overcrowding and long waits in the Emergency Department could not be avoided. It has been shown that employing Primary Care Physicians in the Emergency Department reduce the costs of Emergency Departments because Primary Care Physicians do not carry out as many investigations as by the junior doctors in the Emergency Department and the number of admissions are reduced as well.
Conclusion: None of the patients had to wait for more than two hours to be seen in the Urgent Care Centre and we feel that the care provided to the patients by the Urgent Care Centre is highly effective, reduces costs and is satisfying for the patient.
Mohammad ANSARI (Solihull, UK), David FOROUGHI, Ahmed ISMAIL, Aslam R TABANI, Muhammad ARFAN
11:10 - 12:40 #1482 - #1482 - The impact of ramadan on emergency department attendances in a tertiary care hospital of middle east.
#1482 - The impact of ramadan on emergency department attendances in a tertiary care hospital of middle east.
Background:
Emergency Department (ED) patient attendances have an inherent variability during certain periods of the day and month to month1. Predictability of this pattern helps in planning adequate staffing ratios and allocating resources. During the month of Fasting (Ramadan), healthy adult Muslims do not eat or drink from dawn to dusk2. During this month, in the Middle East, there is a significant change in the sleep-wake pattern of the society3. It is not known, if these social and cultural factors affect the ED attendance pattern.
Objectives:
This is a retrospective study of ED patient attendance variability in the day and night shift during Ramadan, in a tertiary care hospital of a country with a predominantly Muslim population. This will improve understanding of patient presentation patterns and will assist managers to align resources with the patient care presentation.
Method:
The data was retrieved from the Hospital’s integrated clinical information system (ICIS). All ED visits during the Islamic calendar year of 1432 (December 7, 2010 - November 25, 2011) were included. Direct admissions to the hospital are excluded. Descriptive statistics for the continuous variables are reported as mean± standard deviation and categorical variables are summarized as frequencies and percentages. Continuous variables are compared by Student’s independent t-test or ANOVA as appropriate; while categorical variables are compared by Chi-square test. The level of statistical significance is set at p<0.05. The statistical analysis of data was done by using the software package SAS version 9.3 (Statistical Analysis System).
Result:
A total of 58,859 patients presented to ED, 33,602 (57.09%) were during the day shift (0700 to 1900 hrs.) and 25,257(42.91%) during the night shift (1901 to 0659 hrs.). A total of 50,470 patients (85.75%) were discharged home and 5,142 (8.73%) were admitted to the hospital. Average monthly patient visits during the day were 2,800 (57%) and 2,105 (42%) during the night shift. There was a statistically significant difference in the arrival time of the patients during Ramadan and the attendance pattern was reversed; 1614 (39%) patient during the day and 2,568 (61%) during the night shift (p<0.0001) (Table 1). However, there was no statistical difference in patient admissions and discharges (p>0.1).
Conclusion:
ED patient attendance pattern changed during Ramadan with greater number of patients presenting during the night. Therefore, allocation of resources in ED of tertiary care Hospitals of predominantly Muslim populations, should match the nocturnal arrival pattern of the patients.
Taimur BUTT (Riyadh, SAUDI ARABIA), Israr AHMED, Abdelmoneim ELDALI, Hameed Ullah KHAN
11:10 - 12:40 #1494 - #1494 - CEM books- A facebook for emergency department.
#1494 - CEM books- A facebook for emergency department.
I am Dr Anantha Nag Kadiyala, an Emergency medicine Consultant working in United Kingdom at Bradford Royal Infirmary. I would like to present this excellent software tool which would benefit Emergency departments to maintain and monitor safety. College of Emergency Medicine (CEM) books is a suite of mobile & web applications designed by NHS consultants and managers being used in emergency departments (ED) to better understand the demands on their systems, share information and make intelligent informed decisions. Users quickly enter logs and situation reports with live metrics of personalised performance indicators. These are analysed to give an overall visual status of a department and predict performance. Status and issues are escalated to key individuals able to enact immediate responses. In app access to key documents, phone numbers and web links promotes real time consistent adherence to current trust policies.
Features:
1. Situation Reports: Structured assessments of your department’s key performance indicators could be quickly entered to create a comprehensive understanding of departmental status.
2. Handover: Capture departmental handovers in an accessible, retrievable and searchable format. It uses the Royal College approved ABCDE handover structure with added personalised features specific to the department.
3. Log Book: Quickly enter structured situation, background, assessment & recommendation (SBAR) logs detailing important events and interactions. This would help sharing the experiences and difficulties by the staff working in the department. These logs can be tagged to categorise and identify the themes targeting important issues.
4. Escalation & Sharing: Relevant Information is escalated vertically and shared horizontally across the organisation allowing team members to see and respond in real time.
5. Analysis: Key Performance Indicators could be visualised by hour, day, week & month. Recurrent themes could be searched by using tags. The status of the Emergency department could be divided into three categories (red, amber and green) depending on the safety. For e.g. Indicators of emergency department of Bradford Royal Infirmary are as follows.
- Patient Vs doctor ratio
- Ambulance hand over time
- Time to triage
- Capacity of resuscitation room, paediatric, majors and minors cubicles
- Average time to see a patient in each area of the department
- Number of senior doctors, Nursing staff
- Number of patients awaiting beds
- Specialist review time in ED
6. Notifications: Notifications can be sent as in app push messages, emails or text messages. Notifications could be tailored according to the personal need.
7. Feedback: Staff requested friends and family feedback ensures local ownership and control. Feedback is anonymously linked to staff members, teams, and live departmental performance. Paper and administration free system promotes personal, team and business values.
8. Rule Book: Immediate access to all relevant departmental documents. Built in governance structure to ensure only approved current guidance with clear ownership & expiration dates will be available.
9. Phone Book: Immediate access to all relevant departmental phone numbers. It foregoes the need for landlines and calls to switchboard operators. Personalised favourites lists could be created if necessary.
Anantha Nag KADIYALA (Bradford, UK), Brad WILSON
11:10 - 12:40 #1507 - #1507 - Capacity modelling of an emergency department observation unit by discrete event modelling.
#1507 - Capacity modelling of an emergency department observation unit by discrete event modelling.
April 2015 we have moved to a new emergency department (ED) with less treating positions while there is a steady increase in the yearly number of patients. Because in the former ED we were already facing flow problems with an increasing length of stays (LOS) we decided to change policies in order to accelerate flow in the ED and between the ED and the hospital. A previous study showed that the introduction of an observation unit (OU) could help to guarantee patient flow in the ED. Therefore a 30-bed OU is deployed in the new hospital. The aim of this preparatory study was to estimate the required number of beds in the OU. The number of beds needed was calculated by discrete event simulation using Arena Software (Rockwell Software). The model maps the patient flow in the ED and between the ED and hospital wards like the OU. Input in the model were admission pattern, interval times for clinical, diagnostic and therapeutic ED interventions, LOS in both the ED and the hospital of a representative sample of 4734 patients, admitted to the ED between October, 1st 2012 and September, 30th 2013. The model allows to estimate the number of observational beds needed for several scenarios. In all scenarios, it was assumed that all patients first are transferred to the OU before they eventually are admitted to another hospital ward, except for 33% of the patients in need of special care like intensive care, obstetrics, psychiatry or paediatrics. Another basic rule was a maximal LOS in the OU of 48h. In order to get a grip on the capacity range of the OU, we introduced different what-if scenarios with variability in the LOS of the ED and the OU. For the ED the values for LOS were not truncated (no maximum) or truncated at a maximum of 8h, 6h and 4h in four different scenarios. For the OU the maximal LOS was 48u but the peak of the triangle distribution of LOS was set at 24, 30 or 36h. Combination of different scenarios for the LOS at the two levels of the ED and the OU induce differences in the needed capacity of the OU. The results of the study show that the P75 of required bed positions in the OU range between 26 (no maximal LOS in ED combined with peak LOS in OU of 24h) and 34 (LOS in ED maximal 4h, peak LOS in the OU of 36h). Discrete event simulation, if based on a representative database, allows to map patient flow revealing bottlenecks and to perform what-if scenarios for capacity without disturbing the real life practice. This approach helps to choose the best scenario to optimize the patient flow in the future ED to the OU with 30 positions. The model shows that the OU cannot handle all admitted ED patients and therefore some ED patients will still have to be admitted directly at the correct hospitalisation ward bypassing the OU.
Diederik VAN SASSENBROECK (GENT, ), Tim DEBACKER, Paul GEMMEL, Paul CALLE
11:10 - 12:40 #1594 - #1594 - A protocol-driven organisation in Observation Units Services reduces admission and increases appropriateness: an Italian comparative study.
#1594 - A protocol-driven organisation in Observation Units Services reduces admission and increases appropriateness: an Italian comparative study.
Background
The health care reform of the last years in Italy brought to a significant reduction of hospital beds for acute admission and the Emergency Departments (ED) have to intervene on the organisation of more structured Observation Units (OU) in order to observe and treat patients with a high probability of early discharge, who need a management longer than 6 hours (limit for a simple ED visit). In general, the maximum length of day in the OU is 30 hours.
In many regions of Italy the OUs have been structured with dedicated beds and organised with specific protocols for some pathological conditions. In the Piedmont region such protocols have some defined outcome indicators, previously established and reviewed periodically. In other regions such process is in progress and specific protocols are not yet available.
Methods
In this study we have compared the performance of the EDs of two secondary hospitals: the first, in Piedmont region (S. Andrea hospital, Vercelli), with a structured OU and defined protocols and the second, in Marche region (S. Lucia Hospital, Macerata), without a structured OU. We have focused the attention in the management of 4 specific conditions-atrial fibrillation (AF), hypoglycaemia, epilepsy/seizures, head injury-to assess the adherence to such indicators. The results of Macerata hospital have been evaluated according to the indicators of Vercelli.
Results
In Vercelli hospital the ED visits were 30348 from January to December 2013; the overall admission rate was 12.5% of the admissions; 3893 pts were kept in the OU (12,8%) and among them 751 were admitted after the observation period (18,8%).
In Macerata hospital the 2013 ED visits were 29686 and the overall admission rate was 20.2%; 1451 patients were kept in the OU (4,89%) and the admissions were 596 (41,1%).
The mean length of stay in the OUs was around 18 hours in both hospitals.
The outcome indicators for the 4 protocols considered were: AF <5% admissions, Hypoglycaemia <10% admissions, Epilepsy/seizures <30% admissions, head trauma 100% CT scan in anti coagulated patients.
All the outcome indicators have been respected by the Vercelli OU, while the admission rate for AF in Macerata was 14%, for Hypoglycaemia 60%, for Epilepsy 46%. The head trauma indicator was met in both hospitals
Conclusions
A structured OU allows to increase the number of patients observed and to decrease the total number of admissions, improving the appropriateness with a rational use of hospital beds.
The presence of specific protocols allows to better categorize patients and to evaluate the appropriateness of the interventions according to the relative outcome indicators.
Aldo TUA, Barbara GABRIELLI (VERCELLI, ITALY), Roberta PETRINO, Tamara MARIANI, Domenico BORRUSO, Michele SALVATORI, Roberta TERRIBILE
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Oral Paper 2
Pre-hospital and transportation
Moderators: Joost BIERENS (Thesis Coordinator EMDM) (Brussels, BELGIUM), Gregor PROSEN (MARIBOR, SLOVENIA)
11:10 - 12:40 #1063 - #1063 - From chest-pain onset to the angioplasty, observation of delays in different stages of pre-hospital management of acute coronary syndrome with ST-segment elevation: prospective study.
#1063 - From chest-pain onset to the angioplasty, observation of delays in different stages of pre-hospital management of acute coronary syndrome with ST-segment elevation: prospective study.
Introduction: In the strategy of ST-segment elevation myocardial infarction (STEMI) management, response time of a mobile intensive care unit (MICU) may be influenced by urban population density, and accessibility to the catheterization laboratory (cath-lab).
Objective: Evaluate delays in STEMI management, for each stage, from onset chest-pain to the catheterization.
Method: Data derived from a prospective register including non-complicated STEMI having primary percutaneous coronary intervention (PCI), managed by 6 medical care intensive units (MICU) of a French city: 3 in town (T) and 3 in suburb (S). The observed variables were the place of management (T or S), the time delays of the various stages: time delay from chest-pain onset to the first medical contact (FMC) by the patient to the pre-hospital despatching emergency medical service – time delay FMC to MICU arrival – cath-lab door (cath-lab) – needle – catheterization (KT). We compared delays between MICU T and S using the Wilcowon test (p value < 0,05).
Results: In 2012, 137 STEMI have been included, T= 62 (45%), S= 75 (55%). Charts reports time delays of various stages. Global median time delays of management were T= 113 [110; 130] min vs S= 112 [101; 125] min (p= 0.8906). Median time delays from the 15-call to FMC were T= 20 [13; 35] min vs S= 22 [14; 36.5] min (p=0.4122) with a higher dispersion for the MICU S. Median time delays from FMC to the cath-lab were T= 49.5 [40.3; 60] min vs S= 53 [45.3; 61.8] min (p= 0.1365) with a higher dispersion for the MICU T in this case. The MICU did not influence anymore the time delays of management since they have confided the patient to the cath-lab team. Median time delays from the cath-Lab to needle were T= 20 [10; 30] min vs S= 19 [11.5; 26] min (p= 0.8546). Finally, median delays needle to KT were T= 13.5 [7.5; 15] min vs S= 13 [10; 20] min (p= 0.2707). By stage, there was no significant statistical difference for a patient managed by a MICU in suburb or in town. The MICU S came later but took less time to dispatch the patient to cath-lab.
Discussion: the distribution of cath-lab more scattered in suburb, but more easily accessible that in town does not seem to influence time delays of management by the MICU, and thus doesn’t affect the management of STEMI patients. There is therefore no loss of opportunity for a patient in our region managed by a MICU in town or in suburb respectively. Other factors must be studied on a more important sample of patients.
Hugues LEFORT (Metz), Alain COURTIOL, Aurélie LOYEAU, Laurence SZTULMAN, Yann-Laurent VIOLIN, Amandine ABRIAT, Jonathan GONZVA, Olivier YAVARI-SARTAKHTI, Isabelle KLEIN, Michel BIGNAND, Jean-Pierre TOURTIER
11:10 - 12:40 #1083 - #1083 - A prospective registry: best performance for prehospital reperfusion decisions in case of high volume of managed ST-segment elevation myocardial infarction (STEMI)?
#1083 - A prospective registry: best performance for prehospital reperfusion decisions in case of high volume of managed ST-segment elevation myocardial infarction (STEMI)?
Introduction: Amount of reperfusion therapy (primary percutaneous coronary intervention (pPCI) or fibrinolysis) performed is a determinant of mortality in STEMI patients. The decision to propose reperfusion therapy is a cornerstone of STEMI patient management in the pre-hospital setting, and the 2012 European Society of Cardiology guidelines suggest that the frequency of reperfusion decisions represents a marker of quality of care.
Objective: To determine whether the number of STEMI managed by Mobile Intensive Care Units (MICU) and Emergency Medical System services (SAMU: Service d'Aide Médicale Urgente) is a determinant of the frequency of prehospital reperfusion decisions.
Methods: The eMust registry was set-up by the regional health authority of the 12-million-population of Paris region in France to prospectively collect data on all STEMI patients transported by the physician-staffed SAMU ambulances. The registry has been ongoing since 2003 and all data gathered up till 2013 were used for the present analysis. Emergency physicians from MICU initiate treatment in the prehospital setting and take the initial decision of reperfusion (primary PCI or fibrinolysis). Results were statistically significant if p< 0.05.
Results: During the 11-year study period, 18,294 STEMI patients were included by 8 SAMU and 41 MICU were dispatched on site. The mean number of STEMI managed by each SAMU was 2,287, with a minimum of 139 and a maximum of 300; and a mean number of those managed by each MICU of 457 with a minimum of 7 to a maximum of 152 inclusive. Decisions made by each MICU to send the patients for reperfusion therapy ranged from 73% to 97%. Total decisions were pPCI: 76% and fibrinolysis: 24%. Decisions by each SAMU to send the patients for reperfusion therapy ranged from 90% to 95%. There was a significant difference in the frequency of reperfusion decision between SAMU and MICU (Chi2 test, p < 0.0001) in the region, between 2003 and 2013: 18% of prehospital thrombolysis, 74% of direct referral to the Cath Lab, 7% of non-decision. However, this frequency of decision was not correlated (R= 0.1264) to the volume of managed STEMI (SAMU or SMUR) without being significant (T-distribution, p= 0.4371).
Gilles LENOIR, Jonathan GONZVA, Hugues LEFORT (Metz), Yves LAMBERT, Aurélie LOYEAU, Nicolas DANCHIN, Thévy BOCHE, François DUPAS, Sophie BATAILLE, Frédéric LAPOSTOLLE
11:10 - 12:40 #1146 - #1146 - Presence of Staphylococcus aureus and Enterococcus in Danish ambulances. A cross-sectional study.
#1146 - Presence of Staphylococcus aureus and Enterococcus in Danish ambulances. A cross-sectional study.
Background
Every year approximately one out of ten Danish patients contract an healthcare associated infection (HAI). Staphylococcus aureus and Enterococcus are, among others, known as prominent in the group of pathogenic bacteria that underlies HAI, causing the patients unnecessary genes and prolonging their hospitalization. Bacterial colonization often occurs due to indirect patient-to-patient transmission, caused by poor hygiene complience. This study aimed to determine the level of contamination with S. aureus/MRSA and Enterococcus/VRE on pre-cleaned blood pressure cuffs in the Danish medical service. This study is conducted in cooperation with the "Emergency Medical Services, Capital Region of Denmark", Copenhagen Fire Brigade and Frederiksberg Fire Brigade.
Method
In the Capital Region of Denmark, 50 blood pressure cuffs from 39 different ambulances were tested for S. aureus and Enterococcus in this cross-sectional pilot study. Prints were collected using specific agar plates, no earlier than one minute after cleaning with Ethanol wipes. Furthermore, positive prints were typed and determined of resistance.
Results
Both S. aureus and Enterococcus were present on pre-cleaned blood pressure cuffs however, to a limited extent. The average level of contamination by S. aureus was 0.54 CFU per 25 cm2 (SD 1.98). Minimum and maximum values were ranging from 0 to 11 CFU per 25 cm2 and the prevalence of 50 prints were 10%. The average level of contamination by Enterococcus was 0.06 CFU per 25 cm2 (SD 0.42). Minimum and maximum values were ranging from 0 to 3 CFU per 25 cm2 and the prevalence of 50 prints were 2%. The positive Enterococcus isolate belonged to Enterococcus faecalis, and showed no resistant genes. All S. aureus isolates were methicillin sensitive S. aureus (MSSA).
Conclusion
Potentially pathogenic bacteria are detectable on equipment thought to be clean. However, none of the detected bacteria showed resistant properties, which could indicate a low rate in the prehospital setting. The findings of pathogens after cleaning may be due to cross-contamination, improper cleaning or limited effect of the cleaning procedure. Therefore, a thorough examination of the contamination level, effect of different cleaning procedures as well as increased focus on hygiene challenges in the prehospital setting is recommended.
Heidi Storm VIKKE (Kolding, DENMARK), Matthias GIEBNER
11:10 - 12:40 #1202 - #1202 - Using of LUCAS II device for CPR by regional no-urban Medical Emergency Service.
#1202 - Using of LUCAS II device for CPR by regional no-urban Medical Emergency Service.
Background: LUCAS II was developed for automatic chest compressions during cardiopulmonary resuscitation (CPR). Current evidence on the use of this device in out-of-hospital cardiac arrest (OHCA) is still insufficient.
Purpose: The aim of this study was to compare the effect of CPR for OHCA with and without LUCAS by Regional non-urban Emergency Medical Service (EMS) in physician-present pre-hospital medical system (randes-vous system).
Methods: We analyzed a prospective registry of all consecutive OHCA patients in four EMS stations, two of them used LUCAS device in all CPR, the EMS crews in other two stations used manual CPR. Individuals with contraindication to LUCAS or with EMS-witnessed arrest were excluded.
Results: From May 2010 to June 2014 337 patients were included in the OHCA registry. Fifty-nine patients were excluded from the analysis because of contraindications to LUCAS or EMS-witnessed arrest. Data from 278 patients were included in the analysis, 144 with LUCAS and 134 with manual CPR.
We observed more witnessed arrests in LUCAS group (64,18% vs. 79,17%,p=0,0074) and more asystoly as initial rhythm in LUCAS group (48,51% vs. 69,44%,p=0,0004). We did not find significant differences in return of spontaneous circulation (ROSC) between the groups (30,6% in nonLUCAS vs. 25% in LUCAS, p=0,35), in ROSC in arrests of cardiac etiology (31,25% vs. in non LUCAS vs. 24,18% in LUCAS, p=0,31) and in ROCS if initial rhythm was ventricular fibrillation (51,43% in nonLUCAS vs. 46,43% in LUCAS, p=0,80). In LUCAS group we observed significant more conversions from non-shockable to shockable rhythm (10,10% vs. 20,7%, p=0,0396). 180 days follow up was provided by in patients (85% of patients with ROSC in both groups). We observed significant more survivors in nonLUCAS group (p=0,0198). We did not find any survival difference in arrests of presumed cardiac etiology (p=0,3175).
Conclusions: The use of automated chest compressions with LUCAS system in our study did not improve survival rate in OHCA. We observed significantly higher 180-days mortality in LUCAS treated patients by regional non-urban EMS.
Jiri KARASEK (Liberec, CZECH REPUBLIC), Rostislav POLASEK, Alena RECHOVA, František KLEIN, Petr OSTADAL
11:10 - 12:40 #1242 - #1242 - Telemedicine consultation with physician at the emergency medical center from ambulances enables emergency medical technicians to treat-and-leave more patients – a before and after pilot study.
#1242 - Telemedicine consultation with physician at the emergency medical center from ambulances enables emergency medical technicians to treat-and-leave more patients – a before and after pilot study.
• Background / introduction
Ambulance dispatch is the first step on the path of treatment of acutely ill patients. Changing the course of this path affects all parts of the health care system involved in emergency patient care.
In this pilot-study we manned the Emergency Medical Dispatch Center (EMDC), Aarhus, 24/7 with physicians experienced in emergency care. All non-critically ill patients (category B&C) in the Central Denmark Region who called 1-1-2 and received an ambulance were given telemedicine assessment by the EMDC physician. The purpose of the assessment was to treat-and-leave if judged safe.
• Participants and methods
Trial design: Controlled before and after study
Intervention: Systematic prehospital teleconsultation from ambulances to EMDC physician 24/365 15-28 September 2014.
Control: Fraction of patients treated and left 16-29 September 2013 without telemedicine assessment.
Participants: All non-critically ill patients in the Central Denmark Region who called 1-1-2 and received an ambulance.
Outcome measures:
- Fraction of non-critically iLl patients treated and left.
Statistics: chi2
- Safety of telemedicine based treat-and-leave.
- Rate of treated-and-left patients admitted to hospital within three days
- 30 day mortality
Statistics: chi2
• Results
- Patients treated and left.
In 2013 641 non-critically ill 1-1-2 patients received an ambulance compared to 774 in 2014. The fraction of patients being treated and left was 0.3320 in 2014 (257 patients) and 0.2605 in 2013 (167 patients) giving an OR=1.410, 95%CI [1.112, 1.791], P=0.0035. In total 125 patients were treated-and-left after telemedicine assessment by EMDC physician.
- Safety. Data analysis is ongoing.
• Discussion/conclusion
The fraction of non-critically ill 1-1-2 patients treated and left after telemedicine assessment is surprisingly high.
This could indicate an unused potential for the EMDC physician in the prehospital patient care and that the EMDC physician may play a more active part in the care of emergency patients in the future.
Safety evaluation awaits.
• Acknowledgements
The study war partly funded by the Prehospital Emergency Medical Services, Aarhus, Central Denmark Region.
Nikolaj RAABER (Aarhus C, DENMARK), Ingunn RIDDERVOLD, Morten BOETKER, Niels-Christian EMMERTSEN, Hans KIRKEGAARD
11:10 - 12:40 #1276 - #1276 - Pulmonary oedema: is morphine still indicated?
#1276 - Pulmonary oedema: is morphine still indicated?
Pulmonary oedema: is morphine still indicated?
Paul Slavu(1), Sorina Podariu(1), Corina Sintea(1), Vlad Fisca(2), Daniela Taran(2), Mirela Badescu(2), Iris Muresan (3)
1. Emergency department, SMURD Sibiu, Sibiu, Romania
2. Emergency department, UPU-SMURD Sibiu, Sibiu, Romania
3. Lecturer, "Lucian Blaga" University of Sibiu, Romania
Speaker: Sorina Podariu
Keywords: acute pulmonary oedema, morphine, protocols
BACKGROUND
During the last three years, SMURD (Mobile Emergency Service for Resuscitation and Extrication) Sibiu MICU was sent to an important number of cardiac related cases reported as shortness of breath, mostly during night time.
Although shortness of breath can be associated with several illnesses, one life threatening condition is acute pulmonary oedema. Without proper and prompt medical care, survival chances are greatly decreased. Although it may have other underlying causes, in the majority of cases it originates from heart conditions, especially left ventricle insufficiency. The commonly used distinction between cardiogenic, non-cardiogenic and of unknown causes is used to describe the affection as accurately as possible.
The aim of this study is to asses a proper path of treatment by relying on internationally accepted protocols while drawing from the knowledge of extensive practical experience. The study focuses on presenting our observation that by including morphine in the treatment of pulmonary oedema, SMURD Sibiu frequently sees a faster and easier recovery of patients. Using only diuretics and nitrates does not have the same rate of success.
This practice is regulated by current protocols that limit the use of morphine. Concerns are expressed by some physicians about the possible risk that it might present to the patient, including an increase in the risk of death after discharge from hospital. As a result, alternative medication is sometimes considered.
METHODS
This study is retrospective and it is based on the SMURD (Mobile Emergency Service for Resuscitation and Extrication) Sibiu database accumulated over a period of 3 years, from 2012 to 2014. It includes 101 cases of acute pulmonary oedema.
RESULTS
From a total number of 101 patients with acute pulmonary oedema, 51 were treated with morphine, 78 cases happened during the night, 33 between 8 am in 8 pm.
While following the results of the administrated treatment, when including morphine 38 patients have improved and 12 patients had persisting symptoms. When using only diuretics and nitrates, 27 patients have improved and 23 patients persisted with symptoms.
Out of these, 9 patients suffered cardiac arrest on the way to the hospital, and 2 of them deceased, although CPR and ALS were performed.
CONCLUSIONS
Assessment of our data suggested that morphine administration enhances even more chanches of our patients, proving they recover easier, comparing the use of diuretics and nitroglycerin only. Even more, morphine can be administrated when the use of nitrates and diuretics must be postponed due to haemodynamic instability.
Paul SLAVU, Daniela TARAN, Sorina PODARIU (, ROMANIA), Corina SINTEA, Vlad FISCA, Mirela BADESCU, Iris MURESAN
11:10 - 12:40 #1369 - #1369 - Dispatcher-Assisted Cardiopulmonary Resuscitation Program and Outcomes after Pediatric Out-of-hospital Cardiac Arrest.
#1369 - Dispatcher-Assisted Cardiopulmonary Resuscitation Program and Outcomes after Pediatric Out-of-hospital Cardiac Arrest.
Background : The dispatcher-assisted bystander cardiopulmonary resuscitation (DA-BCPR) is expected to influence the outcomes of pediatric out-of-hospital cardiac arrest (OHCA).
Objective: We investigated and compared the association and the effect size of DA-CPR on survival outcomes according to location of the event.
Methods: All EMS-treated OHCAs less than 19 years of age in Korea were analyzed from January, 2012 through December, 2013, excluding patients witnessed by EMS providers or missing outcome information. Exposure group were No-BCPR group for patients who did not receive BCPR, BCPR-NDA group for patients who received BCPR without DA, and BCPR-DA for patients who received DA-BCPR. The endpoint was survival to discharge. Multivariable logistic regression analysis was performed to calculate the adjusted odds ratios (AORs) and 95 % confidence intervals (CIs) for outcomes by exposure group (reference=No-BCPR group) with and without an interaction term between exposure and location of arrest.
Results: A total of 1,013 eligible patients were finally analyzed. Among these patients, 39.8% had received BCPR (16.6% BCPR-NDA and 23.2% BCPR-DA). The survival to discharge rate was significantly higher in BCBP-NDA (10.7%) and BCPR-DA (9.0%) compared with No-BCPR group (4.3%) (p=0.002). AORs (95% CI) for survival to discharge compared with No-BCPR group were 1.73 (1.03-3.12) in BCPR group, 1.71 (0.85-3.46) in BCPR-NDA, and 1.39 (0.72-2.69) in BCPR-DA group, respectively. The AORs (95% CI) of BCPR-NDA and BCPR-DA in public location were 3.30 (1.12-9.72) and 2.95 (1.00-8.67) while BCPR-NDA and BCPR-DA in private location were 1.62 (0.68-3.88) and 1.15 (0.53-2.51), respectively.
Conclusion: The DA-CPR was associated with better outcomes in pediatric OHCA patients whose arrest occurred in public location, but not in private location.
Yu Jin LEE (SEOUL, KOREA), Sang Do SHIN, Seung Chul LEE, Kyoung Jun SONG, Eui Jung LEE, Young Sun RO, Ki Ok AHN
11:10 - 12:40 #1508 - #1508 - Adverse events during inter-hospital transportation of critically ill patients: A prospective analysis.
#1508 - Adverse events during inter-hospital transportation of critically ill patients: A prospective analysis.
Objective. To assess the quality and quantity of adverse events during physician- and nurse-led inter-hospital transfers and to define transport characteristics that could be linked to an increased rate of adverse events.
Methods. Prospective observational study with case-control design in 2 hospitals in Belgium, one tertiary and one secondary referral centre with registration of patient and transport characteristics during inter-hospital transfers. Overall adverse events (OAE) were categorized as technical, operational and communication problems. Retrospectively labelled medical adverse events (MAE) and prospectively registered harmful adverse events (HAE) were documented for every transfer. All reported OAE were retrospectively appraised by the investigators for being a high-risk transport (HRT).
Patients: 688 adult patients who were transferred to or from both hospitals by physician or nurse led transport with complete registration forms.
Results. The mean age was 64,4 (SD 16,8) with a 4:3 male/female ratio. Mean M-SOFA score was 3,0/20, resp. 4,6/20 and 2,4/20 for hospital 1 and 2. Average transfer time was 45 min (SD 32 min).
OAE were present in 16,9% of transfers, with 3,9% MAE and 1,3% bringing patient harm. 3,7 % was judged to be a HRT. 1 patient died during pre-transport stabilisation.
In multivariate analysis, two factors remain significantly associated with an increased risk of HAE: operational problems (odds ratio, 16.889; P=0.001) and communication problems (odds ratio, 7.165; P=0.01). Technical problems, nurse lead transportations, duration of the transportation, and the M-SOFA score were not significantly associated with the risk of HAE.
Conclusion. The rate of adverse events is comparable or lower to what was found in the scarce literature on incidence of adverse events during inter-hospital transfers, depending on definition. Operational problems and communication problems are the two categories that are significantly associated with an increase of harmful adverse events. These findings call for stricter preparation of transfers, both for training of personnel and communication. Extensive and repeated training is paramount to reduce the number of MAE and harm. Clear and standardized communication is important to reduce harm, and will also increase efficiency.
Cathelijne LYPHOUT (Antwerp, BELGIUM), Duchatelet CHRISTOPHE, Jochen BERGS, Koen DESCHILDER , Willem STOCKMAN , Koen BRONSELAER
11:10 - 12:40 #1535 - #1535 - Prehospital or in-hospital administration of ticagrelor to open coronary artery in acute myocardial infarct with st-segment elevation (stemi). Atlantic study.
#1535 - Prehospital or in-hospital administration of ticagrelor to open coronary artery in acute myocardial infarct with st-segment elevation (stemi). Atlantic study.
Background: The direct-acting platelet P2Y12 receptor antagonist ticagrelor can reduce the incidence of major adverse cardiovascular events in patients with STEMI.
Goal: Evaluate if prehospital administration of ticagrelor improves coronary reperfusion and clinical outcome.
Methods: International, multicenter, randomized, double-blind study involving patients with ongoing STEMI of less than 6 hours duration, comparing prehospital (in the ambulance) versus in-hospital (in the catheterization laboratory) treatment strategy. In the prehospital group, patient received a 180 mg loading dose of ticagrelor before transfer and a matching placebo in the catheterization laboratory. All patients subsequently received ticagrelor at a dose of 90 mg twice daily for 30 days.
Coprimary end points: proportion of patients who did not have a 70% or greater resolution of ST-segment elevation before percutaneous coronary intervention (PCI) and proportion of patients who did not meet the criteria for TIMI flow grade 3 in the infarct-related artery at initial angiography.
Secondary end points: included the composite of death, myocardial infarction, stent thrombosis, stroke, or urgent revascularization at 30 days.
Safety end points: included major or minor bleeding but excluding bleeding related to coronary-artery bypass grafting (CABG), within the first 48 hours and over the 30-days treatment period.
Results: During two years (Sept. 2011- Oct. 2013), 1862 patients were enrolled and randomized by 102 ambulances of 13 countries over 4 continents. 909 patients received ticagrelor in the ambulance and 953 patients in one of the 112 PCI centers. The medium times from symptom onset to STEMI diagnosis, from randomization to angiography, and between the two loading doses (i.e., prehospital vs. in-hospital) were 73, 48, and 31 minutes, respectively. More than 95% of the patients received one of the two loading doses of the medication study and more than 99% received at least one dose of aspirin. The majority of patients with STEMI received maintenance treatment of ticagrelor (86%) and aspirin (92%).
For all the patients included, the median time between onset of symptoms and PCI was 159 minutes.
There was no significant difference between the prehospital and in-hospital groups in terms of the proportion of patients who did not have a 70% or greater resolution of ST-elevation before PCI, nor those who did not have a TIMI flow of grade 3 in the infarct-related artery at initial angiography.
There was no significant difference between the two groups for the composite end point of death, bleeding events, major cardiovascular events or stent thrombosis. However, definite stent thrombosis was reduced in the prehospital group both at 24 hours (p=0.008) than at 30 days (p=0.02), vs in-hospital group.
Rates of composite major and minor bleeding events that were not related to CABG, were low at each stage of the study and did not differ significantly between the two groups.
Conclusion: The present study shows that the administration of the potent P2Y12 receptor antagonist ticagrelor shortly before PCI does not improve reperfusion of the culprit artery before the procedure but is safe and may prevent post-procedural acute stent thrombosis.
Olivier STIBBE (Paris), Pascal DANG-MINH, Hugues LEFORT, Olga MAURIN, Catherine RIVET, Jennifer CULOMA, Gilles MONTALESCOT, Jean-Pierre TOURTIER, Frédéric LAPOSTOLLE
11:10 - 12:40 #1634 - #1634 - Non-Invasive ventilation in acute pulmonary edema. Does it have immediate clinical effects in prehospital setting?.
#1634 - Non-Invasive ventilation in acute pulmonary edema. Does it have immediate clinical effects in prehospital setting?.
Introduction: Non-Invasive ventilation (NIV) is an adjuvant treatment for Acute Pulmonary Edema (APE). Early treatment with NIV could be applied in the prehospital setting if it demonstrated symptoms improvement in a shorter time.
Aim: To analyze if time to get to an optimal oxygen saturation and respiratory rate, shortens when NIV is added to standard medical treatment, instead of using high concentration oxygen mask.
Methods: A cohort’s prospective non-matched observational study was performed. Patients with suspected APE (confirmed at hospital arrival), treated either with NIV or with high concentration oxygen mask, plus standard medical treatment by Advanced Life Support Units from the Pre-hospital Emergency Medical System of the city of Barcelona between 1st October 2013 and 31th January 2014 were included. Time to get to oxygen saturation over 95% and a respiratory rate under 30 respirations per minute was analyzed with a survival analysis (Kaplan Meier and multivariate Cox regression), adjusting by possible confounders.
Results: 103 patients with APE were included. 56,3% were females and the mean age was 79,7 (SD:9,6) years old. NIV was applied in 44,7% of the patients during a mean of 51 (SD:13,4) minutes. Oxygen saturation improved over 95% in a median of 12 minutes (CI95%: 9,5-14,5) when NIV was applied, opposite to a median of 37 minutes (CI95%:30-44) when oxygen mask was applied (Log Rank p<0,001). Time to get to respiratory rate under 30 respirations per minute shortened from 57 minutes (CI95%:41,6-78,3) when oxygen mask was applied to 36 minutes (CI95%:31,1-40,9) when NIV was applied (Log. Rank p=0,002).
After adjusting results by Systolic blood pressure, first measured oxygen saturation and initial respiratory rate, oxygen saturation over 95% enhancement ratio significantly improves when NIV is applied; HR=5,32 (CI95%:2,8-10; p<0,001). Respiratory rate enhancement ratio after adjusting by previous ischemic heart disease, initial respiratory rate and complete medical administration also improves significantly; HR=2,54 (CI95%:1,4-4,7; p=0,014).
Conclusions: NIV shortens time to improve oxygen saturation and respiratory rate when applied in patients suffering an APE. Further studies are needed to confirm this results and to know if NIV has effect over other parameters such as respiratory effort or the subjective feeling of dyspnea.
Silvia SOLÀ-MUÑOZ, Francesc CARMONA-JIMÉNEZ (Barcelona, SPAIN), Àngels LÓPEZ-CANELA, Jorge MORALES-ÁLVAREZ, Xavier ESCALADA-ROIG, Quim RIOS-SAMBERNARDO
11:10 - 12:40 #1712 - #1712 - Five years of experience providing prehospital emergency medical service in centralized organizational model.
#1712 - Five years of experience providing prehospital emergency medical service in centralized organizational model.
The World Health Organization regards emergency medical service (EMS) system as an integral part of any effective and functional health care system. In order to improve EMS provision in Latvia a major change in organization of prehospital EMS was made in 2009. Before 2009 prehospital emergency medical care (EMC) in Latvia was provided through decentralized organization model. Latvia had overall 43 institutions owned by municipalities which provided EMS within municipality’s service area only. Lack of accessibility, quality and equity in EMC provision was evident and large discrepancies throughout the country in terms of training, staffing and coverage of the ground ambulance system existed. In 2009 gradual merging of EMC providers and reorganization of two public institutions (incl. Center of Disaster Medicine) was initiated. Although the merge was complex and complicated process on 1st of July, 2010 unified State Emergency Medical Service (SEMS) started to provide prehospital EMC in all the territory of Latvia. The aim of the reform was to improve quality and equal accessibility of prehospital EMC by introducing unified management system of resources, centralization of incoming calls and dispatching, provision of unified standards for equipment and medicines, development of unified guidelines and unified training system. Centralization resulted in development of common regulations what lead to unified EMC delivery. Differences in EMC availability due to patient location were diminished and EMC provision was more equal than ever. In 2010 Operational Management center was established and direct number ‘113’ for medical emergencies was introduced. Outcomes of centralized EMC provision includes cost effectiveness, transparent expenditures of State budget, unified information and quality management system, electronic database of medical records and unified administration. The average response time interval for highest priority cases in rural and urban areas was diminished from 19,8 / 10,4 min in 2009 to 18,3 / 10,1 min in 2014. Many experts, including World Bank, have recognized prehospital EMS reform in Latvia as one of the most successful examples in health care organization.
Ilze BECA (Riga, LATVIA), Renate PUPELE, Liega ZALCMANE
11:10 - 12:40 #1743 - #1743 - Evacuation of severely burned patients by HEMS.
#1743 - Evacuation of severely burned patients by HEMS.
Objectives: The aim of this work is to analyse the procedures of dealing with patients with burns applied by the HEMS teams both in terms of rescue operations and transporting patients from hospitals to Burn Centres.
Materials: Between 2011 and 2014 the Polish Helicopter Emergency Medical Service (Lotnicze Pogotowie Ratunkowe) executed 1347 interventions involving victims of burns. Direct flights to the location of an incident accounted for 59.8% and the remaining 40.2% were transports of patients from hospitals to Burn Centres. In the period subject to analysis those flights constituted 4.2% of all missions of the Polish Helicopter Emergency Medical Service.
Results: In the analysed group of patients, based on the International Classification of Diseases, Tenth Revision, the largest group (48.6%) consisted of persons with thermal burns of multiple body regions, 14% of patients had burns on 60-80% of Total Body Surface, and 2.9% were diagnosed with respiratory tract burn injuries.
The median duration of the mission from notification to delivery of the injured was 77 minutes in case of flights to accident location (which indicates that the HEMS teams apply the sty and play strategy) and 165 minutes in case of transporting patients from hospitals to Burn Centres.
Among the transported patients 347 (25.7%) were subjected to endotracheal intubation and 85.6% of all intubations applied to patients prepared for transportation from hospitals to Burn Centres. Crystalloid intravenous infusions and pain therapy were applied as treatment of 99.1% of all patients. During the missions 0.4% patients had cardiac arrest and were resuscitated.
Conclusions: The use of HEMS in case of dealing with patients with burns is of material importance in providing quick transport to Burn Centres, specifically in case of childrens with burns.
A significant part of interventions involved the “stay and play” strategy.
The procedures of preparing patients for helicopter transportation involved protecting the airways with substitute ventilation which related to over one fourth of all patients.
Przemyslaw Wiktor GUŁA (Krakow, POLAND), Robert GAŁĄZKOWSKI, Arkadiusz WEJNARSKI
11:10 - 12:40 #1791 - #1791 - Optimization of EMS design. Advanced vs Basic.
#1791 - Optimization of EMS design. Advanced vs Basic.
Objective: Polish EMS model is based on Advanced Life Support Ambulances (partially with physicians partially with ALS trained paramedics). However only less then 5% of total number of interventions require advanced life saving procedures. The current model does not allow for optimal use o emergency physicians in prehospital settings.
It requires guidelines for building new double tier (advanced/basic) response system.
Material and methods: Retrospective analysis of 43437 EMS interventions during one year period in mixed city-country terrain. 17 EMS teams (5 with physician) located in 13 ambulance sattions with single (999) dispatch centre covered the population of over 576 000 people. The number of calls was 10,9 per 100 inhabitants.
Results: Almost 60,7% calls to the local dispatch (999) centre lead to the dispatching of EMS team. 72,5% of interventions were the ALS-paramedic teams and 27,5 % were responded by emergency - physician ambulances. The median response time was 6,5 min in the city and 10,5 min in country. In more then 30% of the EMS interventions there were no medical emergencies. 66,7% of patients were transported to the ED. Advanced life saving procedures allowed to physicians only amounted to 1,5% of cases. In the phyician ambulances group 32,7% of patients had iv line ,32,7% followed by intarvenous drug administration. 3,8% of patients were intubated. Paramedics requested support of physician or HEMS amounted to less then 1% of missions.
Conclusions: The Polish EMS system is highly abused by unfounded requests. It must be optimised in terms of function of double tier response as well as flexible use of emergency physicians in prehospital area.
Przemyslaw Wiktor GUŁA (Krakow, POLAND), Robert GAŁĄZKOWSKI, Remigiusz MORYTO
11:10 - 12:40 #1802 - #1802 - NonSTEMI Prehospital RisK Score.
#1802 - NonSTEMI Prehospital RisK Score.
INTRODUCTION:
Ischaemic heart disease is the first cause of death in developed countries. For several years it has been demonstrated that patients suffering from Acute Coronary Syndrome (ACS) with persistent ST elevation (STEMI), benefit of primary angioplasty (PCI), directly making the transfer from the point of first medical contact to the cardiac catheterization laboratory. For patients with Non-ST-Segment Acute Coronary Syndrome (Non-STEMI) several risk SCOREs have being developed. The gold Standart is GRACE SCORE. However, these Scores are designed for the hospital environment, which represents a delay in shipments of a subgroup of patients to centers of high specialization.
The aim of this study is to create a predictive ability model of prehospital risk SCORE for patients suffering NSTEMI in order to transfer them to the appropriate hospital.
Objective:
Define and create a prehospital emergency care Scale for predicting high risk cardiovascular events comparable to GRACE SCORE in NSTEMI, that allows the transfer of the patient to the appropriate Center.
Methods:
Prospective cohort study, of patients admitted to the Coronary Care Unit of a Tertiary Hospital during the period from January 2009 to December 2013 in Barcelona.
Inclusion criteria: patients over 18 years old with a diagnosis of NSTEMI for whom GRACE has been calculated.
The recruitment was carried out consecutively.
Study variables: GRACE at admission, sex, age, cardiovascular risk factors, history of ischemic heart disease, vital signs, ECG abnormalities, presence of complications.
Descriptive and comparative analysis. Patients were stratified into high risk and not high risk (low and medium risk), according to GRACE Score and were compared to the new Scale. A predictive model was obtained using logistic regression and the selected variables were compared with high risk of GRACE using the Spearman rank correlation coefficient and Kappa statistic. The efficiency of the model was assessed with a ROC curve.
Results:
420 patients were included, 72.6% of them were men with a median age of 67,4 years. 149 (35,5%) patients had a high-risk Grace, 271 (64.5%) had low or moderate risk Grace.
The new Scale is composed of 6 items, scored from 0 to 11 points, and high risk is defined over 5 points. These items are: age, Killip-Kimball, Systolic blood pressure, Heart Rate, ST desviation ≥ 0.5mm and previous angina. The new Scale compared with binary Grace (high risk/not high risk) showed a Spearman correlation= 0.78 and a Kappa=0.79. Sensitivity was 90.8% and specificity 89.9%, Likehood ratio (LR+)=7.5, positive predictive value (PPV)=93,2%, negative predictive value (NPV) =84% and a global efficiency of 89.8%. The area under the curve (AUC) of the estimated model was 0,893, 95% interval confidence (0, 86-0, 93).
Conclusions:
1 - The new Score predicts patients comparable with high risk GRACE Score that should be transferred to a hospital with PCI available 24 hours 365 days.
2 – The Score can be a pre-hospital tool to determine the target center for patients with High-Risk Non-STEMI.
Jorge Arnulfo MORALES ALVAREZ (Barcelona, SPAIN)
11:10 - 12:40 #1829 - #1829 - Early Exclusion of Major Adverse Cardiac Events in Emergency Department Patients with Chest Pain: a prospective observational study.
#1829 - Early Exclusion of Major Adverse Cardiac Events in Emergency Department Patients with Chest Pain: a prospective observational study.
BackgroundIn the management of adult chest pain patients presenting to an Emergency Department (ED) with suspected acute coronary syndrome (ACS), we aimed firstly to validate diagnostic accuracy of a modified Thrombolysis in Myocardial Infarction (TIMI) score with high-sensitive cardiac troponin T (hs-cTnT) to rule out major adverse cardiac events (MACE), and secondly to compare modified TIMI score with combinations of heart-type fatty acid binding protein (H-FABP) and a modified HEART score.
Methods This prospective observational study was conducted in the ED of a university hospital in Hong Kong, recruiting patients aged 18 years or older with chest pain and suspected ACS. Patients underwent triage assessment, electrocardiography, blood sampling for laboratory hs-cTnT, H-FABP point of care test, and TIMI and HEART scoring.
Results 602 consecutive patients were recruited and MACE occurred in 42 (7.0%) patients within 30 days. A modified TIMI score of zero alone identified 65 (11%) patients, and a HEART score ≤2 identified 96 (16%) patients, as having low risk for 30-day MACE. No MACE occurred in these groups giving both scores a sensitivity and negative predictive value of 100%, and respectively a specificity of 11.6% and 17.1%. Use of both TIMI and HEART scores improved specificity further to 22.0%. Early H-FABP had a sensitivity of 42% and a specificity of 91%.
Conclusions A modified TIMI score of zero or a HEART score of ≤2, incorporating a single hs-cTnT level, will identify patients with low risk of 30-day MACE for early discharge within 2 hours of ED arrival.
Colin GRAHAM (Hong Kong, HONG KONG), Cw LAM, Kh CHEUNG , Yk LEUNG, Nm CHENG, Py CHAN, Timothy RAINER
11:10 - 12:40 #1936 - #1936 - Patient characteristics in pre-hospital medical care. Is there a difference in between physician and non-physician dispatched patients?
#1936 - Patient characteristics in pre-hospital medical care. Is there a difference in between physician and non-physician dispatched patients?
Background
In Germany an increasing number of patients in emergency departments (ED) are presented by ambulance services. National studies investigating the pre-hospital emergency services are rare. A particularity in the emergency care in Germany is the distinction between paramedic-staffed ambulances and physician-staffed ambulances. The purpose of this study was to examine the difference between physician and non-physician dispatched patients.
Methods
This explorative study includes patients who were dispatched by ambulance services in the internal or surgical ED at Charité Virchow-Klinikum in Berlin, providing maximum medical care. Routinely available data were retrieved from ambulance protocols for every patient admitted via ambulance between Mai 1st until June 30th 2014. The ambulance protocols provide information on date and time of ambulance service, demographic details, vital parameters, injuries, intensity of pain as well as diagnostic and therapeutic procedures. They were matched with data from the hospital information system (e.g. Manchester-Triage-System category (MTS), in-hospital mortality). Patients were excluded, if the distinction between paramedic-staffed ambulances and physician-staffed ambulances was not raised in the data. All analyses were stratified for ambulance services with and without physician.
Results
In total 1070 datasets were analyzed (median age 53 years, IQR 35-71; female 46%). 62% were medical ED-patients, 36% surgical and 2% neurological. Physicians were included in 30% (n=322) of all ambulance transports with the highest proportion in patients between 70 and 79 years (18%).
The majority of emergency missions for the study population were registered on Mondays (18%) and the minority on Wednesdays (12%). The majority of physician-staffed ambulance transports was on Mondays (21%) and the minority on Fridays (11%). Within a day emergency services were most frequently called between 12am and 6pm (29%). Nearly two third of all emergency missions took place at private apartments (59%). 18% of all missions were conducted in public areas. Ambulance transport from general practitioners and nursing homes to the ED were observed in a proportion of 3% and 4% respectively.
The urgency of treatment was documented in five categories for 789 patients by pre-hospital emergency staff. 7% of the cases were classified as non-urgent and 45% as normal. A higher proportion of physician-assisted ambulances vs. paramedic-staffed ambulances was associated with cases which were classified as urgent (48%vs32%), as very urgent (21%vs5%) and as life-threatening (9%vs1%). Similar results could be seen in the ED´s with a higher proportion of physician dispatched patients in the orange (45%vs22%) and the red (19%vs2%) MTS-level. In contrast, the proportion was lower in the yellow MTS-level (30%vs52%) as well as in the green and blue MTS-levels. No difference could be found in the length of stay (median 4 days). The in-hospital mortality was higher in patients which were dispatched by physician-assisted ambulances (6%vs3%).
Conclusion
The majority of ambulance transports was conducted on Mondays. Physician-staffed ambulances were more involved in older patients and cases with urgent conditions. This finding was underlined by the higher in-hospital mortality of patients in this group. Further analyses will address clinical course and pre-hospital procedures.
Johann FRICK (Berlin, GERMANY), Anna SLAGMAN, Julia SEARLE, Clara THOMAS, Judith MAHLIG, Tobias LINDNER, Martin MÖCKEL
11:10 - 12:40 #1985 - #1985 - Out-of-hospital use of laryngeal tube - a large observentional study.
#1985 - Out-of-hospital use of laryngeal tube - a large observentional study.
Introduction
Because of concerns of low success rate and unidentified oesophageal intubation of orotracheal intubation in the prehospital settings, supraglottic devices have received widespread acceptance in emergency medical systems. There are more devices on the market and there is still need for a larger evaluation of these devices in relation to their reliability and safety. In this large observational study we prospectively evaluated the effectiveness and safety of use of the laryngeal tube (LT-D) by trained physicians and paramedics in prehospital airway management in two periods.
Methods
In 2009 we started to train all paramedics and physicians in the largest Slovak EMS provider Falck Zachranna in insertion and management of LT-D. In the company there is no strict protocol for securing the airways and some physicians do not intubate regularly. The participants who demonstrated the ability to ventilate a manikin effectively with a bag through correctly inserted LT-D were given competence to use it clinically. The quality and safety of the process was monitored by mandatory filling of the protocol after every placement of LT-D. We have recorded demographic data, indications, paramedics vs physicians insertions, difficulties in placement, complications and rate of successful ventilation. We have compared the safety and effectiveness data of LT-D from two periods - 2009-2011 and 2012-2014.
Results
In the years 2009-2014 a total of 152, 228, 424, 504, 512 and 614 LT-Ds have been used. In the first period we evaluated 804 and in the second period 1630 protocols. In both periods 82% of tubes have been inserted by paramedics and 18% by physicians. The rate of male has been stable at around 65%. The main reason for insertion was in 74% and 77%, resp. cardiovascular failure (mostly cardiac arrest). LT-D has been replaced by endotracheal intubation in 28% and 23%, resp. (physician based ambulance has been called). The ventilation was not possible in 6.8% and 5.1% resp.; that means success rate of 93.2% and 95.1%, resp. Aspiration before or after insertion has been observed in 2.7% and 4.0%, resp. Insertion has been considered easy in 75% and 78%, resp.
Discussion
This is to our knowledge by far the largest study with LT-D in pre-hospital settings evaluating 2,436 LT-D insertions. Most participants reported that handing of the LT-D was easy and they only required three insertion practice sessions with a manikin to feel confident. The tube was mostly used by paramedics who are not allowed to intubate in Slovakia. We encouraged physician not to replace well placed LT-D by paramedics by intubation and have observed decreasing rate of it. We have also recorded small increase in success rate and stable rate of aspiration during the observation period.
Conclusions
In this large study we confirmed previous evidence that LT-D is easy to handle with a high success rate of the placement. The LT-D replacing bag and mask ventilation frees the hand of paramedics, helps to safely secure airways for non-emergency physicians and helps to secure difficult/failed airways for anaesthesiologists and emergency physicians in prehospital care.
Stefan TRENKLER (Košice, SLOVAKIA), Monika PAULIKOVA, Miroslav HUMAJ
11:10 - 12:40 #2041 - #2041 - Are there alternatives to acute hospitalization for elderly medical patients? - a randomised clinical trial.
#2041 - Are there alternatives to acute hospitalization for elderly medical patients? - a randomised clinical trial.
Introduction: The Danish public healthcare service to elderly patients with acute medical conditions is uncoordinated. The General Practitioner (GP) is responsible for the patient but is challenged by difficult communications with other healthcare sectors and has a busy workday often without the ability to see the patient immediately. Short admissions, as well as the risk of loss of information at the transfer from secondary to primary sector, may result in sub-optimal diagnosis and treatment pathways, especially for elderly patients with complex medical issues. The municipalities have implemented initiatives to ensure an alternative to hospitalization, but this acute municipal care did not focus specifically on cross-sectorial collaboration and has not been evaluated. The aim of the project was to evaluate various cross-sectorial collaborations with focus on elderly medical patients: I) How many medically ill elderly will use an acute municipal care as an alternative to hospitalization, and what are their characteristics? II) Is there a difference if a medical specialist at the hospital is responsible for the examination and treatment instead of the GP? III) Is there a difference between treatment at a municipal acute care centre and home treatment from an acute care team?
Method: The project design was a randomized clinical trial in which the primary outcome was the number of admissions within 7 days, depending on whether a medical specialist or the GP was responsible for the treatment. Simultaneously, mortality, mental and physical changes as well as the satisfaction of the patient and relatives were registered as secondary outcomes. The collected data were also used to assess the impact of treatment from municipal acute care centre or acute care team on the same outcomes.
Results: 131 patients were included. The patients were predominantly women of high age with daily need of help at home. By triage assessment, the included patients were rated as ill as the average hospitalised patients. Half of the patients was able to take care of themselves after 48 hours of treatment, and about a quarter needed extra help at home or an extended stay at the care centre. Men were hospitalised twice as often as women.
Half of the patients examined by the hospital’s medical specialists were admitted immediately, while only a quarter of the patients examined by the GP were admitted. There were no significant difference in mortality, physical or mental restoration between the patients treated by the medical specialist and the GP, but the low number of participants may have hidden real differences. There was no significant difference in the numbers of admissions in the two municipal acute care, and there was no difference in how quickly patients recovered mentally and physically or in mortality and satisfaction.
Conclusion: The acute care team and acute care centre offers an equally good treatment. A hospital based outpatient clinic appears to increase the number of acute admissions of elderly medical patients. It can therefore be concluded, that the cooperation between GP and municipal acute care can reduce the number of admission of elderly medical patients.
Helene SKJOET-ARKIL (Aabenraa, DENMARK), Christian Backer MOGENSEN
11:10 - 12:40 #2075 - #2075 - Croatian Index of Emergency call Admission in Recognizing Out of Hospital cardiac arrest(OHCA).
#2075 - Croatian Index of Emergency call Admission in Recognizing Out of Hospital cardiac arrest(OHCA).
Croatian Index of Emergency Call Admission in Recognizing Out of Hospital Cardiac Arrest
Radmila Majhen Ujevic, MD, Leo Luetic, MD
Key words: Index, Medical Dispatch Unit, OHCA, recognize, red response, agonal, training, education
Introduction: Medical Dispatch Unit (MDU) is essential part of the chain of survival and enables rapid and accurate medical response in case of OHCA. Recognition of OHCA is achieved on criteria based dispatch in the form of Croatian Index of emergency call admission, which has bee used in Croatia for three years. We made a survey to see how accuurate Index was in predicting OHCA in Split-Dalmatian County which has cca 455000 inhabitants.
Methods: quantitative analysis of data collected in one-year period. We compared cases of OHCA noted in our registry of deaths ( EMS confirmed arrest in the field), as dioagnosis R96-R99 ( Ill-defined and unnown causes of mortality according to International Classification of Disease ICD) and I46 ( cardiac arrest) to the criteria in Index during call receipt. Citeria considering possible OHCA were A01.01 ( Adult unconscious, not breathing) and all other criteria fulfilling the condition " does not respond to shaking and calling". deaths caused by trauma, other external factors, terminal disease with expecting death as well as children were excluded from the survey.
Results: there were 945 cases where EMS confirmed cardiac arrest caused by medical problems in the field. In the group of 618 calls ( 65,40%) admitted as red response, 276 calls (44,66%) were orrectly presumed to be OHCA. In the group of 321 calls (34,34%) admitted as yellow response, 112 calls (34,89%) were correctly presumed to be OHCA ( H criteria concerning definitive, irreversible expected death). In 6 calls (0,97%) dispatched as green response there were 3 calls (50%) accureately presumed to be OHCA. In the group of red response there were 82 calls (13,27%) admitted and dispatched as criteria A01.03 ( person unconscious, but breathing) that EMS pronounced as cardiac arrest in the field.
Conclusion: More training in MDU through re-listening of incoing calls and reassessmentof criteria ( finding out which criteria are mostly used instead of A.01.01) is needed in intention to improve OHCA recognition. This is particularly important in recognizing agonal breathing, not to be misjudged as normal breathing that might delay quick beginning of CPR. However, the benefit of patients was not jeopardised since they have received red response. More research might be needed in comparing response times in presumed OHCA and cases assessed like other red response, but not OHCA ( core item in Utstein Style Report). Recent possibility of recording procedures like CPR phone instructions by dispatcher enables further research in improvent of chain of survival ( early recognition and early CPR). Important factor contributing this aim are public programmes of education in basic life support/AED in community.
Radmila MAJHEN UJEVIC, Radmila MAJHEN UJEVIC (Split, CROATIA), Leo LUETIC
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Management
Education
Moderators: Pier Luigi INGRASSIA (Novara, ITALY), Rob ROGERS (USA)
14:10 - 14:40 The future of medical education. Chris NICKSON (South Yarra, AUSTRALIA)
14:40 - 15:10 Medutainment: Is this the way to teach Emergency Medicine? Simon CARLEY (Manchester, UK)
15:10 - 15:40 Connecting education and patient care. Victoria BRAZIL (AUSTRALIA)
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Italy invites
Anticoagulanti ed emergenze mediche
Moderators: Francesco BORGOGNONI (ITALY), Giuseppe PEPE (ITALY)
14:10 - 14:30 Stroke ischemico: vena, arteria o tutte due? Paolo CERRATO (ITALY)
14:30 - 14:50 Stroke emorragico: che succede con i NAO. Giancarlo AGNELLI (Perugia, ITALY)
14:50 - 15:10 Embolia polmonare: trattarle tutte? Simone VANNI (Florence, ITALY)
15:10 - 15:30 Fibrillazione atriale: cosa è cambiato? Alberto CONTI (Toscana, ITALY)
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Clinical Questions: Controversies
Infectious Disease & Sepsis
Moderator: Christoph DODT (München, GERMANY)
14:10 - 14:40 Timing of antibiotics – Myth or fact? Eric BATARD (Nantes, FRANCE)
14:40 - 15:10 Controversies in the identification and treatment of sepsis. Colin GRAHAM (Hong Kong, HONG KONG)
15:10 - 15:40 Which goal to aim for in the ED during early-goal directed therapy in treatment of sepsis? Kurt ANSEEUW (Medical doctor) (ANTWERP, BELGIUM)
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14:10-15:40
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State of the Art
Obstetric Emergencies
Moderators: Inger SONDERGAARD (PHYSICIAN) (ALLEROED, DENMARK), Anna SPITERI (Consultant) (Malta, MALTA)
14:10 - 14:40 The killers in obstetrics that you shouldn’t miss in your ED. Cornelia HARTEL (Consultant in Emergency Medicine/ Director of Medical Education in Emergency Medicine) (Stockholm, SWEDEN)
14:40 - 15:10 Pelvic inflammatory disease. Maria Grazia FRIGO (ITALY)
15:10 - 15:40 Management of obstetric emergencies. Judith TINTINALLI (Chapel hill, USA)
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Research
Trauma
Moderators: Basar CANDER (TURKEY), Francesco DELLA CORTE (ITALY)
14:10 - 14:40 Decompressive craniectomy in traumatic brain injury. Hadie ADAMS (UK)
14:40 - 15:10 Direct transportation to neurosurgical units for patients with isolated head injury. Fiona LECKY (Professor of Emergency Medicine) (Sheffield, UK)
15:10 - 15:40 Predicting outcome in traumatic brain injury. Karim TAZAROURTE (Chef de service) (Lyon, FRANCE)
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YEDM
Sim Wars
Moderators: Pier Luigi INGRASSIA (Novara, ITALY), François LECOMTE (Paris, FRANCE)
Coordinators: Abdo KHOURY (PH) (Besançon, FRANCE), Youri YORDANOV (Médecin) (Paris, FRANCE)
Facultys: Elaine ERASMUS (Cape Town, SOUTH AFRICA), Sian GERATY (SOUTH AFRICA), Natalie MAY (Oxford, UK), Patrick PLAISANCE (Paris, FRANCE), Thomas PLAPPERT (Fulda, GERMANY), Pieter Jan VAN ASBROECK (Consultant in Emergency Medicine) (Hasselt, BELGIUM), Sabina ZADEL (SLOVENIA)
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Paediatric Track
Status of PEM in Italy
Moderators: Ian MACONOCHIE (UK), Santiago MINTEGUI (Barakaldo, SPAIN)
14:10 - 14:40 Paediatric Emergency Medicine in Italy. Niccolò PARRI (Attending Physician) (Florence, ITALY)
14:40 - 15:10 Italian National Guidelines on Head Injury management in children in the ED. Liviana DADALT (ITALY), Silvia BRESSAN (Padova, ITALY)
15:10 - 15:40 Barriers and opportunities to the implementation of PEM. Simone RUGOLOTTO (ITALY)
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Oral Paper 1
Imaging and Ultrasound II
Moderators: Ammar ALANI (UK), Gregor PROSEN (MARIBOR, SLOVENIA)
14:10 - 15:40 #1180 - #1180 - Determining the clinical significance of errors in pediatric radiograph interpretation between emergency physicians and radiologists.
#1180 - Determining the clinical significance of errors in pediatric radiograph interpretation between emergency physicians and radiologists.
Study Objective
Emergency physicians (EPs) are expected to review and interpret plain radiographs in order to make treatment and disposition decisions. These radiographs are subsequently reported by a radiologist whose interpretation may differ. The clinical consequence of these discrepancies is uncertain. The objectives of this study were to a) review the rate and nature of radiograph discrepancies interpreted by emergency physicians versus radiologists in the pediatric emergency department, and b) determine the clinical significance of these discrepancies.
Methods
We conducted a retrospective review of discrepant radiology reports from a single site pediatric emergency department from October 2012 to December 2014. All radiographs were initially interpreted by the staff emergency physician; where the final radiology impression differed, the report was identified as a ‘discrepancy’ per department protocol. Radiographs were categorized as chest, abdomen, axial skeleton, upper extremity, lower extremity, soft tissue neck, or other. Based on the final report, the discrepancy was classified as false positive, false negative or not a discrepancy. Clinically significant errors that required a change in the management of the patient were tracked.
Results
There were 25,304 plain radiographs completed during the study period. Of these, 293 (1.16% of total radiographs) were identified by radiology as discrepant from the EP interpretation. The most common were chest radiographs (41.6%) due to missed pneumonia, followed by upper and lower extremities (26.3% and 15.7% respectively) due to missed fractures. Of 293 discrepancies, 208 (71.0%%) were false positives, 45 (15.4%) false negatives, and 40 (13.7%) were not true discrepancies upon further review. One hundred and five (0.4% of all radiographs completed) were clinically significant, requiring subsequent change in patient management.
Conclusions
There is a low rate of discrepancy between emergency physician and radiologist interpretation of pediatric emergency radiographs. The majority of errors are with radiographs of the chest and extremities. Educational efforts to improve emergency physician accuracy in interpretation of these types of radiographs may be beneficial.
Jonathan TAVES (Hamilton, CANADA), Steven SKITCH, Celine KIM, Rahim VALANI
14:10 - 15:40 #1882 - #1182 - The use of bedside ultrasound to assess fluid responsiveness in septic patients: increasing use in an Emergency Department High-Dependency Unit.
#1182 - The use of bedside ultrasound to assess fluid responsiveness in septic patients: increasing use in an Emergency Department High-Dependency Unit.
Introduction: The use of non-invasive strategies to assess fluid responsiveness of septic patients is spreading worldwide. Aim of this study was to assess the prevalence of bedside ultrasound evaluation of fluid responsiveness in a population of septic patients admitted in an Emergency Department High Dependency Unit (ED-HDU).
Methods: We identified two study periods: April, 2010-March, 2011 and February–December 2013 and we retrospectively analyzed all medical records of patients admitted in the ED-HDU in those periods with a diagnosis of sepsis/severe sepsis/septic shock. The evaluation of fluid responsiveness was performed considering the inferior vena cava collapsibility index, the left and right ventricular global systolic function and the presence of interstitial syndrome at the chest ultrasound.
Results: We retrospectively identified 126 septic patients in 2010 and 79 during 2013, mean age 73±14 years, 51% male gender, mean Sequential Organ Failure Assessment (SOFA) score 5.4±3.5.
The ultrasound evaluation of fluid responsiveness was carried out in a significantly greater proportion of patients in 2013 compared to 2010 (72/79, 91% vs 75/126, 60 %, p <0.0001). The proportion of patients in whom an ultrasound exam did not allow a definition of fluid responsiveness because of a bad acoustic window or lack of information in the medical record, remained comparable from 2010 to 2013 (29/75, 39% vs 27/72, 38%, p = NS).
The number of fluid challenges was similar between the patients evaluated and those not evaluated by ultrasound (82/126, 65% vs 33/56, 59%, p = NS).
Patients who were not assessed with ultrasound or in whom an evaluation was not possible were more frequently hemodinamically stable than patients assessed by ultrasonography (32/56, 57% vs 36/126, 29%, p=0.004).
Compared with patients treated empirically, patients evaluated by ultrasonography showed a SOFA score significantly higher both at the admission in ED-HDU (6.3 ± 3.6 vs 5.2 ± 3.4, p = 0.030) and after 24 hours ( 5.93 ± 3.6 vs 4.5 ± 3.0, p = 0.045), included a higher proportion of septic shock (32 vs 17%, p = 0.018) and a central venous catheter was placed more frequently (35 vs 19%, p = 0.015).
In the hemodynamically instable patients, stabilization was achieved more frequently in patients evaluated by ultrasound compared with patients treated empirically (32/126, 25% vs 11/114, 10%, p=0.0078).
The percentage of patients who never reached a hemodynamic stabilization was similar for patients with and without ultrasound evaluation (30/126 and 27/114 p = NS).
Conclusions: The bedside ultrasound evaluation of the fluid responsiveness in septic patients has significantly increased after a three year period. It was performed more frequently in hemodynamically instable patients than stable ones and it allowed to achieve a stabilization in a higher proportion of patients compared with empiric fluid administration.
Margherita LUZZI (Firence, ITALY), Lucia TAURINO, Irene TASSINARI, Beatrice DEL TAGLIA, Camilla TOZZI, Francesca INNOCENTI, Riccardo PINI
14:10 - 15:40 #1184 - #1184 - Impact of lung ultrasound findings in the assessment of acute heart failure in the emergency department.
#1184 - Impact of lung ultrasound findings in the assessment of acute heart failure in the emergency department.
Introduction:
Lung ultrasonography (LUS) has recently emerged as a non-invasive tool for the differential diagnosis of pulmonary diseases. However, its use for the diagnosis of acute decompensated heart failure (ADHF) still raises some concerns. In patients with heart failure, many indexes are available for noninvasive identification of pulmonary congestion: plasma levels of brain natriuretic peptide (proBNP) (pg/ml); number of B-lines at lung ultrasound.
Objectives:
The primary goal of this study was to determine accuracy for diagnosing acutely decompensated heart failure (ADHF) with the use of B3 and B7 line patrons and the relation with proBNP.
Methods:
We conducted a prospective cohort study with 62 patients whom presenting with acute dyspnea, the emergency physician was asked to categorize the diagnosis as ADHF. Lung ultrasound was performed in all patients and B-lines were counted and compared before and after treatment. Finally, data were compared and quantitative and categorical variables were worked out along with other statistical analysis through estimated indicators.
Results:
The LUS was satisfied in 100 percent of patients. The LUS-implemented approach had a significantly higher accuracy, in the 63.9 % of studied patients we detected pulmonary edema with elevation of natriuretic peptides (sensitivity 88%; 95% CI, 85.3-91%; specificity 72.3%; 95% CI, 65-69%) and more number of B lines (sensitivity 97.6%; 95% CI, 97-99.1%; specificity 93.5%; 95% CI 91.7-99.2%). The area under de ROC curve was of 0.91 (CI 95%: 0.83-0.93 p: 0.0001) with the higher point of sensibility in relation with B7 lines patron (sensitivity 96.2% and specificity 74.9%). In 45.5% of patients detected B3 lines patron after treatment with depletive diuretics.
Conclusions:
The implementation of LUS with the clinical evaluation may improve accuracy of ADHF diagnosis in patients presenting to the emergency department. The B7 lines patron in LUS had been a good correlation with pulmonary edema.
Julio ARMAS CASTRO, Julio ARMAS CASTRO (ELCHE, SPAIN), Blas GIMÉNEZ FERNÁNDEZ, Juan Carlos REAL LÓPEZ
14:10 - 15:40 #1317 - #1317 - Evaluation of the diagnostic accuracy of a lung ultrasound-implemented protocol for of acute dyspnea in the emergency department - a randomized controlled trial.
#1317 - Evaluation of the diagnostic accuracy of a lung ultrasound-implemented protocol for of acute dyspnea in the emergency department - a randomized controlled trial.
Background
Acute dyspnea is a diagnostic challenge for emergency physicians (EPs). The discrimination between cardiac and non-cardiac causes is essential for improving patients’ management. Lung ultrasound (LUS) has emerged as a non-invasive valuable tool for this diagnosis. We have recently shown in a multicenter study that the use of a LUS-implemented diagnostic approach may improve the diagnostic accuracy in ED patients with acute dyspnea (Chest, 2015)..
Objectives
Aim of this study was to compare, in ED patients with acute dyspnea, the diagnostic accuracy of a LUS-implemented approach with a standard diagnostic approach, that includes chest radiography (CXR) and natriuretic peptide measurement.
Patients and Methods
This was a randomized controlled multicentric trial involving two Italian EDs (AOU Città della Salute e della Scienza di Torino, and Careggi University Hospital, Florence). The study protocol was approved by the Ethical Commitees of the involved centers.
Patients presenting to the ED with acute shortness of breath as main complaint were eligible. After the initial clinical assessment (i.e. history, physical examination, ABG analysis and EKG), the EP was asked to discriminate the presuntive etiology of acute dyspnea (cardiac or non-cardiac). To complete the diagnostic evaluation, patients were subsequently randomized to either LUS (performed by the same EP – iLUS arm), or CXR and Nt-proBNP (iCXR arm).
A new presumptive diagnosis was recorded (iLUS or iCXR, respectively) using results of the diagnostic tests. At discharge from ED, a final ED dyspnea diagnosis, based on all diagnostic information available, was finally recorded. After hospital discharge, the entire medical records were independently reviewed by two expert EPs, blinded to LUS results, in order to assign the etiology of patient’s dyspnea (in case of disagreement, a third operator, a certified cardiologist, reviewed the same clinical information and assigned the final diagnosis). Sample size was calcolated as about 500 patients.
Results
Patients were enrolled from January, 2014 to March, 2015. Data are available for the first 205 cases (103 in iLUS arm; 41% of patients had cardiac dyspnea; 12 cases needed to be assigned by cardiologist, 7 randomized to the iCXR arm). The median age was 79 years (range 28-100 years) (p-value >.05), M/F ratio was 0.95 (p-value >.05).
iLUS protocol had a sensitivity of 93.8% (95% CI 82.8-98.7) and a specificity of 94.5% (CI 84.9-98.9) for the diagnosis of cardiac dyspnea, with a ROC area of 0.94. iCXR diagnostic approach had a sensitivity of 86.1% (CI 70.5-95.3) and a specificity of 87.9% (CI 77.5-94-6), with a ROC area of 0.87.
Median evaluation time for implemented diagnoses was 3 minutes (range 2.5-15 minutes) for iLUS, and 92 minutes (range 64-265 minutes) for iCXR.
Conclusions
Preliminary results (based on less than half of the patients enrolled in this RCT) suggest that the iLUS protocol has a higher diagnostic accuracy for the diagnosis of cardiac dyspnea in patients admitted to ED than the iCXR approach, nowadays considered the standard of care.
Emanuele PIVETTA (Torino, ITALY), Pietro TIZZANI, Federica BOVARO, Maria TIZZANI, Camilla TOZZETTI, Monica MASOERO, Luca PIGOZZI, Maria Grazia VEGLIO, Francesca GIACHINO, Paolo BARON, Fulvio MORELLO, Valeria BUSSO, Paolo FASCIO PECETTO, Davide CASTAGNO, Giulio PORRINO, Milena M MAULE, Andrea EVANGELISTA, Paolo QUAGLIA, Ottavio DAVINI, Stefano GRIFONI, Corrado MOIRAGHI, Peiman NAZERIAN, Alberto GOFFI, Enrico LUPIA
14:10 - 15:40 #1402 - #1402 - Specificity of Bedside Ultrasound to diagnose Renal stones/hydronephrosis in the Emergency Department.
#1402 - Specificity of Bedside Ultrasound to diagnose Renal stones/hydronephrosis in the Emergency Department.
Specificity of Bedside Ultrasound to diagnose Renal stones/hydronephrosis in the Emergency Department
Introduction :
Flank pain is considered one of the very common presentations of patients in Emergency Departments on a daily basis. Due to the high sensitivity and specificity of CT scan, it has become the standard imaging modality for evaluating acute flank pain with the potential of renal claculi. The introduction of emergency department US however has made it one of the most preferred initial modalities for detecting renal stones considering the fact that it is commonly available, inexpensive and risk free when it comes to radiation exposure.
Several studies have looked into the sensitivity and specificity of US compared to CT in diagnosing renal stone disease. Moreover, the advantages of US being radiation free, more time and cost effective might make it a better option in the management of an ED patient.
2. Objectives :
To compare bedside US with CT in detecting renal calculi and hydronephrosis in adult patients presenting to ED with acute flank pain.
3. Study design :
Prospective diagnostic cohort study of adult patients presenting to ED with acute flank pain. Patients had a bedside US by an emergency physician in ED prior to CT (gold standard) to assess for signs suggestive of renal calculi/ hydronephrosis. The findings of the bedside imaging were documented in the patients' chart with an indication of whether or not any signs of renal calculus or hydronephrosis are detected. CT scans were reported by the radiologist who does not get an access routinely to the chart during the patient's active ED visit.
4. Inclusion criteria :
All adult patients (18 years and older) who present with acute flank pain and not previously diagnosed to have renal calculi.
5. Exclusion criteria:
Patients who have been already diagnosed with renal stones.
6. Setting:
The study was carried out in the Emergency department of University hospital Birmingham.
8. Consent :
A verbal consent was taken from all the patients and documented in the notes.
Results:
The results were very reassuring. We had total 24 patients in our pilot study. 8 were females and 16 were male. The mean age was 54years (28-90). All the patients had departmental US followed by the CT KUB. The bedside ultrasound showed sensitivity of 83.3% (95% CI= 36-97%), specificity 100% (95% CI= 82-100%), negative predictive value 95% (95% CI= 75-99%) and positive predictive value 100% (95% CI= 48-100%).
Conclusion:
Our results clearly show the effectiveness of bedside ultrasound in the hands of ED physicians. Patients without evidence of stones and hydronephrosis on ED bedside US could be safely assumed to have no stones or less than 6 mm if detected on CT. The smaller stones typically do not require surgical intervention. Hence based of the clinical judgement patients with negative US can be discharged home or further imaging can be requested.
M Azam MAJEED, Noora ALSUKAITY (Birmingham, UK), Ahmed AL HUBASHI
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Oral Paper 2
Neurological Emergencies
Moderator: Gautam BODIWALA (UK)
14:10 - 15:40 #1088 - #1088 - Can patients at high risk of non-convulsive seizure be identified in the emergency department?
#1088 - Can patients at high risk of non-convulsive seizure be identified in the emergency department?
Background: Non-convulsive seizure and non-convulsive status epilepticus (NCS/NCSE) might present with altered mental status (AMS) without any sign or symptom of seizure. Our previous work has revealed that 5% of ED patients with AMS have NCS/NCSE. Since EEG is not routinely available in the ED, most cases of NCS are not diagnosed in the ED. More than 50% of NCS cases are diagnosed more than 24 hours after ED presentation, and usually in the intensive care unit. Objective: To identify the clinical findings that could predict high risk of NCS/NCSE in ED patients with AMS.
Methods: Retrospective analysis of prospectively collected data. Inclusion criteria: Adult ED patients with AMS. Exclusion: Patients with immediately correctable cause of AMS (e.g. hypoglycemia, narcotic overdose). EEGs were recorded upon presentation and were interpreted by on-call epileptologists within one hour of recording. EEGs were recorded either by standard EEG and microEEG (Bio-Signal Group Inc.) or by microEEG alone. Proportions are presented as percentages with 95% CI. Continuous variables are presented as medians and quartiles (25%,75%). Group comparisons are performed with Mann-Whitney U or Fisher’s exact tests, when appropriate (alpha 0.05, two-tailed).
Results: We enrolled 332 patients with AMS (median age: 66 [quartiles: 50,78), 50% male). In total, 16 patients were diagnosed with NCS (5%, 95%CI, 3 - 8%). Only age was significantly different between the NCS vs. Non-NCS groups (p = 0.032). Previous history of seizure was reported only in 63% (95%CI, 39 - 82%) of NCS patients. Only 31% (95%CI, 14 - 56%) of NCS patients had abnormal neurological exam (other than AMS). Among patients who had head CT, only 20% (95%CI, 6 - 46%) had abnormal findings. Because of the small number of NCS cases, performing a multivariate analysis was not possible.
Conclusion: Increase in age is associated with higher risk of NCS/NCSE in AMS patients. There are no other clinically useful variables that could predict or increase the pre-test probability of NCS/NCSE in such patients. ED physicians ought to have a high index of suspicion for NCS/NCSE in ED patients with AMS. EEG should be the standard of care in all patients with undifferentiated altered mental status.
Shahriar ZEHTABCHI (Brooklyn, USA), Samah ABDEL BAKI, Ahmet OMURTAG, Andre FENTON, Richard SINERT
14:10 - 15:40 #1187 - #1187 - sumatriptan and propofol VS Sumatriptan and placebo in acute migraine.
#1187 - sumatriptan and propofol VS Sumatriptan and placebo in acute migraine.
Introduction: Headache are responsible for 2.2% of emergency department visits .Triptans are used as a migraine specific medication to terminate migraine headach attacks . Although triptans have been introduced as asafe and effective treatment for migraine attacks this class of drugs has well known side effects and contraindications.Several studies have shown that subanesthetic doses of propofol areefficacious as rescue therapy for acute migraine headache in adult andchildren.In this study we are comparing the effect of infusion propofol with subcutaneus sumatriptan in treatment of acute migraine headache.
Method: This study is the randomized double blind prospective clinical trial.Ever 35 known migraine paitent meeting the international headache society (IHS) criteria are enrolled in this study and randomly allocated into two groups.In first group 30 microgaram per kilogaram propofol infused in 100cc normal salin in 1 hour with 6 mg sumatriptan subcutaneus injected.In the second group 6 mg sumatriptan subcutaneous injected with placebo.
Result:There are significant differences between the two groups in respons to treatment.The primary outcome (pain intensity) is significant lower 30 minutesafter treatment in group one (pvalue< 0.05). In group one 75% of the paitent had vertigo and sleepy that improved10 minutes after completion of drug.In second group 66.7% of the paitent had chest tightness. No paitent had hemodynamic instability in both group.
Conclusion: This study has shown that sumatriptan and propofolis more effective with faster respons and better pain control 30minutes after treatment than sumatriptan and placebo.
Reza FARAHMAND RAD, Akram ZOLFAGHARI SADRABAD (TEHRAN, IRAN, ISLAMIC REPUBLIC), Marziyeh GHILIAN, Mohammad Davood SHARIFI
14:10 - 15:40 #1357 - #1357 - Relationship between full outline of unresponsiveness score coma scale and glasgow coma scale of stroke patients in emergency room, Siriraj hospital.
#1357 - Relationship between full outline of unresponsiveness score coma scale and glasgow coma scale of stroke patients in emergency room, Siriraj hospital.
Relationship between full outline of unresponsiveness score coma scale and glasgow coma scale of stroke patients in emergency room, siriraj hospital
Surabenjawong U, M.D.*, Sonmeethong W, M.D.*, Prayoonwiwat N, M.D.**, Nakornchai T, M.D.*,
*Department of Emergency Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700.
Background: The Full Outline of Unresponsiveness Score Coma Scale (FOUR score), a recent coma score, was developed to solve some limitations of the well-known Glasgow Coma Scale (GCS). From previous studies, FOUR score can predict the neurological outcome in an intensive care and traumatic patients better than GCS. However, there is no report in stroke patients.
Methods: The prospective cohort study was conducted in adult patients, diagnosed with acute stroke in emergency department of Siriraj hospital. Patients with history of previous head injury were excluded. Every patient was evaluated with both FOUR score and GCS by trained emergency physicians. The primary outcome was the correlation between both scores. The Modified Rankin Scale (MRS), Cerebral Performance Category (CPC) and 3-month mortality rate predicted by FOUR score and GCS were defined as the secondary outcomes.
Results: After analyzing data of 60 stroke patients in emergency department, mean FOUR score of the population was 14.05 (SD 4.02) and mean GCS was 12.45 (SD 3.74). FOUR score and GCS had an excellent correlation with r = 0.821 (p value <0.001). With cut-off point for mortality prediction of 10 and 9 for FOUR score and GCS respectively, FOUR score predicted 3-month mortality rate better than GCS with area under the curve (AUC) of 1.00 (p value <0.001, 95% CI 0.94-1.00) while AUC for GCS was 0.99 (p value <0.001, 95% CI 0.92-0.99). FOUR score was also outstanding in predicting the poor neurological outcome (MRS 4-6 and CPC 3-5) with cut-off point of 10 (AUC of 1.00, p value <0.001, 95% CI 1.00-1.00). Meanwhile, the GCS with cut-off point of 9 had AUC for predicting neurological outcome of 0.94 (p value <0.001, 95% CI 0.91-1.02).
Conclusion: FOUR score and GCS had an excellent correlation for evaluating the consciousness in acute stroke patients. FOUR score is not inferior to GCS for predicting 3-month mortality and poor neurological outcome.
Keywords: acute stroke, Full outline of unresponsiveness score coma scale, Glasgow Coma Scale
Usapan SURABENJAWONG (Bangkok, THAILAND), Thanyaporn NAKORNCHAI, Weeraphon SONMEETHONG
14:10 - 15:40 #1496 - #1496 - Delays to diagnostic brain imaging in childhood arterial ischemic stroke.
#1496 - Delays to diagnostic brain imaging in childhood arterial ischemic stroke.
Background: Acute ischemic stroke (AIS) in children is an uncommon but potentially devastating condition. Prompt recognition is crucial to guide appropriate management in the acute care setting. The gold standard for the diagnosis of stroke is brain magnetic resonance imaging (MRI). Long delays to diagnosis are the most important barrier to thrombolysis in children. This may be a consequence of both delayed presentation to medical attention and in-hospital factors including limited access to diagnostic brain imaging.
Objective: primary outcome was to determine the time to first neuroimaging in children diagnosed with ischemic stroke. Our secondary aim was to identify patient and process factors that contributed to delayed neuroimaging.
Design/Methods: Retrospective study of children with a radiologically confirmed stroke in a tertiary care center, RCH Melbourne, between January 2003 and December 2012. Data on presentations to a referring hospital prior to transfer to our center were also collected.
Results: 71 episodes of AIS and 19 of TIA were recorded. The time from symptom onset to hospital arrival was 2.5h (IQR 1-19) for patients who first presented to another hospital and 3.6h (IQR 1.3-18.5) for first presentations to our center. Overall time from hospital arrival to first neuroimaging was 3.3h (IQR 1.2-8.3). 66% of children received CT as the first imaging modality in a median time of 1.5h (IQR 1.0-3.7), but the scan was only diagnostic in 25% of cases, whilst MRI was the first imaging performed in 34% of cases, in a median time of 3.9h (IQR 1.4-13.7) and it was diagnostic in 100% of AIS. Time to final diagnosis (on either CT or MRI) was 11.3h (IQR 4.1-22.5). Sedation was used in 28% of children (12% of CT scans and 41% of MRI scans). Children who underwent their first scan more than 3h after hospital presentation were more likely to receive an MRI as first neuroimaging modality (OR 10.75, 95% CI 3.56-33.72) and to have a final diagnosis of TIA (OR 7.34, 95% CI 2-33). Use of sedation was not significantly associated with a delay in neuroimaging (OR 1.83, 95% CI 0.67-4.97).
Conclusions: Despite the poor diagnostic accuracy, CT was still the first neuroimaging modality performed in the majority of patients with AIS, often within 3 hours from arrival. MRI had superior sensitivity to CT, but was more likely to be performed beyond this time window. Use of sedation did not seem to be associated with delayed neuroimaging. Development of acute stroke imaging protocol to maximise diagnostic yield in minimum time are urgently needed.
Marco DAVERIO (Padova, ITALY), Mark MACKAY, Silvia BRESSAN, Franz BABL
14:10 - 15:40 #1497 - #1497 - Recurrent childhood arterial ischemic stroke management in the emergency department.
#1497 - Recurrent childhood arterial ischemic stroke management in the emergency department.
Background: Acute ischemic stroke (AIS) is uncommon in childhood, but recurrent strokes occur relatively frequently (up to 1/3 of the patients), particularly in cases with atherosclerotic arteriopathies and cardiac disease. The gold standard for the diagnosis is magnetic resonance imaging (MRI). Whilst significant delays in the diagnosis have been previously reported in children with a first episode of AIS, recurrences should be recognized earlier and time to final diagnosis reduced.
Objective: To describe the clinical characteristics, time to diagnostic neuroimaging and differences in the acute management of recurrent AIS episodes compared with first presentations.
Design/Methods: Retrospective study in a Pediatric tertiary referral hospial of children diagnosed with AIS between January 2003 and March 2014. Data on presentations to referring hospitals prior to transfer were also collected.
Results: 70 patients were included with a mean follow up of 5.6 years (SD 2.3). Of these, 11 subjects had a total of 23 episodes of recurrent stroke, occurring at a median of 208 days (IQR 37-395) after the index stroke. Patients with a recurrence were older (median age 8.04 vs 6.23 years) and more often females (82.6% vs 55.7%, p=0.021). Recurrent episodes tended to arrive more often by private car and presented with signs and symptoms different to first presentations (less non-focal/diffuse features, like altered mental status and vomit, less focal motor features, like focal limb weakness and dysarthria and more nuanced symptoms, like focal numbness). All the 70 patients with a first AIS underwent neuroimaging, whereas neuroimaging was not performed in 3 recurrent episodes, where a clinical diagnosis of TIA was made after neurology consultation. Computed Tomography (CT) was the first scan modality in 2/3 if first strokes but still the first in 50% of the recurrences, being diagnostic in 17% of cases overall. Time from symptom onset to hospital arrival was not significantly shorter for patients with a recurrence (p>0.05). Time to first and diagnostic scan was significantly longer for patients with a recurrent episode compared with first presentations (respectively p=0.015 and p=0.021).
Conclusions: Knowledge of prior stroke does not seem to have a positive effect on decreasing time delays to arrival at hospital or time to brain imaging. Most recurrent strokes were associated with self-limited symptoms. Despite the low diagnostic accuracy CT scan was still the first neuroimaging performed in half of the recurrent episodes. Development of acute stroke imaging protocol to maximise diagnostic yield in minimum time are urgently needed in children.
Marco DAVERIO (Padova, ITALY), Silvia BRESSAN, Franz BABL, Mark MACKAY
14:10 - 15:40 #1596 - #1596 - When life runs out in seconds - high-speed thrombectomy protocol in ischemic stroke.
#1596 - When life runs out in seconds - high-speed thrombectomy protocol in ischemic stroke.
Background: In ischemic stroke caused by a thrombosis of a large brain artery, two million neurons, 12 kilometers of axons and 14 billion synapses are lost every minute. IV-thrombolysis (IV-tPA) in such cases appears ineffective, while mechanical thrombectomy (MT) is reported to be a powerful tool to open the occlusion (1). However, the favorable effect of recanalization is highly time-dependent (2). American Stroke Association recommends a door-to-punction time shorter than 120 minutes. At Tampere University Hospital approximately 70 patients per year are presently treated with MT. Since 2013, we have used a validated MT protocol that includes key personnel from paramedics to interventional neuroradiologist. Hence, we wanted to evaluate the current efficacy of our protocol. Previously, consecutive series of patients with door-to-recanalization time of less than 90 minutes on average have not been reported.
Materials and Methods: From 1.1.-12.4.2015, all consecutive MT patients were identified from our hospital records. We collected the following data: symptom onset time, door-to-punction time, door-to-recanalization time, NIHSS (National Institutes of Health Stroke Scale) at arrival and at 24h post recanalization, and TICI (Thrombolysis In Cerebral Infarction) score 0-3 (0=no flow- 3=complete tissue reperfusion). A total of 18 consecutive patients (mean NIHSS 17 at arrival, range 6-22) treated with MT were identified, of whom 14 were also treated with IV-tPA.
Results: Our preliminary results show that the median door-to-punction time was 25 minutes (range 14 min – 1h 33min) and the median door-to-recanalization time was 66 minutes (range 30 min – 128min). The median symptom-onset-to-recanalization time was 4 h 40 minutes (excluding 3 wake-up-strokes). Recanalization was not achieved in two patients. The remaining 16 had a minimum TICI score 2b and displayed a favorable outcome at 24 hours (mean NIHSS 6, range 0-19).
Discussion: Early reperfusion is the main factor predicting good outcome in stroke recanalization therapy. Our current protocol enables systematic high-speed recanalization in patients with proximal brain artery thrombosis. We achieved at least TICI 2b recanalization in 90% of the cases.
References:
- Berkhemer OA, Fransen PS, Beumer D et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015 Jan 1;372(1):11-20.
- Mazighi M, Meseguer E, Labreuche J et al: Dramatic recovery in acute ischemic stroke is associated with arterial recanalization grade and speed. Stroke. 2012 Nov;43(11):2998-3002.
Tessa TILLGREN (Tampere, FINLAND), Satu-Liisa PAUNIAHO, Pasi JOLMA, Jutta KERÄNEN, Juha-Pekka PIENIMÄKI, Henna SIIPPAINEN , Hannu PÄIVÄ, Jyrki OLLIKAINEN
14:10 - 15:40 #1707 - #1707 - The Relationship Between Optic Nerve Sheath Diameter Measured on Computerized Tomography and Mortality in Patients with Cerebrovascular Infarction.
#1707 - The Relationship Between Optic Nerve Sheath Diameter Measured on Computerized Tomography and Mortality in Patients with Cerebrovascular Infarction.
OBJECTIVE: We aimed to assess the possible correlation between optic nerve sheath diameter (ONSD) measurements on initial brain computerized tomography (CT) images and National Institutes of Health Stroke Scale (NIHSS), Glasgow Coma Scale (GCS) and the relationship with mortality in ischemic stroke patients admitted to Emergency Department.
FINDINGS: Total of 143 patients were included to this study. Case group was constituted from 70 patients and the control group from 73. Mean age of the case group (n=70) was 72.1±12.9(32-95), and 51.2% of the patients were female and 48.8% were male. Control group mean age (n=73) was 68.9±10(35-88), 53.7% of the patients were female and 46.3% of the patients were male.There was no statistically significant difference among groups in terms of gender distribution and mean age (p=0.437).The case and control groups were observed having similar comorbidities, however, statistically significant differences were only detected in terms of HT, previous cerebrovascular event and DM risk factors between the case and control groups. Mean ONSD values measured on CT were 5.52±0.76 mm for the right eye and 5.79±0.85 mm for the left eye in the case group and 5.04±0.52 mm for the right eye and 4.95±0.58 mm for the left eye in control group. According to these results, a significant difference was determined between right and left eye mean ONSD measurement values in the case and control group patients (for right ONSD, p=0.01; for left ONSD, p=0.01). Mean hospitalization time of the case group patients were 16.1 days and mean duration of stay in intensive care unit was 13.7 days. Mean NIHSS points of the case group was 9 and mean GCS score was 14. There was no significant difference between survivors and non-survivors in the case group in terms of each eye ONSD values (for right ONSD, p=0.84; for left ONSD, p=0.73).
RESULTS: There is a linear relationship between intracranial pressure and optic nerve sheath diameter meaurement values on unenhanced brain computerized tomography images in ischemic stroke patient population. Final data of our study indicate that ONSD measurement values could be used for prediction of intracranial pressure in ischemic stroke patient population but for the prediction of mortality, ONSD measurement values alone stand insufficient. Optic nerve measurement on brain tomography images can be used as an non-invasive method for detection of increased intracranial pressure in cases where invasive intracranial monitorization is contraindicated or alternative non-invasive monitorization devices such as USG are not availible.
Mehmet Akif ONAL, Sedat KOCAK (KONYA, TURKEY), Gulay SAHINER ONAL, Necdet POYRAZ, Muhammet Rasit OZER, Mustafa GULPEMBE, Basar CANDER
14:10 - 15:40 #1932 - #1932 - Causes of emergency vertigo stratified by age and gender.
#1932 - Causes of emergency vertigo stratified by age and gender.
Introduction:
Vertigo is a common complaint of patients who seek care in the emergency department (ED). In terms of signs and symptoms, overlap exists among the many potential causes. The report of symptoms can be vague, inconsistent, or unreliable. Life-threatening disorders can masquerade as benign disorders. What are the main causes of emergency vertigo?
Objective:
To explore the causes of emergency vertigo stratified by age and gender to improve the diagnostic efficiency
Methods:
A prospective observational study was conducted over seven months. All the patients presented to the ED with vertigo were included. The demographics, co-morbidities, clinical and biological data and in-hospital procedures were collected. The etiologies were identified and stratified by age and sex.
Results:
Inclusion of 122 patients. Mean age 53 +/- 16 years. Sex ratio = 0.87. Comorbidities n (%): hypertension 39 (32%), Diabetes 23 (19%), history of vertigo 52 (43%), coronary artery disease 7 (6%), stroke 9 (8%). Mortality was 1%. The top three diagnoses were benign paroxysmal positional vertigo (BPPV in 91 cases, 75%), central vertigo in 13 patients (PCI, 11%) and hypertensive peak in 9 cases (7,4%).
Stratified by age, the main cause of vertigo for the patients < 30 years (N=12) is BPPV (100%). For the patients aged between 30-45 years (N= 30), BPPV was found in 25 patients (83%), central vertigo (n = 2, 7%), iatrogenic cause, hypertensive peak and CO poisoning in one patient each. BPPV (n=26, 75%), psychological factors (n=3, 8%), central vertigo (n=2, 6%), iatrogenic cause (n=2,6%), one patient had cardiac cause and another patient CO poisoning, for 45-60 years group (N=35). For the group of patients aged between 60-75 years old (N=35), central vertigo was found in 8 cases (23%), BPPV was found in 20 cases (57%), hypertensive peak (n=7, 20%), cardiac cause (n=2, 6%) and psychological factors in one case. For the elderly group > 75 years (N=10), BPPV was found in 8 (80%) of patients, and central vertigo in 1 (10%), hypertension was found in one patient (10%).
Stratified by gender, there was no difference for the main three etiologies: BPPV, central vertigo or hypertensive peak. But psychological factors were more common in women, and cardiac causes more found in men.
Conclusion:
The main causes of emergency vertigo were: BPPV, central vertigo and hypertensive peak. BPPV should be considered initially when vertigo was triggered repeatedly by positional change, especially for young patients. In elders with vertigo, central vertigo and hypertension were common. In women psychological factors should be considered and diagnosis and treatment should be offered timely.
Rania JEBRI (Ben Arous, TUNISIA), Anware YAHMADI, Soumaya MAHDHAOUI , Sami SOUISSI, Mouna GAMMOUDI, Wided BOUSSLIMI, Sawsen CHIBOUB, Mahbouba CHKIR
14:10 - 15:40 #893 - #893 - Ischemic Preconditioning Maintains Immunoreactivities of Glucokinase and Glucokinase Regulatory Protein in Neurons of the Gerbil Hippocampal CA1 Region Following Transient Cerebral Ischemia.
#893 - Ischemic Preconditioning Maintains Immunoreactivities of Glucokinase and Glucokinase Regulatory Protein in Neurons of the Gerbil Hippocampal CA1 Region Following Transient Cerebral Ischemia.
Glucokinase (GK) plays a key role in the control of blood glucose homeostasis. In the present study, we investigated the effect of ischemic preconditioning (IPC) on immunoreactivities of GK and its regulatory protein (GKRP) following 5 min of transient cerebral ischemia in gerbils. The gerbils were randomly assigned to 4 groups (sham-operated-group, ischemia-operated-group, IPC plus (+) sham-operated-group and IPC+ischemia-operated-group). IPC was induced by subjecting the gerbils to 2 min of ischemia followed by 1 day of recovery. In the ischemia-operated-group, a significant loss of neurons was observed in the stratum pyramidale (SP) of the hippocampal CA1 region (CA1) at 5 days post-ischemia; however, in the IPC+ischemia-operated-group, neurons in the SP were well protected. In the immunohistochemical study, immunoreactivities of GK and GKRP in neurons of the SP were distinctively decreased in the CA1, not CA2/3, from 2 days post-ischemia, and hardly detected in the SP at 5 days post-ischemia. In the IPC+ischemia-operated-group, immunoreactivities of GK and GKRP in the SP of the CA1 were similar to those in the sham-group. In brief, our findings show that IPC dramatically maintains immunoreactivities of GK and GKRP in neurons of the SP of the CA1 after ischemia-reperfusion and indicate that GK and GKRP may be necessary for neurons to survive against transient cerebral ischemia.
Jun Hwi CHO, Chan Woo PARK, Taek Geun OHK, Yoon Sung KIM (Chuncheonsi, KOREA), Myoung Chul SHIN, Moo Ho WON
14:10 - 15:40 #901 - #901 - The impact of thrombolytic treatment or endovascular thrombectomy on oxidant-antioxidant status and lymphocyte DNA damage in patients with acute ischemic stroke.
#901 - The impact of thrombolytic treatment or endovascular thrombectomy on oxidant-antioxidant status and lymphocyte DNA damage in patients with acute ischemic stroke.
Purpose: This study aimed to investigate the impacts of thrombolysis and thrombectomy on lymphocyte DNA damage and oxidative stress parameters for the treatment of adult patients with ischemic stroke in early post-stroke period (within the first 4-6 hour of stroke) based on clinical and radiological findings.
Materials and methods: Over a 7-month period (May 2014 through November 2014), 62 consecutive adult patients who presented to the Emergency Department of Bezmialem Vakif University and diagnosed as an acute ischemic stroke were included in this prospective clinical study. Thirty-two patients who met the inclusion criteria and 30 eligible healthy volunteers as control subjects were enrolled. Patients were divided into 3 groups according to their National Institute of Health Stroke Scales (NIHSS) on admission. Additionally, patients were stratified into three different groups based on modified Rankin Scale (mRS) at 24 h after thrombolytic treatment or endovascular thrombectomy. Plasma lymphocyte DNA damage and Total Oxidant Status (TOS), Total Antioxidant Status (TAS) and Oxidative Stress Index (OSI) were assessed in all groups classified with respect to NIHSS and mRS, both on admission and at 24 h after the treatment. The results were compared between the groups.
Results: Plasma TOS and OSI levels and lymphocyte DNA damage were found to be significantly higher, whereas plasma TAS levels were significantly lower in patients with stroke compared with those in the controls (all comparisons, p<0.001). According to the comparison of NIHSS groups with respect to the stroke severity; increased lymphocyte DNA damage levels and decreased TAS levels were observed (p< 0.001 and p=0.034, respectively). When the patients were classified into subgroups with respect to mRS, plasma TOS and OSI levels and lymphocyte DNA damage tended to be higher in group 3 which comprised patients with the most neuronal dysfunction compared to those in groups 1 and 2 (p=0.003, p=0.001 and p=0.006, respectively).
Conclusion: Lymphocyte DNA damage and TAS, as biomarkers of early oxidative changes can be regarded as an objective alternative criterion to the stroke assessment scales for determining severity of brain damage in patients with ischemic stroke. Additionally, lymphocyte DNA damage, TOS and OSI levels as an early biological indicators can help to identify neurologic health and well being and to evaluate the effectiveness of thrombolytic treatment or endovascular thrombectomy in such patients.
Eda YIGIT, Ozgur SOGUT (Istanbul, TURKEY), Mehmet YIGIT, Ali DUR, Kenan TURKDOGAN, Taha Okkes KÜCUKDAGLI
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State of the Art
Disaster & Biohazards
Moderators: Massimo AZZARETTO (Associate Researcher) (Novara, ITALY), Ives HUBLOUE (Chair) (Brussels, BELGIUM)
16:10 - 16:40 Mass civilian shootings: Are we ready to face this new threat? Alain PUIDUPIN (Médecin anesthésiste réanimateur) (Paris, FRANCE)
16:40 - 17:10 Quarantine and isolation: Understanding public health measures to manage an outbreak. Kristi KOENIG (USA)
17:10 - 17:40 Training in disaster medicine: technology available for new challenges. Pier Luigi INGRASSIA (Novara, ITALY)
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Italy invites
Il Micro e il Macro nel paziente critico
Moderators: Mauro CHIESA (ITALY), Andrea MAGNACAVALLO (ITALY)
16:10 - 16:30 Non si vede ma c'è. Fernando SCHIRALDI (Napoli, ITALY)
16:30 - 16:50 Meglio sapere che c'è. Rodolfo SBROJAVACCA (Udine, ITALY)
16:50 - 17:10 Se c'è si deve vedere. Roberto COPETTI (Latisana, ITALY)
17:10 - 17:30 Mettiamo insieme i pezzi del puzzle. Gian CIBINEL (Torino, ITALY)
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Clinical Questions: Controversies
Trauma
Moderators: Simon CARLEY (Manchester, UK), Fiona LECKY (Professor of Emergency Medicine) (Sheffield, UK)
16:10 - 16:40 How should we teach trauma care in 2015? Mary Rose CASSAR (Zebbug, MALTA)
16:40 - 17:10 Trauma systems: Local care or major trauma centre? Raed ARAFAT (ROMANIA)
17:10 - 17:40 Is it all about the golden hour? Francesca INNOCENTI (PHYSICIAN) (FIRENZE, ITALY)
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Moderators: Abdelouahab BELLOU (BOSTON, USA), Madalenna LETTINO (ACCA President Elect) (ITALY)
16:10 - 16:40 Acute Cardiac Care Association of the European Society of Cardiology: Past, present, future and collaboration with EuSEM. Madalenna LETTINO (ACCA President Elect) (ITALY)
16:40 - 17:10 Pragmatic Use of cardiac biomarkers in the emergency department. Mario PLEBANI (ITALY)
17:10 - 17:40 Pragmatic Management of Atrial Fibrillation in the Emergency Department. Abdelouahab BELLOU (BOSTON, USA)
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Infectious Disease & Sepsis
Moderators: Christoph DODT (München, GERMANY), Jean Louis VINCENT (BRUXELLES, BELGIUM)
16:10 - 16:40 Early sepsis detection. Christian HOHENSTEIN (PHYSICIAN) (JENA, GERMANY)
16:40 - 17:10 Blood sugar in septic ED patients? Important or useless to consider? Christoph DODT (München, GERMANY)
17:10 - 17:40 Reducing late sepsis complications in the Emergency Department. Jean Louis VINCENT (BRUXELLES, BELGIUM)
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YEDM
Sim Wars
Moderators: Pier Luigi INGRASSIA (Novara, ITALY), François LECOMTE (Paris, FRANCE)
Coordinators: Abdo KHOURY (PH) (Besançon, FRANCE), Youri YORDANOV (Médecin) (Paris, FRANCE)
Facultys: Elaine ERASMUS (Cape Town, SOUTH AFRICA), Sian GERATY (SOUTH AFRICA), Natalie MAY (Oxford, UK), Patrick PLAISANCE (Paris, FRANCE), Thomas PLAPPERT (Fulda, GERMANY), Pieter Jan VAN ASBROECK (Consultant in Emergency Medicine) (Hasselt, BELGIUM), Sabina ZADEL (SLOVENIA)
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Paediatric Track
Scenario-based Guidelines in PEM
Moderators: Tom BEATTIE (UK), Ian MACONOCHIE (UK)
16:10 - 16:35 Simulation of Head Injuries. Silvia BRESSAN (Padova, ITALY)
16:35 - 17:00 Simulation of Anaphylaxis. Cathelijne LYPHOUT (Consultant in EM) (Ghent, BELGIUM)
17:00 - 17:25 Simulation of Breathlessness. Youri YORDANOV (Médecin) (Paris, FRANCE)
17:25 - 17:40 Speakers' Forum. Ian MACONOCHIE (UK)
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Oral Paper 1
Administration & Healthcare Policy
Moderators: Gautam BODIWALA (UK), Lisa KURLAND (SWEDEN)
16:10 - 17:40 #967 - #967 - ER throughput: staff perceptions of delays.
#967 - ER throughput: staff perceptions of delays.
Background: There are many potential delays in throughput in a busy academic emergency department. Identifying these delays can help the organization serve patients better and more efficiently. Perceptions vary regarding which factors contribute most to delays in throughput.
Objectives: This study aims to identify some of these factors and analyze the perceptions of delays among staff members.
Methodology: All full-time clinical staff of the University of Chicago emergency department were asked to select the top 5 delays (among 19 options) that detract from overall throughput. Staff was also asked to choose the top 5 improvable delays in throughput. Responses were sorted by group: attending, resident, nurse and technician. The percent of total participants within one group that selected a particular option was compared to the other groups.
Results: Response rate among physicians was 56% while response rates among other staff was 34%. 50% of all responses were physicians while 50% were other staff members. The top selections among physicians were: waiting for consultants, image acquisition, inpatient bed assignments, distractions and lab results. The top selections among ancillary staff were: physician decision time, inpatient bed assignments, waiting for consultants, radiologist read of images, image acquisition.
Discussion: All groups indicated that the largest perceived delays are outside of the ER’s control. Staff within one group typically characterized the largest delays as ones that fall within the responsibility of another group, minimizing delays their own group is accountable for. The largest perceived delays tend to be operations that a group is least involved with or disrupts a group’s own workflow.
Conclusion: Better communication between staff groups is needed to understand delays contributing to overall workflow. Since perceptions of delays are so varied among staff groups, data-driven methodologies to improve workflow are important to avoid fallacies related to perceptions in overall ER throughput delays.
Spiegel TOM, Archit GULATI (Chicago, USA)
16:10 - 17:40 #1473 - #1473 - Factors associated with lenght of stay in a Spanish Emergency Department.
#1473 - Factors associated with lenght of stay in a Spanish Emergency Department.
Introduction: Length of stay (LOS) is a key measure of emergency department (ED) throughput and a marker of overcrowding. Excess LOS in the ED has been identified as a relevant indicator for measuring quality of care in the ED and has been linked to an increase in risk for patients. Time studies that assess key ED processes could help clarify the causes of patient care delays and prolonged LOS and contribute to develop innovative and cooperative strategies that should lead to improving patient flow within the ED and improve quality of care and patient satisfaction.
Objective: This abstract aims to identify factors associates with LOS in the ED in a University Hospital in Madrid, Spain.
Methods: This study was conducted at the General ED of Hospital La Paz, a University urban tertiary care centre located in Madrid, Spain. Hospital La Paz catchment area covers 850.000 people. The ED saw over 104.000 patients a year and is staffed by 24 attending emergency physicians. Hospital La Paz ED consists of three levels of care: I. Walk-in clinic (WIC); II. Emergency Care Unit (ECU); III. Acute Medical Care Ward (AMCW), with 24 beds. The source of information for this work was a statistical representative sample obtained from all patients attending the General ED of Hospital La Paz from 3 years: 2008 (33,7%), 2010 (28,1%) and 2013 (38,2%). The sample selected patients from 3 months (August, February, May, November), and 3 days of the week (Sunday, Monday, Wednesday). Information was retrospectively extracted from medical records as well as from clinical administrative data bases. Analysis was conducted through multivariable linear regression considering LOS in the ED as dependent variable.
Results: Overall, data was obtained from 956 patients, being 54.2% female, and 3.3% functionally dependent. 59.3% were allocated to the WIC, 7.1% to the ECU, and 33.4% to the AMCW. Mean age was 55.7 and Charlson index was 1.5. Mean LOS was 552.5 minutes and median was 315.0 minutes. A hospital admission was indicated for 19.8% of all patients. The most relevant use of clinical resources was: consultation with specialists (32.5%), urinalysis (10.0%), diagnostic imaging (46.9%), and blood test (60.5%).
No significant differences in LOS were obtained by number of patients attending the ED, year, month, day of the week, hour of admission to the ED, age, sex or Charlson index. Variables showing a significant effect on LOS in a multivariable regression analysis were: dependency status, level of care, blood tests, diagnostic imaging, urinalysis, consultation with a specialist, and type of discharge from the ED. An interaction was found between hospital admission and level of care, as patients admitted to the AMCW who were eventually hospitalized have lower LOS than patients who were discharged from the ED.
Conclusions: These data shows that both internal (requesting of both consulting and diagnostic services, and the process of care in the AMCW) and external factors (delivery of consulting services and diagnostic tests) should be investigated in a comprehensive research-based strategy aimed at optimizing LOS in the ED.
Antonio SARRÍA SANTAMERA (Madrid, SPAIN), Ana MARTÍNEZ VIRTO, Manuel QUINTANA DIAZ
16:10 - 17:40 #1848 - #1848 - Fever in the under five's: Impact of an integrated electronic health record on compliance with national standards on documentation and management.
#1848 - Fever in the under five's: Impact of an integrated electronic health record on compliance with national standards on documentation and management.
Background: The National Institute of Health and Care Excellence (NICE) in the UK mandates standards for the assessment, documentation and management of children under 5 years presenting with fever (Clinical Guideline 130). Auditing compliance with these standards has always been hampered by poor documentation. Fully integrated health care records offer an opportunity to not only improve documentation but also to implement clinical decision tools and links to patient information resources.
Methods: We compared documentation and management of 50 consecutive febrile (temperature > 37.5 degrees C) paediatric patients aged under 5 years presenting to our emergency department before (2012) and four months (December 2014) after the introduction of a fully integrated electronic health record system (EPIC). This type of electronic health care record is widely used in the US (69% of children's hospitals) but our Hospital is one of the first in the UK to adopt such a system. Five standards were assessed:
1) Use of the NICE traffic light system (clinical decision tool) when assessing febrile children in the ED
2) Recording of observations (temperature, heart rate, respiratory rate, capillary refill time and blood pressure)
3) Safety netting information provided to families
4) Appropriate use of antibiotic treatment
5) Investigations performed in children of the highest risk category
Results:
Standard 1: The children's risk category could be determined from the documentation in 84% of cases (90% in 2012), no reference to the use of the NICE tool was made by any of the clinicians. The tool is available for reference in the ED but not integrated as a decision tool in EPIC. This was no different to the previous audit in 2012.
Standard 2: Althought the recording of baseline observations was similar, the documentation of capillary refill time and blood pressure had dropped (see table 1).
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Observation
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Standard achieved in 2015
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Standard achieved in 2012
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Temperature
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98%
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100%
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Heart rate
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98%
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95%
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Respiratory rate
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98%
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95%
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CRT/BP
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38%
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64%
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Standard 3: The proportion of patients in the intermediate category that had appropriate safety netting advice given and documented in the record was 66% in 2014 compared to 36% in 2012, although the numbers were small.
Standard 4: Antibiotic prescribing was appropriate in 100% of cases (no different to 2012).
Standard 5: Documentation of appropriate investigations performed in the highest clinical risk group had dropped from 100% in 2012 to 80% since introduction of EPIC.
Conclusion: EPIC does not appear to have resolved the problem of poor documentation. Severity was not determinable in a greater percentage of cases compared with 2012. Documentation of safety netting is still lacking, albeit improved since 2012. Improvements have been seen in the measurement and recording of the observations temperature, heart rate and respiratory rate. However, recording and documentation of capillary refill time and blood pressure still remains much lower than in 2012. The prescription of antibiotics appears to be in accordance with NICE guidelines. Implementation and integration of clinical decision tools may be required at system design stage to improve compliance with national standards.
T.f.a. MARSHALL-ANDON (Cambridge, UK), Peter HEINZ
16:10 - 17:40 #1026 - #1026 - Patients’ knowledge about drugs prescribed and the transmission of medical information in the healthcare circuit : A prospective study.
#1026 - Patients’ knowledge about drugs prescribed and the transmission of medical information in the healthcare circuit : A prospective study.
Background: Quality medical care means that physicians have the appropriate medical information. The objective of this study is to evaluate the medical information in thehealthcare circuit (i.e knowledge about prescription medications and quality of referral letters).
Methods: We present here a prospective multicentric study of 892 patients, from December 2013 to July 2014 within 3 Emergency Departments (ED) including 648 patients. In outpatient care, 133 patients were interviewed by 3 specialists and 111 patients in 2 general practices.
Results: In our study, 30.6% of patients getting to the ED are more than 75 years old (versus 15.4% in outpatient care). 65.5% of primary care patients have optimal treatment knowledge versus 43.4% in the ED (12.3% for ≥ 75 years old). A statistically significant relationship was established between age or polypharmacy and knowledge of treatment. 11.3% of patients have full knowledge of their treatment (when more than 5 items were prescribed). Patients referred by general practitioners (GP) in the ED were 3.6 times more likely to not know their treatment. We also studied the relationship between high risk medication (such as: vitamin K antagonist, antiplatelet, psychotropic drugs, antibiotics) and treatment knowledge. Patients consuming these drugs have 7 times less likely to have an optimal knowledge and were 3.6 times more addressed to the ED. Only 18% of patients consulting at the ED have structured referral letters (anamnesis, clinical examination, argued hypothesis). The quality of GP's letters was unsatisfactory, only 36.2% were well structured. Those of the Emergency medical service were of even lower quality: 9.0% were structured. When the patient is admitted in the ED, he is most likely to ignore its treatment: more than 50% of patients are unable to quote it. Using an individualized treatment card could be a reliable way to transfer medical information.
Conclusion: Our study based on the transmission of medical information reveals that the population most at risk of treatment ignorance is the one older than 75 years, with a treatment consisting of more than 5 items and with prescription medication having a high risk of iatrogenic complications. The proportion of elderly patients is increasing in all ED. The assessment phase on arrival is fundamental and determines the future orientation of the patient. Our key objective in the ED is to identify fragile patients. Quality medical care begins with appropriate communication between physicians.
Céline RENFER (Strasbourg), Carmen HAMMANN, Hakim SLIMANI, Fanny SCHWEITZER, Charles-Eric LAVOIGNET, Mihaela MIHALCEA-DANCIU, Pierrick LE BORGNE, Pascal BILBAULT
16:10 - 17:40 #1614 - #1614 - How emergency medicine senior doctors spend their time at the emergency department; systematic review of time and motion studies.
#1614 - How emergency medicine senior doctors spend their time at the emergency department; systematic review of time and motion studies.
Review question How senior emergency doctors spend their time at the emergency department (ED).
Background Given the demands placed on senior doctors in terms of time and expertise, it is valuable to summarise the literature that describes and quantifies how senior emergency doctors utilize their time. A better understanding of this will, in turn, assist policy makers to maximise the potential benefits that senior doctors confer. The secondary objective for the review was to create a standardized classification of activities that are performed in the ED by senior doctors in order to assist researchers in this field who may use this list of activities for collaborative research.
Design Systematic review.
Data sources Databases searched included: Cochrane Library, MEDLINE, EMBASE, CINAHL, and Web of Science. Reference lists and citations of the retrieved studies were scrutinized for additional studies.
Review methods Databases were searched for Time motion studies (TMS) examining the role how senior doctor spend their time in the ED published from 1998 to 2014. Studies were included if they were observational TMS or work-sampling studies , undertaken in Type I adult or mixed population EDs and described the activities of senior doctors. The systematic literature search was followed by assessment of risk of bias of each individual study fulfilling the inclusion criteria using an evidence-based quality appraisal developed by the authors. Data extraction was based on a form designed and piloted by the authors.
Data synthesis Narrative synthesis was performed.
Results Ten TMS were included in the review. The majority were small single-site studies conducted in academic EDs in developed countries. Generally, studies were liable to several biases including observer and Hawthorn bias. Time spent on direct patient care was the most commonly reported outcome. Direct patient care occupied around 28.1 to 40% of the senior doctors’ time with a mean, median of 33 and 32.7 respectively. In comparison, indirect patient care was reported by five studies where it referred to all activities apart from direct care. This ranged from 51.3% - 69% for academic senior emergency doctors and 45% for community ED senior emergency doctors. Time spent on communication was reported in seven studies. It ranged from 8.3%-42%. Eight studies reported data on documentation. It ranged from 8.5% in the most recent study by Kee et al., to 28% as reported by Chisholm. Teaching and supervision was included in the categorisation of all studies except three but no particular trend was detected. Personal time or social time was reported in six studies. This accounted for 3% to around 17% of the senior doctors’ time.
Conclusion: Senior doctors spend a significant amount of time on activities related to indirect patient care. Senior emergency doctors can manage several tasks concurrently in an interrupt-driven and busy environment. It is also proposed to use the suggested category classification presented in this review (table format) in future studies looking at time analysis of doctors in an ED setting.
Maysam ABDULWAHID (Sheffield, UK), Janette TURNER, Suzanne MASON
16:10 - 17:40 #1615 - #1615 - The impact of senior doctor assessment at triage on emergency department performance measures: Systematic review and meta-analysis of comparative studies.
#1615 - The impact of senior doctor assessment at triage on emergency department performance measures: Systematic review and meta-analysis of comparative studies.
ABSTRACT
Study question To determine if placing senior doctor at triage versus standard single nurse in a hospital emergency department (ED) improves ED performance by reviewing evidence from comparative design studies using several quality indicators.
Design Systematic review.
Data sources Cochrane Library, MEDLINE, EMBASE, CINAHL, Cochrane Effective Practice and Organisation of Care (EPOC), Web of Science, Clinical trials registry website. In addition, screening studies references, citation search were used to identify relevant studies.
Review methods Databases were searched for comparative studies examining the role of senior doctor triage, published from 1994 to 2014. Senior doctor was defined as a qualified medical doctor who completed high specialty training in emergency medicine. Articles with a primary aim to investigate the effect of senior doctor triage on ED quality indicators such as waiting time (WT), length of stay (LOS), left without being seen (LWBS) and left without treatment complete (LWTC) were included. Articles examining the adverse events and cost associated with senior doctor triage were also included. Only studies with a control group, either in a randomized controlled trial (RCT) or in an observational study with historical controls, were included. The systematic literature search was followed by assessment of relevance and risk of bias of each individual study fulfilling the inclusion criteria using Effective Public Health Practice Project EPHPP bias tool. Data extraction was based on a form designed and piloted by the authors for dichotomous and continuous data.
Data synthesis Narrative synthesis and meta-analysis of homogenous data was performed.
Results Of 4506 articles identified, 25 relevant studies were retrieved; 12 were of the weak pre-post study design, 9 were of moderate quality and 4 were of strong quality. The majority of the studies revealed improvements in ED performance measures favoring senior doctor triage. Pooled results from 2 homogeneous Canadian RCTs showed a significant reduction in LOS of medium acuity patients (WMD -26.26 min 95%CI -38.50 to -14.01). Another 2 RCTs revealed a significant reduction in WT (WMD -26 min, 95%CI -31.68 to -20.65). LWBS was reduced in 2 Canadian RCTs [RR = 0.79, 95% CI 0.66 to 0.94]. This was echoed by the majority of pre-post study designs. Senior doctor triage did not change the occurrence of adverse events. No clear benefit of senior doctor triage in terms of patient satisfaction or cost effectiveness could be identified.
Conclusion This review demonstrates that senior doctor triage (SDT) can be an effective measure to enhance ED performance, although cost versus benefit analysis is needed. The high risk of bias in the nature of evidence identified, however, mandates more robust multi-centered studies to confirm these findings.
Maysam ABDULWAHID (Sheffield, UK), Andrew BOOTH, Maxine KUCZAWSKI, Suzanne MASON
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Oral Paper 2
Education and Simulation Training / Point of Care Research
Moderators: Lars Petter BJORNSEN (Emergency Physician) (Trondheim, NORWAY), Gregor PROSEN (MARIBOR, SLOVENIA)
16:10 - 17:40 #1183 - #1183 - The RESPECT EM! (NL) Project: Research Education and Stimulation Program Creating Tomorrow’s Emergency Medicine in the Netherlands.
#1183 - The RESPECT EM! (NL) Project: Research Education and Stimulation Program Creating Tomorrow’s Emergency Medicine in the Netherlands.
The RESPECT EM! (NL) Project
Research Education and Stimulation Program Creating Tomorrow’s Emergency Medicine in the Netherlands
A collaborative effort by the Departments of Emergency Medicine of UCSF/Fresno and Westfriesgasthuis
Introduction
Published scholarly activity by Dutch emergency physicians has markedly trailed the overall development of the specialty of EM in the Netherlands. In a 2013 Dutch study by Koning et al (1), EM trainees revealed that “scientific research should be facilitated more.” The same study concluded that, “Even though research and publications are essential to positioning EM as a fully qualified specialty, residents lag behind in a research role. While they were stimulated to undertake research, they received very little support.” The same is true for EM trainers, supervisors and faculty members. Another 2013 study by Ahmed et al found that structured residency research programs are associated with higher resident research productivity and publication rates (2).
Objectives
With this perspective in mind, Westfriesgasthuis EM Residency Directors approached a US-based consultant with research and medical writing expertise. The thought being that a consultant could quickly and easily “import” research and medical writing capability into an ED primed to receive that knowledge. A team of resident and faculty physicians was assembled at the Westfriesgasthuis to participate in the project, the endpoint of which is publication of at least one scholarly project by each team member.
Methods
The program’s timeline is 36 months. It starts with an intensive series of facilitated face-to-face educational sessions. Early topics to be covered include: research and medical writing – why do it?; problems and blocks to research initiation, progress and completion; research resources; performing a medical literature search; article/publication types; funding one’s project; publication/presentation venues; collaborating with others; framing a publishable project; and statistics. All participants will have at least one defined publishable project ready to start at the end of this intensive seminar series. Thereafter, the research consultant will be available electronically to mentor and advise program participants. Three months after the start, the research consultant will return for face-to-face sessions to further participant’s progress. Interim progress assessments and project assistance will be provided by the Residency Directors. As participant’s projects near completion, editing and article submission will be assisted by return on-site visits.
Conclusion
We see RESPECT EM! as a valuable model for others in EM wishing to spur the development of their own research and medical writing programs.
A descriptive article detailing the RESPECT EM! project will be readied for submission to a scientific journal.
References
(1) Koning SW, Gaakeer MI, Veugelers R. Three-year emergency medicine training program in The Netherlands: first evaluation from the residents' perspective. Int J Emerg Med. 2013;6(1):30.
(2) Ahmad S, De Oliveira GS Jr, McCarthy RJ. Status of anesthesiology resident research education in the United States: structured education programs increase resident research productivity. Anesth Analg. 2013;116(1):205-10.
Michael D BURG, Matthijs R DOUMA (Hoorn, THE NETHERLANDS), Eva P BAERENDS, Tom BOEIJE, Nieke MULLAART-JANSEN
16:10 - 17:40 #1348 - #1348 - Point of Care Emergency department Acute Rapid Laboratory (PEARL): win win for the lab and for ED?
#1348 - Point of Care Emergency department Acute Rapid Laboratory (PEARL): win win for the lab and for ED?
Background: We evaluate the impact on the throughput process for patients’ with the implementation of a dedicated laboratory POCT Acute Rapid Laboratory protocol (PEARL) in the Emergency Department.
Methods :Comparative study of Turnaround time (TAT) delays for Troponin, Brain Natriuretic Peptide (BNP), D Dimers before and after the implementation of a POCT in ED (41,000 visits/year) during 2 months (Feb-March 2014-2015). We used the Lean process to analyze time to send blood samples from the ED to the Central laboratory : Turnaround Time (TAT), delay for results, impact on Length of Stay (LOS). Patients’ characteristics: sex ratio, age, medical chief complaints, level Triage (Australian Triage Scale), TAT for urgent (routine process) and very urgent for critical ill patients, delay for results and LOS.
Results: during the same period (01/02 to 31/03) the number of ED visits was similar (+5%) 6748 patients (2014) vs 7354 (2015). We analyzed 1354 vs 1812 blood samples for Tn, BNP and D Dimers. We use lab tests for rapid diagnosis for patients’ chief complaints like chest pain , coma dyspnea with/without an acute respiratory distress, Congestive Heart Failure (CHF)or for patients in the resuscitate room with life threatening conditions (4% of total ED visits).Turnaround Time with POCT was significant (p<0,05) shorter with an average earlier (- 55 to 74,8 mn) for results for Troponin, D Dimers and BNP with the PEARL Protocol (Fig.1) . The average Length of Stay (LOS) was significant shorter (- 55 mn) for patients with Triage Scale Level 1 of severity.
Discussion: Patient’s flow in the ED and the Lean process focus on the throughput model have a significant impact on the timeliness and quality of care in the ED. In literature, Point of Care Testing (POCT) has been found to increase the number of patients discharged in a timely manner, expedite triage of urgent but non-emergency patients, and decrease delays to treatment initiation. Using POCT, caregivers can perform, analyze, obtain, and act on test results at the bedside significantly faster than if samples were sent out to a central laboratory. If used effectively, POCT has the potential to decrease delays to treatment initiation, increase ED efficiency, optimize transport for blood samples to the Central lab, influence patient care positively and alleviate the negative effects of long waiting times. Close collaboration with the central laboratory Department is necessary to evaluate PEARL protocol’s impact for quality care and on financial cost for patients.
Conclusions: Prolonged waiting times and treatment delays can have substantial effects on patient outcomes . Rapid TATs from POCT represent clinical decision making and a good quality care patient management . When used in the appropriate context, our POCT PEARL protocol reduce delays to treatment initiation in the critically ill, improve outcomes, increase timely patient rates for frequent complaints like chest pain, rapid diagnosis of Myocardial Infarction, Thrombosis or Congestive Heart Failure. Costs of POCT per analysis seem to be outweighed by the total gain of expedited patient flow in the appropriate setting.
Eric REVUE (Chartres), Laurence BURC, Martine VEILLARD, Antoine LAUDAT, Dominique PELIE, Alexandre HENNIART, Stephanie LEGROS
16:10 - 17:40 #1380 - #1380 - POCT in the Emergency Department: Impact of POCT-Technology on Efficiency and Effectiveness of the Treatment Process in Emergency Departments.
#1380 - POCT in the Emergency Department: Impact of POCT-Technology on Efficiency and Effectiveness of the Treatment Process in Emergency Departments.
Background
In many German hospitals, emergency departments (ED) suffer from crowding effects caused by an extended average length of stay (ALOS single troponin test: 2h 54 min; ALOS serial troponin tests: 7h 12 min). Due to the fact that between 30 % and 70 % of patients entering the ED do not require emergency-status, the waiting times for troponin (cTn) test results of patients with “non-specific thoracic pain” (12 % of ED-patients) are one reason for non-acceptable LOS in the ED. In addition, the variation in the turn-around-time (TAT) between collecting the blood sample and availability of test results fluctuates between 42 and 121 minutes (average TAT = 73 minutes): a non-controlled process with high variance and a blockade of ED resources.
Objectives
The objective of this study was to clarify to what extent a POCT-solution for troponin contributes to avoiding crowding effects and to reducing LOS of ED-patients. Additionally, the impact of how an investment into POCT pays off in terms of reducing staff workload and containing costs was examined. Furthermore, the importance of learning curve effects and the employees' resistance to change were analyzed.
Methods
A randomized single-center trial was conducted at a university-affiliated hospital with 80.000 ED patient visits per year. In the first study phase, cTn measurement of patients with suspicion of NSTE-ACS was performed in a central laboratory setting (62 patients). One week after having implemented a POCT-solution for cTn, another 46 patients were observed in terms of therapeutic turn-around-time (tTAT) and LOS in the ED (second phase). Six months later, the third phase including 48 patients took place. Again, tTAT and LOS were measured and learning curve effects were analyzed. To compare the central laboratory and the POCT-setting, ED-staff who performed POCT (26 people) were queried on different items (e.g. satisfaction with workflow effectiveness; patient risks ) in order to identify resistance to change and the acceptance of the POCT-setting in all three phases of the study.
Results
POCT was associated with an accelerated availability of cTn test results (lab: 72 min; POCT: 15 min), a shorter time to physician notification of cTn level (90 min; 48 min) and a reduced ALOS by 54 minutes. Furthermore, a potential of cost savings between 560 and 1.100 € p.d. was identified.
Conclusion
POCT for cTn measurement has clinical relevance for ED patients with “non-specific thoracic pain,” especially for high-risk patients with a low suspicion of ACS (“late responders”). POCT contributes to reducing “crowding effects,” containing process costs, and increasing patient satisfaction because of reduced ED waiting times. A POCT-setting for cTn measurement is significantly more acceptable to the ED staff than in a central lab setting.
Discussion
A change of setting from central lab testing to POCT in fact means a shift of workload from lab to ED-staff. The employees’ motivation to use a new implemented technology as a part of a new workflow organization is crucial to achieve a high level of effectiveness and efficiency. This level could be leveraged if additional parameters critical to therapy are measured by POCT (e.g. CRP).
Wilfried VON EIFF (Muenster, GERMANY), Markus WEHLER, Daniel JANSEN
16:10 - 17:40 #1386 - #1386 - Agreement between emergency physician and cardiologist in left ventricular function evaluation after short training.
#1386 - Agreement between emergency physician and cardiologist in left ventricular function evaluation after short training.
Background: Delayed diagnosis and treatment in shock patients may lead to multiorgan dysfunction syndrome (MODS) and eventually death. Volume status assessment in shock patient is a crucial key to guide early management in emergency room. Nowadays, limited echocardiography becomes an important tool to assess volume status because it is non-invasive and easily to perform.
Methods: Cross sectional study was conducted in emergency department, Siriraj hospital from October to December 2014. The patients presented with shock or uncertain volume status were included. All investigators underwent short course training in limited echocardiography, including lecture and workshop. Emergency physicians (EP) performed echocardiography and classified left ventricular function (LVF) into 3 categories; good, moderate and poor contraction. A blind cardiologist re-evaluated all video files and estimated LVF to determine a correlation using kappa statistic.
Results: Ninety-seven patients compatible with inclusion criteria were enrolled. Of these, overall agreement between EP and cardiologist was 79.4% and weighted kappa was 0.73. Percentage of LVF correlation estimation between EP and cardiologist in good, moderate and poor contraction were 62%, 9.8% and 7.6%, respectively. Accuracy in diagnosis pericardial effusion was 100%. The most appropriate view rated by cardiologist was subxyphoid view (94.6%) and the least appropriate view was apical 5-chamber view (70.7%).
Conclusions: Emergency physician with short training in limited echocardiography can assess LVF by visual estimation with high agreement compare with cardiologist.
Apichaya MONSOMBOON (Bangkok, THAILAND), Thiti PATARATEERANON, Surat TONGYOO
16:10 - 17:40 #1676 - #1676 - The death in simulation randomized trial: effect of simulated patient death on emergency worker’s anxiety.
#1676 - The death in simulation randomized trial: effect of simulated patient death on emergency worker’s anxiety.
Study objectives: The outcomes on learners of simulated patient death remain controversial. A few studies reported conflicting results, and psychological and cognitive effects on learners are unclear. We sought to assess the impact of simulation-based training with unexpected manikin death on the learners ‘anxiety when facing life threatening situation (LTS).
Methods: We conducted a prospective multicenter randomized trial on teams that work in an emergency department (ED). Each team included a core of one resident, two nurses and one care giver. They participated in a simulation-based training with a scenario of a 35 year old man in the ED with ventricular fibrillation due to a Brugada syndrome. We randomly assigned each team in two groups: after three shocks, the patient returns in spontaneous cardiac activity (life group LG), or the patient ends in asystole (death group DG). To ascertain the death, the learners were told that patient was declared dead after 45 min of advanced life support. Subjects were aware that they participated in a study about emotional responses in the settings of LTS and they were told during the pre-course that manikin’s death was an eventuality. Our primary endpoint was the assessment of anxiety when facing a LTS, evaluated through the State part of the State-Trait Anxiety Inventory (STAI). Participants were asked to fill this questionnaire before, then one month after the course. We recorded data on their satisfaction on a 1-10 scale. We used the paired Student t-test for comparison of parametric data. Gaussian distributed variables are expressed as mean (Standard deviation SD) and non-Gaussian as median [25-75 interquartile range IQR]. We calculated the exact 95% confidence interval (CI) for mean differences.
Results: Forty subjects were included in the pilot study. Five were excluded as they refused to complete the study. Amongst the 35 analyzed participants, they were 22 in the DG and 13 in the LG, including eight (22%) residents, 14 (43%) nurses, nine (25%) care givers and four (10%) medical students. Mean age was 28 years (SD 6) and 71% were women. Median duration of the scenario and debriefing was 14.6 min [IQR 14.4-14.7] and 25.0 min [IQR 22.6-27.1] respectively. Before the simulation training, median baseline STAI score was 45 [IQR 38-51], similar in both groups (45 [IQR 40-52] in LG vs 44 [IQR 36-50] in DG, p=0.36). Median STAI score was significantly improved at one month after the session, with a mean difference of 5.1 (95%CI [2.5 – 7.7]). We report a trend towards greater reduction in the DG, although not significant: 6.1 (95% CI [1.9 – 10.0]) vs 3.5 (95% CI [0.6 – 6.3]) in LG, p=0.30. Satisfaction of the learners was excellent in both groups, with a median rate of 10 [IQR 8 – 10].
Conclusions: Simulation based training on LTS reduced anxiety amongst learners, whether the manikin died or not. We report a trend towards higher stress reduction at one month after a simulated patient death.
Anne-Laure PHILIPPON (Paris), Jérôme BOKOBZA, Amélie HURBAULT, Bruno RIOU, Alexandre DUGUET, Yonathan FREUND
16:10 - 17:40 #1871 - #1871 - Point of Care Ultrasound; Are we practicing safely?
#1871 - Point of Care Ultrasound; Are we practicing safely?
Point of Care Ultrasound; Are we practicing safely?
Introduction
Clinicians increasingly use Point of Care Ultrasound (PoCUS) as an adjunct to history and examination to facilitate crucial clinical decision-making. This is frequently seen in Emergency Medicine in the United Kingdom to a degree that acquisition of Level 1 competency in PoCUS is now compulsory for Emergency Medicine higher specialty trainees. However little is known about the scale of use of PoCUS by clinicians, especially in relation to its governance (reporting, recording, storage, supervision/review and audit). Therefore we conducted a survey looking into clinical governance of Point of Care Ultrasound in the Yorkshire and Humber region in the United Kingdom.
Methodology
We conducted a survey within the Yorkshire and Humber region looking in to the governance of Point of Care Ultrasound in Emergency Departments. The questionnaire comprised of questions related to usage and governance.
Results
Out of the 18 Emergency Departments we inquired, 13 replied (72.22%), of which 3 are trauma centres and 6 are trauma units. All departments have US machines with M mode, B mode and colour doppler capabilities and have curvilinear and linear transducers. Every department uses PoCUS for FAST, AAA, ECHO in life support and Central & Peripheral vascular access. Around 50% of the departments utilise PoCUS for foreign body removal, shock assessment and DVT diagnosis while 30-40% use it for regional anaesthesia and hepato-biliary studies.
7 out of the 13 (54%) departments have a dedicated PoCUS lead . While Emergency Medicine Consultants and middle grades/ registrars use the US machine in every department, other specialty clinicians use the same machine in 2 (15%) departments.
Only 4/13 (30%) of departments store the images in Picture Archiving and Communication System (PACS) and the rest of the departments store them in either on the US machine hard drive or as thermal prints. 10/13 (77%) departments record the report directly on patient notes while 4/13 (31%) record them in templates.
9/13 (70%) of the departments do not have built in “safety net” where 4/13 (30%) of the departments have a safety net where non-signed off operators’ scans are supervised immediately or reviewed on a later date by a Level 1 or 2 accredited operator. Only 3/10 (23% ) of the departments have an audit process in place and only 5/13 (38%) has a written policy/ guideline on governance of use of Point of Care US in ED.
Conclusion
From our survey it is clear that Point of Care Ultrasound is used widely by Emergency physicians in their departments. It also highlights deficiencies and inconsistencies around governance in recording, reporting, safety netting and auditing. We feel this needs to be urgently addressed in order to comply with nationally agreed Radiology Guidelines to ensure the safe use of PoCUS by clinicians. Our Emergency Department has developed a Clinical Governance Policy for Point of Care Ultrasound and are in the process of developing a Trust Point of Care Ultrasound Policy to include all clinicians undertaking Point of Care Ultrasound in their clinical practice.
Asoka WEERASINGHE, Zafir AHMED (Dewsbury, UK), Chamika MAPATUNA, Alison MCGUINESS
16:10 - 17:40 #1879 - #1879 - Bridging the Gap: Interprofessional Mental Health Simulation-Based Training in the Emergency Department to Improve Collaborative Working.
#1879 - Bridging the Gap: Interprofessional Mental Health Simulation-Based Training in the Emergency Department to Improve Collaborative Working.
Background
It has been recognised that increasing numbers of patients are presenting to Emergency Departments (ED) in mental health crisis, whilst access to specialist psychiatric services in certain areas is limited. In addition, there is a high need for early recognition of mental health problems and a call for more continuous provision of care. Collaborative working between emergency department staff and mental health clinicians is essential in providing high quality care for patients presenting with mental distress. We describe and evaluate an interprofessional mental health simulation-based training (SBT) course for front line staff working in an inner city ED.
Aims
The primary aim was to improve collaborative working across specialties and professions when caring for patients with mental health difficulties in the ED.
Methods
A half-day interprofessional SBT course was developed in which participants engaged in three scenarios following one simulated patient’s journey through the ED. A debrief model was used to allow participants to learn positively and constructively from their shared experiences.
Changes in participants’ attitudes were examined using pre and post self-rating questionnaires. Statistical analysis was conducted using Wilcoxen Rank Signed Rank Test. Qualitative data was obtained from follow-up focus groups, which further examined participants’ experience of being in the simulation, and their integration of learning into practice.
Results
37 individuals of a broad professional mix participated: security officers, ED nurses, emergency medicine residents, psychiatry residents, and mental health nurses.
Attitude scores moved in a positive direction significantly for half the items. Most significant was increased comfort with the participants’ own roles and responsibilities as a member of the multidisciplinary team (p = 0.004) and with those of other team members (p = 0.011) when caring for patients with mental health difficulties.
Thematic analysis of follow-up focus groups revealed that the intervention encouraged reflection on other professions’ perspectives and consideration of colleagues’ particular skills and expectations when working with patients who present in mental health crisis. Participants reflected on how they would put into practice “joint working” by sharing information and involving other team members from different disciplines earlier.
Conclusions
This study presents evidence that interprofessional SBT is an effective tool in encouraging teams to reflect on factors which impact on effective collaborative working when managing patients presenting in mental health crisis in the ED. Further work is needed to establish whether this leads to a sustained cultural change across the ED.
Humphreys ROSEMARY (, ), Simon CALVERT, Sean CROSS
16:10 - 17:40 #1947 - #1947 - A retrospective analysis of ambulance arrivals at a major trauma unit in South Wales: are emergency services being used appropriately.
#1947 - A retrospective analysis of ambulance arrivals at a major trauma unit in South Wales: are emergency services being used appropriately.
Introduction: Inappropriate use of emergency medical services has been discussed for over a decade within mainstream media and medical publications. The majority of epidemiological studies and investigations into this problem have been from the ambulance service, reporting service abusers and 999 calls that do not result in transportation to hospital. This study analyses the patient cohort who have dialled 999 resulting in transportation to hospital, with medical assessment, diagnosis and outcome of the attendance contributing towards the decision of whether the call to emergency service was appropriate or inappropriate.
Method: We conducted a retrospective analysis of all ambulance admissions at a Major Trauma Unit in South Wales. The emergency department notes of all patients arriving by ambulance from January 1st though March 31st 2015 were reviewed. Key information regarding presenting complaint, triage disposal, clinical observations, diagnosis, treatments required and outcome of attendance were collated. These contributred toward an overall analysis of appropriate utilisation of the emergency medical services in the local area.
Results: 6600 ambulances attended A&E during the 3 month study period, including 11 air-ambulance retrievals, representing 35.4% of total patient attendances. From this cohort, 2426 patient (36.8%) were either admitted or transferred to another specialist centre. 4174 patients (63.2%) did not require admission, 37.6% were referred back to the general practitioner, 12.5% were discharged with no follow-up necessary, 4.1% were discharged with a follow-up in the emergency department, 4.2% referred to other outpatient health services, and 314 patients (4.8%) discharged themselves against medical advice, or failed to wait for assessment.
Conclusions:
Following medical assessment within the emergency unit, over 60% of patients required minimal or no intervention, and monitoring in the community by the patient or GP services was the most frequent outcome. Additional sources of ambulance utilisation included: over-reactions from minor injuries or ailments, concern from surrounding persons, and immediate perceived difficulties in transport were among reasons for dialling 999. Ease of access in panicked situations resulted in a default cry for help. For some patients, key phrase triggers when other services were sought (e.g. NHS Direct)
Advanced medical facilities and highly trained paramedics continue to be used for alternative purposes opposed to time critical or life threatening emergencies, with ease of access and cultural expectation being significant underlying narratives. Improving the availability and communication links of other alternative services, in addition to the level of training to identify patients who require emergency assessment, could mean the avoidance of a large proportion of emergency unit attendances, with more appropriate use and utilisation of emergency facilities for their intended purpose.
Based on our study we propose a model for a multicenter study and we suggest an update of the EM and general practice training curricula, with emphasis on patients' medical education.
Samuel TYRRELL, Mahendra KAKOLLU, Samuel TYRRELL (Swansea, UK)
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17:40-18:40
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Award Ceremony
Moderator: Colin GRAHAM (Hong Kong, HONG KONG)
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Room Istanbul |
Room Madrid |
Room Parigi |
Room Roma |
Room Atene |
Room Dublino |
Room Lisbona |
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08:30-09:00
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Keynote Session 2
Moderator: Christoph DODT (München, GERMANY)
08:30 - 09:00 Disasters and Humanitarian crises: different emergencies which demand a professional response. Francesco DELLA CORTE (ITALY)
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09:10-10:40
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State of the Art
Resuscitation
Moderators: Wilhelm BEHRINGER (Director) (Jena, GERMANY), Jana SEBLOVA (Emergency Physician) (PRAGUE, CZECH REPUBLIC)
09:10 - 09:40 Optimal therapy during cardiac arrest. Bernd BOETTIGER (GERMANY)
09:40 - 10:10 Optimal therapy after successful resuscitation from cardiac arrest. Wilhelm BEHRINGER (Director) (Jena, GERMANY)
10:10 - 10:40 Prediction of neurologic outcome after cardiac arrest. Graham NICHOL (USA)
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Italy invites
Simulazione: nuovo standard nella formazione
Moderators: Giuliano BERTAZZONI (ROMA, ITALY), Claudio MENON (ITALY)
09:10 - 09:30 Formare i formatori di simulazione avanzata. Riccardo PINI (Director, E.D. High Dependency Unit) (Florence, ITALY)
09:30 - 09:50 La formazione SIMEU: sempre più simulazione. Patrizia VITOLO (Torino, ITALY)
09:50 - 10:10 La simulazione in Medicina dei Disastri. Piccola e grande scala. Pier Luigi INGRASSIA (Novara, ITALY)
10:10 - 10:30 La simulazione strumento essenziale per lo “European board Examination in Emergency Medicine”. Roberta PETRINO (Head of department) (Italie, ITALY)
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State of the Art
ENT + Eye Emergencies
Moderators: Andrew APPELBOAM (Exeter, UK), Christian HOHENSTEIN (PHYSICIAN) (JENA, GERMANY)
09:10 - 09:35 Update of ENT-procedures: Tricks of the Trade. Damian MACDONALD (CANADA)
09:35 - 09:50 Update on epistaxis: Hypertension, coagulation and other myths. Thomas PLAPPERT (Fulda, GERMANY)
09:50 - 10:15 Let us see: Eyes in the ED. Andy NEILL (IRELAND)
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EuSEM meets ESA
The Future of Emergency Medicine
Moderators: Luca BRAZZI (ITALY), Roberta PETRINO (Head of department) (Italie, ITALY)
09:10 - 09:40 Emergency Medicine UK - a model fit for export? Clifford MANN (President) (United Kingdom, UK)
09:40 - 10:10 The multi-disciplinary Emergency Department. Clemens KILL (PHYSICIAN) (Marburg, GERMANY)
10:10 - 10:40 Emergency Medicine in Germany - why not a specialty? Bernd BOETTIGER (GERMANY)
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Research
Neurological Emergencies
Moderators: Vincent BOUNES (Toulouse, FRANCE), Jonathan EDLOW (USA)
09:10 - 09:40 Endovascular treatment of acute ischemic stroke: the future is now. Jonathan EDLOW (USA)
09:40 - 10:10 STANDING: development of a novel bedside algorithm for differential diagnosis of vertigo. Stefano GRIFONI (Firenze, ITALY)
10:10 - 10:40 How good is early CT for diagnosis of SAH (and can we do away with the LP)? Martin WIESE (UK)
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YEMD
Eye Opener Quiz
Moderators: Ibrahim ARZIMAN (EMERGENCY MEDICINE SPECIALIST) (ANKARA, TURKEY), Riccardo LETO (Chief of ED) (Overpelt, BELGIUM)
09:10 - 09:40 Quiz round 1. Riccardo LETO (Chief of ED) (Overpelt, BELGIUM)
09:40 - 10:10 Quiz round 2. Pieter Jan VAN ASBROECK (Consultant in Emergency Medicine) (Hasselt, BELGIUM)
10:10 - 10:40 Quiz Final. Ibrahim ARZIMAN (EMERGENCY MEDICINE SPECIALIST) (ANKARA, TURKEY)
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EuSEM Nursing Track
Trauma
Moderators: Door LAUWAERT (BELGIUM), Petra VALK-ZWICKL (SWITZERLAND)
09:10 - 09:40 The Norwegian Course in Trauma Nursing. Ole-Petter VINJEVOLL (Trondheim, NORWAY)
09:40 - 10:10 Hip fractures among the elderly: What did we find out in Iceland? Sigrun S. SKULADOTTIR (ICELAND)
10:10 - 10:40 Nursing care to trauma patients: Local experience. Katriona PALU (ITALY)
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Oral Paper 1
Paediatric Emergencies II
Moderators: Tom BEATTIE (UK), Ron BERANT (Staff Physician) (Ramat-Gan, ISRAEL)
09:10 - 10:40 #1011 - #1011 - Malpractice lawsuits in pediatric emergency medicine in The Netherlands: what can we learn?
#1011 - Malpractice lawsuits in pediatric emergency medicine in The Netherlands: what can we learn?
Malpractice lawsuits in pediatric emergency medicine in The Netherlands: what can we learn?
Dorien Geurts, MD1 , Wendela Leeuwenburgh-Pronk, MD2, Annemarie de Koning, LL.M.3, Henriëtte Moll, MD, PhD1
Affiliation:
1 Department of Pediatrics, Erasmus MC - Sophia children’s hospital, Rotterdam, The Netherlands.
2 Department of Pediatrics, Amsterdam Medical Centre- Emma children’s hospital, Amsterdam, The Netherlands.
3Sennef De Koning Van Eenennaam Attorneys at law, The Hague, The Netherlands.
Introduction
Malpractice lawsuits in pediatric emergency medicine are rare in The Netherlands. They can be very traumatic for patients and parents as well as for professionals. Physicians working at the pediatric emergency department evaluate and treat a broad spectrum of diseases at different times in the disease course, in a setting at risk for delayed diagnosis and treatment. Children with a serious bacterial infection (SBI), a complicated disease course and children with complex needs and multiple drug use, in whom a common illness can have a complicated disease course are more prone for medical errors
The aim of the study was to give an overview of all malpractice lawsuits in pediatric emergency medicine in The Netherlands in the last decade and to evaluate which lessons can be learned.
Methods
We performed a retrospective study on all medical lawsuits against Dutch pediatricians from 2001 to 2014. Within a medical lawsuit we identified 11 categories: patient history, (delay in) diagnosis and/ or treatment, medical guidance, following guidelines, composing medical record, communication, doctor patient confidentiality, (delay in) referral, (lack of) case managing in children with complex needs.
Results
The annual frequency of medical lawsuits is about 1500 in the Netherlands. In the study period, we identified 129 pediatric medical lawsuits, concerning pediatricians in 123 and residents in pediatrics in 6 cases. Of 129 lawsuits 97 (75%) were declared unfounded, 5 (4%) were declared founded without a disciplinary measure taken and 25 (20%) were founded, followed by a disciplinary measure.
19 pediatric medical lawsuits were identified, 50% percent of patients were under the age of 2 years, 12 patients were male, 5 patients died. The medical error was acknowledged in 16 cases concerning 6 patients with SBI (sepsis/ meningitis and pneumonia) and 7 patients with complex needs and a complicated disease course. In about 80% the lawsuits concerned one or more of the following categories: (delay in) diagnosis (58%) and/ or treatment (63%), medical guidance (74%) and communication (42%).
Conclusion
Malpractice lawsuits in pediatric emergency medicine mostly concern children with SBI and children with an unexpected complicated disease course. The greater part of lawsuits concerned: (delayed) diagnostics and/ or therapy, medical guidance and/or communication. Safety measures to prevent medical errors should especially focus these items as well as the increasing number of children with complex needs and multiple drug use.
Dorien GEURTS (ROTTERDAM, THE NETHERLANDS), Wendela LEEUWENBURGH, Annemarie KONING, DE, Henriette MOLL
09:10 - 10:40 #1231 - #1231 - Parental recognition of their ill child in pediatric emergency care.
#1231 - Parental recognition of their ill child in pediatric emergency care.
Background Fever in children is a frequent presenting problem at the emergency department. However, in a minority of cases it concerns serious bacterial infections (SBI) and the clinical picture of SBIs can overlap with that of non-SBI’s. One study performed in primary care has identified ‘parental concern’ as an alarming sign for serious illness.1 In contrast, agreement between parents and health professionals on specific clinical symptoms is reported to be limited. 2
Aim The goal of this study is to determine the association between parental concern of serious illness and the assessment of ‘ill appearance ’ by a health care professional.
Methods Data were obtained from a prospective cohort study conducted at Erasmus MC-Sophia Children’s Hospital focusing on the clinical course of children with fever (aged below 16 years) after their first visit to the emergency department. Standardized telephone questionnaires included several signs and symptoms including parental concern of serious illness in their child. Clinical data (general characteristics, vital signs, symptoms and signs, ill appearance) were documented in a standardized electronic patient record at assessment at the ED. Association between ‘parental concern’ as reported by parents and the ill appearance as assessed by the nurse were tested with chi-square analyses.
Results Results were based on data of 1765 children and their parents. The median age was 22 months (IQR 11-48 months). Fifty-seven percent (n=1000) were male. Forty-nine percent (n=855) were self-referred and 51% were referred by primary care. Parents were concerned for serious illness in 1333 children (83%). In 273 out of 315 children with ill appearance assessed by the nurse, parents reported their concern on serious illness in their child (sensitivity 87%). Parents also reported concern for serious illness in 1060 out of 1293 (82%) children without ill appearance (specificity 18%). Specificity improved little with older age (15% below year of age to 22% at 2 to 5 years of age). MTS triage urgency classification and referral type did not influence the association between ‘parental concern’ and the health professional’s report.
Conclusion Even in children who are not considered to appear ill as reported by health professionals, still the majority of parents are concerned on their child’s serious illness. Thus, parents are not able to rule out serious illness of their child. Education to parents may better focus on explaining reassuring signs (so-called green flags) in febrile children, rather than only alarming signs.
References
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Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians' gut feeling about serious infections in children: observational study. BMJ. 2012;345:e6144
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Blacklock C, Mayon-White R, Coad N, Thompson M. Which symptoms and clinical features correctly identify serious respiratory infection in children attending a paediatric assessment unit? Arch Dis Child. 2011 Aug;96(8):708-14.
Tarik KARRAMASS (Rotterdam, THE NETHERLANDS), Evelien DE VOS KERKHOF, Henriette MOLL, Rianne OOSTENBRINK
09:10 - 10:40 #1263 - #1263 - E-PEDCARE: first results of an international prospective registry of pediatric Out-of-Hospital and Emergency Department Cardiac Arrest.
#1263 - E-PEDCARE: first results of an international prospective registry of pediatric Out-of-Hospital and Emergency Department Cardiac Arrest.
INTRODUCTION. The mortality of pediatric Cardiac Arrests (CA) remains high despite efforts towards its reduction, and survivors often have profound neurological impairments. The characteristics, treatment and outcomes of pediatric CA are still incompletely studied and clinical practice guidelines are based on insufficient evidence.
PARTICIPANTS AND METHODS. E-PEDCARE is a prospective multicenter study (60 hospitals in 4 countries) of Out-of-Hospital CA (OHCA) and Emergency Department CA (EDCA) in patients admitted in Emergency Departments. Data collection and reporting are done according to Utstein Style, focussing on both the epidemiology and the variables associated with survival and neurological outcomes. We describe the preliminary results after the first nine months of data collection.
RESULTS. We have analysed 41 consecutive CA, 12.2% of which were EDCA. The median age of the sample was 6.4 years (interquartile range 1.2-12.0), 48% were male. The CA happened at home (39%), street (17.1%), school (4.9%), sports ground (2.4%) and other places (36.6%). The etiology was: presumed cardiac (22.2%), trauma (19.5%), respiratory (17.1%), drowning/submersion (14.6%), other non-cardiac (12.2%) and unknown (14.6%). There was a bystander in 46.3% of cases. However, “phone resuscitation” was started in only 17.1%.and “phone-cardiopulmonary resuscitation” in 17.1%. The initial rhythm was asystole in 56.1% of CA, bradycardia in 19.5%, ventricular fibrillation in 7.3%, pulseless electrical activity in 4.9%, pulseless ventricular tachycardia in 2.4% and unknown rhythm in 7.3%. The most frequent known rhythm before return of spontaneous circulation (ROSC) was ventricular fibrillation (6/41, 14.6%) followed by asystole (4/41, 9.8%). Automated external defibrillator was used in 5 patients (12.2%). Overall, the median time between CA and the start of life support was 4 minutes (interquartile range 5-14), the median time between CA and first dose of adrenaline 7.8 minutes (4-16.8) and the time to first shock where relevant, 6 minutes (1-11). 8 (19.5%) patients were treated with hypothermia.
Outcomes in 36 children with OHCA: ROSC in 66.7% and sustained ROSC in 58.3% with 50% admitted to the intensive care unit. Six children are still inpatients. Eleven others have been discharged: 8 with a paediatric overall performance category (POPC) 1, one with POPC 2, two with POPC 3).
Outcomes in 5 patients with EDCA: ROSC in 4 and sustained ROSC in 3, one of whom is still in the hospital. Two children survived to discharge, one with a POPC of 3, the other child with a POPC of 1.
CONCLUSION. The preliminary results of the E-PEDCARE registry demonstrate a clearly higher OHCA and EDCA survival (with acceptable to good neurological outcome) than previously reported. Further results from this registry might further clarify and strengthen these observations. Continuous efforts are needed in order to know which variables are associated with better outcomes of CA in children.
Nieves DE LUCAS (Madrid, SPAIN), Antonio RODRÍGUEZ-NÚÑEZ, Patrick VAN DE VOORDE, Jesús LÓPEZ-HERCE, Ignacio MANRIQUE, Jesús PAYERAS, Sofía MESA, Asunción PINO, Carla PINTO, Nuria CLERIGUÉ, Zulema LOBATO, Diana MOLDOVAN, Esther CRESPO, Santos GARCÍA GARCÍA, . PEDIATRIC CARDIAC ARREST STUDY GROUP
09:10 - 10:40 #1809 - #1809 - Paediatric Out-of-Hospital-cardiac arrests and Emergency Department-cardiac arrests: factors associated with survival to discharge and improved neurological outcome.
#1809 - Paediatric Out-of-Hospital-cardiac arrests and Emergency Department-cardiac arrests: factors associated with survival to discharge and improved neurological outcome.
INTRODUCTION. Mortality of paediatric Cardiac Arrests (CA) remains high despite efforts towards its reduction, and survivors may have profound neurological impairments. We don’t know enough about factors associated with better outcomes (survival to discharge and neurological outcome). Asystole has been described as a predictor of worse outcome; however we don’t know the neurological outcomes of survivors whose first rhythm was asystole. Paediatric Logistic Organ Dysfunction (PELOD) score in 24 first hours might be useful to predict outcome and be useful for physicians to inform parents).
PARTICIPANTS AND METHODS. We are conducting an international prospective study (60 hospitals of 4 countries) using Utstein style with paediatric OHCA (Out-of-Hospital Cardiac Arrest and EDCA (Emergency Department Cardiac Arrest) in patients admitted to Emergency Departments. Factors associated with survival to discharge and neurological outcome to discharge were analyzed (paediatric overall performance category –POPC–) from 1st Jun 2014 to 31st March 2015. To analyze categorical variables we used Pearson Chi-Square or Fisher's Exact test. For quantitative variables we used Student test and Mann-Whitney U test.
RESULTS. We have analyzed 41 consecutive paediatric CA, 3/41 with unknown rhythm, 7/41 were still at hospital, 87.8% of them were OHCA, and the rest of them were EDCA. The median age of the sample was 6.4 years (interquartile range 1.2-12.0). 48% of the patients were male.
We found association between survival to discharge and:
· first rhythm different to asystole, p= 0.01. 15.0% (3/20) of patients whose first rhythm was asystole survived to discharge vs 63.6% with different known rhythm (7/11),
· lower PELOD score in first 24 hours (p=0.033).
We found association between POPC≥ 4 to discharge and:
· first rhythm different to asystole, p= 0.01. 15.0% (3/20) of patients whose first rhythm was asystole had POPC≥ 4 vs 63.6% with different known rhythm (7/11),
· lower PELOD score in first 24 hours (p=0.034).
2 children whose first rhythm was asystole survived to discharge, both with POPC 3 at that moment.
CONCLUSIONS.
In our paediatric OHCA and EDCA study, patients whose first CA-rhythm was different to asystole survived to discharge and had better neurological outcome (nevertheless some patients whose first rhythm was asystole survived to discharge with POPC 3). We need a larger tracing and to know more about other variables that may be associated with good outcome despite asystole as first rhythm.
PELOD in first 24 hours seems to be a good predictor of survival to discharge and a good neurological outcome to discharge.
Nieves DE LUCAS (Madrid, SPAIN), Ian K MACONOCHIE, Antonio RODRÍGUEZ-NÚÑEZ, Patrick VAN DE VOORDE, Jesús LÓPEZ-HERCE, Miguel FONTE, Laura PÉREZ GAY, Sonia CAÑADAS, Isabel DURÁN HIDALGO, Raquel JIMÉNEZ, García Herrero MARIA ÁNGELES, Maria Teresa ALONSO SALAS, Raul MORALES PRIETO, Marisa HERREROS FERNÁNDEZ, . PEDIATRIC CARDIAC ARREST STUDY GROUP
09:10 - 10:40 #1839 - #1839 - Does pediatric sedation with combined ketamine/propofol (ketofol) result in fewer adverse events than ketamine or propofol alone?
#1839 - Does pediatric sedation with combined ketamine/propofol (ketofol) result in fewer adverse events than ketamine or propofol alone?
Background
Ketamine and propofol are commonly used for procedural sedation of children in the ED. Each works by a different mechanism and has different adverse effects. The rationale for combining ketamine and propofol is that each drug may counterbalance or offset the adverse effects of the other and combined use permits administration of a lower dose of either drug. This study seeks to determine if sedation with ketofol in pediatric patients has fewer adverse effects than sedation with ketamine or propofol alone.
Methods
By retrospective review data was extracted from charts of 43 pediatric patients who underwent ketofol sedation in the ED of an urban, academic medical center
staffed by board-certified emergency and pediatric emergency physicians from the USA, Canada and UK. The incidence of the following adverse reactions was
compared: hypoxia, hypotension, respiratory depression, vomiting, and agitation/emergence reaction. The specific aim is to determine if these adverse events with ketofol occur in a lower incidence than with ketamine or propofol alone. Statistical analysis is by Fisher's exact test.
Results
Forty-three children were included in this study. Vomiting was the only adverse event noted, in 4.6% (2/43) of patients. Each propofol-associated adverse event, respiratory depression, and hypotension, occurred less frequently with ketofol. With regard to ketamine-associated adverse events, there was no statistical difference in the incidence of vomiting, and no statistical difference in emergence reactions. The lack of decrease in emergence reaction was the result of small sample size only. Any increase in sample size of 1 or more patients could have demonstrated a lower incidence of emergence reactions as well.
Conclusions
Use of ketofol in children results in fewer adverse reactions than from propofol alone. Regarding ketamine adverse effects, there was no difference in incidence of vomiting relative to than ketamine alone. Clinicians who use either or both of these sedating agents should consider using combined ketamine/propofol in children for the purpose of lessening the chance of the most common adverse events, particularly propofol-related events.
Khuloud BANIMATAR (Adu Dhabi, UNITED ARAB EMIRATES), Glyn BARNETT, David SOLOMON, Robert HOFFMAN
09:10 - 10:40 #1905 - #1905 - Helmet use and clinical characteristics of children presenting to the emergency department for recreational vehicle-related head injuries.
#1905 - Helmet use and clinical characteristics of children presenting to the emergency department for recreational vehicle-related head injuries.
Objective: Head injuries (HI) associated withrecreational vehicle (RV) use are a common reason for pediatric presentations to emergency departments (ED). While helmet use is an established preventative strategy, information regarding RV-related HI and helmet use in the pediatric population is scarce. This study examines helmet use and clinical characteristics of children presenting to the ED with an RV-related HI.
Study Design: Retrospective study conducted in the ED of the Royal Children’s Hospital, Melbourne, of children
Results: RVs involved in the 647 presentations identified were bicycles (36.3%), push scooters (18.5%), motorcycles (18.4%), horses (11.7%), skateboards (11.6%), all-terrain vehicles (2.8%) and go-karts (0.6%). Motorcycle, horse and bicycle riders recorded the highest helmet use (83.2%, 82.9% and 65.1% respectively). Motorized vehicles were associated with a higher need for neurosurgery (odds ratio (OR) 4.2, 95%CI 1.4-12.6). Computed tomography (CT), traumatic findings on CT and neurosurgery rates were higher in non-helmeted children (OR 2.5, 95%CI 1.7-3.8; OR 4.4, 95%CI 2.5-7.6, and OR 7.1, 95%CI 1.9-26.8, respectively). Children with a parietal site of impact were more likely to sustain an intracranial injury regardless of helmet use (OR 3.74, 95%CI 1.21-11.55).
Conclusion: Helmet use varied by RV with highest usage rates amongst motorcyclists and horse-riders. Motorized RV-related accidents accounted for the majority of neurosurgical interventions. Helmet use was associated with a lower CT and neurosurgery rate and should be encouraged/reinforced at the time of ED assessment, besides legislative and social marketing strategies. Further reduction of intracranial injuries might be achieved through enhanced helmet design to improve protection of the parietal area.
Silvia BRESSAN, Marco DAVERIO (Padova, ITALY), Ruth BARKER, Charlotte MOLESWORTH, Franz BABL
09:10 - 10:40 #1961 - #1961 - Use of the sport concussion assessment tools to monitor post-concussion recovery.
#1961 - Use of the sport concussion assessment tools to monitor post-concussion recovery.
Background: The most recent version of the Sport Concussion Assessment Tool (SCAT3) and its version for children younger than 13 years (ChildSCAT3) are recommended as a postconcussion tool for sideline assessment by the International Concussion in Sport Group. Their key ageappropriate components include: a symptom scale; a rapid cognitive tool (the Standardized Assessment of Concussion–SAC) and the Balance Error Scoring System (BESS). No study to date has assessed the use of these tools in acute care and concussion clinic settings to monitor postconcussion recovery.
Objective: To examine the repeat use of the SCAT3 and ChildSCAT3 to monitor postconcussion recovery in the first 2 weeks following a concussion.
Methods: Prospective longitudinal study of children 5-18 years who presented to a tertiary children's hospital emergency department (ED) within 48h of their concussion. Children were administered the age appropriate assessment tool in the ED (T0), within 4 days following the ED visit (T1) and 2 weeks post injury (T2).
Results: 96 patients completed the 2week follow up over a 14-month period (56 younger and 40 older than 13 years). There was a progressive significant reduction in symptom number and severity by the 2week assessment in both age groups (p <0.05 for the comparisons T0 vs T2 and T1 vs T2). While the SAC showed a progressive improvement in performance by the 2week time point (p <0.05 for the comparisons T0 vs T2, T1 vs T2) in both age groups, no significant difference over time was found for the BESS. However, 30% of patients could not undergo the balance test in the ED (T0), because they were too unwell at the time of initial assessment.
Conclusions: The SCAT3 and ChildSCAT3 may be valuable tools to monitor postconcussion recovery from the acute care to the outpatient follow up setting. The utility of the BESS for the acute assessment and follow of children presenting to the ED setting following a concussion should be further explored.
Silvia BRESSAN (Padova, ITALY), Michael TAKAGI, Ridings DEAN, Vanessa RAUSA, Ed OAKLEY, Gavin DAVIS, Vicki ANDERSON, Franz BABL
09:10 - 10:40 #2025 - #2025 - The Risk Factors Associated With Severe Clinical Course in Children With Carbon Monoxide Poisoning.
#2025 - The Risk Factors Associated With Severe Clinical Course in Children With Carbon Monoxide Poisoning.
THE RISK FACTORS ASSOCIATED WITH SEVERE CLINICAL COURSE IN CHILDREN WITH CARBON MONOXIDE POISONING
Leman Akcan Yıldız1, Özlem Tekşam1, Ayşe Gültekingil Keser1, Selman Kesici2,Benan Bayrakci2
Hacettepe University Medical Faculty Department of Pediatrics
1Division of Pediatric Emergency Medicine
2Division of Pediatric Intensive Care
Background and Aims:
Carbon monoxide (CO) poisoning is the most common cause of fatal intoxication in children. Children are more susceptible to its hypoxic and cytotoxic effects. Depending on the severity of exposure, patients with acute CO poisoning have various clinical manifestations ranging from mild symptoms such as headaches, dizziness, and impairment of higher cerebral function to severe symptoms such as mental confusion, collapse, convulsions, and paralysis. This study aims to determine the demographic, clinical and laboratory characteristics of children with CO poisoning, and to analysis the risk factors associated with severe clinical course of carbon monoxide poisoning in children.
Methods:
All children diagnosed with CO poisoning in a single tertiary center from January 2004 to March 2014 were included. Data were obtained from hospital records. Severe clinical course depends on carbon monoxide poisoning was defined as children with multiorgan failure, or requiring inotropic drugs or mechanical ventilation or death. To determine the risk factors associated with severe clinical course, multivariate logistic regression by using backward elimination was done.
Results:
Total 331 patients with a mean age of 9.0 (range: 13 days – 18 years) were included. COHb levels at presentation were significantly associated with presence of headache, nausea and vomiting, fatigue, seizures and altered consciousness (p<0.05). Hyperbaric oxygen therapy (HBOT) was administered to 93/331 (28.1%) patients. 51 patients (15.4%) were admitted to the ICU, 18 patients (5.4%) had severe clinical course and 6 patients (1.8%) died. Altered consciousness, seizure and neurologic or cardiac findings in physical examination, low GCS score, high leukocyte counts and troponin-T and high glucose levels were found as risk factors associated with severe clinical course of carbon monoxide poisoning (p<0.001).
Conclusions:
Low GCS score, elevated leukocyte count and high troponin-T level at presentation were the most significant risk factors associated with severe clinical course in children with carbon monoxide poisoning. Emergency physicians could consider these risk factors to identify patients with an increased risk of poor clinical course.
Leman AKCAN YILDIZ, Ozlem TEKSAM (ANKARA, TURKEY), Ayse GULTEKINGIL KESER, Selman KESICI, Benan BAYRAKCI
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Oral Paper 2
Trauma I
Moderators: Alastair MEYER (Melbourne, AUSTRALIA), Paola PERFETTI (Consultant in Emergency Medicine) (Verona, ITALY)
09:10 - 10:40 #1091 - #1091 - BENEFICE OF ROUTINE URINALYSIS IN PATIENTS WITH A BLUNT ABDOMINAL TRAUMATISM ADMITTED TO AN EMERGENCY ROOM.
#1091 - BENEFICE OF ROUTINE URINALYSIS IN PATIENTS WITH A BLUNT ABDOMINAL TRAUMATISM ADMITTED TO AN EMERGENCY ROOM.
INTRODUCTION: Abdominal trauma represent 15 to 20% of lesions observed in trauma and are associated with a mortality of 10-30 %. They are mainly represented by closed lesions due to a contusion of solid organs (spleen, liver, kidneys, pancreas) , or perforation of hollow organs (duodenum , small intestine, colon ). Search intra abdominal injury post traumatic pass through the abdominal CT scan but another exam, urinaysis is frequently used in emergency services during abdominal trauma to search hematuria. The diagnostic and especially prognostic interest of microscopic hematuria remains controversial in abdominal trauma. The aim of our study was to investigate whether the microscopic hematuria of urinalysis in patients with a blunt
trauma mechanism is in correlation with abdominal lesion.
METHODS : We realized a retrospective, multicentric and observational study between January 2012 and August 2014. Patient with an age ≥18 years old, admitted to the emeregncy unit, had an abdominal CTscan and a urinalysis were included. Demographic, clinical and therapeutic variables were examined from hospital files. Main outcome measure was the correlation between microscopic hematuria on urinalysis and the existence abdominal injuries found thanks to the injected scanner.
RESULTS : 100 patients were included. 56 patients had microscopic hematuria, 17 gross hematuria and 44 no hematuria. The sensitivity and specificity of microscopic hematuria in patients with abdominal injury were respectively 72.2% [54.8-85.8] and 53.1% [40.2-65.7]. The PPV was 46.4% [33-60.3]. The NPV was 77.3% [62.2-88.5]. In univariate analysis, we did not find any significant difference to find an abdominal injury in patients aged over 50 years old (p = 0.96), in men (p = 0.20), patients with anticoagulants (p = 0.3), with medical history (p = 0.88) or with abdominal pain (p = 0.06). The risk was significally increased in case of hypovolemic shock (p <0.001), hematoma on abdominal wall (p = 0.001), acute abdomen (p = 0.001) and anemia (p = 0.014). In multivariate analysis adjusted for age and gender, risk factors for abdominal injury were hypovolemic shock with OR 9 (p = 0.002) and abdominal pain OR 3.5 (p = 0.039). Microscopic hematuria is not predictive of an abdominal injury and its absence does not exclude the diagnosis of abdominal injury.
CONCLUSION : We don’t recommand the realisation of urinalysis in people with blunt abdominal trauma in the aim of finding microscopic hematuria. We encourage the realization of the abdominal CT scan in case of hypovolemic shock or abdominal pain in patient with abdominal trauma.
Farès MOUSTAFA (Clermont-Ferrand), Charlotte LOZE, Jennifer SAINT-DENIS, Nicolas DUBLANCHET, Loic DOPEUX, Sabine VILLANOVA, Christophe PERRIER, Jeannot SCHMIDT
09:10 - 10:40 #1191 - #1191 - Evaluation of Gunshot Wounds in the Emergency Department.
#1191 - Evaluation of Gunshot Wounds in the Emergency Department.
Introduction
In this study we aimed to evaluate injury patterns of patients admitted to the emergency department with gunshot wounds, results of imaging studies, treatment modalities, outcomes, mortality ratios, and complications.
Material and Methods
This is a retrospective descriptive study including a total number of 142 patients admitted to Hacettepe University Emergency Department with gunshot injuries between January 1, 1999 and December 31, 2013. The Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), Injury Severity Score (ISS), and the Trauma and Injury Severity Score (TRISS) probability of survival for penetrating trauma were calculated for all patients.
Results
Among the 142 patients in the study, 128 (90.1%) were male. The mean age was 36 years. On admission the average GCS score was 13, the mean RTS was 6.64, median ISS was 5 and the median TRISS probability for survival was 99.4% for penetrating trauma. Fluid was detected in 3 (13%) patients in FAST whereas intra-abdominal solid organ injury and bowel injury were detected in 11 (58%) patients in abdominal CT. The pneumothorax, hemothorax and lung injuries were detected in 10 (43.5%) patients, whereas hemothorax was detected only in one patient with thoracic injury by chest X-ray. Twenty four (16.9%) patients died; 18 patients (75%) had isolated severe intracranial injuries, two (8.9%) had thoracic injuries with head and neck injuries, and four (16.7%) patients had intra-abdominal organ injuries (one with concomitant head injury). Ten patients were brought to the ED in cardiopulmonary arrest. In dead patients, GCS, RTS and TRISS were significantly lower and ISS were significantly higher than in surviving patients. The twenty three 23 (95.8%) patients were in critical injury level (ISS 25-75, actually ISS>50) in the exitus group.
Conclusion
Mortality rates in gunshot wound patients with cranial injuries are very high. Spontaneous return is not seen in patients brought to the ED in arrest state. The bullets can cause internal organ injuries which can be greater than expected. In thoracoabdominal gunshot wound injuries, conventional X-ray and bedside FAST can be ineffective in detecting the whole extent of intrathoracic and intra-abdominal injuries. Thus thoracic and abdominal CT should be planned early for hemodynamically stable patients in order to eliminate causes of fatality and make a timely and correct diagnosis. ISS, RTS and GCS are useful in predicting prognosis and mortality. Especially in patients with ISS scores >50 the mortality rate can be as high as 96%.
Mehmet Ali KARACA (ISTANBUL, TURKEY), Nil Deniz KARTAL, Bulent ERBIL, Elif OZTURK, Mehmet Mahir KUNT, Tevfik Tolga SAHIN, Mehmet Mahir OZMEN
09:10 - 10:40 #1310 - #1310 - Trial of ultrasound guided femoral nerve block for isolated femur fractures using echogenic needles.
#1310 - Trial of ultrasound guided femoral nerve block for isolated femur fractures using echogenic needles.
Objectives: Femur fractures are very common traumatic injuries seen in the emergency department (ED). Adequate pain control is often challenging despite the wide availability of pharmacological agents. Femoral nerve blocks (FNB) for pain control have been used for many years showing safety and effectiveness when performed correctly. Ultrasound (US) guidance has dramatically improved its success and safety. In our department, we train residents to perform peripheral nerve blocks for pain control and procedural analgesia. In order to maximize the success of US guided FNB, echogenic needles (micro laser etched near the tip of transducer to increase visibility) are now available. This study aims to determine if a difference in success rate exists between using standard needles vs echogenic needles in US guided FNB.
Methods: We performed a prospective, double-blinded, randomized trial involving adult patients presenting to the ED with an isolated femur fracture. Patients at least 18 years old, able to verbalize pain level using a visual analog scale (VAS) 1-10, and mentally competent were included. We excluded pregnant and prisoner patients, also those with significant concomitant injuries, cognitive impairment, unable to verbalize pain, allergic to local anesthetics, severe liver disease, existing peripheral neuropathies in the affected limb, local signs of infection in the inguinal area, and those with coagulopathies or anticoagulated. Allocation concealment was performed by a third party. Needles were included in tamper-proof envelops. Patients and physicians were blinded to needle selection. Using 0.25% Bupivacaine with epinephrine we performed a lateral, medial and posterior perineural injection (5 mL each). Pain score using VAS was recorded prior to and after the FNB (at 15, 30, 45, and 60 minutes). The primary outcome (dependent variable) was the success of the NB measured by pain control. The needle type was considered the independent variable.
Results: We have included a preliminary data set of 10 patients ages 21-81, five males. All received a variety of analgesics prior to the FNB without adequate pain control. Prior to the NB all patients had pain 5-10 VAS despite receiving intravenous analgesics. To assess pain scores between the treatment groups over time, a repeated measures ANOVA was conducted. Based on this analysis, there was no statistically significant difference in pain scores between the groups (P=0.298). Similarly, when assessing the pain difference between baseline (enrollment) and 60 minutes after the FNB: the pain scores dropped by a median of 6 points for patients in the regular needle group while those on the echogenic needle group had a median drop in pain score of 9.5. To formally assess that difference of pain scores, an ordinal logistic regression model was fit. There was no statistically significant difference between groups (P=0.138). No adverse events have been reported with the included population.
Conclusions: FNB with US guidance offers a safe and efficient alternative for pain control in patients with isolated femur fractures in the ED. With US guidance, echogenic needles do not offer a technical advantage over standard needles.
Carlos ROLDAN, James LEONI (Houston, USA), Rosa BANUELOS
09:10 - 10:40 #1415 - #1415 - Whole-body scan in trauma patients without clinical suspected injuries.
#1415 - Whole-body scan in trauma patients without clinical suspected injuries.
INTRODUCTION:
Polytrauma is the main mortality cause in under 40 population. The initial management in the ATLS connects fast and priority treatment of lesions with imaging tests. Traditionally imaging tests matched X-ray with fast ultrasound and CT dedicated body regions. In recent years, the whole-body scan is increasingly used in the assessment of these patients.
Objectives:
To describe the usefulness of Whole-body scan in the assessment of polytrauma patient and its ability to detect lesions not diagnosed through primary and secondary review.
To assess the criteria for activation trauma code (Physiological, anatomical, injury mechanism) as determinants factors to the indication of Whole-body scan. In our region trauma code is activated by pre-hospital emergency services, to permit the triage and derivation to trauma-especialized center.
METHODS:
Between January 2014 and December 2014 whole body scan performed in trauma patients with severe trauma code activated were retrospectively revised. The data collected were: demographic data, level of trauma code criteria activation (depending of four categories of parameters: physiological variables, anatomical injuries, trauma mechanism or predisposition), clinical signs of injury by anatomical region (skull, cervical spine, chest, abdomen-pelvis, thoracic-lumbar spine). Those were compared with injuries diagnosed by Whole body scan
Using classification and regression trees (CARTSs) we pretended to identify potential predictors to look for injuries not suspected on the clinical examination. A prediction model using the pre-admission clinical evaluation of trauma patients variables was developed: physiological variables, anatomical injuries, trauma mechanism or predisposition.
RESULTS:
A total of 117 trauma patients whole body scan performed were collected. A 81% were male with 48 years old average age. The most common activation trauma code criteria were: trauma mechanism (60%) and physiological variables (23%). Injuries were diagnosed in 84,4% of whole body scan. By anatomical regions most common injuries were: 38% skull, 55% thorax, 27,4% abdomen-pelvis. A total of 17 patients don’t have clinical signs of injury on the clinical examination. In 6 of this patients (35,3%) injuries were diagnosed by whole body scan.
After ussing CARTs analysis the predictors for unsuspected injuries not detected by first evaluation were: fall more than 6 meters, vehicle smash with ejection from vehicle or other passenger died or vehicle deformation or more than 60 km/h speed and pedestrian/cyclist smash with vehicle. By anatomical region involved: skull fracture, fail chest, smashed pelvis, more than two long proximal bones crashed or paralysis of limbs were predictors for unsuspected injuries.
DISCUSSION
The use of whole body scan in trauma patients makes possible to find injuries not suspected on the clinical examination. It is very important to know the circumstances around the trauma event registered by pre-hospital emergency medical services. At the presence of a single criteria of trauma severity, patients have a high risk of injury. The whole body scan should be performed in those patients. Furthermore, if no injuries are detected, we can discharge the patient from emergency department in a short time.
Jesús GÁLVEZ MORA, Ana Isabel CONDON ABANTO (Zaragoza, SPAIN), Alejandro SAMITIER PASTOR, Domingo RIBAS SEGUI, Gilmar PUGNET, Francisco AVILES JURADO
09:10 - 10:40 #1467 - #1467 - Mild traumatic brain injury at emergency department: descriptive study.
#1467 - Mild traumatic brain injury at emergency department: descriptive study.
Background:
Mild Traumatic Brain Injury (MTBI) is one of the most common reasons for emergency departments care; it account for over three-quarters of the Traumatic Brain Injury [1]. The management of mild head injury is still controversial [2]. A better understanding of demographic, clinical and prognosis of these patients have an important clinical and organizational implications.
Purpose:
The aim of this study is to identify demographic characteristics, clinical findings and outcomes data of MTBI patients admitted in emergency department.
Participants and methods:
A prospective observational study that was conducted over three months [December 2014 – February 2015]. We included a consecutive adults who were at least 18 years, presented with a MTBI defined according to the criteria of the Head Injury Severity Scale ( HISS).
Results:
One hundred thirty- five patients were enrolled. Mean age = 42± 20 years, 73% were male. Mechanisms of injury were (%): traffic accident (52,5), falls (19,3), assault (18,5) and work accident (9,7). The way of the patient’s arrival at the emergency department was provided by (%): own means (47), pre-hospital care system (53). Patient history (%): hypertension (15), diabetes (7), atrial fibrillation (3), anticoagulants therapy or antiplatelet agents (10) and Alcohol intoxication (14). Clinical findings showed were : GCS =15 (81%), loss of consciousness suspected or confirmed (40%), Repeated vomiting (≥ 2 episodes) (7,5%), clinical signs of depressed or basal skull fracture (10,5%) and physical evidence of trauma above the clavicles (36,3%). Eighty – two percent of our population had a brain computed tomography (CT) wich demonstrated intracranial hemorrhage in 35% cases. Death at 1 month was 1% and thirty -seven patients called had post – concussion syndrome.
Conclusion:
Mild traumatic brain injury is more common in males and in young adults. Traffic accident was the main cause. The observed mortality remains low despite a high incidence of intracranial hemorrhage.Identifying clinical risk factors regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging.
- Cassidy JD et al. JRehabil Med 2004, 43:28-60
- Undén et al. BMC Medicine 2013, 11 :50.
Hana HEDHLI, Imene BOUKHALFA (Bizerte, TUNISIA), Sarra BELLILI, Sarra JOUINI, Houssem AOUNI, Sana BOUKADIDA, Asma ALOUI, Béchir BOUHAJJA
09:10 - 10:40 #1481 - #1481 - Comparison of trauma scores to predict mortality in emergency department patients.
#1481 - Comparison of trauma scores to predict mortality in emergency department patients.
Introduction :
Trauma is a time sensitive condition. Initial assessment for severity is essential for care and clinical making decision. Multiple scoring systems have been developed englobing anatomic scores, physiologic scores and combined scores. The aim of this study was to compare the prognostic performance of the scoring system tools in trauma patients admitted to the emergency department (ED) in terms of mortality at day seven.
Methods:
This was a single prospective cohort study. Trauma patients admitted to the emergency ward were enrolled and different scores were calculated: Injury Severity Score(ISS), Trauma Injury Severity Score(TRISS), Revised Trauma Score (RTS), Mechanism, Glasgow Coma Scale, Age and Arterial Blood pressure score(MGAP), and the new Glasgow Coma Scale, Age and Systolic Blood pressure score (GAP) . The primary outcome was the mortality at day seven. For each score, the Area under receiver operating characteristics curve (AUC) was assessed and we determined the predictive positive value( PPV) and the predictive negative value (PNV). A P-value <0,05 was considered significant.
Results:
A total of 287 trauma patients were enrolled. Main characteristics were: Mean age +/- SD = 40+/-17 years ; Sex-ratio= 4,6 ; Traffic accidents were responsible in 74% of cases, ejection was noted in 40%. ISS = 21+/-11 and 212 patients (74%) have an ISS >= 16. Evolution n(%): intubation : 101(35); Surgery 160 (56); Mortality at day seven : 63 (23). The average levels of ISS, TRISS, RTS, MGAP and GAP were significantly different in non survivors than in survivor group with a p-value <0,001. Main characteristics of scores by analyzing the ROC for mortality at day 7: ( Score: AUC; p; PPV; PNV) were respectively : [ TRISS: 0,909; p<0,001; 66%; 95%]; [ ISS: 0,855; p<0,001; 38%; 95%]; [RTS: 0,834; p<0,001; 54%; 93%] ; [GAP: 0,871; p<0,001; 52%; 93%] ; [ MGAP: 0,865; p<0,001; 59%; 92%].
Conclusion:
All the tested scores have shown good prediction for mortality at day seven after Trauma. Whereas the TRISS defined better the mortality. Moreover, GAP and MGAP scores wich can be rapidly assessed on physiological parameters have shown as good predictive performance as anatomical and combined scores and could be proposed for early assessment in emergency ward.
Rym HAMED, Inès CHERMITI (Tunis, TUNISIA), Hana HEDHLI, Houssem AOUNI, Asma ALOUI, Sirine JAOUANI, Mohamed MEZGHANNI, Béchir BOUHAJJA
09:10 - 10:40 #1541 - #1541 - Health-related quality of life in patients with mild head trauma: relationship with the presence of intra-cranial injury.
#1541 - Health-related quality of life in patients with mild head trauma: relationship with the presence of intra-cranial injury.
Background: The relationship between intra-cranial injury (ICI) and health-related quality of life (HRQOL) after a traumatic brain injury (TBI) has been examined in limited populations, especially after a mild trauma. The aim of this study was to test if neurological deterioration or presence of ICI affected the experience of HRQOL of these patients six month after index event.
Methods: Over the 5.5-year study period (June 2008- December 2013), we retrospectively analyzed medical records of 551 patients who were admitted in our Emergency Department High Dependency Unit for trauma. At admission we registered the mechanism of injury, Injury Severity Scoring (ISS), Head Abbreviated Injury Score (AIS); Glasgow Coma Scale (GCS) and clinical parameters were estimated in the Emergency Room (ER) and in HDU at admission (T0), at 12 hours (T1) and after 24 hours (T2). Six months after the ED-HDU discharge, a telephone interview using the Physical (PCS) and Mental (MCS) Health Composite Score (SF12) was conducted; patients reported their QOL both at present and before trauma. We could contact 243 patients, who completed the study.
Results: The study population included 171 male patients, mean age 55±21 years; mean ISS and mean Head AIS were 11±8 and 0.8±1.1. During the acute phase 15 patients showed a neurological deterioration (GCS-), while 228 always showed a normal GCS (GCS+); 80 (33%) patients showed intra-cranial injury. Before the event the most part of our study population had a normal (greater than 39) PCS and MCS score (respectively 97 and 96%). After the event the proportion of patients with normal score values significantly decreased (PCS 63%, p<0.0001; MCS 69%, p=0.006). In the whole study population we observed a significant reduction in both MCS (before: 55±7, after: 46±13; p<0.0001) and PCS (before: 53±5, after: 43±11; p<0.0001) scores after the injury compared with the previous period. PCS score after the event was comparable in presence of GCS deterioration (43±10 in GCS+ vs 38±11 in GCS-) or ICI (43±10 in patients without ICI vs 41±11 in patients with ICI, all p=NS); MCS score was significantly worse in patients who developed a neurological deterioration (36±13 in GCS- vs 46±31 in GCS+, p=0.004) compared with patients who did not; ICI presence did not demonstrate any influence on mental HRQOL 6 months after the event (MCS 45±12 in patients with ICI vs 46±14 in patients without ICI, p=NS; PCS 41±11 in patients with ICI vs 43±10 in patients without ICI, p=NS).
Conclusion: HRQOL deteriorated significantly in this population of mild trauma patients, but this worsening was not associated with the presence of ICI; an early neurological deterioration was otherwise associated with a significantly worsening of the mental component compared with patients with normal or improving GCS. The limited number and the heterogeneity of GCS- patients in this study population requires to be very cautious in interpreting this relationship.
Federica TRAUSI (Florence, ITALY), Irene TASSINARI, Beatrice DEL TAGLIA, Francesca INNOCENTI, Riccardo PINI
09:10 - 10:40 #1959 - #1959 - NICE 2014 Paediatric head injury guidelines: impact on care in a mixed emergency department.
#1959 - NICE 2014 Paediatric head injury guidelines: impact on care in a mixed emergency department.
In Paediatric Emergency Departments across Europe, head injury is a common presentation. The vast majority (80%-90%) are mild in severity and do not require specialist intervention. From the TARN (Trauma and Research Network) 2012 data of severely injured children, 75% have a head injury, carrying a 7.5% mortality. There is a bimodal peak in the prevalence of head injuries, with infants and those age 6-16 most at risk, and two thirds being male.
In our District General Hospital serving an estimated paediatric population of 77000, we see up to 12 children a day with a head injury.
It is therefore vital to assess those children at risk of a significant head injury, investigate and treat appropriately. The NICE 2007 guidelines were based on CHALICE clinical decision rules, that have not been formally prospectively validated.
In 2014 NICE, incorporating data from the PECARN and CATCH studies, identified clinical features of children at very low risk of clinically significant brain injury after trauma, and have adapted their guidelines accordingly:
In our study, we retrospectively identified 536 children presenting to our Emergency Department over a 6 month period. Of these, 525 met the inclusion criteria for out study. Of the 525, 111 children would have met the CT imaging criteria in the NICE 2007 guideline, but only 21 met the 2014 guideline, a reduction of 81%. The number of CT Brain scans performed was 18 (3.4% of presentations). Only one CT showed a clinically significant subdural haemorrhage, and was referred to neurosurgery. The remaining CT scans were reported as normal, aside from one non-traumatic incidental finding.
We kept 21% of patients in the Emergency department for observation, and had no reattendances after discharge, and no mortalities. This study illustrates that the update in the NICE 2014 guidelines has reduced the criteria for CT imaging on children with a head injury by approximately 80%, without increasing mortality.
Elizabeth LITTLE (Banbridge, IRELAND), Conor EGLESTON, Ryang CHO
09:10 - 10:40 #966 - #966 - Role of Ultrasonography and Computed Tomography in Pediatric Blunt Abdominal Trauma.
#966 - Role of Ultrasonography and Computed Tomography in Pediatric Blunt Abdominal Trauma.
Background: Blunt abdominal trauma (BAT) is a major cause of death in children. Focused Abdominal Sonography in Trauma (FAST) is a rapid, bed side and cost saving screening tool for trauma patient. Decision for surgery or conservative treatment is based on clinical, laboratory, and imaging criteria.
This study aims to:(1) Assess feasibility and accuracy of FAST and Computerized Tomography (CT) in the emergency department (ED) as screening for the detection of intra-abdominal injuries in pediatric patients with BAT; and (2) Correlate the different findings to patient fate.
Design: Prospective cross-sectional study.
Setting: Level 3 trauma center of Alexandria main University hospital, Alexandria, Egypt.
Participants and Methods: We included all patients aged ≤ 18 years presenting with BAT, admitted between May 2013 and April 2014. After clinical assessment, and laboratory investigations, FAST was done to all patients by radiologists plus CT for selected populations. One week follow up was done for all cases.
Results: Included were 150 patients (72.6% males) with a median age of 9 years (range 3 days -17 years). Fifty four percent had road traffic accident, while 39.3% reported fall from height. Seventy three (48.7%) children did not show hemoperitoneum upon FAST, and 77 patients (51.3%) with intra-abdominal collection. Of them, 68 (45.3%) cases were discharged home immediately after full survey. Positive cases with FAST had hemoperitoneum that was minimal in 53 (68.8%), mild in 19 (24.7%), and moderate in 5 (6.5%) cases. Fifty patients were managed conservatevly. Fifteen patients were operated and 6 cases died. FAST findings were significantly related to the grade of shock (95% confidence interval [CI], P<.001). FAST showed 97.6% sensitivity, 95.12% specificity, 100% positive predictive, and 0% negative predictive values (95% CI). Thirty eight patients underwent contrast CT. Significant relations were found between FAST and CT as regards the mean examination time (11.29 versus 54.72 minutes) (95% CI, P<.001), detection of fluid collection (95% CI, P=.004). The Spleen was the most common injured organ in both investigation tools where in FAST 15 (19.5%) cases versus 16 (39%) cases with CT (95% CI, P=.002), followed by the liver; 13 cases detected by both FAST and CT . We tested the impact of different parameters against patient outcome using Univariate and Multivariate binary logistic regression. We found significant relations with the grade of shock (P=.01), Odds ratio (OR= 2.95), abdominal examination in both analyses (P=.02, OR=2.42), presence, and grade of fluid collection detected by FAST only in univariate model (95% CI, P<.001).
Conclusions: Our data favors wider use of FAST as screening and follow up tool for free fluid in children with BAT with high sensetivity and specificity. CT scan should be used in selected cases to guides non operative decisions as the duration of hospitalization, intensity of care, and length of activity restriction. It requires more facilities and time in the crowded ED. Clinical examination remains a significant parameter in decision making.
Soad EL-SAYED (Alexandria, EGYPT), Adel REZK, Saber WAHEB, Habashy AL-HAMMADI, Hatem BESHIR
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Meet the Experts
European Education: Trainers Forum
Moderators: Ruth BROWN (Speaker) (London, UK), Inger SONDERGAARD (PHYSICIAN) (ALLEROED, DENMARK)
09:10 - 09:30 Introduction to Specialist Education forum. Ruth BROWN (Speaker) (London, UK)
09:30 - 09:50 Introduction to EBEEM. Riccardo PINI (Director, E.D. High Dependency Unit) (Florence, ITALY)
09:50 - 10:10 How should specialist training and learning consist of? Cem OKTAY (FACULTY) (ANTALYA, TURKEY)
10:10 - 10:30 How to learn the basic sciences while working on the shop floor. Cristian BOERIU (Assoc.Professor) (Targu Mures, ROMANIA), M Ashraf BUTT (CAVAN, IRELAND)
10:30 - 10:40 Challenges of curriculum coverage. Sabine LEMOYNE (Senior Staff Member) (Edegem, BELGIUM)
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State of the Art
Infectious Disease & Sepsis
Moderators: Christoph DODT (München, GERMANY), Martin MOCKEL (BERLIN, GERMANY)
11:10 - 11:40 Volume therapy – How much is too much? Martin MOCKEL (BERLIN, GERMANY)
11:40 - 12:10 Specific sepsis therapies – Anything new we need to know? Jean Louis VINCENT (BRUXELLES, BELGIUM)
12:10 - 12:40 Antibiotic Therapy in the ED – The essentials of selection and dosing. Christoph DODT (München, GERMANY)
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Italy invites
Farmaci e droghe
Moderators: Clemente GIUFFRIDA (ITALY), Francesco STEA (ITALY)
11:10 - 11:30 Farmacovigilanza e interazioni tra farmaci. Vito PROCACCI (Foggia, ITALY)
11:30 - 11:50 Le nuove droghe: come affrontarle. Carlo LOCATELLI (Pavia, ITALY)
11:50 - 12:10 Le stragi del sabato sera: è possibile evitarle? Vincenzo NATALE (Vibo Valenza, ITALY)
12:10 - 12:30 Uso e abuso dei farmaci da parte dei mecici. Franco APRA (Torino, ITALY)
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Clinical Questions: Controversies
Resuscitation
Moderator: Graham NICHOL (USA)
11:10 - 11:40 When to start and when to stop CPR after cardiac arrest? Markus SKRIFVARS (FINLAND)
11:40 - 12:10 To drug or not to drug during cardiac arrest? Graham NICHOL (USA)
12:10 - 12:40 At which tempeature should we cool patients after cardiac arrest? Wilhelm BEHRINGER (Director) (Jena, GERMANY)
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Administration / Management
Overcrowding and Patient Flow in the ED
Moderators: Gautam BODIWALA (UK), Johannes HOHENAUER (AUSTRIA)
11:10 - 11:35 Doc's times and their impact on patients' flow. Alessio BERTINI (Pisa, ITALY)
11:35 - 12:00 Re-engineering the Front End of the ED: A Tool to Manage ED Crowding. David BROWN (USA)
12:00 - 12:25 Lab in the ED and Point of Care. Paul JARVIS (UK)
12:25 - 12:40 Lean ED and ambulance triage. Veli Pekka HARJOLA (Head of Department) (Helsinki, FINLAND)
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Research
Geriatric Emergency Medicine
Moderators: Abdelouahab BELLOU (BOSTON, USA), Simon CONROY (Leicester, UK)
11:10 - 11:40 Agenda and Road Map for the Implementation of a European Research in Geriatric Emergency Medicine. Abdelouahab BELLOU (BOSTON, USA)
11:40 - 12:10 Improving the quality of older peoples’ care in the ED. Jay BANERJEE (Leicester, UK)
12:10 - 12:40 Meta-Analysis of Screening Instruments to Predict Adverse Outcomes in Older Patients in the ED. Simon. P. MOOIJAART (LEIDEN, THE NETHERLANDS)
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YEMD
Think About Thinking: A Way To Improve Your Soft Skills?
Moderators: Riccardo LETO (Chief of ED) (Overpelt, BELGIUM), Senad TABAKOVIC (Zürich, SWITZERLAND)
11:10 - 11:40 Metacognition: I think, therefore I am? Simon CARLEY (Manchester, UK)
11:40 - 12:10 Cognitive Biases and Debiasing Strategies: stone aged minds in modern skulls. Senad TABAKOVIC (Zürich, SWITZERLAND)
12:10 - 12:40 Metacognition in Simulation & Debriefing: not how - but why. Rainer GAUPP (SWITZERLAND)
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EuSEM Nursing Track
Nursing Interventions and Standing Orders
Moderators: Door LAUWAERT (BELGIUM), Ole-Petter VINJEVOLL (Trondheim, NORWAY)
11:10 - 11:20 Switzerland. Petra VALK-ZWICKL (SWITZERLAND)
11:20 - 11:30 Belgium. Yves MAULE (MANAGER DE SOINS) (LIEGE, BELGIUM)
11:30 - 11:40 Norway. Ole-Petter VINJEVOLL (Trondheim, NORWAY)
11:40 - 11:50 The Netherlands. Christien VAN DER LINDEN (THE NETHERLANDS)
11:50 - 12:00 Italy. Luciano CLARIZIA (ITALY)
12:00 - 12:10 Iceland. Gudbörg PÁLSDOTTIR (ICELAND)
12:10 - 12:40 Summary recommendations for Europe. Door LAUWAERT (BELGIUM)
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Oral Paper 1
Pain Management II
Moderators: Juliusz JAKUBASZKO (POLAND), Itay SHAVIT (ISRAEL)
11:10 - 12:40 #1027 - #1027 - Trial of haloperidol vs. placebo in addition to conventional therapy in ED patients with gastroparesis.
#1027 - Trial of haloperidol vs. placebo in addition to conventional therapy in ED patients with gastroparesis.
Objectives: Gastroparesis (GP) is a motility dysfunction that is often associated with disabling symptoms such as nausea, vomiting, and abdominal pain. Typically, emergency department (ED) management includes various analgesics and antiemetics, but symptoms are often refractory to conventional therapy. Some of the most common non-invasive treatments that have been used for GP include dopamine antagonists, macrolides and 5-HT4 agonist. Haloperidol has been utilized clinically for the management of nausea, vomiting and abdominal pain in patients under palliative care. We propose that haloperidol in addition to conventional therapy will result in more efficient treatment for patients with GP.
Methods: We performed a randomized, double-blind, placebo controlled trial involving adult ED patients who presented with an acute GP exacerbation. Patients > 17 years old with a prior diagnosis of GP who presented with intractable nausea, vomiting, and abdominal pain attributable to GP were eligible for the study. Exclusions included prolonged QT, hypotension, and other abdominal pathology, known allergy to haloperidol, pregnancy, prisoners, or inability to give informed consent. In addition to conventional therapy, eligible patients were randomized to a placebo or experimental group receiving 5 mg haloperidol IV. The severity of the subjects’ nausea, vomiting and abdominal pain were assessed on the Likert Scale (LS) upon arrival to the ED, and at 0 minutes, 15 minutes, 30 minutes, 45 minutes and 1 hour after treatment. The primary endpoint was the proportion of patients with GP that reported relief of symptoms at one hour. Secondary outcomes included disposition status, ED length of stay, and symptom improvement based on mean change in LS.
Results: This analysis includes the preliminary data of 10 patients, 5 in each group. There was a greater reduction in abdominal pain at 1 hour with haloperidol (6.9) compared to the placebo (2.8). There was also a greater reduction in nausea in the experimental group (3.4) compared to the placebo (1.4). Based on the drop in pain and nausea score from prior to and an hour after treatment, almost all individuals receiving haloperidol experienced relief in pain and nausea (5/5 and 4/5, respectively) compared to 3/5 and 2/5 for the placebo group.
Conclusions: Haloperidol in addition to conventional therapy is superior to standard therapy alone in treatment of GP and should be considered in the management of patients with GP in the ED. Larger studies are needed to validate these findings.
Carlos ROLDAN (Houston, USA), Linda PANIAGUA, Yashwant CHATHAMPALLY, Peter CARLSON
11:10 - 12:40 #1139 - #1139 - Reliability of long term pain intensity recall in elderly emergency department patients.
#1139 - Reliability of long term pain intensity recall in elderly emergency department patients.
Background: The recall of past pain intensity is frequently used in clinical research but many questions its validity. Emotional distress, level of pain encountered at trauma, medication, cognitive status and actual pain level are factors that could affect the ability to recall past pain in elderly patients. The objective of the study is to evaluate the reliability of memory of pain and to identify the factors that affect it in elderly ED patients.
Methods: This is a sub-study of a larger Canadian prospective multicenter study that evaluate functional decline in elderly (≥65) patients treated in ED for minor traumatic injury. Patients were recruited from April 2011 to January 2014 across seven university-affiliated ED in 5 major cities (Quebec, Montreal, Ottawa, Toronto and Hamilton). Patients hospitalized, living in a long term establishment, were unable to give verbal consent, unable to attend follow-ups or to communicate in French or English were excluded. Patient characteristics (including cognitive status), pain intensity on a 0-10 numeric rating scale (NRS) at triage and on initial interview (done less than 2 weeks after injury) was recorded. Three months after the injury, patients were contacted by phone and asked to recall pain intensity during their first interview (baseline).
Results: A total of 671 patients were interviewed at baseline and at 3-months with a mean age of 76.8 years (SD±7.6) and (72.4%) were women. Intraclass correlation coefficient between memory of pain and pain at baseline was poor (0.31, 95%CI: 0.15-0.44). Elderly patients tend to overestimate the level of pain intensity they had at baseline by a mean of 1.8 units (95%CI 1.5-2.1) of a 0-10 numeric rating scale (mean memory of pain at 3 months = 5.0 vs 3.2 at baseline). No effects of age, sex, medication, social support, education level, comorbidities or cognitive status were significantly associated with the ability to remember pain. Stepwise multiple regression showed that pain at ED triage (12% of explained variance), pain at baseline (9% of explained variance) and actual pain at 3 months (3% of variance explained) significantly predicted pain memory.
Conclusion: The recall of pain of elderly after 3 months is poor and is influenced by the pain intensity at the time of injury and actual pain. The validity of the long term recall of pain in clinical research is seriously questioned.
Raoul DAOUST (Montréal, CANADA), Marcel EMOND, Marie-Josée SIROIS, Jeffrey PERRY, Jacques LEE, Lauren GRIFFITH, Eddy LANG, Jean PAQUET, Jean-Marc CHAUNY
11:10 - 12:40 #1253 - #1253 - Paediatric procedural sedation and analgesia in the Dutch ED- A prospective multicentre cohort study.
#1253 - Paediatric procedural sedation and analgesia in the Dutch ED- A prospective multicentre cohort study.
Objectives
Procedural Sedation and Analgesia (PSA) in paediatric patients in the Emergency Department (ED) has been shown to be safe in international literature. This article describes paediatric PSA practices and outcomes in The Netherlands, aiming to determine its safety and effectiveness in a country with a relatively new Emergency Medicine (EM) Training Programme.
Methods
A multicentre, prospective, observational cohort study. Data were collected from January 2006 until October 2012 in 7 different Dutch hospitals. Children aged 0-16 years with ASA class I and II were included. The participating centres collected data using the national ED PSA forms.
Primary outcome measure was the number of adverse events. Their severity was graded according to the 2012 International Sedation Task Force adverse event-reporting tool by Mason et al. Secondary outcome measure was effectiveness of PSA, for which the following parameters were used: amnesia, level of sedation, pain score and whether the intervention was successful.
Results
A total of 351 sedations were performed. The median age was 10 (IQR 6-13). Interventions most commonly performed were fracture reductions (68.9%) and joint relocations (14.8%). Esketamine was the most commonly used sedative (42.1%), followed by propofol (35%) and midazolam (22.9%).
Adverse events occurred in 14 children (4.0%). For esketamine these were: vomiting (n=4), agitation (n=2), bradycardia (n=1), allergic reaction without anaphylaxis (n=1) and unplanned admission (n=1). For propofol, there were 4 cases of apnoea, 2 of whom needed temporary bag valve mask-assisted ventilation. One child needed airway repositioning. For midazolam, no adverse events were recorded. In none of the children did an adverse event result in an adverse outcome, other than one child being admitted for 3 hours because of persistent drowsiness after subcutaneous esketamine. There was no significant difference in the number of adverse events between the sedatives. Level of sedation was the only significant predictor for adverse events (p=0.015).
Amnesia was present in 86.8% of children (n=227). The level of sedation was recorded as minimal (21.6%), moderate (55.4%), deep (22.3%) or general anaesthesia (0.7%) for midazolam and propofol (n=148). With esketamine, 60% of children were dissociated (n=100). The median numerical rating scale pain score for children who were not amnesic was 2 (n=31).
A total of 21 interventions (6.1%) failed. In 3 cases (0.9%) this was (partly) due to inadequate sedation.
Conclusion
In this multicentre observational study of paediatric ED sedation in The Netherlands, adverse events occurred in 4% of children. None were severe. Our event rate of 4% compares well with rates of 2.3-17.8% found in large international studies. These data suggest that in a country where EM is relatively new, EPs can deliver paediatric PSA safely and effectively. Adverse events were managed appropriately by the sedating EPs and none of the children suffered negative sequelae. Our results could be seen as an encouragement to other European countries with an unmet need for procedural pain management in the ED.
Eva P BAERENDS (Amsterdam, THE NETHERLANDS), Maybritt KUYPERS, Gael Jp SMITS
11:10 - 12:40 #1337 - #1337 - Using saline injections to treat myofascial pain syndromes.
#1337 - Using saline injections to treat myofascial pain syndromes.
Objective: Myofascial pain (MP) is regional pain originated in muscle and fascia. It is characterized by a regional referred pain and the presence of a reproducible trigger point. MP is frequently under diagnosed and undertreated in the emergency department (ED). Patients often undergo extensive diagnostic tests before ultimately being diagnosed with MP. The prevalence of MP in middle-aged adults is estimated to be 37% in men and 65% in women. Trigger point injection (TPI) is the safest and most effective treatment option for MP in the ED. Conventional medications used for TPI add cost and have potential adverse effects, while normal saline (NS) does not. The objective of this study is to compare the effectiveness of TPI with NS and conventional active drug mix (CADM) in relieving pain in patients diagnosed with MP in the ED.
Methods: We designed a prospective, randomized, double-blinded trial involving adults diagnosed with MP of the trapezius, gluteus medius/minimus, iliocostalis thoracis-lumborum, quadratus lumborum, or paraspinal muscles in the ED. Patients with allergies to lidocaine or steroids, signs of infection at injection site, pregnancy, prisoners and those unable to consent were excluded. Patients, physicians and scribers were blinded to the treatment selection. The subjects were randomized into two groups: TPI with 1mL NS or CADM (9:1 of lidocaine 10 mg/mL + triamcinolone 40 mg/mL). The procedure was performed under sterile conditions using a 25 gauge needle. Pain was quantified using a 0 – 10 Numerical Rating Scale (NRS). The pain intensity was recorded upon arrival to the ED, before TPI, after TPI and upon discharge. Patients were followed up by blinded scribers 2 weeks after discharge to assess pain intensity, duration of pain relief, satisfaction with treatment, and presence of complications or missed diagnosis. The primary outcome measured was the level of pain relief after TPI. The secondary outcome was the duration of pain relief.
Results: To date, 44 patients age 22-82 have been enrolled. The duration of pain ranged from 2 days to 9 years. On arrival, the interquartile range (IQR) of pain scores was 8-10 NRS. Most patients (78.6%) had taken analgesics prior to TPI without relief of symptoms. Twenty one patients had previously visited an ED or clinic with negative diagnostic tests to exclude gastrointestinal, vascular, gynecological, pulmonary, renal and cardiac conditions. Eight patients were lost to follow up. Immediately post-TPI, median pain score in both groups was 0. The median duration of pain relief 2 weeks post-TPI was 4 days (IQR: 0-6) for the CADM group and 5 days (IQR: 0-6) for the NS group (P=0.903). At 2 weeks, all patients on average had more than a 50% reduction in pain from baseline.
Conclusions: MP can be easily diagnosed and treated in the ED by emergency physicians. TPI with normal saline is equally as effective as conventional medications to treat MP. They provide similar duration of pain relief at 2-week follow up post treatment. This could provide a safer and cheaper alternative to treat MP.
Carlos ROLDAN, Na HU, James LEONI, Seth REHRER, Carrie BAKUNAS, Andres BAYONA (Houston, USA), Rosa BANUELOS
11:10 - 12:40 #1401 - #1401 - Evaluation of pain management in an emergency department.
#1401 - Evaluation of pain management in an emergency department.
Introduction: Inadequate pain management remains a major challenge for health care providers. The aim of this study was to evaluate the prevalence of oligoanalgesia and its causes.
Methods: We performed a prospective observational study over a period of one month. Patients with age>15 years with moderate or severe pain [visual analog scale (VAS) >30mm or numeric scale (NS) >3] at hospital admission were included. Patients not communicating or confused were excluded. The quality of pain management was evaluated according to information in the ED medical records by using a standardized collection form, and its impact on patients (evolution of the pain and the degree of patient satisfaction) was recorded with a questionnaire at discharge. Oligoanalgesia was defined as a NS>3 or VAS>30mm at hospital discharge.
Results:During the study period 580 patients were included (mean age 41±18 years, sex ratio = 0.97). Of them,67% had pain. The pain was assessed by the medical staff only in 55% of cases during the care and in only 2% at discharge. The majority of patients (n=457) had moderate or severe pain and 15% of them did not express their pain spontaneously. The pain was essentially evaluated by the numeric scale (79% of cases), then by the simple verbal scale and visual analog scale in 16% and 5% of case respectively. Only 48% of patients enrolled received analgesic treatment. Morphine was used only for 7 patients while 33% of patients had severe pain. The analgesic was prescribed on median time 22min (IQR25-75, 14-37). The prevalence of oligoanalgesia was 80% and only 26% of patients were satisfied at discharge.
Conclusions:Our study demonstrates that acute pain is undertreated. The oligoanalgesia was essentially due to the not evaluation of the pain and combination of undelivered and delivered but unachieved analgesia.
Wiem KERKENI (Mahdia, TUNISIA), Yosra YAHIA, Ousji ALI , Sana MABSOUT, Ichraf BACHA, Khawla RAMMEH, Ali BEN ABDELHAFIDH , Wael CHAABANE, Soudani MARGHLI
11:10 - 12:40 #1457 - #1457 - The performance of a safe procedural sedation in the Emergency Department by physicians of different specialities, a comparison.
#1457 - The performance of a safe procedural sedation in the Emergency Department by physicians of different specialities, a comparison.
BACKGROUND
In order to perform a safe procedural sedation, apart from knowledge and use of medication, a pre-procedural questionary (1), preoxygenation (2), an appropriate technique (3), monitoring (4) and documentation of the procedure and recovery (5) are also important issues.
METHODS
These different aspects (1,2,3,4,5) of a safe procedural sedation for shoulder- and ankle reductions performed by physicians of different specialities in our Emergency Department (ED)⎨general surgeon and orthopedist (SoED), anaesthesiologist of the OR (AoOR), anaesthesiologist (AoED) and emergency physician (EP) working on the ED (AEPoED)⎬were compared.
Ethical Committee approval was obtained. 193 Patient files in a 3 years period were retrospectively analysed.
RESULTS
The given percentages are related to the amount of patients treated by each group of speciality.
(1) Pré-sedation questionary was documented in a sufficient way in 1% of the cases treated by the SoED, 12% by the AoOR and 31% by the AEPoED (64% by the AoED and 12% by the EP). (2) Preoxygenation was never performed by the SoED, in 33% of the cases treated by the AoOR and in 43% by the AEPoED (100% by the AoED and 12% by the EP). (3) There was no sedation technique performed in 37% of the patients treated by the SoED and 6% by the AEPoED (0% by the AoED and 8% by the EP). Sedation was applied in 39% by the SoED, 92% by the AoOR and 89% by the AEPoED (100% by the AoED and 80% by the EP). (4) Basic monitoring was used in 1% by the SoED, 31% by the AoOR and 24% by the AEPoED (43% by the AoED and 12% by the EP). Monitoring with ETCO2 was never applied by the SoED, in 2% by the AoOR and 21% by the AEPoED (57% by the AoED and 0% by the EP). (5) The sedation procedure was well documented in 40% of the patients treated by the AEPoED (100% by the AoED and 8% by the EP), in 23% by the AoOR and in 1% by the SoED. Recovery was documented in a sufficient way in 25% by the AEPoED (64% by the AoED and 4% by the EP), 14% by the AoOR and never by the SoED. Guidelines to discharge the patients were well documented in 15% by the AEPoED (42% by the AoED and 0% by the EP), 6% by the AoOR and 0% by the SoER.
CONCLUSIONS
Overall, the investigated different aspects of a safe procedural sedation were best carried out and documented by the physicians working in the ED.
Preoxygenation and documentation are aspects which are easily overlooked.
Safety of a procedural sedation in the ED is essential and should be improved by implementing guidelines for non-anaesthesiologists working in the ED.
Sefan NEYRINCK (EVERBERG, BELGIUM), Tom SCHMITZ, Ives HUBLOUE
11:10 - 12:40 #1842 - #1842 - Intranasal ketamine for acute traumatic pain: A prospective, randomized clinical trial of efficacy and safety.
#1842 - Intranasal ketamine for acute traumatic pain: A prospective, randomized clinical trial of efficacy and safety.
Introduction: Ketamine has been well studied for its efficacy as an analgesic agent. However, intranasal (IN) administration of ketamine has only recently been studied in the emergency setting.
Objective: Elucidate the efficacy and adverse effects of a sub-dissociative dose of IN Ketamine compared to IV and IM morphine.
Methods: Single-center, randomized, prospective, parallel clinical trial of efficacy and safety of IN ketamine compared to IV and IM morphine for analgesia in the emergency department (ED). A convenience sample of 90 patients aged 18-70 experiencing moderate-severe acute traumatic pain (≥80mm on 100mm Visual Analog Scale [VAS]) were randomized to receive either 1.0mg/kg IN ketamine, 0.1mg/kg IV MO or 0.15mg/kg IM MO. Pain relief and adverse effects were recorded for 1 hour post-administration.
Primary Outcomes: Primary outcome was efficacy of IN ketamine compared to IV and IM MO, measured by “time-to-onset” (defined as a ≥15mm pain decrease on VAS), as well as time to and degree of maximal pain reduction.
Results: The 3 study groups showed a highly significant, similar maximal pain reduction of 56±26mm for IN Ketamine, and 59±22 and 48±30 for IV MO and IM MO, respectively. IN Ketamine was non-inferior to IV MO with regards to time to onset (14.3±11.2 v. 8.9±5.6 minutes, respectively) as well as in time to maximal pain reduction (40.4±16.3) versus (33.4±18), respectively. Subjective side-effects of analgesia elucidated that subjects receiving IN Ketamine showed greater frequency of difficulty in concentrating and fewer levels of dry mouth. Furthermore, IN ketamine and IV MO showed greater levels of dizziness when compared to IM MO. IN Ketamine showed greater levels of confusion than IV MO. Objective hemodynamic and respiratory measurements trended towards increased hemodynamic stability in IN ketamine patients but did not reach statistical significance.
Conclusions: IN ketamine shows efficacy and safety comparable to IV and IM MO. Given the benefits of this mode of analgesia in emergencies, it should be further studied for potential clinical applications.
Shachar SHIMONOVICH (Shoham, ISRAEL), Roy GIGI, Amir SHAPIRA, Tal SARIG-METH, Danielle NADAV, Mattan ROZENEK, Debra GERSHOV, Pinchas HALPERN
11:10 - 12:40 #1982 - #1982 - Effects of a 6-hours training program in changing short and medium term Emergency Physicians behaviour regarding pain management.
#1982 - Effects of a 6-hours training program in changing short and medium term Emergency Physicians behaviour regarding pain management.
Background:
Acute pain is one of the most frequent symptoms in emergency department (ED) admissions, but its management is often neglected, placing patients at risk of oligoanalgesia. An attitude of suspicion against oppioid, a culture of ignoring the problem, a low knowledge of the pain management guide line and a chaotic environment present formidable obstacles for effective pain management in the emergency setting. The aim of this study was to evaluate the effects of the implementation of local guidelines for pain management in ED patients with pain at admission or anytime during their stay in our ED.
Methods:
To improve the quality of pain treatment in the emergency room, and to improve the appropriateness of prescribing pain medications, we organized a 6 hours training program, in collaboration with the Pain Management Unit of our hospital, for emergency medicine physicians and emergency medicine residents.
A before-after observational study was used to investigate changes in pain management between the three months prior to the training programme and the three-six months following it.
Consecutive adult ( sixteen years old or older) patients admitted with acute pain from any cause or with pain at any time after admission were enrolled. A total of 10169 patients were sampled in the first control period (T0) and respectively 10577 in the second period (T1, three months after the training) and 9696 in the third period (T2, six months after the training). Each period was comparable as color code, sex and age.
We have considered the use of oppioid, NSAIDs and paracetamol in endovenous or oral formulation and we expressed it in vials for 100 patients.
Results:
The use of oppioid is increased in the periods under consideration from 2.29 vials/100 patients of the control phase to 4.42 vials/100 patients in the second phase and 3.89 vials/100 patients in the third phase; both the difference between the control period and the second phase (T0-T1) and between the control and the third phase (T0-T2) calculated with X2 test were statistically significant (p<0,001). This increase remains in a short-medium term.
While the use of NSAIDs and paracetamol remains stable in the three periods.
Conclusions:
This study shows that a training program for pain management lead to improve pain attention in a short term and this advantage slightly decreases in a medium term. We observed also a statistically significant increase of oppioid use after the training course and it can be due to a increase attention to pain management induced by the course. This pilot study shows that you could change emergency physicians behaviour regarding pain management with a simply 6-hours training course and this change remains in a short-medium term.
Giuseppe LAURIA (Cuneo, ITALY), Bartolomeo LORENZATI, Emanuele BERNARDI, Letizia BARUTTA, Elisa PIZZOLATO, Attilio ALLIONE, Luca DUTTO, Elena MAGGIO, Bruno Maria TARTAGLINO
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Oral Paper 2
Cardiovascular Emergencies III
Moderators: Ulf EKELUND (Malmö, SWEDEN), Timothy Hudson RAINER (UK)
11:10 - 12:40 #1085 - #1085 - Admission to cath-lab beyond 120 minutes: in hospital mortality for prehospital ST elevation myocardial infarction.
#1085 - Admission to cath-lab beyond 120 minutes: in hospital mortality for prehospital ST elevation myocardial infarction.
Background: Improving timely access to life saving reperfusion therapy is well recognized as being a major goal of ST-segment elevation myocardial infarction (STEMI) care. Primary percutaneous coronary intervention (pPCI) is the recommended reperfusion therapy if performed by an experienced team within 120 minutes after first medical care (FMC).
Aim: to assess the impact of delay on in-hospital mortality of STEMI patients transported for pPCI to the catheterization laboratory (cath-lab).
Methods: Data was collected from 2003 to 2013 throughout an ongoing prospective registry that included all STEMI managed within less than 12 hours by mobile intensive care units (MICU) squads in a metropolitan area. The medical dispatch center (SAMU - centre 15) allowed a direct transfer to pPCI-capable hospital bypassing the emergency department. Comparison of in hospital mortality among two groups; with a delay from FMC to cath-lab less than 120 minutes for group 1 more than 120 minutes for group 2. Data were compared using Chi 2 test (significant if p < 0.05).
Results: 10.210 patients were included in the registry during the period. 2.454 patients (24%) received prehospital fibrinolysis and 7.756 patients (76%) were directly admitted to the cath-lab for pPCI. In-hospital mortality was significantly lower (p < 0.0001) in group 1: 122 patients (1.8%) among 6.645 patients, than in group 2: 46 patients (4.1%) among 1.111 patients.
Discussion: Increase of in-hospital mortality for unselected STEMI patients transferred from scene to cath-lab is strongly correlated to time to pPCI beyond 120 minutes, beyond recommended delay. A system delay of less than 120 minutes remains a major goal to achieve for prehospital teams. Thrombolysis remains an alternative.
Yves LAMBERT, Sophie BATAILLE, Laurent REBILLARD, Nicolas DANCHIN, Aurélie LOYEAU, Lionel LAMHAUT, Jean-Michel JULIARD, François DUPAS, Frédéric LAPOSTOLLE, Hugues LEFORT (Metz)
11:10 - 12:40 #1352 - #1352 - High plasma lactate dehydrogenase at presentation to the Emergency Department predicts in-hospital mortality in acute aortic syndromes.
#1352 - High plasma lactate dehydrogenase at presentation to the Emergency Department predicts in-hospital mortality in acute aortic syndromes.
Background. The diagnosis of acute aortic syndromes (AAS) requires complex integration of clinical data, blood tests and imaging exams. Lactate dehydrogenase (LDH) is a widely expressed intracellular enzyme which reduces pyruvate to lactate during hypoxia, and plasma LDH is a biomarker of tissue ischemia. Measurement of plasma LDH is rapidly and almost universally available to Emergency Departments (ED), and increased levels of LDH are typically found in hemolysis and in myocardial or skeletal muscle ischemia. Furthermore, increased LDH has been associated with mortality in acute conditions such as pulmonary embolism, pneumonia and acute intestinal ischemia. Indeed, increased plasma LDH has been reported in patients affected by AAS, indicating potential use for diagnosis and/or for prognostic stratification. However, focused experimental data is lacking.
Methods. This was a retrospective diagnostic accuracy and prognostic study of plasma LDH, conducted on consecutive patients evaluated in two Emergency Departments for suspected AAS, from 2008 to 2014. In the study period, consecutive patients were enrolled in a registry if the following inclusion criteria were satisfied: (1) presence of chest pain, back pain, abdominal pain, syncope or signs/symptoms of perfusion deficit; (2) unclear diagnosis after initial medical evaluation; (3) order of an urgent aortic imaging exam by the attending physician to identify/exclude AAS. Trauma patients were excluded. All patients underwent computed tomography angiography for conclusive diagnosis. LDH was assayed at presentation to the ED, as part of the initial diagnostic workup. Diagnostic accuracy of LDH was evaluated by ROC analysis and by calculating sensitivity, specificity, predictive values and likelihood ratios. In-hospital mortality was analyzed by Kaplan-Meier plots and log-rank test.
Results. 999 of 1,578 patients with suspected AAS had plasma LDH assayed at presentation in the ED. The final diagnosis was AAS in 201 (20.1%) patients, while alternative diagnoses (AltD) were made in 798 (79.9%) patients. Median LDH at presentation was 424 (interquartile range [IQR] 366-558) UI/l in patients with AAS, and 383 (IQR 331-461) UI/l in patients with AltD (P<0.001). Using the higher normality cutoff of 450 UI/l, the sensitivity of LDH for AAS was 44% (95% CI 37-51%) and the specificity was 73% (95% CI 69-76%). All-cause in-hospital mortality in patients with AAS was 23.8%. Survival curve analysis showed 32.6% in-hospital mortality in AAS patients with LDH ≥450 UI/l and 16.8% in AAS patients with LDH P=0.017). The hazard ratio for in-hospital mortality associated with LDH ≥450 UI/l was 2.34 (95% CI 1.28-4.28). In logistic regression analysis, LDH ≥450 UI/l was found as an independent predictor of adverse outcome, together with age>65 years and hypotension.
Conclusions. The present results question the utility of LDH in the ED as a diagnostic assay in patients with suspected AAS. Instead, they define plasma LDH as a biomarker potentially allowing prognostic stratification of patients with AAS. Patients with AAS and high levels of LDH in the ED deserve special attention.
Fulvio MORELLO (Torino, ITALY), Anna RAVETTI, Giovanni LIEDL, Peiman NAZERIAN, Francesca GIACHINO, Simone VANNI, Emanuele PIVETTA, Stefano GRIFONI, Giuseppe MONTRUCCHIO, Corrado MOIRAGHI, Giulio MENGOZZI, Enrico LUPIA
11:10 - 12:40 #1398 - #1398 - Emergency presentation of paediatric myocarditis key signs, symptoms and investigations; professional opinion vs literature evidence.
#1398 - Emergency presentation of paediatric myocarditis key signs, symptoms and investigations; professional opinion vs literature evidence.
Myocarditis is a potentially life-threatening inflammatory disorder of the myocardium. In paediatrics, despite the well-established morbidity and mortality associated with it, myocarditis remains an enigmatic diagnosis and is too frequently missed on first presentation. The long-term prognosis of patients with myocarditis is more favourable if it is recognised quickly and managed aggressively however, diagnosis is challenging as initial presentation can be anywhere on a spectrum from insidious inflammation of the myocardium to fulminant disease with acute, severe cardiogenic shock. Consensus recommendations regarding the diagnostic methods in children within the emergency setting are lacking as currently no single clinical or imaging finding confirms or refutes the diagnosis with absolute certainty. Current practice therefore varies and Emergency clinicians need to be aware of when to suspect the disease in children and be aware of the diagnostic utility of the investigations available in order to manage patients accordingly.
The overall aim of this study was to review the literature and determine whether:
1. Is there a specific constellation of clinical symptoms or signs that are pathognomic of paediatric myocarditis?
2. Is there is a sensitive and specific investigation that could confirm or deny the diagnosis?
This evidence was then compared to current opinions in a tertiary paediatric emergency department regarding the clinical presentation and appropriate investigation of paediatric myocarditis and see if current clinician practice mirrors the literature evidence.
Opinion was sought from 36 paediatric emergency clinicians from a tertiary hospital encompassing senior trainees (paediatric and emergency medicine) and consultants. This body of professionals all found the diagnosis to be difficult and the majority felt a guideline would be useful to aid the management of these patients.
Key findings from the literature were that unexplained symptoms in a previously healthy child such as vomiting, tachycardia, dysarrhthymia or progressive respiratory distress should trigger investigation for a cardiac cause and in particular myocarditis. This should include ECG, Chest radiograph with consideration of Echocardiogram and cardiac biomarkers. In general this was echoed in professional opinion of when to suspect paediatric cardiac disease. In terms of investigations however, despite the literature evidence finding in favour of ECG and Chest radiograph, professional opinion felt that bedside echocardiogram would be the most useful discriminatory test in the Emergency department. The utility of cardiac biomarkers remain an area of uncertainty, an opinion that mirrored the literature, however myocardial biopsy was overestimated in terms of its sensitivity. (Statistical analysis will be provided)
A provisional algorithm for diagnosis is offered with a red-flag system of signs of symptoms that trigger the next level of investigation. This is however with the caveat that this generic approach may not clinically possible without causing over-investigation of well children. Probably the most important aspect in improving diagnosis of myocarditis in children is to improve awareness of the diagnosis, lowering the index of suspicion of this important diagnosis.
Jessica GREEN (Bristol, UK)
11:10 - 12:40 #1405 - #1405 - Hypertension predicts major adverse cardiac events after discharge from the emergency department with unspecified chest pain.
#1405 - Hypertension predicts major adverse cardiac events after discharge from the emergency department with unspecified chest pain.
Introduction: Chest pain is a common reason to seek medical care at the emergency department (ED), and more than half of chest pain patients are discharged with the diagnosis unspecified chest pain. After discharge a small amount will nevertheless experience a major adverse cardiac event (MACE). Chest pain patients are often evaluated with the help of risk scores that are based on risk factors for cardiovascular disease (CVD). However, the predictive value of risk factors such as hypertension, diabetes, treated hyperlipidaemia or previous CVD have not been sufficiently studied in this setting.
Aims: To investigate the predictive value of CVD risk factor for MACE after discharge from the ED in patients with unspecified chest pain, with a special focus on hypertension.
Material and Methods: This register-based retrospective cohort study included all patients over 18 years discharged with the diagnosis “unspecified chest pain” from a Swedish hospital ED between 2006 and 2013. Information about medical history and drug prescriptions were collected from national registers and related to the occurrence of MACE (myocardial infarction, unplanned revascularisation or death) within 30 days of discharge. Odds ratio for the different variables were calculated with logistic regression analysis and the additive discriminatory value of treated hypertension to a risk factor model were calculated with category-free net reclassification improvement (cNRI).
Results: A total of 83 673 patients were included. Among patients that were discharged directly from the ED (n=74329) 0.8% experienced a MACE within 30 days whereas the incidence was 4.0% among patients discharged after an initial short term ward admission (n=9344). Among patients that were discharged directly from the ED a history of treated hypertension (OR 4.0, CI 3.3-4.8 p<0.001), diabetes mellitus (OR 3.9, CI 3.0-4.9, p<0.001), hyperlipidaemia (2.0, CI 1.4-2.8 p<0.001), and CVD (OR 6.1, CI 5.0-7.3, p<0.001) were associated to MACE. The addition of treated hypertension to a risk factor model based on all others significant risk factors improved net reclassification (cNRI 48%, CI 15-59%). The odds ratio for MACE increased with the number of anti-hypertensive drugs up to three different drug classes among patients discharged directly from the ED. Among patients discharged after an initial admission no linear correlation between number of drugs and the OR for MACE were found.
Conclusions: A history of treatment or hospitalisation for CVD or CVD risk factors were all associated to incident MACE within 30 days after discharge from the ED with unspecified chest pain, both in patients that were discharged directly from the ED and in those that were discharged after an initial short term ward admission. Awareness about risk factors, and specifically hypertension, for adverse outcome after discharge among chest pain patients can lead to improved evaluations at the ED and fewer cases of misdiagnosis. Our findings support the use of patient history in risk scores, such as HEART score, which has not been properly evaluated previously.
Åsa OMSTEDT (Solna, SWEDEN), Jonas HÖIJER, Therese DJÄRV, Per SVENSSON
11:10 - 12:40 #1436 - #1436 - Pulmonary embolism after a long haul flight towards a "footbridge syndrome"?
#1436 - Pulmonary embolism after a long haul flight towards a "footbridge syndrome"?
INTRODUCTION :
Episodes of faintness, even cardiac arrests upon the arrival of long haul flights are frequent. The diagnosis of pulmonary embolism is regularly confirmed. The population exposed to this risk is considerable. Circumstances it occurs are badly known, in particular, moment of arisen the symptoms.
MATERIAL AND METHODS :
Systematic review of suspect patient of pulmonary embolism, after a long haul flight, taken care in the Roissy Charles de Gaulle Airport, by the Emergency Medical Departement 93, from 1993 till 2013.
Inclusion : Age upper to 16 years. Pulmonary embolism confirmed by lung angioscanner or lung scintigraphy of ventilation-drip.
Assessement criterion :
- Moment of arisen the symptoms : during the flight, on the footbridge(of the rise at the exit of the plane up to the airport), in the airport.
- Risk reported in the time of exposure : known duration of flight, time spent on the footbridge estimated at one hour and in the airport at two hours.
RESULTS :
156 patients where included in this study.
Symptoms arisen 21 time (13%) during flight, 132 time (85%) on the footbridge, one (1%) time in the airport and two time in unknown circumstances.
Duration accumulated by flight : 1.866 hours.
The number of event per hour were : 0.01 during flight, 132 on the footbridge and 0.5 in the airport.
CONCLUSION :
Pulmonary embolism after a long haul flight occurs essentially on the footbridge. The migration of the thrombus would occur in the rise or during the first steps.
The name of "the footbridge syndrome" should be preferred to the usual name of "syndrome of the economic class".
Arabietou TRAORÉ, Sylvie GUINEMER , Hayatte AKODAD (Bobigny Cedex), Sabine GUINEMER, Pascal ORER, Armelle ALHERITIERE , Paul-George REUTER, Frédéric ADNET, Frédéric LAPOSTOLLE
11:10 - 12:40 #1803 - #1803 - Adjustments in the use of new antiplatelet agents in acute coronary syndrome in the Emergency Department.
#1803 - Adjustments in the use of new antiplatelet agents in acute coronary syndrome in the Emergency Department.
OBJECTIVE: To evaluate the adaptation of new antiplatelet therapy in acute coronary syndrome (ACS) in the emergency Department.
MATERIALS AND METHODS: This is a descriptive study of patients that have been seen in the emergency department with ACS from November 15, 2013 to February 15, 2014. We analyzed clinical and laboratory variables obtained from the Information System of our Hospital (Lozano Blesa Universitary Hospital, Zaragoza, Spain).
RESULTS: 105 patients were treated for ACS with an average age of 70.71 years (SD 13.82). 72 were men (68.6%) and 33 women (31.4%). 82 (78.1%) were ACS without ST elevation (NSTEMI) and 23 (21.9%) elevation (STEMI). Acetylsalicylic acid (ASA) was provided to 81 patients (77.1%), Clopidogrel to 54 (51,4%), Ticagrelor to 18 (17,1%) and Prasugrel to 3 (2.9%). Non invasive therapy was provided to 89 patients (84.8%) and coronary angiography to 16 (15.2%). 18 patients (17.1%) had high risk of bleeding (CRUSADE> 40) and ASA was administered to 13 of them, Clopidogrel to 11, Prasugrel to 1 and Ticagrelor to 1. 87 patients (82.9%) had low risk of bleeding (CRUSADE <40), and AAS was administered to 68 of them, Clopidogrel to 43, Ticagrelor to 17 and Prasugrel to 2. Thrombotic risk (TIMI) in NSTEMI was high in 9 patients (8.6%), intermediate in 32 (30.5%) and low in 41 (39%), prescribing ASA to 7 high-risk patients, 22 of medium risk and 34 of low risk; Clopidogrel was provided to 5, 14 and 34 respectively, Ticagrelor to 2, 6 and 6 respectively and Prasugrel wasn´t provided to any NSTEMI.
CONCLUSIONS: Non invasive therapy is the treatment most often used in ACS and ASA is the antiplatelet most used. Clopidogrel is the association with ASA most frequent, followed by Ticagrelor (that it is the only alternative to Clopidogrel in patients with NSTEMI with medical treatment). Most of the ACS admitted in our Emergency Department are NSTEMI. The use of Ticagrelor is used less than Guidelines recommendations in patients with intermediate or high risk of thrombosis, and its use in patients with low risk is still higher, against current recommendations. It would be recommendable to apply strictly the scales of risk to the correct choice of antiplatelet therapy in ACS. Patients with high risk of bleeding are a minority, and the use of Ticagrelor or Pasugrel in these patients is exceptional, in agreement with the current Guidelines.
Cristina Ana BAQUER SAHUN (Castejon del Puente, SPAIN), Daniel SAENZ ABAD, Marta BASTAROS BRETOS, Carmen LAHOZA PEREZ, Maria MARTINEZ DIEZ, Marta JORDAN DOMINGO, Raquel MONTOYA SAENZ, Eduardo ESTEBAN ZUBERO, Beatriz SIERRA BERGUA, Miguel RIVAS JIMENEZ
11:10 - 12:40 #1844 - #1844 - Does Coronary CTA Increase the Downstream Testing and Cost of Acute Chest Pain Workup? A Single Center Randomized Prospective Study.
#1844 - Does Coronary CTA Increase the Downstream Testing and Cost of Acute Chest Pain Workup? A Single Center Randomized Prospective Study.
Does Coronary CTA Increase the Downstream Testing and Cost of Acute Chest Pain Workup? A Single Center Randomized Prospective Study.
Ahmad Nama, Ronen Durst, Ayelet Shauer, Aluma Weiss, Dorith Shaham, Yelena Milovanov, Israel Gotsman, Yaakov Asaf, Darawshe Aziz
Heart Institute, Radiology Department and Emergency Medicine Department
Hadassah University Hospital
Jerusalem, Israel
Background:
Coronary CTA has high negative predictive value in ruling out ACS and shortens the duration of hospital admission in patients with acute chest pain. However, it is thought to increase the downstream testing and cost of chest pain workup. To evaluate this we compared the number of catheterizations, duration of hospitalization and the cost of downstream evaluation between patients who performed CTA as the first test and patients who underwent stress tests (GXT) in our chest pain unit.
Methods and results:
82 patients admitted with acute chest pain and low- intermediate probability for ACS were randomized to coronary CTA versus GXT. Patients were treated according to the results of the test. Follow up was continued up to six months. The primary endpoint was the number and cost of downstream diagnostic tests at three and six months after discharge. Secondary endpoints were number of coronary interventions and duration of hospitalization. Costs of exams were calculated according to the official ministry of health tariff.
Mean duration of hospitalization was 2.1±1.3 in the CTA arm and 2.2 ±1.7 in the GXT arm (p=0.87). At three months mean number of ambulatory tests per patient was 0.24±0.62 in the CT arm and 0.43±0.71 in the GXT arm (p= 0.21), and at six months it was 0.22±0.42 and 0.57±0.82 (p= 0.05) accordingly. The cost of these exams ( NIS ) was 332±1,044 in the CT arm versus 708±1,532 in the GXT arm (p=0.2) and at six months 239±755 versus 580±1,201 (p=0.2) accordingly. 6 patients in the CTA arm underwent invasive coronary angiography, of which four had coronary interventions, while 4 patients in the GXT group had invasive coronary angiography, and only one of them had a coronary intervention.
Conclusions: Evaluation of acute chest pain with coronary CTA does not prolong the duration of hospitalization, causes less downstream testing at six months after discharge, and was not found to be more expensive than evaluation with GXT.
Ahmad NAMA (Jerusalem, ISRAEL)
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Meet the Experts
European Education: Trainers Forum
Moderators: M Ashraf BUTT (CAVAN, IRELAND), Cornelia HARTEL (Consultant in Emergency Medicine/ Director of Medical Education in Emergency Medicine) (Stockholm, SWEDEN)
11:10 - 11:40 How to train. Anna SPITERI (Consultant) (Malta, MALTA)
11:40 - 12:10 Demo: what is a viva? Inger SONDERGAARD (PHYSICIAN) (ALLEROED, DENMARK)
12:10 - 12:30 Demo: what is an OSCE? Nikolas SBYRAKIS (GREECE)
12:30 - 12:40 Close and comments from panel.
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State of the Art
Pain Management & Sedation
Moderators: Sabine LEMOYNE (Senior Staff Member) (Edegem, BELGIUM), Alastair MEYER (Melbourne, AUSTRALIA)
14:10 - 14:40 Paediatric analgesia and sedation: Top tips to change your practice. Natalie MAY (Oxford, UK)
14:40 - 15:10 Acute pain management: How to get it right. Jim DUCHARME (Mississauga, CANADA)
15:10 - 15:40 Pre-hospital pain management. Sean MOORE (CANADA)
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Hot off the press
Moderators: Polat DURUKAN (TURKEY), Colin GRAHAM (Hong Kong, HONG KONG)
14:10 - 14:40 ProMISe (Protocolised Management In Sepsis). Paul MOUNCEY (UK)
14:40 - 15:10 Improving the Emergency Treatment of Supraventricular Tachycardia: The REVERT Trial. Andrew APPELBOAM (Exeter, UK)
15:10 - 15:40 Triage Rule-out Using high-Sensitivity Troponin (TRUST). Edd CARLTON (UK)
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State of the Art
Psychological Emergencies
Moderators: Serra PITTS (UK), Anna SPITERI (Consultant) (Malta, MALTA)
14:10 - 14:40 Screening and intervention for intimate partner violence. Karin RHODES (USA)
14:40 - 15:10 Identifying hidden vulnerabilities in emergency patients. Mary DAWOOD (UK)
15:10 - 15:40 Considering the transgender patient. Melanie STANDER (SOUTH AFRICA)
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EuSEM meets
SAEM
Moderators: Abdelouahab BELLOU (BOSTON, USA), Ali RAJA (USA)
14:10 - 14:30 Society of Academic Emergency Medicine: Past, present, future. Deborah DIERKS (USA)
14:30 - 14:50 European Society for Emergency Medicine: Past, present, and future. Luis GARCIA-CASTRILLO (Espagne, SPAIN)
14:50 - 15:10 Academic EM: Why is it important for the development of Emergency Medicine Specialty? Richard WOLFE (USA)
15:10 - 15:30 Implementation of a Strategy for Research Excellence in Emergency Medicine. Ali RAJA (USA)
15:30 - 15:40 Panel discussion. Roberta PETRINO (Head of department) (Italie, ITALY), Andra BLOMKALNS (USA)
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Resuscitation
Moderators: Eric REVUE (Head of the ED and prehospital EMS) (Paris, FRANCE), Markus SKRIFVARS (FINLAND)
14:10 - 14:40 Resuscitation research 2015, tops and flops. Markus SKRIFVARS (FINLAND)
14:40 - 15:10 Multicenter Resuscitation Studies: From Concept to Implementation. Graham NICHOL (USA)
15:10 - 15:40 Cerebral Resuscitation - Brain cells, Kids and Health Politics. Bernd BOETTIGER (GERMANY)
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YEMD
Junior Abstracts session
Moderators: Ibrahim ARZIMAN (EMERGENCY MEDICINE SPECIALIST) (ANKARA, TURKEY), Pieter Jan VAN ASBROECK (Consultant in Emergency Medicine) (Hasselt, BELGIUM)
14:10 - 15:40 EYSA Congress Abstracts (Regular Session).
14:10 - 14:40 EYSA Abstracts with critical appraisal. Blair GRAHAM (Research Fellow) (Plymouth, UK), Sabina ZADEL (SLOVENIA)
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EuSEM Nursing Track
Trends in Emergency Nursing
Moderators: Frans DE VOEGHT (THE NETHERLANDS), Gudbörg PÁLSDOTTIR (ICELAND)
14:10 - 14:40 Echography by nurses in ED. Yves MAULE (MANAGER DE SOINS) (LIEGE, BELGIUM)
14:40 - 15:10 The role of a clinical pharmacist on the ED as benefit to the ER nurses. Matthias GIJSEN (BELGIUM)
15:10 - 15:40 Emergency nurses and their impact on trauma team-approach. Rolf EGBERINK (researcher / PhD student) (Enschede, THE NETHERLANDS)
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Oral Paper 1
Trauma II
Moderators: M Ashraf BUTT (CAVAN, IRELAND), Timothy Hudson RAINER (UK)
14:10 - 15:40 #1110 - #1110 - Tiered trauma team activation effective in a Dutch level 1 trauma centre.
#1110 - Tiered trauma team activation effective in a Dutch level 1 trauma centre.
Background: Tiered trauma team response may contribute to efficient in-hospital trauma triage by reducing the amount of resources required and by improving patient outcomes. Therefore, in April 2009 a two-tiered trauma team activation (TTA) protocol was implemented in an emergency department (ED) of a level 1 trauma centre in the Netherlands. It is not clear what the effects of the two-tiered TTA protocol are over a longer period of time.
Objective: The aim of this study was to analyse effects of a two-tiered TTA protocol by comparing hospital mortality, LOS in the ED, LOS in the hospital and number of trauma team member activations, before and after its implementation in April 2009.
Methods: A pre-post analysis was conducted using trauma registry data and medical records over a five year period. The ED of the non-academic hospital serves as a supraregional level 1 trauma centre for an area with approximately 1,000,000 inhabitants in the Eastern part of the Netherlands and the German border region. Annually about 27,000 patients visit the ED and more than 300 times a trauma team is activated. Before April 2009 a trauma team consisted of 10 members, after implementation the modified trauma team consisted of five members and the full trauma team of 10 to 12 members. All trauma patients treated in the ED between January 1st 2008 till December 31st 2012, who were admitted to the hospital, transported to another hospital or died in the ED, were included.
Results: In total 6,641 patients were identified in the trauma registry, of which 1,403 before implementation and 5,238 after implementation. Mean age was lower in the after-group (51.0 years; SD 26.4) compared to the before-group (53.4 years; SD 26.4) (p<0.01). The mean Injury Severity Score (ISS) was higher in the after-group; before 7.9 (SD 6.5) versus after 8.2 (SD 8.1), p<0.1. The overall mortality rate was lower in the after-group (4.9% versus 3.6%; p<0.05) and the median LOS in the hospital was also lower in the after-group (6 days versus 4 days; p<0.01). The median LOS in the ED was similar before and after implementation (149 min before-group versus 151 min after-group). In the 45 month after-period the mean number of team activations per month was 8.3 (modified team) and 14.7 (full trauma team), resulting in a mean number of team member activations per month of 41.7 (modified team), and 147.3 (full trauma team, 10 members) to 176.8 (full trauma team, 12 members) respectively. The mean number of team member activations per month saved is 12.2 to 41.7, compared to when for all team activations (n=1038) a trauma team of 10 members was activated (mean number of member activations 230.6 per month).
Discussion: After implementation of a two-tiered TTA protocol the number of trauma team members activated is lower than before April 2009, despite an increasing number of trauma patients and trauma team activations. No signs of adverse outcomes for patients were identified.
Rolf EGBERINK (Enschede, THE NETHERLANDS), Lianne BOSHUIZEN, Maarten IJZERMAN, Arie VAN VUGT, Carine DOGGEN
14:10 - 15:40 #1077 - #1077 - A simple, quick and atraumatic method: prospective study of the ARC technique in cases of anterior shoulder dislocation.
#1077 - A simple, quick and atraumatic method: prospective study of the ARC technique in cases of anterior shoulder dislocation.
Introduction: Anterior shoulder dislocation is a frequent cause of consultation in an emergency room (ER). Many reduction methods have variable results with potential risk of secondary complications. The ARC technique, discovered in 2005, seems to be simple, quick and atraumatic.
Objective: Based on video recordings, we aimed to validate the five dynamic criterias (abduction, adduction, elevation, scapula control and medial rotation) showing the reduction movement (CriRed) by measuring the relationship between the quality of their realization and the clinical success of dislocation reduction.
Method: This was a monocentric and prospective study. Inclusion criteria were all patients arriving at the emergency room (ER) and suffering from a recent anterior shoulder dislocation without any fracture. The shoulder reduction process was recorded by video. Then, this video was shown independently to two physicians who were blinded from one another and who did not have a relationship with the ER. They had to judge if the 5 CriRed were correctly applied. The video did not show them if the technique was successful or not.
We studied variables such as the number and quality of the CriRed, complications (osseous, vascular and nervous) observed after the reduction and clinical success of reduction. A patient was classified as “a success for the study” if in the same time the CriRed were judged to be well done and if the reduction was clinically successful at the ER. We used a Fischer test, with a significant p-value of < 0.05. The accordance between the 2 physicians was measured by the Kappa coefficient (k).
Results: From December 2013 to June 2014, 16 patients were included, with a median age of 48 [22- 66], 10 (62%) were male. Reduction success rate was 69%. No secondary complications were found. A total of 38 manipulations were recorded. The accordance between the two physicians was high (k=0.66). When the technique was perfectly applied (5 CriRed judged to be done well), reduction success rate was 89% (n=8/9; p<0.05) but decreased to 20% when CriRed was incomplete (n=6/29; p<0.05). The CriRed “adduction” was present in 90% of successful reductions. The CriRed “scapula control” was missing in 66% of failure reductions. Study limits include repetition bias (several manipulations were sometimes necessary).
Discussion: When properly applied (5 CriRed), ARC technique was highly successful and didn’t have secondary complications. Mistakes discovered on videos were useful for physicians to improve their technique of shoulder dislocation reduction. Results have to be confirmed by a larger study so that the use of the ARC technique can be more widely spread.
Mathieu BEIS, Valéry COLIN, Benoit FRATTINI, Marilyn FRANCHIN, Xavier DELANNOY, Julien DUBOIS-POT, Laurence SZTULMAN (PARIS), Sabine LEMOINE, Daniel BAUGNON, Maurice RAPHAEL, Jean-Pierre TOURTIER
14:10 - 15:40 #1286 - #1286 - The use of tranexamic acid in paediatric major trauma.
#1286 - The use of tranexamic acid in paediatric major trauma.
Introduction: Tranexamic acid (TXA) is an anti-fibrinolytic compound that inhibits activation of plasminogen. It is used in the management of patients presenting with severe bleeding after trauma. The research in support of this intervention was based on multi-centre data for over 20,000 adult patients which found that all-cause mortality was reduced, but this was based on a purely adult population. (1) This outcome has been extrapolated for application to the paediatric population based on data of the use of TXA in paediatric cardiac and orthopaedic surgery. A RCPCH (Royal College of Paediatric and Child Health) position statement in November 2012(2) recommended 15mg/kg loading dose, then 2mg/kg/hr. They strongly urged further research to be conducted in this area. A recent publication of a study 4327 paediatric trauma patients from a US military hospital had 59 patients who were given TXA and there was a trend towards reduced mortality of these patients (8.5% vs 18.3% p=0.055).(3)
Methods: We conducted a retrospective review of all paediatric data (age 16 or less) entered into the UK Joint theatre trauma registry from 2006 – 2013. This is a register of all patients treated at the deployed UK military hospitals in Afghanistan or Iraq. Mortality was compared between those who received TXA and those who did not. Sub-group analysis was performed on those with ISS>15.
Results: 535 patients met the inclusion criteria of being under age 16 and treated for trauma. The study group had a mean age of 9.2 (SD of 4.1), and 76% were male. Mechanism of injury was mostly by an explosion (58%, 309/535) or by gunshot wounds (27%, 124/535). Other mechanisms included blunt trauma from a fall, crush or MVC (9% 49/535),burns (8% 44/535) or rarely from drowning (0.1% 6/535). Of the entire study group 65 received TXA, and 22% (14/65) of those died. This mortality rate is higher than the non-treatment group where 18% (86/470) died. However, the injury severity score was much higher in the TXA treated group with 79% (48/65) having an ISS >15, versus only 43% (204/470) in the no TXA group. Looking at this subgroup of sicker patients with an ISS >15 (and therefore suffering from major trauma) they had an increased chance of survival if given TXA; 73% (35/48) vs 62% (127/204) (p=0.18)
Conclusion: In paediatric patients who present with severe trauma there is a tendency to an increased survival if given TXA.
- MRC CRASH-2 Trial Collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010 376: 23-32
- RCPCH evidence statement. Major trauma and the use of tranexamic acid in children. November 2012
- Borgman M, Spinella P, Pidcoke H, Cap A, Cannon J. 1029: Tranexamic acid for pediatric trauma. Critical Care Medicine. 2014;42(12):A1607-A8 10.097/01.ccm.0000458526.76358.a9.
Charlotte BROWN (london, UK), Savithiri RATNAPALAN
14:10 - 15:40 #1332 - #1332 - Predictors of injury after a fall downstairs.
#1332 - Predictors of injury after a fall downstairs.
Introduction
Falling downstairs as a criteria for major trauma activation is often overlooked. Compared with other high risk mechanisms, it is often regarded as less significant. Previous studies showed alcohol, male gender and advancing age increase the risk of falling downstairs and subsequent injury.
Method
The aim of this study is to examine the fall downstairs as a mechanism of injury in an adult population and identify the risk factors and how they affect the pattern of injury.
The study was retrospective and comprised all trauma patients who initiated a Trauma Team activation in the emergency department (ED) at Aintree University Hospital, a joint partner in the Major Trauma Centre (MTC) collaborative for Cheshire and Merseyside. The data was collected from July 2012 and March 2015, and obtained from the ED Trauma Audit and Research Network (TARN) records.
The outcome measures the presence of injury and body regions injured. The study used descriptive statistics and logistic regression to analyse the data.
Results
An overall of 2205 trauma patients triggered a trauma team activation. In total 487 (22%) patients presented after a fall downstairs. The mean age was 60 years (standard deviation 18.8). There were 257 (53%) male and 230 (47%) female patients.
Alcohol consumption was suspected in 196 (40%) patients. Median age was 69 years in the sober group (IQR 50.5 – 81) and 53 years (IQR 43-63) in the group where alcohol consumption was suspected.
301 (61%) patients sustained an injury with of 147 (49%) injured patients sustaining a head injury. Chest (42.5%), cervical spine fractures (21.6%) and thoracic/lumbar spine fractures (19.6%) were the other significant injuries sustained respectively.
Using logistic regression age, male gender and alcohol were all found to be significant predictors (p<0.05) of injury. Age was found to be a significant (p<0.05) predictor of all four injuries. Male gender was a significant predictor (p<0.05) of chest injuries with an odds ratio of 2.11. Alcohol was a significant predictor of head injury with an odds ratio of 3.31.
Discussion
The study identifies two clear cohort of patients who fall downstairs: a younger and intoxicated cohort of patients and an older non-intoxicated cohort of patients.
Age, male gender and alcohol intoxication were all significant predictors or injury. Age was a predictor of all injuries which is likely due to frailty. Intoxication is a significant predictor of head injury possibly due to the reduced GCS prior to fall whilst the risk of chest injury is twice as high in men compared to women.
Conclusion
This study reinforces the need to be suspicious of head injuries in the intoxicated patients and have a lower threshold for imaging in the elderly patient.
Hridesh CHATHA, Abdo SATTOUT (Liverpool, UK), Nina MARYANJI, Michael HICKEY
14:10 - 15:40 #1335 - #1335 - Risk of delayed traumatic intracranial hemorrhage in anticoagulated patients with minor blunt head trauma : A systematic review and meta-analysis.
#1335 - Risk of delayed traumatic intracranial hemorrhage in anticoagulated patients with minor blunt head trauma : A systematic review and meta-analysis.
Background
Anticoagulated patients are exposed to an increased risk of bleeding after head trauma. Some guidelines sugest that all patients with coagulopathy should routinely undergo strict observation during the first 24 hours after injury and should have a control computed tomography (CT) before discharge. Controversy exists regarding the cost-utility of this strategy and no meta-analysis has ever been published on this topic.
Objectives:
The aim of this study was to aproximate the 24 hours risk of delayed intracranial hemorrhage in anticoagulated patients with minor head injury and a normal initial CT.
Method
We conducted a systematic review and meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. EMBASE, Medline, and Cochrane Library were searched using controlled vocabulary and keywords. Search terms were as follows: ((((hemorrhage[MeSH Terms] OR intracranial hemorrhage[MeSH Terms] OR brain hemorrhage[MeSH Terms] OR delayed bleeding[Title/Abstract] OR delayed hemorrha*[Title/Abstract]))) AND ((tbi[Title/Abstract] OR traumatic brain injury[Title/Abstract] OR craniocerebral trauma[MeSH Terms] OR brain injury, chronic[MeSH Terms] OR brain injuries[MeSH Terms]))) AND ((coumarins[MeSH Terms] OR warfarin[MeSH Terms] OR anticoagulants[MeSH Terms])) without langage or date limitations. Data were collected by 2 independent reviewers and aggreement was obtain by consensus. The proportion of patients with delayed bleeding over the total number of patients with repeat CT was used to conduct a single arm meta-analysis. We used logit proportion transformation to estimate the pooled risk to present delayed bleeding. The pooled proportion was calculated as a back-transformation of the weighted mean of the transformed proportions, using a random-effects model. Heterogeneity was tested with the I2 test. Results are presented with 95% confidence interval.
Results
The search yielded 892 citations of which 89 full-texts were reviewed with 5 studies meeting the final criteria, for a total of 1556 patients. The overall estimated risk of delayed bleeding was 1.3% (95%CI 0.5 to 3.2). Heterogenity was high with an I2 test at 70% (p = 0.009).
Conclusions
To our knowledge, this is the first meta-analysis assessing the risk of delayed bleeding in anticoagulated patients with head trauma. This risk is relatively low and this knowledge will help physicians to make enlighted decisions and avoid unnecessary second scan.
Jean-Marc CHAUNY (Kirkland, CANADA), Martin MARQUIS, Raoul DAOUST
14:10 - 15:40 #1480 - #1480 - Prognostic value of initial arterial lactate level versus lactate clearance in trauma patients.
#1480 - Prognostic value of initial arterial lactate level versus lactate clearance in trauma patients.
Introduction:
Blood lactate has been recognized as a prognostic biomarker in acute pathology. Several studies proposed the clearence of lactate rather than its initial value for predicting mortality (1) . The aim of this study was to assess the prognostic value of the initial blood lactate versus its clearance after 2 hours admission of trauma patients in the emergency department (ED).
Methods:
This was a prospective study over 14 months. Inclusion criteria were: severe trauma patients over 18 years admitted to the ED. Measurements of the initial value of arterial bood lactate (Lact1) and at 2 hours after admission (Lact2). Clearance of lactate (Lactclear) was defined by ((Lact1-Lact2/ Lact1)x100).The primary outcome was the mortality at day seven. Non parametric tests were used for statistical comparison between Lact1 and Lactclear in survivors and non survivors.
Results :
A total of 190 patients were enrolled. Age = 41 +/- 19 years. Sex-Ratio= 4. Injury Severity Score (ISS) = 21 +/- 12. ISS >= 16 were found in 64% of patients. Sixty-two per cent of patients have an initial lactate > 2 mmol/l. Measurment of Lact2 was obtained in 115 patients. Median LactClear was 28% ( range from -212% to 85% ). Evolution parameters n(%) : Intubation :63(33); Surgery 138(73); mortality at day seven: 50 (26).The initial lactate level was significantly higher in non survivors versus survivors ( median, range) : (2,9 mmol/l (range from 0,9 to 10,9) versus 2,1 mmol/l (range from 0,4 to 8,8); p<0,001). However no significant difference was found in lactate clearance between survivors and no survivors. Cut-off of initial lactate value was 2,8mmol/l; p<0,001.Odds ratios were respectively : in univariate analysis( RR 3,88 CI 95% 1,97 to 7,63 )and multivariate analysis ( RR 1,97 CI 95% 1,4 to 2,7).
Conclusion:
In this cohort, initial value of arterial lactate in trauma patients admitted to the emergency ward was a higher prognostic marker than lactate clearance at Hour 2 after admission in terms of mortality at day-seven.
(1) : Zhang Z and Xu X . ccmjournal 2014 ; 42 : 9
Rym HAMED (Tunis, TUNISIA), Khaled SAIDI, Sarra JOUINI, Imen BOUKHALFA, Hana HEDHLI, Dorra CHTOUROU, Fatma AJLANI, Béchir BOUHAJJA
14:10 - 15:40 #1725 - #1725 - Randomized comparison of tape versus semi-rigid and versus lace-up ankle support in the treatment of acute lateral ankle ligament injury.
#1725 - Randomized comparison of tape versus semi-rigid and versus lace-up ankle support in the treatment of acute lateral ankle ligament injury.
Abstract
Background: Functional treatment is the optimal non-surgical treatment for acute lateral ankle ligament injury in favour of immobilization treatment. According to the Cochrane Systematic Review concerning different functional treatment options (tape, semi-rigid brace, lace-up brace) for acute lateral ankle ligament injuries ‘there is no most effective treatment neither clinically nor costs based on currently available randomised trials’.The objective of this study is to compare these three different functional treatments for acute lateral ankle ligament injuries with regard to clinical outcome.
Methods: This study is designed as a randomized controlled trial to evaluate the difference in functional outcome after treatment with tape versus semi-rigid versus lace-up ankle support (brace) for grade II and III acute lateral ankle ligament injuries.
Results: One hundred and ninety-three patients (52% males) were randomised, 70 patients were treated with a tape, 60 patients with a semi rigid brace and 63 patients with a lace-up brace. There were no significant differences in any baseline characteristic between the 3 groups. Mean age of the patients was 37.3 years (35.1 – 39.5; SD 15.3). In 48 % of patients the right side was injured. Fifty-one percent of the patient had a Tegner score of 1, 24 % had a score of 2, and 25% had a higher Tegner score.
One hundred sixty-one (59 + 50 + 52) patients completed the study until final follow-up; 32% lost to follow-up. In 2 patients treated with tape support the treatment was changed to a semi rigid brace because of skin blisters. Except for the difference in Foot and Ankle Outcome Score sport between the Lace-up and the semi rigid brace, there are no differences in any of the outcome measures after 6 months follow-up.
Discussion: The most important finding of current study was that there is no difference in outcome 6 months after treatment with a tape, semi rigid brace and a lace up brace. In all treatment groups patients had better functional results (Karlsson and FAOS) at follow-up compared to baseline.
M.p.j. VAN DE BEKEROM, R.j.l.l. VAN DE KIMMENADE, I.n. SIEREVELT, K.m. EGGINK (Nijmegen, THE NETHERLANDS), G.m.m.j. KERKHOFFS, C.n. VAN DIJK, E.e.j. RAVEN
14:10 - 15:40 #1828 - #1828 - Predicting Probability of Return to Work at One Year after Moderate and Major Trauma in Hong Kong: a prospective, multicentre, cohort study.
#1828 - Predicting Probability of Return to Work at One Year after Moderate and Major Trauma in Hong Kong: a prospective, multicentre, cohort study.
Background and Objectives
There is very little published data on post-trauma return to work (RTW) in the developed world, including Hong Kong. The aim of this study was to provide preliminary data for patients in Hong Kong with moderate and major trauma on RTW status.
Methods
From 1st January 2010 to 31st December 2011, a multi-centre prospective cohort study of trauma patients was conducted in Hong Kong. Patients admitted to the Prince of Wales Hospital (PWH), Queen Elizabeth Hospital (QEH) and Tuen Mun Hospital (TMH) were recruited, and followed up for 12 months. Adult patients aged ≥18 years with moderate or major trauma (defined as an injury severity score, ISS >8) who were entered into the trauma registry were included. The primary outcome was RTW at 12-month post injury. After univariate analysis, variables with p<0.2 were entered into a multiple logistic regression model, with insignificant variables removed by the backward stepwise elimination until only significant variables remained.
Results
Of the 400 patients recruited to the study (mean age 53.3 years; range 18-106; 69.5% male), the successful follow up rates at 1, 6- and 12-months was 81.3%, 61.3% and 44.0%. In patients who were employed before injury, RTW was lowest (20.9%) at 1-month and gradually increased to 37.5% at 12-months.
A univariate analysis showed that RTW was significantly associated with age
Discussion
The 12-month post-trauma RTW rate for patients who survive the initial insult and have an ISS> 8 was <40%. Younger age, no abdominal injury, higher one-month PCS and one- month MCS scores predicted RTW within 12-months.
Word count 336
Acknowledgement
This study was supported by Health and Health Services Research Grant 07080261 and Health and Medical Research Fund Grant 10110251.
Colin GRAHAM (Hong Kong, HONG KONG), Cw LAM, Kh CHEUNG , Hh YEUNG, Kk YUEN, Ws POON, Hf HO, Cw KAM, Timothy RAINER
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Oral Paper 2
Management / ED Organisation II
Moderators: Lars Petter BJORNSEN (Emergency Physician) (Trondheim, NORWAY), Juliusz JAKUBASZKO (POLAND)
14:10 - 15:40 #1319 - #1319 - Economic evaluation of management of acute dyspneas in the emergency department using lung ultrasound and natriuretic peptides.
#1319 - Economic evaluation of management of acute dyspneas in the emergency department using lung ultrasound and natriuretic peptides.
Background
Acute dyspnea is a diagnostic challenge for emergency physicians. The discrimination between cardiac and non-cardiac causes is key for improving patients’ management in the Emergency Department (ED). Lung ultrasound (LUS) has emerged as a non-invasive valuable tool in this scenario. We have recently shown in a multicenter study that the implementation of LUS with clinical evaluation (“iLUS” approach) may improve acute dyspnea diagnosis accuracy in the ED (Chest, 2015). Natriuretic peptide (i.e. NT-proBNP/BNP) dosage is still indicated for ruling out decompensated heart failure diagnosis among dyspneic patiens, also with a large grey zone.
Objective
Aim of this study was to compare costs of management of acute dyspnea in the ED using LUS versus natriuretic peptides dosage in order to differentiate acute decompensated heart failure from other causes of acute dyspenea.
Patients and Methods
We designed a multicenter prospective observational study in seven Italian EDs, between November 2010 and October 2012. Patients presenting to the ED with acute dyspnea as the main complaint were eligible. LUS was mandatory for all enrolled patients but NT-proBNP/BNP dosage was not. The study protocol was approved by the Ethical Commitees of the involved centers. After clinical evaluation, all patients underwent a LUS scan. Then clinical and iLUS diagnosis were recorded. For this study, we analyzed all natriuretic peptides results available. Costs were calculated based on those provided at AOU Città della Salute e della Scienza di Torino (coordinator center of the study).
Costs for LUS were i) purchase a three probes portable ultrasound machine, ii) 10 years amortization, iii) maintenance (6% of original prize), iv) training of operators, and v) execution time. NT-proBNP/BNP costs were i) loan of instruments for dosage, and ii) working time of laboratory crew.
Net reclassification improvement (NRI) is a recently proposed (Statist. Med. 2008) statistical tool for evaluating the usefulness of a new diagnostic tool.
Results
Nt-proBNP/BNP dosage was available for a subcohort of 486 patients.
NRI for iLUS was 20.6 (CI 95% 14.3-27.2), for LUS alone 6.5 (CI 95% 0-14.8), and null for natriuretic peptides dosage.
NT-proBNP/BNP dosage was totally valued at about 50 euros/test.
We evaluated LUS training using cost of participation to a Winfocus-Simeu (Italian National Society of Emergency Medicine) course in emergency ultrasound, and we based estimation of execution time for each LUS evaluation on table of charges of Ethical Committee of AOU Città della Salute e della Scienza di Torino (20 minutes of a staff physician’s work value 20 euros). Patients with natriuretic peptide dosage available were enrolled by 14 emergency physicians with a median execution time for LUS of about 5 minutes. Total cost for LUS approach was 31.5 euros/test (reduced to 21.5 euros after implementation of process).
Conclusions
Our study shows LUS approaches, both alone and iLUS, has a higher NRI and lower costs than natriuretic peptides in differentiating acute dyspnea in the ED, with a progressive reduction of costs for LUS approach after starting training programme.
Emanuele PIVETTA (Torino, ITALY), Alberto GOFFI, Eva PAGANO, Giulio MENGOZZI, Giana CIBINEL, Enrico LUPIA
14:10 - 15:40 #1700 - #1700 - Which shift characteristics affect handover duration and rates? A prospective multicentric study.
#1700 - Which shift characteristics affect handover duration and rates? A prospective multicentric study.
Introduction: Handover is a poorly examined transaction in ED’s especially among physicians and is an area deserving further research.
Aim: to analyze independent factors effecting handover duration in ED. Secondary aim was to identify factors affecting the ED handover rates.
Methods
A prospective, cross-sectional, observational and descriptive study at seven ED’s of urban tertiary referral teaching hospitals.
Results
A total of 267 handover sessions (44.6% conducted in off-hour time period) were included with a mean duration of 22.3 min (range 1-80 min). Handover duration per patient was 3.5±1.7 (3.3-3.7). The numbers of shifts examined were 267 with a median duration of 15 hours (8-24 h). Verbal violence and technical failures occurred in 16.9% and 13.1% of the shifts, respectively.
Multivariate logistic regression analysis showed that rate of biochemical analysis per patient (OR: 1.069, 95%CI:1.013-1.128), rate of imaging studies per patient (OR: 0.880, 95%CI: 0.798-0.970), rate of handover per shifts (OR: 0,387, 95%CI: 0,191-0,781), handover duration/Number of handovered patients(OR: 0.260, 95%CI: 0.099-0.684), rate of consultation per patient(OR: 1.380, 95%CI:1.070-1.780) were independent parameters effecting handover duration.
Multivariate logistic regression analysis showed that Shift duration (OR:1.352, 95%CI:1.178-1.551), Rate of hospitalizations per patient (OR:0.799, 95%CI:0.674-0.946), Rate of Biochemical Analysis per patient(OR:1.059, 95%CI:1.030-1.089), Rate of imaging Studies per patient(OR:0.945, 95%CI:0.912-0.978), Rate of microbiological tests per patient(OR:1.095, 95%CI:1.022-1.173), Mean number of physicians per shift (OR:2.841, 95%CI:1.699-4.750), Handoverduration/numberofhandover (OR:2.004, 95%CI:1.393-2.882) were independent parameters effecting handover duration.
The AUC for the shift duration cut-off value of 8.5 was 0.796 (0.744-0.849). The sensitivity, specificity, +LR, and -LR detected for the shift duration cut-off value of 8.5 were 97.8%, 22.6%, 1.26, and 0.98, respectively.
Conclusion: Handover duration and rate are independently effected by certain shift characteristics. Shortening shift duration may lower handover rates.
Atıf BAYRAMOGLU (Erzurum, TURKEY), Necati SALMAN, Celik GULHAN KURTOGLU, Ayhan SARITAS, Onur KARAKAYALI, Ozlem BILIR, Ayhan AKOZ, Ali KARAKUS, Eroglu MURAT, Mucahit EMET
14:10 - 15:40 #1782 - #1782 - To which extent is GP referral to the Emergency Department appropriate?
#1782 - To which extent is GP referral to the Emergency Department appropriate?
Objective In context of the increasing problem of ED overcrowding, most research on (in)appropriateness of ED use has focused on patient’s perceptions and motivation for choosing the ED for non-urgent medical problems. In contrast to patient-self referral, general practitioners (GPs) have the ability to make appropriate referrals which might be helpful in reducing ED-crowding by patients who could be helped more efficiently elsewhere. There is however only limited research on whether or not these referrals are always justified. This study aims to investigate in a prospective way to which extent ED referrals by GPs are appropriate, based on patient’s initial clinical presentation and GP’s differential diagnosis.
Methods An observational prospective study was performed at the ED of the University Hospitals Leuven. Referral letters (n=187) were analyzed on major motives of referral and allocated to one or more of 15 categories. Consecutively, they were independently assessed twice on appropriateness of referral using a newly created operational definition. ED referrals were considered appropriate if GP’s differential diagnosis included one or more of following conditions requiring immediate diagnosis and treatment: respiratory distress, shock, acute chest pain, cardiovascular symptoms, severe abdominal pain, altered state of consciousness, acute neurological signs, acute hematologic disorders, sepsis, severe traumatic injuries, acute psychosis or suicidal ideation, and certain endocrine emergencies. Referrals were also coded as appropriate if the patient received an ESI code 1 or 2 at triage or if predictable need existed for interventions not available out-of-hospital.
Results Among 187 referrals, 73.8% was considered appropriate. Excellent inter-observer agreement was observed (kappa 95.8%), demonstrating that the operational definition is an effective tool to reliably assess referrals as appropriate or not. The 24.6% inappropriate referred patients presented more often with social or psychiatric difficulties, infectious or inflammatory problems, or ‘other’ complaints in comparison to the appropriate referred group.
Conclusions To our knowledge, there is no previous study assessing appropriateness of GP referrals in a prospective way, not taking results of technical examinations or discharge diagnosis into account. Results demonstrate that a substantial amount of GP referrals, nearly 1 out of 4, were considered inappropriate according to the predetermined criteria. This suggest that GPs might have different, more contextual than purely medical reasons for ED referral. These potential discrepancies in mutual expectations, attitudes and perceptions on appropriate ED use, might reflect a hiatus in the current health care system. Further research is needed to link inappropriate referrals to underlying motives of referring GPs. These findings could contribute in devising an improved health care organization model, in which each patient is referred to an appropriate place to receive the most suited treatment and care, based on a well understood principle of subsidiarity.
Heidi MICHIELSEN (Borsbeek, BELGIUM), Julie HULENS, Marc SABBE
14:10 - 15:40 #1908 - #1908 - Categorizing short term readmissions in an academic emergency department in north India: Exploring approaches to reduce them.
#1908 - Categorizing short term readmissions in an academic emergency department in north India: Exploring approaches to reduce them.
Objective: Categorizing short term readmissions in Emergency Department (ED) and exploring methods to reduce avoidable ED readmissions.
Introduction: Readmissions in the ED are multifaceted. A recent meta-analysis illustrated that less than a quarter of readmissions could be considered avoidable. Research till now, has focused on the predictive risk factors and the most common diagnosis of readmission. Less is known about its systemic causes. A study was undertaken to identify factors associated with this quality care indicator.
Method: Prospective observational data from electronic hospital and patient health records was collected from 1st September 2013 through 31st August 2014 at Max Superspecialty Hospital, Saket, New Delhi, India. The number of ED readmissions within 72 hours of index ED registrations were considered. Exclusive and hierarchical categorizations of these ED readmissions were done as: Avoidable readmissions- due to inadequate care or due to poorly managed transitions during discharge; Unavoidable readmissions- due to complications or due to recurrences; Unrelated readmissions (different body systems); Planned readmissions; Readmissions after LAMA (leave against medical advice). Statistical analysis was done using SPSS 16.0 and cross-tabulation technique applied on patient variables.
Results: A total of 19,205 ED registrations were recorded through the year. Of these, 473 patients (2.46%) got readmitted in the ED within 72 hours of their index ED registration. Rates of both, short term ED readmission and ED registration showed minimal month to month variability. The mean age of patients was 43 years, with minimal gender disparity. Males (253) outnumbered females (220) marginally. Of 473 short term ED readmissions, 181 (38%) were avoidable followed by 86 (18%) unrelated followed by 82 (18%) unavoidable followed by 76 (16%) readmissions after LAMA followed by 48 (10%) planned readmissions. In the avoidable readmission category, 66 (36%) readmissions were due to inadequate care while 115 (64%) due to poorly managed transitions during discharge from the ED. In the unavoidable readmission category, 44 (52%) readmissions were due to complications while 38 (48%) due to recurrences of signs and symptoms.
Conclusion: A readmission could be due to healthcare factors- hospital or primary care associated; or patient related- patient’s understanding of disease, management, compliance, adequate follow-up, social support; or disease associated- progression, exacerbations, recurrences, complications, co-morbidities; or a combination of all the above. Our analysis suggests that addressing the transit during discharges from ED, by bridging the gap and sustaining the quality of care from hospital to home, may promisingly improve patient outcome. Thus, interventions are targeted at three levels. Firstly, the pre-discharge interventions must include discharge planning, medication reconciliation and setting up a follow-up visit prior to departure from the ED. Secondly, the post-discharge interventions may include home care and ambulance services, assigning case or transition care managers who would educate the patient about the disease, its management, follow-up visits and answer all concerns. Thirdly, the administrative interventions may include ED readmission policy, readmission prevention checklist and automated marker in electronic hospital and health records which may expedite readmission identification, address its origin and help in reducing the avoidable ED readmissions.
Dolly YADAV, Dolly YADAV (Gurugram, INDIA), Prasad C S, Tamorish KOLE
14:10 - 15:40 #1916 - #1916 - Assessment of self-referred patients in an academic hospital in The Netherlands.
#1916 - Assessment of self-referred patients in an academic hospital in The Netherlands.
Background:
In western europe, the gp plays a significant role in providing after-hours care, with 77% of the GP s in italy, 89% in the UK, and 97% in the Netherlands providing after-hours arrangements. A substantial number of patients visit the emergency department (ED) without a referral by a general practitioner. Many of these self-referrals may lead to inefficient care. We examined ED use and assessed the characteristics of self-referrals and their need for hospital emergency care.
Objective:
To assess the appropriateness and characteristics of self-referrals to the ED of an acadamic hospital. And whether there is a difference compared to a community hospital.
Methods :
Observational study conducted at RadboudUMC Nijmegen an academic hospital and a level 1 traumacenter. Data were collected on all self-referred patients in august 2013 and 2014. The appropriateness of an ED visit was determined on; (1) urgency at entering the ED (triage), (2) diagnostic testing or treatment done and (3) final destination after ED visit.
Results:
A total of 3656 patients visited the ED during the inclusion period; 860 were self-referrals (23,5%) The majority of the self-referred patients were male ( %) and most self-referrals were under the age of 40. Our first results showed that 31,6% of the self-referrals presented themselves during office hours. Most patients (72,2%) were classified as non-urgent (triage >1 hour).
The majority (55,7%) required diagnostic testing such as: x-ray (38%), laboratory investigations (16%), ECG (9,2%), computed tomography (11,6%), sonography (3,1%).
Eventually 28,8% of patients were admitted to the hospital and 71,2% were discharged.
Conclusion:
Preliminary results showed that 27,8%-55.7% of self-referred patients were scored as appropriate ED visits, determined by the urgency and requirement for additional diagnostic testing. These results are comparable previous results from ED visits to a community hospital in the Netherlands.This study is a pilot and more patients are being included and an analyses making use of all determinates follows.
Stacey MANS ('s Hertogenbosch, THE NETHERLANDS), Evelien VAN EETEN
14:10 - 15:40 #1976 - #1976 - Patients who present at the emergency department with chest pain are less likely to be admitted to inpatient wards during hospital crowding - a registry study.
#1976 - Patients who present at the emergency department with chest pain are less likely to be admitted to inpatient wards during hospital crowding - a registry study.
Background
Lack of inpatient beds, or “hospital crowding”, is often discussed in the context of ED overcrowding. However, alternate strategies for care delivery in the ED, that take effect when no inpatient beds are available, have been less frequently studied. The aim of the present study is to investigate effects of hospital crowding on the management of patients who present in the ED with chest pain. Study outcomes are inpatient admission, the 72-hour revisit rate and the ED length of stay (EDLOS) for patients not admitted to a hospital ward (i.e. discharged from the ED). The exposure was hospital occupancy at the time of patient presentation in the ED.
Methods
The study was conducted as a registry study on ED admin data from a 420-bed emergency hospital in southern Sweden, during 2011-2013. The association between the exposure and the outcome was addressed in contingency tables (Fisher’s exact test) and by logistic regression models.
Results
12,223 cases were included in the study. Multivariate models revealed a negative association between hospital occupancy and the probability of inpatient admission (OR 0.87, 95% CI 0.79–0.95) at 105% occupancy compared to at 95%. ED length of stay (EDLOS) was longer in patients discharged from the ED at high hospital occupancy (>105%) than in patients discharged otherwise (<95%), 3.55 vs. 3.03 hours (p=.001, Kruskall-Wallis). Moreover, a lower 72-hour revisit rate was observed in patients discharged at times of high hospital occupancy.
Conclusions
Study results suggest that patients who present to the ED with chest pain are less likely to be admitted to inpatient wards at times of hospital crowding. The observed increase in EDLOS and decreased 72-hour revisit rate may reflect a mechanism by which patients are increasingly evaluated and treated in the ED when no inpatient beds are available. This may decrease resource expenditure in inpatient wards and strengthen the position of the ED within the hospital.
Mathias BLOM (Gallivare, SWEDEN), Kjell IVARSSON, Mona LANDIN-OLSSON
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Italy invites
Ricerca e progretti organizzativi
Moderators: Maria Antonietta BRESSAN (ITALY), Aldo PANEGROSSI (Rome, ITALY)
14:00 - 14:20 Sedazione procedurale: il registro nazionale SIMEU. Gian CIBINEL (Torino, ITALY), Fabio DE IACO (Chief) (Imperia, ITALY)
14:20 - 14:40 Il censimento nazionale italiano delle strutture di PS. Riccardo PINI (Director, E.D. High Dependency Unit) (Florence, ITALY), Annamaria FERRARI (Reggio Emilia, ITALY)
14:40 - 15:00 Il monitoraggio 2015 dei PS: la SIMEU insieme ai cittadini. Maria Pia RUGGIERI (Roma, ITALY)
15:00 - 15:20 Il controllo direzionale dell'attività in PS e la valutazione dell'affollamento: un sistema avanzato di supporto. Gian CIBINEL (Torino, ITALY)
15:20 - 15:40 Un assistente virtuale per codifica ICD9CM in Pronto Soccorso. Andrea FABBRI (Chief of Emergency Unit) (Forli, ITALY)
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State of the Art
Trauma
Moderators: Basar CANDER (TURKEY), Matthias MUENZBERG (GERMANY)
16:10 - 16:40 Tranexamic acid in trauma patients - how should we use it. Ian ROBERTS (UK)
16:40 - 17:10 CPR after traumatic cardiac arrest: a mission without a chance of success? Matthias MUENZBERG (GERMANY)
17:10 - 17:40 Obstetric Trauma. Gareth Richard DAVIES (Swansea, UK)
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Hot Topic
Eudcation
Moderators: Cristian BOERIU (Assoc.Professor) (Targu Mures, ROMANIA), M Ashraf BUTT (CAVAN, IRELAND)
16:10 - 16:40 Undergraduate education in Emergency Medicine. Cem OKTAY (FACULTY) (ANTALYA, TURKEY)
16:40 - 17:10 The European Trauma Course (ETC). Paola PERFETTI (Consultant in Emergency Medicine) (Verona, ITALY)
17:10 - 17:40 Innovations in Pediatric Emergency Medicine online training. Tom BEATTIE (UK)
17:40-18:40
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EuSEM Annual General Meeting
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Clinical Questions: Controversies
Pain Management & Sedation
Moderators: Jim DUCHARME (Mississauga, CANADA), Natalie MAY (Oxford, UK)
16:10 - 16:40 Why is managing pain so difficult? Jim DUCHARME (Mississauga, CANADA)
16:40 - 17:10 Pediatric procedural sedation: do you really need a needle? Fabio DE IACO (Chief) (Imperia, ITALY)
17:10 - 17:40 How should we manage opiate seeking behaviour in the Emergency Department? Sean MOORE (CANADA)
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Administration / Management
ED Design: Innovations
Moderator: Wilhelm BEHRINGER (Director) (Jena, GERMANY)
16:10 - 16:40 Organizational Design in Emergency Care / Align your Processes and Structrures to Patient's Demand. Johannes HOHENAUER (AUSTRIA)
16:40 - 17:10 How to design, plan, and build an Emergency Department. Albert WIMMER (AUSTRIA)
17:10 - 17:40 Differential privacy and confidentiality in EM. Tiziana MARGARIA STEFFEN (IRELAND)
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Research
Disaster Medicine
Moderators: Pinchas HALPERN (department chair) (Tel Aviv, ISRAEL), Pier Luigi INGRASSIA (Novara, ITALY)
16:10 - 16:40 Resilience in Italy. Massimo AZZARETTO (Associate Researcher) (Novara, ITALY)
16:40 - 17:10 The THREATS Project. Roberto FACCINCANI (ITALY)
17:10 - 17:40 Research in Disaster Medicine. Jean-Pierre TOURTIER (Médecin en chef) (Paris, FRANCE)
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YEMD
Start to research session
Moderators: Blair GRAHAM (Research Fellow) (Plymouth, UK), Colin GRAHAM (Hong Kong, HONG KONG)
16:10 - 16:55 Formulating a Research question: interactive workshop. Rick BODY (UK)
16:55 - 17:40 Navigating the path to publication. Colin GRAHAM (Hong Kong, HONG KONG)
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EuSEM Nursing Track
ED organization from a nursing point of view
Moderators: Luciano CLARIZIA (ITALY), Yves MAULE (MANAGER DE SOINS) (LIEGE, BELGIUM)
16:10 - 16:40 The briefing dilemma between pre-hospital and in-hospital. Remco EBBEN (Lecturer/researcher) (Nijmegen, THE NETHERLANDS)
16:40 - 17:10 Code white: The first assessment by emergency nurses. Doimo YLENIA (ITALY)
17:10 - 17:40 Nursing solutions in an overcrowded ED. Christien VAN DER LINDEN (THE NETHERLANDS)
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Oral Paper 1
Paediatric Emergencies III
Moderators: Santiago MINTEGUI (Barakaldo, SPAIN), Nikolas SBYRAKIS (GREECE)
16:10 - 17:40 #1309 - #1309 - The diagnostic process of children with afebrile and non-traumatic headaches in paediatric accident and emergency or clinical decision unit.
#1309 - The diagnostic process of children with afebrile and non-traumatic headaches in paediatric accident and emergency or clinical decision unit.
Introduction: Children presenting to Paediatric Accident and Emergency (A&E) or Clinical Decision Unit (CDU) for evaluation of afebrile and non-traumatic headaches are a very heterogeneous group with potentially multiple underlying causes. Their initial assessment is challenging for clinicians, as potentially life-threatening diagnoses must not be missed while unnecessary investigations should be avoided. A second challenge in the emergency department setting is the development of a robust follow-up plan to ensure continuing care.
Methods: We retrospectively audited case notes of 46 children between the ages of 4 and 16 years who presented to the children’s A&E or CDU at the John Radcliffe Hospital Oxford, UK between February and August 2014. The investigators analysed the diagnostic process and decision-making, the thoroughness of neurological examination, the indications for neuro-imaging and the use of headache diaries with eligible patients. This information was retrieved from the hand-written A&E and CDU case notes and the electronic patient records.
Results: Assessment and documentation of the level of consciousness (95%), pupils (86%), tone, power, sensitivity (84%), and blood pressure (80%) was good. Assessment and documentation of reflexes (74%), and cranial nerves (70%) reached intermediate levels, whereas rate of documentation of gait (58%), fundoscopy (50%) and visual acuity (28%) was low. Neuroimaging was performed in 30% of this patient group (CT in 11 cases, MRI in 2 cases and MRI+CT in 1 case). Among these, 1 life-threatening diagnosis was made (intracranial bleed). One fifth of screened case notes contained no diagnosis, whilst over half proposed several differential diagnoses, with different conclusions often reached by different clinicians assessing the same patient.
Summary and conclusion: Assessment and documentation of the complex diagnostic process of atraumatic non-febrile headache is challenging, as shown by the incomplete documentation and variability of diagnoses in our audit. A definite diagnosis is often not achieved in the emergency department setting.
Future plans: We have developed a standardized assessment form to support structured and comprehensive evaluation of these patients. Furthermore a headache diary was developed to support follow-up. The diagnostic value of these forms needs to be evaluated prospectively.
Ulrike Uhlig, Angie Radford and Ullie de Saint Quentin all contributed equally
Ulrike UHLIG (Oxford, UK), Angie RADFORD, Ullie DE SAINT QUENTIN, Savithiri RATNAPALAN
16:10 - 17:40 #1545 - #1545 - Reliability Of The Infrared And Chemical Dot Temperature Measurement Methods In The Cases Below 3 Years Old Admitted In The Pediatric Emergency Unit: A Prospective Study.
#1545 - Reliability Of The Infrared And Chemical Dot Temperature Measurement Methods In The Cases Below 3 Years Old Admitted In The Pediatric Emergency Unit: A Prospective Study.
Aim: This study aimed to determine the most comfortable measurement which is the closest method to rectal measurement of body temperature that is accepted as the gold standard in measurement of core temperature.
Material and Methods: Inthis comparative prospective study; temperature measurement was performed by 4 different methods during same fever period in 354 patients brought to our pediatric emergency unit due to complaint of fever. In each patient; temperature measurement was performed by rectal, axillary, temporal artery and tympanic membrane methods were performed using digital thermometer, chemical dot thermometer and infrared thermometers, respectively.
Results: The cases were 222 male and 132 female patients while mean age was 19.45±13.99 months. The AUC values of AT, TAT and TMT measurements were 0.950, 0.861 and 0.917 (p<0.001, p<0.001 and p<0.001), respectively. ICC values of AT, TAT and TMT measurements in the febrile patients compared with rectal temperature were 0.86, 0.67 and 0.79, respectively. AT measurement method had the highest detected sensitivity compared with rectal temperature (85.71).
Conclusion: It has been detected that AT mesurement method was the most reliable and comfortable measurement method among noninvasive measurement techniques in emergency service applications compared with RT as a less invasive method.
Mehmet ACIKGOZ, Ahmet GUZEL (SAMSUN, TURKEY), Naci MURAT, Arzu KARLI, Ugur SEZGIN
16:10 - 17:40 #1547 - #1547 - Can we use serum SP-D levels as an effective factor instead of clinical severity scores of community-acquired pneumonia in pediatric emergency department? Prospective university hospital experience.
#1547 - Can we use serum SP-D levels as an effective factor instead of clinical severity scores of community-acquired pneumonia in pediatric emergency department? Prospective university hospital experience.
Objectives: To investigate whether serum SP-D level is an applicable indicator in differentiation of bacterial and viral pneumonia and determining clinical severity in the cases with CAP who applied to the emergency services in childhood age
Methods: Totally 67 subjects including 32 patients aged between 1 month to 18 years who applied due to diagnosis of community-acquired pneumonia (CAP) and 35 healthy control subjects were analyzed prospectively. The demographic characteristics, clinical, laboratory and radiological findings, serum SP-D levels, pneumonia clinical severity index, pnemonia etiological prediction score and treatment responses of the patients were evaluated.
Results: Median age of the patients was 17,5 months (1,5-156 months). Serum SP-D level of the patient group was significantly higher than the control group (p<0.001). According to pneumonia clinical severity index; serum SP-D levels in mild (n=7), moderate (n=19) and severe (n=6) pneumonia was significantly higher than the control group (p<0.001, p<0.001 and p<0.001, respectively). The serum SP-D level of the cases with severe pneumonia was very higher than the ones with mild and moderate grade of clinical severity index (p<0.001 and p<0.001, respectively). However the serum SP-D level in the bacterial pneumonia group (n=23) was higher than the viral pneumonia group (n=9) the difference was not statistically significant (p=0.133).
Conclusion: Even though, Serum SP-D has limited efficacy in differentiation of bacterial and viral pneumonia with respect to CAP in childhood, it can be used as an effective bioindicator in determining clinical severity of the disease in the emergency services.
Ahmet GUZEL, Mehmet ACIKGOZ (Samsun, TURKEY), Bulent SISMAN, Adil KARADAG, Naci MURAT, Sukru PAKSU
16:10 - 17:40 #1558 - #1558 - Introducing a safety brief in the paediatric emergency department - Embracing safety as a team.
#1558 - Introducing a safety brief in the paediatric emergency department - Embracing safety as a team.
There has recently been a strong focus on safety in our busy emergency departments. The Berwick Report recognised the need to place quality of care, especially patient safety, above all other aims. The World Health Organisation estimates that 1 in 10 people is harmed whilst receiving hospital care in developed countries. In UK paediatric departments there are 2000 preventable deaths per year when compared to the best performing countries in Western Europe. The RCEM and RCPCH have both identified safety as a top priority, with RCPCH launching Situation Awareness for Everyone (S.A.F.E.) in 2014
We hypothesized that a daily multidisciplinary safety brief would be valuable in identifying possible patient and staff safety issues and communicating them within the Paediatric Emergency Department (ED). We introduced the safety brief in December 2014 with the aims of completing it at least 95% of weekdays at 10am. We named a core team of nurse in charge, senior doctor managing the floor, plus one other doctor and nurse. All staff on duty were encouraged to attend unless the need to continue clinical duties was greater.
The structure of the safety brief was based on recommendations by RCEM and modified to highlight relevant issues. A data collection sheet was designed and this was completed each morning. We were open to feedback on which issues were most pertinent and the data collection sheet was altered accordingly. The information was then collated on a spreadsheet, providing a database from which we could identify recurring issues and work to resolve them.
Outcomes of safety initiatives are notoriously difficult to measure objectively, as there are so many confounding factors in whether adverse incidents occur or are prevented. The change we are working to introduce is in attitudes and environment rather than discrete endpoints. However there are some surrogate markers we have used to evaluate our success.
In the first four months since introducing the safety brief we have completed it on 98% of weekday mornings. There have been an average of five staff at each brief. We have identified 90 issues, an average of 5.3 per week. We have discussed 36 incident reporting forms (IR1s).
We distributed a questionnaire to staff within the Emergency Department. Responses showed that the majority of staff found this a positive intervention, with most stating that the safety brief had improved their awareness of safety issues in the hospital, particularly the ED. Some felt that it had generally improved communication within the department and provided an opportunity for information sharing between medical and nursing professionals.
Since the introduction of the Safety Brief we have seen many other changes focussing on safety and quality improvement. These include introduction of Safety Goal of the Week, nominated nurse and doctor for patient tracking in each shift and neonatal sepsis packs. These reflect a real shift in culture within the department to one which prioritises safe care above all else.
Eleanor MCCORMICK (Craigavon, UK), Julie-Ann MANEY
16:10 - 17:40 #1928 - #1928 - Health-related quality of life in children with clinically-important post-concussive symptoms.
#1928 - Health-related quality of life in children with clinically-important post-concussive symptoms.
Background: Scarce literature exists on the influence of post concussive symptoms (PCS) on healthrelatedqualityoflife (HRQoL) in children.
Objective: We aimed to compare the HRQoL of children with and without clinically important PCS (ciPCS) at 2 weeks postinjury
Methods: Prospective longitudinal study including children 5-18 year old who presented within 48h of their concussion to a tertiary children's hospital emergency department (ED) between September 2013 and June 2014. Children and their parents were administered the Pediatric Quality of Life inventory (PedsQL) within 4 days of ED presentation (reflecting the preinjury baseline status), and at 1 and 3 months following concussion.
ciPCS was defined as an increase in the number (≥3) and severity of symptoms compared with preinjury function (as rated on the Post Concussive Symptom Inventory), in addition to a lack of improvement in symptom burden over time (ascertained by a clinical assessment by medical staff experienced in concussion management).
Results: this study included 79 patients who completed the 2-week follow up. Of these 29% (95%CI 19-39%) had ciPCS at 2 weeks. There was no difference on preinjury PedsQL scores between children with and without ciPCS on both child report (median 80, IQR 63-92 vs 84, IQR 71-91, p>0.05), and parent report (84, IQR 67-95 vs 86, IQR 77-93, p>0.05).
Children with ciPCS had significantly lower PedsQL scores at 1 month compared with baseline on both child report (83, IQR 60-93 vs 95, IQR 90-100, p<0.005) and parent report (71, IQR 55-86 vs 87, IQR 78-95), p<0.005)- data available for 47 patients. This difference was no longer present at 3 months on both child report, (87, IQR 70-97 vs 95, IQR 82-100, p>0.05) and parent report (91, IQR 54-98 vs 96, IQR 85-97), p>0.05)- data available for 64 patients.
Conclusions: PCS burden at 2 weeks folowing a concussion seems to contribute to a worse HRQoL in the first month post-injury. Early and effective intervention for children with ciPCS may result in improved HRQoL. Emergency physicians may take this information into consideration to better plan post-discharge follow up for children presenting with concussion.
Silvia BRESSAN (Padova, ITALY), Michael TAKAGI, Cathriona CLARKE, Ed OAKLEY, Gavin DAVIS, Kevin DUNNE, Franz BABL, Vicki ANDERSON
16:10 - 17:40 #1949 - #1949 - Anticipating and managing the difficult airway in the paediatric emergency department.
#1949 - Anticipating and managing the difficult airway in the paediatric emergency department.
Centralisation of children’s services in the united Kingdon has decreased exposure of district general hospital (DGH) emergency department staff to paediatric airway management, especially in critically ill children. Regional Retrieval Teams such as NWTS - North West and North Wales Paeditric Transport Service, provide advice and support but cannot be considered as the primary difficult airway management team leading to challenging scenarios, particularly for DGH teams managing patients with predicted or known difficult airways. Early recognition of the difficult airway is vital in decreasing morbidity and mortality, and anxiety for those involved. Prompt assembling of a competent multidisciplinary team in the emergency department, with appropriate equipment, drugs, monitoring as well as planning for failure or deterioration represents a major challenge.
The difficult airway is “the clinical situation in which a conventionally trained anaesthetist experiences difficulties with facemask ventilation, tracheal intubation, or both”. Difficult intubation occurs approximately 0.42% (1 in 230) in all elective paediatric tertiary intubations c.f.1.5-8% adult. Of these 0.08% (1 in 1250) occur in healthy children, increasing to 0.24% (1 in 400 ) if under 1 year of age. Difficult mask ventilation occurs in approximately 0.02% (1 in 500), compared to 0.4% (1 in 666) in adults. Can’t intubate can’t ventilate situation occurs 1 in 10-50,000 in adults.1,2 Lack of published data means that paediatric incidence (though probably less) is unknown. Paucity of published data on incidence of difficult airway during emergency intubation for respiratory failure is unknown, but likely to be significantly higher. NWTS data revealed 11.2% incidence of grade 2 or above laryngoscopy (357 intubations of critically sick 1-5 year olds); and in under 2 year olds 21% complication risk eg hypotension, hypoxia.
We describe 4 cases referred to North West and North Wales Paediatric Transport Service (NWTS) from different emergency departments across the North West of the UK, that highlight importance of anticipating problems managing paediatric airways, and the proposed new regional difficult airway and intubation guideline.
The regional airway guideline highlights the importance of alternative plans required to ensure successful outcome. Equipment and monitoring ideally should be standardised across all hospital departments where a critically sick child/neonate may present. Education and regular experience / training in airway management reduces the risk of paediatric airway difficulties. Regional paediatric intensive care transport teams can facilitate access to specialist equipment and transfer to tertiary specialised units when required.
Shirley MULVANEY (appleton, UK), Kate PARKINS, Pete MURPHY, Rajesh PHATAK
16:10 - 17:40 #963 - #963 - Pediatric emergency: creation of an independant nurse consultation.
#963 - Pediatric emergency: creation of an independant nurse consultation.
Paediatric emergency: creation of the first Swiss independent nurse consultation
Introduction: Consultations in the Paediatric Emergency Department (PED) continue to climb regularly. Emergency Nurse Practitioner consultations have long been created in the English speaking countries with very good results.
Methods: Since January 2013, an independent nurse consultation, under delegated medical responsibility, has been created in the multidisciplinary PED of the Children’s Hospital of Lausanne, Switzerland. After identifying the legal requirements, we define the consultation scope, the inclusion and exclusion criteria, and the medical supervision frame and identified the candidates within our senior nursing staff.
Results: Four to five months were necessary to train senior paediatric nurses to an independent consultation. A total of 1565 consultations were seen from January 2013 to December 2014, including children aged 3 to 18 years old, with Australasian Triage Score (ATS) rating 4 and 5. Both medical and surgical conditions were included. The most common pathologies diagnosed were ear-nose-throat (ENT) and infectious diseases (respiratory, ophthalmic and cutaneous). The overall waiting time hasn’t decreased yet. However, the mean consultation time was the same as for the medical consultation.
Conclusion: A well definite working frame, a systematic approach as well as the continual medical supervision possibility, make it a safe, efficient and appreciated consultation, by both patients and professionals. In the future, inclusion criteria will be increased, the age limit will be lowered and our experience will allow the implementation of similar consultations in surrounding hospitals.
Céline REY-BELLET GASSER (Ollon VD, SWITZERLAND), Corinne YERSIN, Mario GEHRI
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16:10-17:40
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Oral Paper 2
Toxicology
Moderators: Kurt ANSEEUW (Medical doctor) (ANTWERP, BELGIUM), Inger SONDERGAARD (PHYSICIAN) (ALLEROED, DENMARK)
16:10 - 17:40 #1006 - #1006 - Poisoning from fire smoke inhalation in Paris area, France - a retrospective observational study.
#1006 - Poisoning from fire smoke inhalation in Paris area, France - a retrospective observational study.
Introduction: Fire smoke inhalation results in relatively rare but sometimes life-threatening poisoning. The aim of this study is to describe prehospital and in-hospital management, early complications and prognostic factors.
Material and methods: We conducted an observational retrospective investigation. All the patients managed by a pre-hospital medical team and presenting signs of fire smoke intoxication with burned body surface area of < 20% and no traumatic injury were included. The following variables were collected: clinical features, comorbidities, arterial blood gases, plasma lactate concentrations, HbCO levels, prehospital resuscitation and treatments, bronchoscopy results if done. Univariate followed by multivariate analyses were performed to identify prognostic factors of survival. Statistic test of Khi2 (Pearson) was significant if p < 0.05.
Results: During a 5-year period, 203 patients were included (mean age: 45 +- 24 years, 110 M/93 F). Time to reach the victims was 30 min and time to provide care was 55 min. Comorbidities were present in 95 patients (46%) including cardiovascular (7.8%), respiratory (6.4%) and psychiatric diseases (2%). No immediate or delayed smoke inhalation-related complications were observed in 155 patients (76%) while 48 patients (24%) presented absolute emergencies: 29 patients (14%) were in cardiac arrest, 15 (7%) with acute respiratory failure and 4 (2%) with severe neurological impairments. Hydroxocobalamin was administered to all patients categorized as absolute emergencies (n=48) allowing in 10 cardiac arrest patients (among 12) in a return of spontaneous circulation after 77 min of advanced cardiac life support. After transportation to hospital, 29 patients were admitted to the intensive care unit (ICU) and 4 to a burn unit. Bronchoscopy showed bronchial edema without necrosis in 24/29 ICU patients. Twenty-seven patients died (mortality rate of 13%) in relation to cardiac arrest (24/29), neurological impairments complicated with acute respiratory distress syndrome (ARDS) and septic shock (2/4) and pneumonia with septic shock (1/15). HbCO was higher in absolute than relative emergencies (p < 0.0001). Blood lactate did not significantly differ between survivors and non-survivors (5.6 ± 3.4 vs. 8.6 ± 5.0 mmol.L-1, p=0.4). Using a multivariate analysis, predictors of death were the delay required to access to victims, prehospital care duration, comorbidities, soot in the airways and HbCO measured in the prehospital setting and Glasgow scale. Only Glasgow scale was associated with mortality (OR, 10.0 [95%-IC, 1.0-100.5]; p=0.05).
Discussion: Fire smoke inhalation mainly result in systemic effects and less in local bronchial complications. All the times in the resuscitation chain have major prognostic impact. Prompt and multidisciplinary management is required to improve final outcome.
Isabelle KLEIN, Marie-Pascale PETIT, Hugues LEFORT (Metz), Daniel JOST, Alexandre ALLONNEAU, Olivier MILOCHE, Michel BIGNAND, Bruno MEGARBANE, Jean-Pierre TOURTIER
16:10 - 17:40 #1214 - #1214 - Epidemiology of Deliberate Self-Poisoning in an french emergency department : a descriptive study.
#1214 - Epidemiology of Deliberate Self-Poisoning in an french emergency department : a descriptive study.
Introduction: Voluntary drugs intoxications is a major health problem in France and also a frequently use pattern in the in the prehospital emergency services (SAMU) and emergencies departments (ED). Variety of drugs offered by the pharmaceutical industry generates many clinical situations which can complicate diagnostic or treatment for emergency physicians. The aim of our study was to assess one-year patient’s characteristics hospitalized for deliberate drug poisoning and their management, in the ED of a french hospital.
Methods: This descriptive and forward-looking study was conducted from January 1st to December 31th 2013 in an ED of a French county, by a computer request. Cases were eligible if patients were over 18 years old and admitted in ED if the cause of admission or the final diagnosis code (International Classification Disease v10) was related to poisoning or suicide attempt. Demographic, clinical, toxicological and therapeutic data were collected for any patients. Categorical variables are presented with absolute (n) and relative (%) frequencies. We used univariate analysis to compare different demographic data. We performed Chi2 test for categorical variables analysis and Student t test for numeric variables analysis. Results were considered significant with a p-value below 0.05 with a significant result (p < 0.05). Numerical data are reported as medians with interquartile ranges [Q1;Q2].
Results: Four hundred and seven patients were included in 2013, whose 78% patients with a psychiatric desorder. Two hundred seventy one (67%) were women and median age was 42 years old [31;52]. The deliberates drugs poisonings were often during winter seasonal (p < 0.01). 54% patients were transported to the ED by first responders, 35 (8%) by a mobile intensive care unit, 116 (29%) by private ambulance and 36 (9%) by own means. The most (91%) had called the emergency number. The delay of medical’s support was 21 [11;35] minutes. The ED length of stay was 284 [51;306] minutes. The most intoxicated patients (85%) were slight symptoms without haemodynamic, respiratory and neurological disorder. Concerning toxicological data, toxics used were mainly: anxiolytic 297 (44%), analgesics 127 (19%), antidepressants 91 (14%), neuroleptics 55 (8%) and drug cardiologic 26 (4%). Only twenty six patients (6%) were transferred to an intensive care unit and two hundred eighty nine (71%) were admitted in hospitalization unit of ED. Overall, eighty (20%) of patients benefited from at least one resuscitation technique (i.e. tracheal intubation, vasopressor support or more than 1L of intravenous fluid bolus) and one hundred one (26%) supported toxicological treatment. The overall mortality was 0.5%.
Conclusion: The most intoxicated patients were not vital sign in our ED. Despite low mortality, the diversity of poisoning requires frequent knowledge updating and clinical assessment rule to improve patient care. Its role is crucial in the detection and management of acute drug overdose.
Mathieu VIOLEAU, Timothée DUB, Hugues LEFORT (Metz), Christophe CARAULT, Mathias SIERECKI, Ivan RAFEI-DARMIAN
16:10 - 17:40 #1224 - #1224 - How to take down a bull in a china shop.
#1224 - How to take down a bull in a china shop.
INTRODUCTION
Agitated patients can be a source of anxiety for staff within the Emergency Department (ED). It is well documented that novel psychoactive drugs, so called “legal highs”, can cause agitation and aggression. Patients presenting to the ED with agitation due to novel psychoactive drugs is increasing. National institute of Clinical Excellence (NICE) guideline CG25 emphasises de-escalation techniques, identifying and treating the provoking factor. Further to this the next step is that of the use of oral, then intramuscular medication. This is in keeping with our local Trust policy, CG25 and guidance set out by the Royal College of Emergency Medicine (RCEM).
AIMS
Our primary objective was to identify patients that presented with agitation due to “legal highs” and determine whether our department was compliant with CG25, our local Trust policy and RCEM guidelines on rapid tranquilisation.
METHODS
Patients were identified using our electronic patient management system (TRAK ED) that presented to the ED between 01/04/2014 – 30/09/2014. Firstly, we used the incident type category and included all patients that presented with a category of intentional self harm, psychiatric condition or unspecified. Secondly, we included all patients that had a free form text written by the receptionist or the triage nurse which included terms such as “overdose”, “poisoning”, “intoxication”, “illicit/recreational drugs”, “legal high”, “unknown substance” and variations of the adjectives “agitated”, “aggressive”, “violent” and “psychotic”. Finally, we included all patients that had a discharge diagnosis of International Classification of Disease (ICD) 10 codes T36-65, F00-F99, R40-46. Patients that presented with an incident type category of accidental poisoning, injury (of any cause) or medical/surgical conditions were excluded.
Once identified, patient’s clinical records were interrogated by two of the authors for further details. The third author re-examined the patient’s record if there was any confusion.
RESULTS
Out of 467 cases, 14 cases were reported at triage as agitated, 20 had intervention for agitation, either physical restraint (2), isolation (2) or chemical restraint (16). 8 patients were given oral medication, 7 were given IV and one received IM. 7 cases of rapid tranquilisation correctly followed the local policy and guidelines. 12 agitated triage patients were successfully de-escalated. The main reason for attendance was drug overdose 178 (38.1%), alcohol and drugs 76 (16.3%), alcohol 66 (14.1%) and legal highs 43 (9.2%). Of the 43 patients that had taken legal highs, 3 of them required some form of chemical treatment. 261 patients were admitted, 4 admitted to ITU and 12 to HDU.
DISCUSSION/CONCLUSION
Drug overdose was the most common cause for agitation. Of the 14 cases that were initially triaged as agitated, only 2 required medications or isolation, indicating that de-escalation techniques were successful and therefore compliant with guidelines. Two thirds of those who required chemical restraint were treated in accordance with the guidelines. In conclusion, lack of full compliance with rapid tranquilisation guidelines. Due to increasing presentations after taking psychoactive drugs, greater awareness of these guidelines is required to manage patients correctly.
Georgina MCROBBIE, Esther REAVES (Westhill, UK), Mike WILSON
16:10 - 17:40 #1232 - #1232 - Clinical management of foodborne botulism poisoning in emergency setting: the Italian case series.
#1232 - Clinical management of foodborne botulism poisoning in emergency setting: the Italian case series.
Background: Foodborne botulism (FBo) is a neuroparalytic disease caused by the blockade of neural transmission in the cholinergic synapses due to botulinum neurotoxins. The onset of clinical manifestations can be rapid and dramatic. Early diagnosis and prompt specific treatment may represent critical aspects in the management of foodborne botulism in Emergency setting. The aim of the presented study is to evaluate clinical presentation characteristics of FBo poisoned patients admitted in Emergency Departments (EDs) to obtain clinical data useful for emergency physicians to make clinical suspicion, diagnosis and early antidotal treatment. Participants and methods: A retrospective analysis of cases of FBo registered at Pavia Poison Control Centre (PCC) was performed during the study period (2007-2013). Implicated food, clinical presentation, latency between symptoms/ED-admission/treatment, clinical course, response to the antidotal administration and laboratory analysis data were analyzed. Results: 98 cases were studied (mean age 55,14±17,9; 53/98 male) and 17 outbreaks (involving more than 2 people) were registered. History was positive for consumption of vegetables (77%) and fish (16%) in water or oil, or meat conserve in 88.7%. In 81 cases (93,2%) causative food were home-made produced, in 4 cases were industrial and in 2 cases were ingested at restaurant. Most common symptoms reported at ED were dysphagia (55,1%) followed by ocular manifestations [diplopia (40%), accommodation troubles (32%), mydriasis (26%) ptosis (18%)] and xerostomia (35%). In three cases dysphagia was the unique neurological manifestation of the poisoning. Twenty-four patients (24%) required mechanical ventilation. Antitoxin was administered in 59 patients (60,2%), with an average of 63 hours after neurological symptoms onset and 26% were treated within 24 hours. In this group 7 patients (26%) required mechanical-ventilation (mean duration 13,6±5,6 days) (vs 53,8% in treated group after 24 hs; mean duration 21±15,5 days). Five adverse reactions were registered. Laboratory analysis confirmed the poisoning in 66,4% of cases; toxin type-B was the most common identified (83,6%). Serotype-A was isolated in 6 cases (12,2%): among these 83% required mechanical ventilation (p=0.004). Neurological permanent sequelae was registered in 1 case and 1 lethal case occurred. Conclusion: Botulism is a rare disease in which early correct diagnosis is difficult and may require a toxicological consultation. This intoxication represents also a medical challenge for the emergency physicians. Clinical presentation at EDs could be undefined, diagnostic procedures could be problematic and patients must be monitored because of dramatic respiratory failure. So, the PCC support is essential for the diagnosis and the management of poisoned patients (e.g. specific laboratory tests, antidotic treatment), and in the identification and surveillance of possible outbreaks.
Davide LONATI (Pavia, ITALY), Luigi FLORE, Sarah VECCHIO, Andrea GIAMPRETI, Valeria M PETROLINI, Fabrizio ANNIBALLI, Dario DEMEDICI, Carlo A LOCATELLI
16:10 - 17:40 #1236 - #1236 - Viper envenomation in Italy: clinical course, laboratory investigations and antidote treatment in a 11 years case series (2002-2012) from Pavia Poison Centre.
#1236 - Viper envenomation in Italy: clinical course, laboratory investigations and antidote treatment in a 11 years case series (2002-2012) from Pavia Poison Centre.
Background: Viper envenomation may be characterized by severe local/systemic symptoms with an estimated mortality up to 1%. Clinical and laboratory disorders and antidote administration are often debated (1). Poisoning severity, laboratory alterations and antidote administration in viper-envenomed patients referred to Pavia-Poison-Centre (PPC) are described in order to evaluate predictable clinical and laboratory factors in viper envenomation management. Participants and methods: All viper bitten patients referred to PPC from 2002-2012 were retrospectively studied among those clinically followed until conclusive outcome. Clinical manifestations and evolution were evaluated according to a Grading-Severity-Score (GSS) (2). Laboratory parameters and antidote treatment were evaluated and related to GSS at acme. Results: During the 11-years study-period, 482 viper bitten patients were evaluated (age 44±23 years; male 65%). At hospital admission 43.2% presented only fang-marks (GSS0), 39% local edema (GSS1), 15.8% regional edema and/or mild systemic manifestations (GSS2), 2% severe local and/or systemic manifestations (GSS3). Among GSS0-admitted patients, 38/208 (18%) developed GSS≥1, and 10/208 (5%) needed antidote because developed GSS≥2. Among GSS1-admitted patients, 73/188 (38.8%) developed GSS≥2, and 59/188 (31.3%) needed antidote. Most GSS2-3 (63-100%) admitted patients received antidote. Among 482 patients, 170 (35%) remained dry bytes and 312 (65%) developed envenomation. Systemic symptoms were mainly gastrointestinal (118/312; 38%), hemodynamic (37/312; 11.8%), neurotoxic (36/312; 11.5%) and local thrombosis (24/312; 8%). Seven patients presented hemodynamic shock and three presented splenic, myocardial, cerebral ischemia respectively. No fatal cases were registered. Mean time-onset of local manifestations from viper byte ranged 11.8-27.5 hours for mild-extensive edema respectively; gastrointestinal and hemodynamic disorders developed within 5-7 hours, neurotoxic effects appeared within 10.7±6.2 hours. Increase of leukocytes, d-dimer, INR and decreased thrombocytes and fibrinogen were statistically related with GSS≥2. Antidote was needed in 44% of symptomatic patients and administered with a mean time of 15.5 hours from viper byte. Most patients (76%) improved after antidote administration. In those (24%) where GSS≥2 was present within few hours from the byte already at hospital admission edema worsened despite antidote administration. Conclusion: Viper bite is a potentially serious event that requires immediate hospital care. GSS0-patients at hospital admission may worsen and require antidote within 12-24 hours after the byte. Leukocytosis and increased d-dimer are related with severe envenomation. Prompt antidote prescription is important and further administration may be evaluated in patients that present severe envenomation already at hospital admission. References: 1. Pozio E. Trop Med Parasitol. 1988 Mar; 39(1):62-6. 2. Audebert F et al. Human and Experimental Toxicology 1994; 13:683-88.
Andrea GIAMPRETI, Gianluca MELATINI, Davide LONATI (Pavia, ITALY), Sarah VECCHIO, Valeria M PETROLINI, Francesca CHIARA, Monia ALOISE, Marta CREVANI, Carlo A LOCATELLI
16:10 - 17:40 #1431 - #1431 - Futile fight - characteristics of poisoning with drugs of abuse in Hungary.
#1431 - Futile fight - characteristics of poisoning with drugs of abuse in Hungary.
Objective: To determine specific features in the clinical course and epidemiology of acute poisonings of different types of novel psychoactive substances (NPS). Methods: Retrospective evaluation of clinical records of patients admitted to our department between 1st December 2013 and 30th November 2014 due to acute intoxication caused by any type of drugs of abuse. The assessment consisted of demographic data, patient’s history, street name of drugs, way of use, coingestant(s), vital signs and parameters , any clinical symptom related to the consumption of drug, treatment. Results: There were a total of 2036 acute poisoning episodes by 1611 patients during one year. 152 patients had more than one episode, 74 patients had more than three episodes. Length of hospital stay was less than 6 hours in 170 patients, 6 to 24 hours in 1262 patients and more than 24 hours in 604 patients. There were a total of 359 acute poisonings caused by classic-type drugs of abuse and 1677 acute poisonings caused by NPS. Three new designer drugs have become wide-spread (causing 1642 intoxications): “penta crystal” (typically containing pentedrone) in 527 patients , “music” (typically containing alpha-PVP or PV8) in 362 patients and “bio-grass or herbal smoke” (containing various synthetic cannabinoids and often kathonines) in 753 patients. There were 1216 males and 461 females intoxicated by NPS. The mean age was 25.2 years, but in the autumn period about one-third of the patients (132/439) were younger than 18 with regard to the use of herbal smoke. The use of classical amphetamine-like stimulants resulted in the followings: accelerated psycho-motoric activity (82.3%), increased heart rate (76.6%) and blood pressure (71.2%), dilated pupils (70.8%), headache (30.2%), chest complaint (28.1%). Hyperthermia was not frequent (5.2%) but very problematic. As for kathinones the most characteristic symptoms were: agitation (78.9%), confusion (72.1%), hallucinations (45.4%), paranoid psychosis (42.5%), rage (34.7%), traumatic injuries (27.6%). Hyperthermia on the central origin did not occur. Cannabis typically caused dizziness (86.9%), nausea/vomiting (80.6%), mild hypotension (29.1%), collapse (14.1%). After using herbal smoke the problems related to the central nervous system were massively higher in number: CNS depression (55.3%), confusion (53.25%) and hallucination (24.3%). According to the Poison Severity Score the intoxication caused by the classical stimulants was dominantly mild (40.6%) or moderate (51.1%); however, the new kathinon-typed drugs typically caused moderate (48.1%) and severe (34.9%) poisoning. We did not register any serious poisoning induced by cannabis, but we identified a great number of moderate (55%) or severe (13.8%) intoxication due to the use of bio-grass. There were altogether 3 fatal cases. After using "penta crystal" and "music" 711 patients were treated with clonazepam, 578 patients with IV fluids, 301 patients with midazolam, 277 patients with haloperidol. Conclusion: The drug market has profoundly changed, including the substances of abuse and their consequences. NPS more often result in serious psychosis, aggressive state and traumatic injuries than classic-type drugs.
Csaba Zsolt PAP, Csaba Zsolt PAP (Budapest, HUNGARY)
16:10 - 17:40 #1520 - #1520 - Epidemiology, age effects, and clinical outcomes of poisoning patients.
#1520 - Epidemiology, age effects, and clinical outcomes of poisoning patients.
Background: Poisoning is one of the injury mechanisms inducing high mortality. Aims of this study were to describe the epidemiology of poisoning, and to identify age effects on clinical outcomes.
Method: An observational study was conducted using ED injury in-depth surveillance. Eligibility was poisoning patients who visited six urban tertiary hospitals’ ED from 2010 to 2012. We excluded the patients with unknown survival outcomes after ED treatment. Endpoints were mortality in ED and hospital. We tested age trends on survival outcomes.
Result: Total of 5416 poisoning patients, 3031 (56.0 %) were female and 2669 (49.3%) used EMS. Anti-psychotic drug was a leading cause of substance (30.5%), followed by artificial substance (21.2%). Insecticides (8.7%), herbicides (6.2%), painkiller (8.6%), and gas poisoning (12.3%) were identified. Among them, 2772 (51.2 %) used substances with self-injury intention, and 1234 (22.8%) consumed alcohol. Admission rate was 28.5% and mortality rate in ED and ward were 2.2% and 1.6%.
By age group, teenage used painkiller (37.1%), and elderly used herbicides and insecticides (32.2% in 60-69 and 38.7% in ≥70) (p-value <0.01). Teenage (60.8%) and mid-old age (61.9% for 30-39, 61.4% for 40-49) groups had more self-injury intention (p-value <0.01). Mortality in ED and ward were increased by age (6.0% and 5.5% for 60-69 and 7.2% and 9.0% for ≥70, respectively) (both p-for-trend <0.01).
Conclusion: Poisoning induced mortality was increased by age. It may be affected by not only natural age effect but also poisoning substances, which elderly more likely to use fatal substances like herbicides.
Seungmin JEONG (SEOUL, KOREA), Ki Ok AHN, Kyoung Jun SONG, Young Sun RO, Sang Do SHIN, Ki Jeong HONG
16:10 - 17:40 #1527 - #1527 - The role of oxidative stress in α-amanitin induced hepatotoxicity in an experimental mouse model.
#1527 - The role of oxidative stress in α-amanitin induced hepatotoxicity in an experimental mouse model.
Objective: To evaluate trends in oxidative stress markers, SOD, CAT, GPx, MDA, TOS, and TAS, in a mouse α-amanitin poisoning model with three different toxin levels.
Methods: The mice were randomly divided into four groups: Group 1 (control group), Group 2 (low dose poisoning group; 0.2 mg/kg α-amanitin), Group 3 (moderate dose poisoning group; 0.6 mg/kg α-amanitin), and Group 4 (high dose poisoning group; 1.0 mg/kg α-amanitin). At hour 0, the their calculated dose of α-amanitin was injected to the mice in poisoning groups intraperitoneally. At hour 48, all mice were sacrificed and their livers were collected for biochemical and histopathological evaluation.
Results: Median liver tissue SOD activity in moderate and high dose groups was significantly higher than the median SOD activity in control (for both, p = 0.001). Median liver tissue CAT activity in Group 2 was significantly higher than the median CAT activity in Group 1 (p = 0.001). Median liver tissue CAT activity in Groups 3 and 4 was significantly lower than the median CAT activity in Group 1 (for both, p = 0.001). Median liver tissue GPx activity in Groups 2, 3, and 4 was significantly higher than the median GPx activity in Group 1 (for Group 2, p = 0.006; for Group 3 and 4, p = 0.001). The median liver tissue MDA levels of Groups 3 and 4 were significantly higher than the median MDA level of Group 1 (for Group 3, p = 0.015; for Group 4, p = 0.003). There was a significant positive correlation between liver CAT activity and liver TAS level, and a significant negative correlation between liver CAT activity and liver TOS level (r = 0.935 and r = −0.789 respectively; for both, p<0.001).
Conclusions: Our findings support a significant role for increased oxidative stress in α-amanitin induced hepatotoxicity. In particular, identifying the pathophysiological mechanism responsible for the direct relationship between CAT, α-amanitin, and TAS levels may be very helpful for further treatment investigations.
Zerrin Defne DUNDAR (KONYA, TURKEY), Mehmet ERGIN, Ibrahim KILINC, Tamer COLAK, Pembe OLTULU, Basar CANDER
16:10 - 17:40 #1551 - #1551 - High pressure injection injuries: toxicological evaluation in urgency in the 20 years experience of Pavia Poison Centre.
#1551 - High pressure injection injuries: toxicological evaluation in urgency in the 20 years experience of Pavia Poison Centre.
Background: To describe clinical manifestations of cases of high-pressure injection (HPI) injuries referred to the Pavia Poison Centre (PPC), in order to identify toxic effects and treatments. HPI injury of hand represent one of the most serious surgical emergencies of the upper extremities. Participants and methods: A 20-year retrospective analysis (1995-2014) assessed all cases for sex, age, injected fluid’s nature, site of HPI, clinical manifestations, treatment, outcome. These factors influence the seriousness, the extensiveness of subcutaneous damage and the functional outcomes of patients [1]. Results: Forty-two cases were studied (37 M; mean aged 40.9±10.5). Mechanism injury described in 24/42 (57%), 20 injection by pressure guns, 4 blast pipe pressure. It mostly concerns non-dominant hand. More than 36% of injections occurs in the index finger. The second most touched region is the hand palm 19%, and only 17% of the injections occur on thumb. The categories so formed were: oily substances (38%), solvent-based paints (17%), water-based paints (14%), organic solvents (12%), fats (10%), solid materials (5%), gas (2%) and unknown (5%). The most serious injuries occurred in the categories of solvent paints and oils. The clinical course was characterized by: edema (69%), pain (63%), punctiform skin lesions (44%), necrosis (16%), local hyperemia (12,5%), tissue functional impotence (9,5%). Ischemic phalanx (9%) and necrosis (6%) were also involved. Fifty-one per cent of patients was admitted to ED within 6 hours after the incident. Outcomes are available for 10 cases that underwent urgent immediate surgical exploration/decompression: 4 showed a finger amputation: 3 solvent-based, 1 water-based paints; 2 reported permanent sensory deficits: 1 paint solvent, 1 hydraulic oil, 1 fat; 1 presented decrease of functionality of the hand; 3 patients recovered without sequelae. The amputation rate of these injuries is up to 10% without adequate treatment and on average, time between inoculation and presentation in ED was 24 h. Conclusion: The real gravity of HPI injuries, due to the apparent safety of initial injury is often missed by the emergency room physician who ignores the potential morbidity of the injury itself. Each victim of HPI injuries should be considered at risk for amputation and be sent immediately to the attention of the surgeon. References: 1. N. Verhoeven Æ R. Hierne. High-pressure injection injury of the hand: an often underestimated trauma: case report with study of the literature. Strat Traum Limb Recon 2008; 3:27–33
Andrea GIAMPRETI, Valeria M PETROLINI, Davide LONATI, Francesca CHIARA (PAVIA, ITALY), Monia ALOISE, Marta CREVANI, Carlo A LOCATELLI
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16:10-17:50
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Italy invites
Ricerca e progretti clinici
Moderators: Nicola GLORIOSO (ITALY), Giuseppe MONTRUCCHIO (ITALY)
16:10 - 16:30 Scompenso cardiaco: lo studio SAFE. Andrea FABBRI (Chief of Emergency Unit) (Forli, ITALY)
16:30 - 16:50 Insufficienza respiratoria: lo studio SIMEU multicentrico sulla dispnea in PS. Emanuele PIVETTA (Torino, ITALY)
16:50 - 17:10 Insufficienza respiratoria: il supporto non invasivo. Roberto COSENTINI (Milano, ITALY)
17:10 - 17:30 Dissezione aortica: score clinici, D-dimero ed ecografia. Peiman NAZERIAN (Firenze, ITALY)
17:30 - 17:50 Cateteri venosi centrali: posizionamento e controlli. Maurizio ZANOBETTI (Firenze, ITALY)
17:50 - 18:10 Sepsi: formazione ed ecografia. Francesca CORTELLARO (Milano, ITALY)
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| Wednesday 14 October |
| Time |
Auditorium Agnelli |
Room 500 |
Room Londra |
Room Istanbul |
Room Madrid |
Room Parigi |
Room Roma |
Room Atene |
Room Dublino |
Room Lisbona |
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| 09:00 |
09:00-10:30
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Human Trafficking and Migrants I
Moderators: Francesco DELLA CORTE (ITALY), Abdo KHOURY (PH) (Besançon, FRANCE)
09:00 - 09:30 Human trafficking. Nagi SOUAIBY (Chief Editor) (Byblos, LEBANON)
09:30 - 10:00 Managing the Syrian crisis in Turkey. Al BEHCET (faculty speaker) (Gaziantep, TURKEY)
10:00 - 10:30 Migrants: Our action in the Mediterranean. Stefano DI CARLO (FRANCE)
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09:00-10:30
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EuSEM meets
IFEM
Moderators: Juliusz JAKUBASZKO (POLAND), Roberta PETRINO (Head of department) (Italie, ITALY)
09:00 - 09:30 The future for international Emergency Medicine. Jim DUCHARME (Mississauga, CANADA)
09:30 - 10:00 Gender issues in EM. Melanie STANDER (SOUTH AFRICA)
10:00 - 10:30 The Italian perspective on Emergency Medicine. Gian CIBINEL (Torino, ITALY)
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09:00-10:30
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State of the Art
Clinical Toxicology
Moderators: Kurt ANSEEUW (Medical doctor) (ANTWERP, BELGIUM), Janos BAOMBE (manchester, UK)
09:00 - 09:30 Inhalative Toxins. Carlo LOCATELLI (Pavia, ITALY)
09:30 - 10:00 The challenges of control and elimination in mass drug administration. Mohammad AL-HELAIL (SAUDI ARABIA)
10:00 - 10:30 New develeopments in recreational drugs. Kurt ANSEEUW (Medical doctor) (ANTWERP, BELGIUM)
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09:00-10:30
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Special challenges in EM I
Moderators: Colin GRAHAM (Hong Kong, HONG KONG), Lisa KURLAND (SWEDEN)
09:00 - 09:25 How to motivate medical staff in a country without prospects for a specialty qualification. Thomas BENTER (GERMANY)
09:25 - 09:50 Six dangerous words: Fallacies of evidence based medicine. Judith TINTINALLI (Chapel hill, USA)
09:50 - 10:15 A first target for savingsin the ED: How to motivate physicians to do more with less. Christoph RASCHE (GERMANY)
10:15 - 10:30 Motivation around career sustainability. Alastair MEYER (Melbourne, AUSTRALIA)
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09:00-10:30
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Administration / Management
Leadership in the EM
Moderators: Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, GREECE), Lars Petter BJORNSEN (Emergency Physician) (Trondheim, NORWAY)
09:00 - 09:30 How to develop a statewide EM system from scratch. Raed ARAFAT (ROMANIA)
09:30 - 10:00 CRM: How to build a team in Emergency Medicine. Riccardo PINI (Director, E.D. High Dependency Unit) (Florence, ITALY)
10:00 - 10:30 How to improve working conditions for Emergency Physicians. Michael DUERR SPECHT (GERMANY)
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YEMD
Extreme Emergency Medicine
Moderators: Luca CARENZO (SIMULATION COMPETITION ONLY) (NOVARA, ITALY), Leonardo D'IMPORZANO (ITALY)
09:00 - 09:30 Unburying evidence in mountain emergency medicine. Giacomo STRAPAZZON (ITALY)
09:30 - 10:00 AMREF Flying Doctors. Matt EDWARDS (Specialist Registrar) (London, UK)
10:00 - 10:30 Tactical Emergency Medicine. Gabriele LOMBARDI (Portovenere (SP), ITALY)
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State of the Art
Geriatric Emergencies
Moderators: Jay BANERJEE (Leicester, UK), Christian NICKEL (Vice Chair) (Basel, SWITZERLAND)
09:00 - 09:30 Management of Delirium in older patients. Jay BANERJEE (Leicester, UK)
09:30 - 10:00 Management of syncope in older patients. Shamai GROSSMAN (USA)
10:00 - 10:30 Management of polytrauma in older patients. Richard WOLFE (USA)
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Oral Paper 1
Critical Care / Airway and Ventilation
Moderators: Anna Maria BRAMBILLA (ITALY), Jan CHRISTIAEN (PHYSICIAN) (BELGIUM)
09:00 - 10:30 #1071 - #1071 - Severe prognosis of overt disseminated intravascular coagulation in patients admitted to an ICU of a medical emergency department.
#1071 - Severe prognosis of overt disseminated intravascular coagulation in patients admitted to an ICU of a medical emergency department.
Introduction: The International Society on Thrombosis and Haemostasis (ISTH) disseminated intravascular coagulation (DIC) score is an independent predictor of poor outcomes and mortality risk, which has been prospectively evaluated in several medical populations of hospitalized patients. Its prognostic significance in outpatients admitted to an intensive care unit (ICU) of an emergency department (ED) is yet undefined.
Methods: In a retrospective cohort study, we analyzed the occurrence of overt DIC in all patients admitted to the university’s emergency department-ICU from 2003-2014 using the ISTH DIC score. The primary outcome was 30day mortality calculated using the Austrian death registry, and we applied binary logistic regression analysis with mortality as dependent variable to ascertain factors associated with death. The university's ED is divided into an ambulant section and an ICU, covering more than 80.000 outpatients per year including around 1200 (1.5%) critically ill patients needing immediate intensive care annually. Data extraction from the electronic medical database (EMD) of the General Hospital of Vienna was accomplished using a standardized algorithm protocol. After abstracting all patients attending the ED within the study period, the primary selection criteria including no current hospitalization and all DIC defining parameters available were applied. All identified cases of overt DIC were manually reviewed by two investigators to determine predisposing pathologies, treatment modalities, mortality rates and frequency of appropriate ICD-10 coding (D65.-, D65.0-5) and to assert diagnosis of overt DIC. The original patient charts were reviewed for individual laboratory results to validate the data obtained electronically. In case of disagreement as to diagnosis of DIC patient records were re-analyzed by both investigator. The reliability of final results was verified in random samples by a third investigator.To test for consistency among data-abstracting investigators an inter-rater reliability analysis (Cohen’s κ; 95% confidence interval, CI) was performed. The Kaplan-Meier method was used to describe survival and the Mantel-Cox test was performed for group comparisons.
Results: Of 35.631 patients with available coagulation analysis 114 had laboratory patterns of overt DIC, who all needed immediate transferal to the ED’s ICU. The initial inter-rater reliability regarding the diagnosis of overt DIC was 0.85 (95% CI, 0.77-0.92). Correct ICD-10 coding for DIC was recorded in only two patient charts (1.8%). The main underlying pathologies included malignancy (solid cancer: 30.9%; hematologic malignancy: 16.8%), cardiovascular diseases (26.5%) and sepsis (16%). All patients with cardiac arrest (73%) had a hyperfibrinolytic type of DIC. One-month mortality was high (52%). Mortality increased significantly to 67% with a DIC score >5 (p<0.001). Hypofibrinogenemia (fibrinogen<200mg/dL) was associated with increased mortality in all DIC cohorts (cardiovascular: 75% vs. 50%, p=0.035; neoplasm: 69% vs. 45%, p=0.044; sepsis: 100% vs. 25%, p=0.002).
Conclusions: Overt DIC is a rare but under-diagnosed event in outpatients requiring intensive care at a medical emergency department. In outpatients cardiac arrest is a dominant cause of DIC presenting with a fibrinolytic phenotype. The degree of hypofibrinogenemia strongly and linearly predicted early death.
Nina BUCHTELE (Vienna, AUSTRIA), Christian SCHOERGENHOFER, Andreas SCHOBER, Peter QUEHENBERGER, Bernd JILMA, Michael SCHWAMEIS
09:00 - 10:30 #1241 - #1241 - Prevalence of resistant pathogens in sepsis in the emergency department of a large urban area southwest of Milan: a pilot study.
#1241 - Prevalence of resistant pathogens in sepsis in the emergency department of a large urban area southwest of Milan: a pilot study.
Background: Choosing adequate empirical antibiotics in the management of sepsis is one of the main concerns, in particular when the source of the infection is unclear. Antibiotics suggested by guidelines are effective for the most of patients with sepsis, however a small percentage of these patients need a different treatment due to the presence of unusual or resistant pathogens. Moreover the increasing use of broad spectrum antibiotics as empirical therapy is by itself linked to the development of resistance.
Aim: to describe the prevalence of resistant pathogens in a population with sepsis admitted to the emergency department (ED) of a university hospital southwest of Milan and to assess the percentage of failure of the first empirical antibiotic therapy. The next step will be the identification of predictors of patients infected by resistant pathogens.
Methods: 62 consecutive patients admitted to the ED with a diagnosis of sepsis were included. We obtained specimens from blood in all cases and CNS fluid, urine, sputum and skin swab as clinically suggested. Up-to-date international and local guidelines have been adopted for the collection and processing of microbiological specimens, for the management of sepsis and for antibiotic treatment. Descriptive statistics has been applied to understand the role of resistant pathogens in the global picture of sepsis.
Results: The mean age of the population was 68 years with a slight prevalence of men. The identified source of sepsis was respiratory tract infection (RTI) in 30,6% of cases, urinary tract infection (UTI) in 29%, abdominal infection in 8,1%, endocarditis in 6,5%, skin 3,2 % and unknown in 19,4%. In 76% of cases we could obtain a microbiologic diagnosis. This picture is different in relation to the source of the infection; microbiological diagnosis was obtained in 94% of UTI, in 75% of endocarditis, in 68,4% of RTI. Data for meningitis, abdominal and skin infections have a low reliability due to the small number of cases collected. Notably we could identify a bloodstream pathogen in 58% of cases with an unidentified source of infection. The most frequent pathogens isolated were Enterobacteriaceae and Streptococcus pneumoniae. Resistant pathogens accounted for 8,5% of cases (all ESBL+). Considering the microbiological results, the first empirical treatment was not adequate in 17% of patients.
Conclusions: considering the well-established link between early and appropriate antibiotic therapy with the reduction of morbidity and mortality, the high percentage of inadequate empirical treatment (17%) should prompt to the development of further studies to better describe the actual scenario of microbial resistance and to identify predictors of antibiotic failure.
References:
Garnacho-Montero et al. Impact of adeguate empirical antibiotical therapy: outcome of patients admitted to the intensive care unit with sepsis . Critical Care Med 2003
Zilberberg et al. Multidrug resistence: inappropriate initial antibiotic therapy and mortality in Gram negative severe sepsis and septic shock: a retrospective cohort study. Critical care medicine 2014
Prina et al. Risk factors associated with potentially antibiotic.resistant pathogens in community-acquired pneumonia. Ann Am Thorac Soc 2015
Simone PASINI, Elena PRINA, Fabia CASTAGNA, Fabio SILINI, Piera PUGLIESE, Greta ROSSIGNOLI, Livio COLOMBO (Milan, ITALY)
09:00 - 10:30 #1259 - #1259 - Clinical experience or equipment:- What matters most for the inexperienced intubators in the management of paediatric airway?
#1259 - Clinical experience or equipment:- What matters most for the inexperienced intubators in the management of paediatric airway?
Introduction:
Respiratory arrest is the predominant cause of mortality in critically ill paediatric patients. Appropriate airway management can be life-saving for these patients, but it is a relatively low-frequency, high risk event, with significant potential for error. Clinicians inexperienced in paediatric airway management are often the first to attend paediatric patients in the emergency setting. We aim to determine if (1) the use of a video laryngoscope can improve intubation outcomes in the hands of inexperienced users; and (2) clinical experience of trainees affects intubation success rate using either traditional or video laryngoscopes.
Methods:
A prospective observational study was conducted involving 22 junior doctors who were inexperienced in the management of paediatric airways. Following a teaching session, participants were asked to deliver bag-mask ventilation and proceed to intubation of 3 manikins – an infant, an infant with a difficult airway (Pierre Robin Sequence) and a child. Intubation of each manikin was attempted with both standard and video laryngoscopes in a random order. The primary outcome measure was successful intubation, defined as one in which chest expansion was demonstrated via a correctly placed endotracheal tube within 120 seconds of removal of the bag-valve mask from the face. Secondary outcome measures included the ability of the participant to deliver effective bag-mask ventilation; the participants’ visualisation of the larynx using both laryngoscopes; and the ease of use of each laryngoscope. Relationships between successful intubation, type of laryngoscopes use, and clinical experience of the trainees were determined.
Results: In the 132 bag-mask ventilation attempts, technique was satisfactory in 129 attempts. Of the 132 intubations attempts examined, there were 15 failed intubations in the standard laryngoscopy group, and 4 failed intubations in the videolaryngoscopy group (Fishers exact test p<0.01). Video laryngoscopy significantly increased the number of successful intubations in the infant with Pierre Robin Sequence manikin (p < 0.01). Video laryngoscopy significantly improved intubation success rate among the most inexperienced trainees (1-3 years of postgraduate training) (p < 0.01) but did not make any difference among the more experienced trainees (>3 years postgraduate training) (p > 0.99). Participants reported improved visualisation of the glottic structures with the video laryngoscope (p <0.001) and 64% of the participants reported a preference for the video laryngoscope over the standard laryngoscope.
Discussion: This study demonstrates that inexperienced intubators get better visualisation of the larynx and improved intubation rates using a videolaryngoscope. The limitations imposed by manikins and the artificial nature of the assessment centre need to be translated to the clinical setting with care.
Conclusions: Clinical experience of the clinician and the equipment used both appear to be important factors in improving success rates in paediatric intubation. Validation in a larger study is required.
Lindsay FORD (Edinburgh, UK), Paula MIDGLEY, Tom BEATTIE, Tsz-Yan Milly LO
09:00 - 10:30 #1397 - #1397 - Severe tetanus: report of 14 cases.
#1397 - Severe tetanus: report of 14 cases.
Background:
Tetanus is a serious infectious disease, affecting over one million people each year worldwide and causing nearly 500,000 deaths per year. The speed of development of the clinical picture and severity of this condition requires hospitalization and treatment in intensive care unit (ICU). The aim of this study was to describe the epidemiological, clinical, therapeutic and evolutionary profile cases of patients transferred from emergency department (ED) to ICU for severe tetanus and evaluate the therapeutic management compared with recent literature data.
Methods :
We conducted a retrospective descriptive study from January 2002 to December 2013 including patients transferred from ED to ICU for a severe tetanus.
Results :
We included 14 cases of severe tetanus. Mean age was equal to 55 ± 16 years and the sex ratio equal to 1.3. A portal of entry was found in 85.7%. The mean incubation period was estimated at 8 ± 4 days, at 3.2 ± 3.7 days for the period of onset and the status phase at 10.3 ± 6.3 days. Trismus was the first to appear and the most frequent reported sign (13 cases). Spasms were found in 5 cases, paroxysms in 11 cases, in 13 cases of contractures and opisthotonos in half of the cases. Initial examination showed no resipratory nor hemodynamic and nor neurological distress. All patients were intubated, 12 at admission and 2 on the second day of hospitalization. Early tracheotomy was performed in nine cases, within 48 hours after intubation. Benzodiazepines were prescribed first intravenously and then orally at doses ranging from 2 to 16 mg /kg /day and maintained at full dose throughout the state phase. The association with phenobarbital was reported in 13 patients. An intravenous loading dose between 5 and 10 mg / kg was administered first then a relay was made orally. The phenobarbital was maintained throughout the status phase. The baclofen was prescribed at a dose of 10-15 mg / d orally. Neuromuscular blocking agents were used in 12 cases and sedation in all cases. Magnesium sulfate was used in 8 patients with a dose of 4 to 6 g / d during the status phase and then at a dose of 1 to 2 g / day. All patients received a tetanus vaccination and a serum therapy. Six of our patients had metronidazole at a dose of 1500 mg / d. The average length of stay was equal to 41 days ± 31 days and a mean duration of mechanical ventilation was 31 ± 27 days. Seven cases of acquired pneumonia mechanical ventilation were identified, 2 cases of catheter related infection, a nosocomial urinary tract infection and 4 cases of fungal infections. Two cases of pulmonary embolism were diagnosed. Trophic complications were observed in six patients. Mortality in our study was estimated at 50%.
Conclusion :
Despite therapeutic advances, evolution of tetanus remains burdened with a high percentage of deaths and it requires a long and expensive treatment. Therefore, efforts must be directed towards the prevention by adequate wound care and a better control of vaccination.
Dorsaf BELLASFAR (tunis, TUNISIA), Nadia KOURAICHI , Afef HAMMAMI, Ines FATHALLAH, Imene BOUKHALFA, Nozha BRAHMI, Aymen MRAD, Youssef BLEL, Mouldi AMAMOU
09:00 - 10:30 #1792 - #1792 -Diagnostic accuracy of focus cardiac and vein ultrasonography in patients with suspected pulmonary embolism presenting with haemodynamic instability.
#1792 -Diagnostic accuracy of focus cardiac and vein ultrasonography in patients with suspected pulmonary embolism presenting with haemodynamic instability.
Introduction. Echocardiography is recommended in patients with shock and suspected pulmonary embolism (PE), but consistent data about the diagnostic accuracy of focus cardiac (FOCUS) and compressive vein ultrasonography (CUS) in this setting are lacking. Aim of present study was to evaluate sensitivity, specificity, positive and negative predictive values of FOCUS and compressive ultrasonography (CUS) in patients with suspected PE presenting with haemodynamic instability.
Methods. We retrospectively analysed data of patients with suspected PE included in two published observational multicentre studies (SPES, NCT01635257; TELOS, NCT01908231). Patients presenting with shock (systolic blood pressure [SBP] less than 90 mmHg or a drop of SBP more than 40 mmHg lasting more than 15 minutes) or hypotension (SBP among 90-100 mmHg without shock) were included. All patients underwent FOCUS and CUS in the emergency department (ED) before final diagnosis. Ultrasound examination was performed by emergency physicians trained in FOCUS. The gold standard was multi detector CT pulmonary angiography (CTPA).
Results. We included 132 patients, with a mean age of 71±15 years, 47% were females, 89 (67%) patients were in shock at presentation, and 43 (33%) showed SBP among 90 and 100 mmHg without shock. Sixty-six (50%) patients had a final diagnosis of PE. FEC showed a sensitivity, specificity, PPV and NPV of 68%, 80%, 78%, and 72% respectively. CUS showed a sensitivity, specificity, PPV and NPV of 53%, 97%, 95%, and 67% respectively. The presence of at least FOCUS or CUS positivity increased sensitivity to 82% (95% CI: 73-88%), without changing specificity (77%, 95% CI 69-84%). Looking at patients with shock, the combined strategy showed a sensitivity of 87% (95% CI: 74-94%) and a specificity of 77% (95% CI: 68-83%).
Conclusion. FOCUS and CUS showed a good sensitivity and specificity for PE in patients presenting with haemodynamic instability, in particular using the combination of cardiac and vein ultrasonography. However, considering the non-negligible rate of false negatives and positives, when patient conditions allowed, CTPA should be considered.
Elisa CIANI, Simone VANNI (Florence, ITALY), Peiman NAZERIAN, Cosimo CAVIGLIOLI, Chiara GIGLI, Giuseppe PEPE, Maddalena OTTAVIANI, Gabriele VIVIANI, Michele BAIONI, Stefano GRIFONI
09:00 - 10:30 #2009 - #2009 - NIV in italian emergency department: preliminary data of an italian prospective observational study.
#2009 - NIV in italian emergency department: preliminary data of an italian prospective observational study.
Background: Acute Respiratory failure (ARF) is an important cause of ED visit. The use of non-invasive ventilation (NIV) in emergency is well established by numerous studies in literature for the treatment of acute cardiogenic pulmonary edema (ACPE) and Acute Chronic Obstructive Pulmonary Disease exacerbations (AECOPD). Other indications like pneumonia and chest trauma are still controversial. In Italy the use of NIV in ED is not uniform and there is no "state of the art" explanation of its use in the acute setting.
Aim of the study: assess the current use of NIV in the Italians EDs in terms of: indications, methods of application and results.
Method: prospective observational multicenter study. We present preliminary data regarding only two centres of the multicenter study. We enrolled patients admitted to the EDs of IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan and of IRCCS San Martino IST of Genoa. All patients had ARF and were treated with CPAP/NIV. Data were collected from January to March 2015. All clinical data (ARF causes, comorbidities, lab values), ventilation features (CPAP/NIV, parameters, interface), blood gas analysis (baseline and within six hours), complications and outcome were collected in a case report form and then analyzed with SPSS statistics v20.
Results: we enrolled 71 patients, 38 males (53.3%) and 33 females (46.5%). The mean age was 77.92 ± 13.6. Patients treated with CPAP were 56 (78.9%), with NIV 15 (21.1%). Most representative comorbidities in the all population were CAD 19 (26.8%), COPD 22 (31%) and CHF 13 (18.3%). Causes of ARF were ACPE: 20 pt (35.7%) in CPAP group, 3 (20%) in NIV group; Pneumonia: 24 (42,9%) in CPAP group 4 (26.7%) in NIV group; AECOPD: 1 (1.8%) CPAP group, 2 (13.3% NIV) (p<0.01). Global mortality was 25.4%, in CPAP group 23.6%, in the NIV group 33.3% (p 0.44). Patients improved: 44 pt (78.6%) in the CPAP group and 9 pt (60%) in the NIV group (p 0.63). Ventilation failure: 9 (16.1%) CPAP, 3 (21.4%) (p 0.14). History of COPD was present in 12 pt (21.4) in CPAP and in 10 (66.7) in NIV (p<0.01), home oxygen therapy in 1 pt (1.8%) in CPAP and 6 pt (40%) in NIV (p<0.01). In the first hours CPAP group had a significant improvement in PAS(151±34.9 to 132±132.41 p<0.01),PAD(79.2±20.9 to 71.5±14.5 p0.02),FC(102.6±24.1 to 89.08±21.5 p<0.01),SO2(88.8±13.9 to 97±3.2 p<0.01),HCO3(23.3±5.9 to 24.2±5.2 p0.01),Lac(2.8±2.7 to 2.04±1.7 p<0.01).NIV group in SO2(89.50±7.3 to 97.40±4.1 p0.02),pCO2(76.5±23.81 to 64.6±12.38 p0.03) and P/F(151.7±51.8 to 252.3±91.3 p0.03). Survivors differed from those who died during hospitalization for: COPD history (25% vs 50% p0.04), DNI condition (20% vs 70% p<0.01).
Conclusions:NIV is preferred to CPAP in the treatment of AECOPD and in patient with history of COPD. We observed no significant differences in terms of mortality and improvement between CPAP and NIV. Presence of comorbidities like COPD and DNI condition seems predict a worse outcome. These are only preliminary data: the study is currently ongoing in other Italian ED to better assess the use of NIV in the emergency setting.
Cutuli OMBRETTA (Genova, ITALY), Ferrari RODOLFO, Groff PAOLO, Margutti ELIANA, Moscatelli PAOLO, Maifreni MARIA LUISA, Gangitano GIAN FILIPPO, Cosentini ROBERTO
09:00 - 10:30 #2062 - #2062 - Niv in italian emergency department to treat hypercapnic acute respiratory failure: prospective multicentre observational study.
#2062 - Niv in italian emergency department to treat hypercapnic acute respiratory failure: prospective multicentre observational study.
Introduction:
Non-Invasive Ventilation (NIV) is utilized both for well established indications – Acute Exacerbations of Chronic Bronchitis (AECB), Acute Cardiogenic Pulmonary Edema (ACPE) or chest infections in immunodepressed patients - as controversial ones, like Pneumonia.
We took a picture of actual NIV utilization in hypercapnic Acute Respiratory Failure (ARF).
Materials and methods:
We prospectively evaluated consecutive ARF patients treated with Continuous Positive Airways Pressure (CPAP) or NIV between 1st of January and 9th of April 2015. All patients were admitted to Emergency Departments (EDs) of IRCCS Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milan and IRCCS San Martino-IST, Genoa.
Patients were divided into hypercapnic (PaCO2 > 45 mmHg, Group1) and hypo or normocapnic (Group2) based on Arterial Blood Gas (ABG) obtained at admission before ventilatory support.
We distinguished between one (CPAP) and two pressure levels (NIV); further distinction has been made between interfaces and modalities.
Study population was analized for comorbidities, ED observation parameters, blood values and serial ABGs.
Prospective evaluation was based on in-hospital mortality, NIV interruption for improvement or other causes, switch to other NIV modality and ABG parameters modification within 6 hours.
Data were analysed and statistics performed with SPSS 20.0.
Results:
65 patient were enrolled in this study. Group1 and Group2 included 33 (51%) and 32 (49%) patients respectively; mean age was 77.7 ±14 years, 35 (54%) were male. In Group1 19 patients (58%) were treated with CPAP, 14 (42%) with NIV; in Group2 31 patients (97%) were treated with CPAP and only one (3%) NIV.
Past medical history was not a significant variable, with the exception of COPD (46% vs 19%, p0.021) and LTOT (18% vs 3%, p0.050), both prevalent in Group1.
Among blood laboratory values, only urea and pro-BNP were significatively different and higher in Group2 (92 vs 55 mg/dl, p0.01 and 15349 vs 5763 pg/L, p0.033 respectively).
Main pathologies precipiting ARF were Pneumonia (26 patients, 39% in Group1 - 61% in Group2), ACPE (19 patients, 26% in Group1 - 74% in Group2) and Pneumonia-ACPE overlap (12 patients, 83% in Group1 - 17% in Group2); minor causes included COPD exacerbation (8 patients, all hypercapnic).
Hospital mortality was similar in the two groups (24% in Group1 versus 31% in Group2).
Analysing in Group1, as expected, the large majority (26 patients, 79%) were acidotic (arterial pH < 7.35) and only 7 patients (21%) had a normal or alkalotic pH – mainly treated with CPAP. Surprisingly, in hypercapnic and acidotic subgroup, patients received equally CPAP or NIV (50% vs 50%) and no difference was noted in outcome (8 patients died, 33%, half treated with CPAP, half with NIV).
Conclusion:
This study reflects real life NIV application in two main italian EDs, focusing on hypercapnic patients.
These are partial results and study population need to be extended, also including other centres, whose recruitment is ongoing. An increasingly frequent NIV indication is symptom relief in extremely poor prognosis patients; this should be taken into account while analyzing data.
Anna Maria BRAMBILLA, Nicola BACCIOTTINI (Vercelli, ITALY), Daniele CAMISA, Antonio VOZA, Emanuela BRESCIANI, Alice MORELLI, Federica GHIONE, Italian Society Of Emergency Medicine SIMEU
09:00 - 10:30 #859 - #859 - S-100 B Concentrations are a Predictor of Decreased Survival in Patients with Major Trauma Independently of Head Injury.
#859 - S-100 B Concentrations are a Predictor of Decreased Survival in Patients with Major Trauma Independently of Head Injury.
Objectives
Major trauma remains one of the principle causes of disability and death throughout the world. There is currently no satisfactory risk assessment to predict mortality in patients with major trauma. The aim of our study is to examine whether
S-100 B protein concentrations correlate with injury severity and survival in patients with major trauma, with special emphasis on patients without head injury.
Data sources, study selection and data extraction
Our cross-sectional data analysis comprised adult patients admitted to our emergency department with a suspected major trauma between 1.12. 2008 and 31.12 2010. S-100 B concentrations were assessed routinely in major trauma patients.
Data Synthesis
A total of 378 (27.7%) of all patients had major trauma. The median ISS was 24.6
(SD 8.4); 16.6% (63/378) of the patients died.S-100 B concentrations correlated overall with the ISS (p<0.0001). Patients who died had significantly higher
S-100 B concentrations than survivors (8.2 µg/l versus 2.2 µg/l,
p<0.0001). Polytraumatised patients with and without head trauma did not differ significantly with respect to S-100 B concentration (3.2 µg/l (SD 5.3) versus 2.9 µg/l (SD 3.8), respectively, p = 0.63) or with respect to ISS (24.8 (SD 8.6) versus 24.2 (SD 8.1), respectively, p = 0.56). S-100 B concentrations correlated with survival (p<0.0001) in all patients and in both subgroups (p = 0.001 and p = 0.006, respectively)
Conclusions
S-100 concentrations on admission are of considerable diagnostic value in the evaluation of injury severity and survival of major trauma patients.
S-100 B concentrations are not significantly different in major trauma patients with and without head injury. Death is associated with increased S-100 B concentrations, regardless of concomitant head trauma.
Carmen Andrea PFORTMUELLER (Vienna, AUSTRIA), Christian DREXEL, Simone KRÄHENMANN-MÜLLER, Alexander Benedikt LEICHTLE, Georg Martin FIEDLER
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Oral Paper 2
Infectious Disease / Sepsis
Moderators: Carmen Diana CIMPOESU (Prof univ. Head of ED) (IASI, ROMANIA), Mehmet Akif KARAMERCAN (ANKARA, TURKEY)
09:00 - 10:30 #1037 - #1037 - Early identification of severe sepsis in the Emergency Department.
#1037 - Early identification of severe sepsis in the Emergency Department.
Introduction: Early identification of septic patients is one of the key elements in appropriate management to recude mortality. Diagnosis of sepsis requires high clinical suspicion as signs of infection and organ dysfunction may be subtle. The systemic inflammatory response syndrome (SIRS) criteria are inaccurate for the early detection of sepsis. Shock index (SI), defined as heart rate/systolic blood pressure, has previously been shown to identify high risk septic patients. Our objective was to compare the ability of SI, individual vital signs, and SIRS criteria to predict hyperlactatemia (serum lactate ≥4.0 mmol/L)(primary outcome), as a surrogate for disease severity and marker for cryptic septic shock, and 28-day mortality (secondary outcome). Methods: We performed a retrospective analysis of a cohort of adult patients presenting to an Urban Hospital Emergency Department (ED) (with 380000 annual visits), from January 1st, 2013 to December 31st, 2013. Adult patients presenting to the ED with a suspected infection were screened for severe sepsis using triage vital signs, basic laboratory tests and an initial serum lactate level. Test characteristics were calculated for two outcomes: hyperlactatemia (marker for morbidity and cryptic septic shock) and 28-day mortality. We considered the following covariates in our analysis: fever (body temperature ≥38° C); systolic arterial pressure <90 mmHg; ≥2 SIRS criteria; and SI >0.7. We report sensitivity, specificity, and positive and negative predictive values for the primary and secondary outcome. Results: 113 patients (82.4%) had complete records and were included in the analysis. 16 (14.1%) patients presented with hyperlactatemia and 20 (17.7%) patients died within 28 days. Subjects with an abnormal SI >0.7 (87.5%) were more likely to present with hyperlactatemia than those with a normal SI (58.2%). The negative predictive value (NPV) of a SI ≥0.7 was 95.3%, close to the NPV of SIRS (96%). Moreover, 28-day mortality is much greater in subjects with SI >0.7 (50%) than those with a normal SI (12.2%). Conclusion: In this cohort, SI >0.7 performed as well as SIRS in NPV and was the most sensitive screening test for hyperlactatemia and 28-day mortality. SI >0.7 is a no-cost bedside triage tool that predict hyperlactatemia and cryptic septic shock, with implications for efficiency and cost effectiveness in ED protocols and for management and prognosis of patients with severe sepsis and septic shock.
Luca NALDI (Sesto Fiorentino, ITALY), Germana RUGGIANO, Daniela BALZI
09:00 - 10:30 #1069 - #1069 - Sensitivity of Procalcitonin, C-Reactive Protein and White Blood Cell Count in severe sepsis and occult bacteremias in relation to the etiology.
#1069 - Sensitivity of Procalcitonin, C-Reactive Protein and White Blood Cell Count in severe sepsis and occult bacteremias in relation to the etiology.
Objective: To analyze the sensitivity of procalcitonin (PCT), C-Reactive protein (CRP), white blood cell (WBC) count and absolute neutrophil count (ANC) for occult bacteremia (OB) and sepsis among previously healthy patients attended at the Pediatric Emergency Department depending on their etiology.
Methods: prospective, multicenter registry developed by the Infectious Disease Working Group of the Spanish Pediatric Emergencies Society (SEUP). Patients with a positive blood culture collected in any of the 22 participating Hospitals are included. Patients recruited between 2011/01/01 and 2013/12/31 with a final diagnosis of severe sepsis or occult bacteremia are analyzed. We defined severe sepsis as the presence of signs of organ dysfunction and OB as the presence of a normal Pediatric Assessment Triangle with no associated focal infection and no associated signs of organ dysfunction. Bacteria with at least 10 cases of one of these pathologies were studied. The following values were considered elevated: PCT≥0.5 ng/mL; CRP>20 mg/L; WBC>15,000/mm3; ANC>10,000/mm3.
Results: there were 931 positive blood cultures, being 711 (76.3%) of them collected in previously healthy patients. Finally, 133 met criteria of OB (most frequently isolated bacteria: S.pneumoniae [50], S. agalactiae [20], S. aureus [17] and E. coli [10]) and 109 met criteria of severe sepsis (most frequently isolated bacteria: S. agalactiae [36], N. meningitidis [26], E. coli [15] and S. pneumoniae [12]. Patients with infections by E. coli and S.agalactiae were younger and were attended with shorter evolution of fever.
Overall, the most frequently elevated test among patients diagnosed with a severe sepsis was PCT (97.2%), followed by CRP (69.2%). Among patients with an OB the four blood tests were elevated in a similar percentage: PCT 53.1%; CRP 43.7%; WBC count 47.4%; ANC 42.9%. In both cases, there were significant differences in relation of these results depending on the etiology.
Among patients with pneumococcal OBs, 82% of them presented leukocytosis and neutrophilia (vs 54.5% and 57.4% of patients in whom PCT and CRP were respectively elevated). The only blood test that was elevated in a significant percentage among patients with OB by S. agalactiae was PCT (62.5%, vs <30% for the other studied tests). OB by S. aureus and E. coli did not significantly elevate any of the studied tests.
Among patients with severe bacterial sepsis, PCT was elevated in at least 85% of them regardless the etiology. CRP was also elevated in a similar proportion except in patients with sepsis by S. agalactiae (31.4%). WBC count and ANC count were only elevated significantly in patients with pneumococcal sepsis (66.7%).
Conclusions: among patients with occult bacteremias and severe bacterial sepsis, sensitivity of PCT, CRP, WBC count and ANC vary significantly depending on the causing bacterium. The WBC count and the ANC can still be useful to rule out a pneumococcal occult bacteremia. Overall the most sensitive test among septic patients is the PCT.
Borja GOMEZ (Barakaldo, SPAIN), Susanna HERNANDEZ-BOU, Santiago MINTEGI, Juan Jose GARCIA-GARCIA, From The Infectious Diseases Working Group BACTERAEMIA STUDY WORKING GROUP
09:00 - 10:30 #1158 - #1158 - Accidental blood exposures among Emergency medical residents in France.
#1158 - Accidental blood exposures among Emergency medical residents in France.
Background: Health care workers are exposed to blood or fluid exposure (BFE). They are therefore at risk for occupational infections. Emergency medicine (EM) physicians and residents are at potential high risk of occupational infections as they routinely care for large amounts of patients with a paucity of information on their past medical history. The aim of this study was to investigate the epidemiological characteristics of BFE and occupational infection risk among EM residents and young physicians (
Methods: We conducted a cross-sectional, anonymous, online survey among EM residents and young physicians in France, from January to April 2015. The survey was designed by consensus among the authors. The link to the online survey was distributed by email via the AJMU network (Association of young emergency medicine practitioners). AJMU aggregates the majority of young EM physicians trained since 2004. Demographic data, history of occupational BFE, details of the last BFE and vaccination status were collected.
Results: 1779 participants were contacted, with a response rate of 36% (n=633). Among the respondents, 459 (72%) reported at least one BFE. Mean age was 30.4 years and 63% were women (n=289). The rate of self reported exposure increased with medical experience: 60% (n=69) for first year residents, 71% (n=86) for second year residents and 77% (n=304) for post graduates (p<0.01). Among participants with at least one BFE, 35% (n=163) never reported the exposure to the relevant medical authorities or support. Only 30% (n=136) always reported their BFEs. Among participants who reported exposure, 78% (n=232) immediately reported it. Among participants who never or not systematically reported their BFE, 62% (n=181/289) did not do it because the procedure was too long, and for 28% (n=82/289) because they estimated the risk as low. The circumstances in which the participants had the most BFE were: suture 57% (n=262), when making precipitated gesture 24% (n=111) or while handling an agitated patient 17% (n=79). Only 19% (n=88) systematically checked the patient’s viral status. One third (n=153) never used condoms with their partner after a BFE and 18% (n=83) never informed their partner of the transmission risk. The latest exposures were most commonly caused by a solid needle 42% (n=191) or hollow-bore needle 27% (n=123). Half of the participants (n=226) reported their last BFE. Only one third (n=166) checked their HIV status with two blood tests even though the BFE was at a transmission risk.
Conclusions: EM residents and young physicians were frequently exposed to BFE, mostly with a solid needle. Post-exposure reporting rates were low. Reporting procedure itself and self-management were the main reasons for BFE underreporting. Simplifying occupational blood exposure procedures might increase BFE reporting rates, and allow appropriate post exposure counseling and/or prophylaxis. Preventing exposure is of major importance among health care workers to avoid occupational infections. EM residents and young physicians should be included in educational programs.
Anthony CHAUVIN (Paris), Alice HUTIN, Thomas LEREDU, Patrick PLAISANCE, Dominique PATERON, Youri YORDANOV
09:00 - 10:30 #1168 - #1168 - Use of broad spectrum antibacterial agents in French EDs : different trends for 3rd generation cephalosporins and fluoroquinolones.
#1168 - Use of broad spectrum antibacterial agents in French EDs : different trends for 3rd generation cephalosporins and fluoroquinolones.
Background : Third-generation cephalosporins and fluoroquinolones are particularly prone to promote bacterial resistance. Their use in Emergency Departments (ED) is poorly known and should be monitored in order to guide antibiotic stewardship programs.
Objectives: To assess the use of antibacterial agents in French Emergency Departments (ED).
Methods : Retrospective study of antibiotics delivered to the adult units of 11 EDs of French academic centres between 2009 and 2012.
Results: The total antibiotic use was 66.4 Defined Daily Doses (DDD) /1000 ED visits in 2012, and increased between 2009 and 2012 (yearly estimate, +1.8 ± 0.9 DDD/1000 ED visits, P=0.048). The broad spectrum agents class, that grouped 3rd-generation cephalosporins and fluoroquinolones, accounted for 39.2% of total antibiotic use, and was highly variable among EDs (range, 31.6% to 49.5% of total antibiotic use). The aminopenicillin and beta-lactamase inhibitor / broad spectrum agents ratio varied among EDs (median [range], 0.91 [0.52 – 1.25]). Between 2009 and 2012, there was a significant decrease for broad spectrum agents (yearly estimate, -0.8%±0.4% of total antibiotic use), antipneumococcal fluoroquinolones (-0.8%± 0.3%) and other fluoroquinolones (-0.9%± 0.3%), and a significant increase for 3rd-generation cephalosporins (+0.7%± 0.3%), aminoglycosides (+0.4%± 0.1%), imidazole derivatives (+0.4%± 0.1%) and lincosamides (+0.1%± 0.0%).
Conclusion: Fluoroquinolones and 3rd generation cephalosporins are widely used in French EDs. Their use is highly variable among EDs. Antibiotics as a whole, and 3rd generation cephalosporins have been increasingly used between 2009 and 2012, while the use of fluoroquinolones has decreased. Reduced ED use of cephalosporins, without increasing fluoroquinolones, should be aimed through antibiotic stewardship programs.
Eric BATARD, Cathelle LEMARCHAND, Marie-Anne VIBET, Nicolas GOFFINET (NANTES CEDEX 1), Edantibiotics Study Group EDANTIBIOTICS STUDY GROUP, Didier LEPELLETIER, Emmanuel MONTASSIER
09:00 - 10:30 #1170 - #1170 - Rapid detection of amoxicillin susceptible Escherichia coli in the urine : a promising tool to limit the use of broad spectrum antibiotics for urinary tract infection in the Emergency Department.
#1170 - Rapid detection of amoxicillin susceptible Escherichia coli in the urine : a promising tool to limit the use of broad spectrum antibiotics for urinary tract infection in the Emergency Department.
Background: The empirical therapy of pyelonephritis is based on a fluoroquinolone or a 3rd generation cephalosporin. However, these agents are particularly prone to promote bacterial resistance to antibiotics, and their use should be restricted. A rapid detection of amoxicillin-susceptible bacteria in the urine would allow to start amoxicillin in the Emergency Department for pyelonephritis without a preliminary broad spectrum empirical treatment.
Objectives: To develop and validate a triple real-time PCR for the diagnosis of Urinary Tract Infection (UTI) due to amoxicillin susceptible Escherichia coli.
Methods: We developed a triple real time PCR for Amoxicillin Susceptible E. coli (ASEC) applied to fresh, uncultured urine. The ASEC PCR detects the E. coli specific gene ycct, and genes of the main beta-lactamases causing amoxicillin resistance in French E. coli isolates (blaTEM and blaCTX-M ). The ASEC PCR is considered positive for ASEC when the PCR is positive for the yccT gene and negative for both blaTEM and blaCTX-M genes. We assessed prospectively the ASEC PCR on patients with suspected urinary tract infection, who have been hospitalized in 2014 for less than 3 days in a French hospital. Routine identification and susceptibility tests were used as the gold standard.
Results: Among 200 patients, routine tests isolated E. coli (n=117, 58%, including 58 amoxicillin susceptible isolates), another bacterium (n=47), or proved sterile (n=36). The ASEC PCR result was obtained in 3 hours and 10 minutes after urine sampling (CI 95% 3:07-3:14). The ASEC PCR was positive in 42 (21%) patients. The specificity of ASEC PCR was 97,9% (CI 95% 95.9 -99.9), the sensibility was 65.0% (CI 95% 58.4-71.6), the positive predictive value (PPV) was 92.9 % (CI 95% 89.3-96.41) and the negative predictive value was 86.7% (CI 95% 82.0-91.4).
Conclusion: The ASEC real time PCR allows a rapid diagnosis of UTI due to amoxicillin susceptible E. coli , as its result is available 3 hours after urine sampling. Thanks to its high positive predictive value, the ASEC PCR may be used to treat UTIs with amoxicillin in the Emergency Department. Its use would have reduced by up to 21% the prescriptions of fluoroquinolones or 3rd generation cephalosporins for pyelonephritis in the ED. The ASEC PCR is a promising tool to save fluoroquinolones and 3rd generation cephalosporins in the ED.
Guillaume CHAPELET, Emmanuel MONTASSIER, Stéphane CORVEC, Nicolas GOFFINET (NANTES CEDEX 1), Laure DE DECKER, Eric BATARD
09:00 - 10:30 #1407 - #1407 - Fractal dimension (Df): A new functional biomarker that helps to quantify clot microstructure across the sepsis spectrum.
#1407 - Fractal dimension (Df): A new functional biomarker that helps to quantify clot microstructure across the sepsis spectrum.
Introduction: Sepsis is a systemic inflammatory response caused by an infection. It is well recognised that this inflammatory response is associated with complex changes in both the coagulation system and the cells that regulate this system [1]. These changes can lead to a hypercoagulable state that can increase the risk of thrombosis, which is dependent on the severity of the disease [2]. In severe sepsis and septic shock, upregulation of the procoagulant pathways and dysfunction of the natural inhibitory pathways can lead to the development of Disseminated Intravascular Coagulation (DIC) [3]. DIC causes microthrombi to form systemically, causing microvascular obstruction, thromboembolic events and organ dysfunction [4]. It also causes increased consumption of platelets and coagulation proteins leading to a bleeding diathesis [5]. However, the complex changes in coagulation pathways in sepsis are poorly understood. This study aims to assess the relationship between sepsis severity and a new biomarker of clot microstructure, fractal dimension (Df) [6], in patients across the sepsis spectrum (sepsis, severe sepsis and septic shock).
Methodology: Adult patients (>18yr old) presenting with sepsis were recruited from the Emergency Department (ED) and Intensive Care Unit (ICU) of a large teaching hospital in Wales. Patients with diseases affecting the coagulation profile (liver failure, coagulation disorders) and who were on anticoagulants were excluded. Rheological analysis was performed on whole, unadulterated blood samples to determine Df. Citrated and EDTA samples were also taken to assess standard markers of coagulation and a full blood count. Healthy volunteers matched for age and gender were also recruited as a control group. This study had ethical approval from the South West Wales research ethics committee.
Results: 95 patients were included in the study: 49 with sepsis, 19 with severe sepsis and 27 with septic shock. 44 healthy volunteers were recruited as a matched control. Mean Dfin the healthy control group was 1.74 ± 0.03. Mean Dfin patients with sepsis and severe sepsis was significantly elevated (1.78 ± 0.07 and 1.80 ± 0.05 respectively (p<0.05, One-way ANOVA Post-hoc Bonferroni correction)). Mean Df in patients with septic shock was significantly reduced compared to all other groups (1.66 ± 0.10 (p < 0.001, One-way ANOVA Post-hoc Bonferroni correction)).
Conclusion: Our results indicate that patients with sepsis and severe sepsis form tight highly branched fibrin clots (as indicated by high Df) that are resistant to fibrinolysis. As the disease progresses to septic shock, much weaker clots are formed (as indicated by low Df) that are more susceptible to fibrinolysis. This may explain the dichotomy of thrombogenicity and bleeding diathesis in patients across the sepsis spectrum. The new functional biomarker, fractal dimension (Df), therefore can be used to quantify clot microstructure across the sepsis spectrum.
References:
1. Remick DG (2007) Pathophysiology of sepsis. Am J Pathol 170: 1435–1444.
2. Donze JD, Ridker PM, Finlayson SRG, Bates DW (2014) Impact of sepsis on risk of postoperative arterial and venous thromboses: large prospective cohort study. Bmj 349: g5334–g5334.
3. Faust SN, Heyderman RS, Levin M (2000) Disseminated intravascular coagulation and purpura fulminans secondary to infection. Baillieres best Pract Res Clin Haematol 13: 179–197.
4. Gando S (2010) Microvascular thrombosis and multiple organ dysfunction syndrome. Crit Care Med 38: S35–S42.
5. Levi M (2007) Disseminated intravascular coagulation. Crit Care Med 35: 2191–2195.
6. Evans P a, Hawkins K, Morris RHK, Thirumalai N, Munro R, et al. (2010) Gel point and fractal microstructure of incipient blood clots are significant new markers of hemostasis for healthy and anticoagulated blood. Blood 116: 3341–3346.
Gareth Richard DAVIES (Swansea, UK), Suresh PILLAI, Gavin MILLS, Keith MORRIS, Phylip Rhodri WILLIAMS, Phillip Adrian EVANS
09:00 - 10:30 #1538 - #1538 - Scoring systems for stratification of septic patients: incremental prognostic value of prognostic scores over age, comorbidity, vital signs and lactate.
#1538 - Scoring systems for stratification of septic patients: incremental prognostic value of prognostic scores over age, comorbidity, vital signs and lactate.
Introduction
The aim of the study was to evaluate the incremental prognostic value of different scoring systems over clinical data in a population of septic patients.
Methods
Retrospective study on 548 septic patients admitted in the Emergency Department (ED)-High-Dependency Observation Unit of Careggi University-Hospital of Florence between June 2008 and May 2014. We calculated retrospectively Modified Early Warning Score (MEWS), Charlson Comorbidity Index, Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation (APACHE) II, Mortality in Emergency Department Sepsis (MEDS), Predisposition, Insult, Response, Organ dysfunction (PIRO). The scores were calculated at the time of ED admission (T0) and after 24 hours (T1) using data obtained from clinical records. A follow-up based on telephone interviews was performed to ascertain 28-days vital status.
Results
Medical records of 548 subjects aged 75±14 years, 52% men, were examined; diagnosis was sepsis in 108 (20%) patients, severe sepsis in 272 (49%) and septic shock in 168 (31%). Overall 28-days mortality rate was 31%; 10% of patients were transferred to an Intensive Care Unit (ICU). The lactate dosage was 4.7±8.5 mmol/L at T0 and 3.4±8.4 mmol/L at T1. The mean T0 SOFA score was 6.1±3.4 at T1 and 5.8±3.2. The different scoring systems showed a modest to moderate discrimination (area under the curve of T0 PIRO: 0.663, T1 PIRO: 0.686, T0 SOFA: 0.718, T1 SOFA: 0.758, T0 MEWS: 0.667, T1 MEWS: 0.694, Charlson: 0.598, APACHE II: 0.775, MEDS: 0.663). Only MEWS at T1 (5.2±2.3 vs 3.7±2.2, p=0.001) and SOFA at both T0 (7.4±3.4 vs 5.9±3.3, p=0.002) and T1 (7.5±3.7 vs 5.7±3.2, p=0.003) were significantly higher in patients who were admitted to ICU. At a multivariate stepwise Cox analysis we firstly entered age (RR 1.037, 95%CI 1.018-1.056, p <0.0001) that was significantly associated with a higher mortality, then Charlson Comorbidity Index (RR 1.090, IC95% 1.037-1.146, p=0.001) that was a significant mortality predictor even when age-adjusted. MEWS score provided incremental prognostic value (RR 1.153, 95%CI 1.062-1.251, p=0.001), making comorbidities to lose their independent prognostic value. T0 lactate value did not show any independent prognostic value. Finally we separately entered two organ dysfunction scores: PIRO and SOFA. SOFA showed an incremental prognostic ability both at T0 (RR 1.206, IC95% 1.136-1.279, p <0.0001) and T1 (RR 1.239, IC95% 1.153-1.331, p<0.0001), while PIRO showed no independent prognostic value at any time. Lactate dosage proved independent prognostic ability only at T1 (RR 2.088, IC95% 1.297-3.360, p=0.002).
Conclusions
SOFA score correlated with both mortality and ICU transfer need and showed incremental prognostic power compared to age, comorbidities, vital signs and lactate dosage.
Chiara DONNINI (SESTO FIORENTINO-FIRENZE, ), Simona GUALTIERI, Eleonora DE VILLA, Camilla TOZZI, Francesca INNOCENTI, Riccardo PINI
09:00 - 10:30 #1609 - #1609 - A new functional biomarker, fractal dimension (Df) that helps to quantify clot microstructure in septic patients with pnuemonia: a subgroup analysis.
#1609 - A new functional biomarker, fractal dimension (Df) that helps to quantify clot microstructure in septic patients with pnuemonia: a subgroup analysis.
Introduction: Sepsis is a systemic inflammatory response caused by an infection. It is well recognised that this inflammatory response is associated with complex changes in both the coagulation system and the cells that regulate this system [1]. Respiratory infections especially pneumonia are one of the most common causes of sepsis seen in the Emergency Department. These patients often require respiratory support. Patients with pneumonia can develop severe sepsis and septic shock. This subgroup analysis aims to quantify changes that occur in clot microstructure [2] in patients with pneumonia from a septic cohort of patients recruited across the sepsis spectrum.
Methodology: Adult patients (>18yr old) presenting with sepsis were recruited from the Emergency Department (ED) and Intensive Care Unit (ICU) of a large teaching hospital in Wales. Patients with diseases affecting the coagulation profile (liver failure, coagulation disorders) and who were on anticoagulants were excluded. Rheological analysis was performed on whole, unadulterated blood samples to determine Df. Citrated and EDTA samples were also taken to assess standard markers of coagulation and a full blood count. Healthy volunteers matched for age and gender were also recruited as a control group. This study had ethical approval from the South West Wales research ethics committee.
Results: 95 patients were included in the initial study, 28 who had pneumonia. Of these 28 patients, 11 had a diagnosis of sepsis, 7 had severe sepsis and 10 septic shock. 10 healthy volunteers were recruited as a matched control. Mean Dfin the healthy control group was 1.74 ± 0.03. Mean Dfin patients with sepsis and severe sepsis was 1.78 ± 0.06 and 1.75 ± 0.10 respectively. Mean Df in patients with septic shock was significantly reduced compared to all other groups (1.63 ± 0.07 (p < 0.001, One-way ANOVA Post-hoc Bonferroni correction)).
Conclusion: Our results indicate that septic patients with pneumonia undergo similar changes in clot microstructure that we observed in the sepsis group as a whole. Patients with sepsis and severe sepsis form tight highly branched fibrin clots (as indicated by high Df) that are resistant to fibrinolysis. As the disease progresses to septic shock, much weaker clots are formed (as indicated by low Df) that are more susceptible to fibrinolysis. This may explain the dichotomy of thrombogenicity and bleeding diathesis in patients across the sepsis spectrum. The new functional biomarker, fractal dimension (Df), therefore can be used to quantify clot microstructure in patients with pneumonia.
References:
1. Remick DG (2007) Pathophysiology of sepsis. Am J Pathol 170: 1435–1444.
2. Evans P a, Hawkins K, Morris RHK, Thirumalai N, Munro R, et al. (2010) Gel point and fractal microstructure of incipient blood clots are significant new markers of hemostasis for healthy and anticoagulated blood. Blood 116: 3341–3346.
Gareth Richard DAVIES (Swansea, UK), Suresh PILLAI, Gavin MILLS, Keith MORRIS, Karl HAWKINS, Phylip Rhodri WILLIAMS, Phillip Adrian EVANS
09:00 - 10:30 #1877 - #1877 - Myocardial dysfunction during sepsis: is it reversible?
#1877 - Myocardial dysfunction during sepsis: is it reversible?
Background: In about 40% of septic patients, a new left ventricular (LV) systolic dysfunction develops. LV ejection fraction (EF) does not represent an accurate parameter for cardiac function’s evaluation in sepsis due to its high preload and afterload dependency. Two-dimensional (2D) echocardiography based analysis of strain (GLS) could represent a valid alternative, providing a measure of myocardial contractility, poorly influenced by loading condition. Aim of this study was to evaluate the reversibility of septic myocardial systolic dysfunction by LVEF and GLS.
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 November 2014 were prospectively enrolled. Anamnestic data and main clinical and laboratory parameters were obtained for each patient to evaluate Sequential Organ Failure Assessment (SOFA) score. An echocardiogram was performed within 24 hours from sepsis diagnosis (T1). LVEF was calculated by Simpson’s rule. The longitudinal GLS was evaluated from apical LV views, with a commercially available system (Philips Q-LAB ver. 8.1). In a consecutive group of survivors we repeated an echocardiogram after 3 months from discharge (T2).
Results: We enrolled 100 consecutive patients; 29% of them died at 28 days. Among 71 survivors, in 24 unselected patients (G1) we could repeat an echocardiographic evaluation after three months; remaining patients (G2) refused to come to the hospital to undergo the second echocardiogram, in most cases for persistent immobilization syndrome. G1 included 16 males, mean age 67±12 years; main comorbidities were hypertension in 68% of patients, diabetes in 54%, coronary artery disease in 17%. Pulmonary sepsis was found in 68% of patients; six patients (25%) developed septic shock. Sepsis severity appeared worse in G1 than G2 patients: T1 SOFA score (G1 5.9±2.7 vs G2 7.2±2.6; p=0,04) and lactate dosage (G1 1.29±0.92 vs G2 2.6±2.94 mmol/l p= 0,01) were significantly higher in G1 compared with G2 patients; nevertheless GLS (GLS% G1: -11.4±3.2 vs G2: -10.9±3.3%; NS) and EF (G1: 52±16 vs G2 50±16%; NS) at the first evaluation were comparable. After three months the echocardiographic evaluation showed a myocardial function’s improvement, demonstrated by both GLS (-11.4±3.2 vs -12.9±2.4%; p=0.03) and EF (52±16 59±13%, p=0,02) better values. Considering individual patients, GLS appeared better at the follow-up compared with baseline evaluation in 17 patients (71%) and it worsened in remaining 7: patients with reversible dysfunction were significantly older compared with patients with worsening dysfunction; indices of sepsis severity, like T1 SOFA (5.8±2.9 vs 6.3±2.4) and T1 lactate dosage (1.3±0.7 vs 1.2±1.4 mmol/l, p=NS) were comparable between the two groups.
Conclusions: Myocardial dysfunction during sepsis appears to be reversible in a high proportion of patients: the limited population size precluded the identification of parameters significantly associated with reversibility.
Chiara DONNINI (SESTO FIORENTINO-FIRENZE, ), Aurelia GUZZO, Valerio Teodoro STEFANONE, Francesca INNOCENTI, Vittorio PALMIERI, Riccardo PINI
09:00 - 10:30 #1941 - #1941 - Role of coagulation and platelet function point of care tests in patients with sepsis and non-infectious systemic inflammatory response syndrome in the emergency department.
#1941 - Role of coagulation and platelet function point of care tests in patients with sepsis and non-infectious systemic inflammatory response syndrome in the emergency department.
Introduction: Systemic Inflammatory Response Syndrome (SIRS) can match with numerous infectious or non-infectious conditions, frequently observed in the Emergency Department (ED). Inflammation and coagulation are closely linked and SIRS is often characterized by early alterations of clotting and platelets, with major thrombotic and bleeding complications. Thrombelastometry (Rotem®) and Impedance Aggregometry (Multiplate®) are point-of-care (POC) technologies with a potential diagnostic and predictive value in critically ill patients. The former is a viscoelastic method able to quickly assess the whole plasmatic coagulation process according to different activation pathways; the latter evaluates global platelet function in response to different stimuli. Early identification of SIRS is a prime target for optimal treatment and the application of acute coagulopathy POC tests in the ED may help to define a peculiar coagulation profile to distinguish the genesis of SIRS, increase diagnostic effectiveness and speed, evaluate the severity of disease and identify high risk patients.
Methods: In this prospective observational study we enrolled 110 patients presenting to 2 local ED, with clinical diagnosis of infectious SIRS (40 sepsis, 38 severe sepsis/septic shock) and non-infectious SIRS (32 severe trauma with Injury Severity Score> 15). Clinical scores and Laboratory values were recorded at first presentation, together with Rotem® tests (Extem for extrinsic pathway, Intem for intrinsic pathway, Fibtem for evaluating fibrinogen and Aptem tests to exclude hyper-fibrinolysis) and Multiplate® tests (ASPI, ADP, TRAP, COL and RISTO test). Trauma patients (T) were considered as controls and compared to sepsis (S) and severe sepsis/septic shock (SS) patients; the group with non-infectious SIRS (T) was furthermore compared to the infectious SIRS (S + SS) group. Final diagnosis, in hospital length of stay and survival were obtained from clinical records.
Results: Significant differences were observed in the Intem clotting time (CT) mean values between the trauma, sepsis and the severe sepsis/septic shock populations (p=0.031). Analysis of clot firmness (MCF and A10) displayed significant differences among the trauma population and populations with sepsis and severe sepsis/septic shock in Extem (p=0.016) and Fibtem (p<0.0001). Rapidity of clot formation (alpha angle) was also significantly increased in the population with infectious SIRS. Multiplate® analysis demonstrated a widespread tendency to hypo-aggregability in the populations with infectious SIRS, via ADP (p=0.005), COL (p=0.001) and TRAP (p=0.002) tests. Diagnostic accuracy of POC tests in discriminating cases of infectious SIRS was good and far superior to classical laboratory variables and clinical scores. Preliminary data furthermore suggest a role for POC tests in patient risk stratification and mortality prediction.
Conclusion: This work represents one of the first examples of joint application of coagulation POC methods in patients with infectious and non-infectious SIRS in the ED. Peculiar alterations of the coagulation system together with a global platelet hypo-aggregability were observed in patients with sepsis, severe sepsis and septic shock since their first presentation. These modifications were able to distinguish with good accuracy the infectious etiology of SIRS, together with stratifying for severity and displaying a potential prognostic role.
Marco ULLA (Torino, ITALY), Claudia GALLUZZO, Elisa PIZZOLATO, Matteo MAGGIOROTTO, Monica MASOERO, Samuele RASO, Manuela LUCCHIARI, Anna Rita VITALE, Enrico LUPIA, Maurizio BERARDINO, Stefania BATTISTA, Giulio MENGOZZI
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Human Trafficking and Migrants II
Moderators: Janos BAOMBE (manchester, UK), Nagi SOUAIBY (Chief Editor) (Byblos, LEBANON)
11:00 - 11:30 Medical data reporting in refugee camps: comparing the refugee camp in Brussels to other data. Gerlant VAN BERLAER (CHIEF OF CLINIC - SENIOR STAFF MEMBER) (BRUSSELS, BELGIUM)
11:30 - 12:00 The impact of refugees in Germany. Christoph DODT (München, GERMANY)
12:00 - 12:30 Interactive discussion.
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EuSEM meets
EM Global Leaders
Moderators: Barbara HOGAN (Past President of the European Society for Emergency Medicine, EuSEM) (HAMBURG, GERMANY), Judith TINTINALLI (Chapel hill, USA)
11:00 - 11:20 Emergency Medicine in the United Kingdom. Clifford MANN (President) (United Kingdom, UK)
11:20 - 11:40 Emergency Medicine in Hong Kong. Clara WU (N.T., HONG KONG)
11:40 - 12:00 Emergency Medicine in South America. Edgardo MENENDEZ (ARGENTINA)
12:00 - 12:20 Emergency Medicine in Saudi Arabia. Ahmad WAZZAN (Makkah, SAUDI ARABIA)
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Clinical Questions: Controversies
Geriatric Emergency Medicine
Moderators: Simon. P. MOOIJAART (LEIDEN, THE NETHERLANDS), Richard WOLFE (USA)
11:00 - 11:30 Comprehensive assessment of older patients: Is it useful in the ED? Simon CONROY (Leicester, UK)
11:30 - 12:00 Dying of nothing: Weakness in older ED patients. Christian NICKEL (Vice Chair) (Basel, SWITZERLAND)
12:00 - 12:30 Do we have to Resuscitate all Cardiac Arrest in Older Patients? Abdelouahab BELLOU (BOSTON, USA)
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Special challenges in EM II
Moderators: Alessio BERTINI (Pisa, ITALY), Juliusz JAKUBASZKO (POLAND)
11:00 - 11:20 Cardiovascular risk scoring. Timothy Hudson RAINER (UK)
11:20 - 11:40 Navigating the Data Jungle: Smart Concepts for Emergency Medicine. Michael DUERR SPECHT (GERMANY)
11:40 - 12:00 Novel marker of acute kidney injury. Polat DURUKAN (TURKEY)
12:00 - 12:20 Admission allowed to the ED after telephone approval? Jan STROOBANTS (Brecht, BELGIUM)
12:20 - 12:30 Panel discussion.
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Administration / Management
Ethics and Philosophy
Moderators: Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, GREECE), Bernard FOEX (Manchester, UK)
11:00 - 11:30 The Ethics of Resuscitation and End of Life Decisions. Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, GREECE)
11:30 - 12:00 Distributive justice and Emergency Medicine. Bernard FOEX (Manchester, UK)
12:00 - 12:30 Cases that make you think. Rick BODY (UK)
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YEMD
Work-Life Balance
Moderators: Alice HUTIN (PARIS, FRANCE), Sabina ZADEL (SLOVENIA)
11:00 - 11:30 How to Avoid Physician Burnout - From a Psychiatric Clinic in the Black Forest to a Camel Market outside Riyadh. Kristi KOENIG (USA)
11:30 - 12:00 Burn out in the ED and strategies for coping with stress in the emergency department. Dean DE MEIRSMAN (Emergency medicine resident) (Paal, BELGIUM)
12:00 - 12:30 Life outside the ED. Jennifer TRUCHOT (Paris, FRANCE)
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Oral Paper 1
Emergency Interventions / Endocrine and Diabetic Emergencies
Moderators: Tom BEATTIE (UK), Robert WUNDERLICH (Scientific Assistant) (Tübingen, GERMANY)
11:00 - 12:30 #1076 - #1076 - Icatibant Outcome Survey: treatment of laryngeal hereditary angioedema attacks.
#1076 - Icatibant Outcome Survey: treatment of laryngeal hereditary angioedema attacks.
Background: Laryngeal attacks may be fatal without prompt and effective treatment. Icatibant is a bradykinin B2 receptor antagonist used to treat hereditary angioedema (HAE) type I/II attacks in adults. We analysed characteristics and outcomes of icatibant-treated laryngeal HAE attacks in a real-world setting.
Methods: The Icatibant Outcome Survey (IOS; Shire, Zug, Switzerland [NCT01034969]) is a prospective, international observational study that monitors the safety and effectiveness of icatibant treatment. Retrospective descriptive analyses of laryngeal HAE type I/II attacks were performed (July 2009-September 2013).
Results: Of 1005 icatibant-treated HAE type I/II attacks (231 patients), 67 were laryngeal (42 patients; 64.3% female): 44 (65.7%) attacks affected the larynx only and 23 (34.3%) multiple sites. Of evaluable attacks, 38/61 (62.3%) and 23/61 (37.7%) were treated with self- and healthcare professional (HCP)-administered icatibant, respectively. Of the 23 attacks treated with HCP-administered, icatibant, emergency room physicians administered treatment for 7 (30.4%) attacks. 43/60 (71.7%) attacks were severe/very severe and 21/67 (31.3%) were in patients on long-term prophylaxis (LTP). Of 21 icatibant-treated attacks in patients receiving LTP, androgens were LTP in 14 (66.7%) attacks and C1 inhibitor (C1 INH) in 7 (33.3%) attacks. 6/67 (9.0%) attacks were treated with concomitant or rescue medication. 64/66 attacks did not require C1 INH rescue medication: 56/64 (87.5%) received one and 8/64 (12.5%) two icatibant injections. C1 INH was used as a rescue medication in 2 attacks with one icatibant injection. Median (IQR) time to treatment was 2.0 (1.0, 8.0) h (31 attacks), time to resolution was 6.0 (2.0, 21.0) h (35 attacks), and attack duration was 8.5 (4.5, 19.8) h (25 attacks). For 2 evaluable attacks treated with a second injection, time between first and second injection was 3.0 and 8.0 h; time from second injection to symptom resolution was 4.0 and 2.0 h, respectively.
Conclusions: Most laryngeal HAE type I/II attacks were successfully treated with a single icatibant injection; a second injection or other medication was only needed in a minority of cases. Patients on LTP might experience breakthrough laryngeal attack resolved with icatibant. The majority of attacks were treated with self-administered icatibant. Admission to the Emergency Room was needed in a minority of HAE laryngeal attacks.
Andrea ZANICHELLI (Milano, ITALY), Hilary J. LONGHURST, Werner ABERER, Laurence BOUILLET, Teresa CABALLERO, Marcus MAURER, Vincent FABIEN
11:00 - 12:30 #1207 - #1207 - Management of diabetic ketoacidosis in emergency department: utility of initial bolus insulin.
#1207 - Management of diabetic ketoacidosis in emergency department: utility of initial bolus insulin.
Background: Diabetic ketoacidosis (DKA) is a serious acute metabolic complication of diabetes. The mainstay in the treatment of DKA involves the administration of regular insulin via continuous intravenous infusion (1, 2). Necessity of a priming dose of regular insulin main controversial (3).
Purpose: This study was designed to assess the efficacy and safety of initial bolus of regular insulin in the management of diabetic ketoacidosis admitted in Emergency Department.
Participants and methods: Placebo-controlled, double blind, prospective, randomized study of patients aged >16 years with moderate to severe DKA seen in emergency department. Patients were randomly allocated to receive: 1) IV bolus of regular insulin 1U/10kg; 2) IV bolus of normal saline .Standardization of: i) the fluid therapy with normal saline and 5% dextrose ii) the insulin therapy via continuous intravenous infusion; iii) the potassium replacement. Data on glucose levels, pH, serum bicarbonate, anion gap (AG), intravenous fluid administration, and length of stay were collected. Outcomes data were: time to glucose control (<250mg/l), insulin dose to recovery, occurrence of complications: hypoglycemia (Capillary blood glucose ˂60 mg/l), hypokalemia (serum potassium ˂3,3 mmol/l).
Results: We enrolled 106 consecutive DKA patients. Mean age =36+/-16.5 years, sex ratio = 0.63. Medical history, N (%): type 1 diabetes, 61 (57.5); type 2 diabetes, 31 (29.3); inaugural, 14 (13.2). Usual treatment, N (%): insulin, 90 (81.1); biguanides, 8 (7.5); sulfonylureas, 8 (7.5). There were no differences between the two groups in clinical and biochemical data: mean age (33 vs 39 years) or the sex ratio (0,6vs 0,7), pH (7,13 vs 7,14 ), serum bicarbonate ( 7,3 vs 7,3 mmol/l), anion gap (29 vs 30 mmol/l ), blood glucose levels (31 vs 34 mmol/l); also in outcomes data: time to glucose control (6 vs 7 hours), insulin dose to recovery (61 vs 62 Units), Length of stay in Intensive Care Unit ( 30 vs 28 hours), complications: hypoglycemia (N =10 vs 11), hypokalemia ( N = 27 vs 31).
Conclusions: Administration of an initial bolus dose of insulin to patients with DKA was safe but it was not associated with significant benefit.
- Kitabchi AE and al. Diabetes Care 2009; 32; 1335-1343
- Savage MW and al. Diabet Med 2011; 28; 508-15
- Kitabchi AE and al. J Clin Endocrinol Metab 2008, 93; 1541-1552
Sarra JOUINI, Fatma HEBAIEB (Tunis, TUNISIA), Rym HAMED, Hela MANAI, Wided BAHRIA, Syrine JAOUANI, Mohamed MEZGHANNI, Bechir BOUHAJJA
11:00 - 12:30 #1284 - #1284 - Comparison of effectiveness of magnesium sulfate VS morphine sulfate in renal colic.
#1284 - Comparison of effectiveness of magnesium sulfate VS morphine sulfate in renal colic.
Comparison of effectiveness of magnesium sulfate VS morphine sulfate in renal colic
Introduction: Renal colic due to renal stone is the most severe pain had been experienced, and is common cause of patient reference to health centers. Intravenous infusion of morphine sulfate is a common treatment, but its side effect is addiction. It has been mentioned that magnesium sulfate due to its calcium receptors antagonization and therefore muscle relaxation, was a pain relief especially in migraine headache.
Methods: This paper compares effectiveness and side effects of intravenous infusion of morphine sulfate
and magnesium sulfate in renal colic patient who were referred to Shahid Sadoughi Educational Hospital.
This paper is a double-blinded randomized control trial study. Sixty patients with renal colic divided in two groups: case group took magnesium sulfate 50 mg/kg intravenous infusion and the control group took morphine sulfate 0.1 mg/kg intravenous infusion. Pain score and probable symptoms during zero, 15 and 30 minutes after infusion in both group recorded by a blind person, and data analyzed by SPSS software.
Results: Pain score and average age were similar in both groups at the first visit. Pain severity after treatment in both groups was significantly decreased (P.Value<0.05). Complete pain relief in control group, in 15th minute was significantly more than case group (P.Value=0.037) but in 30th minute this difference wasn’t significant (P.Value=0.766).
Conclusion: Our findings show that MgSo4 during 15- 30 minutes of treatment, is as effective as morphine sulfate, but its pain relief rate is slower than. So we can use it as a good alternative for morphine sulfate in renal colic patients.
Akram ZOLFAGHARI SADRABAD (TEHRAN, IRAN, ISLAMIC REPUBLIC), Reza FARAHMAND RAD, Soheila AZIMI ABARGHOUEI
11:00 - 12:30 #1410 - #1410 - A new functional biomarker, fractal dimension (Df), that helps to quantify the thrombotic risk in DKA patients.
#1410 - A new functional biomarker, fractal dimension (Df), that helps to quantify the thrombotic risk in DKA patients.
Introduction: Diabetic ketoacidosis (DKA) is a life threatening emergency caused by lack of insulin leading to severe metabolic acidosis and dehydration. Severe dehydration can lead to increased blood viscosity and increased availability of blood coagulation proteins and platelets [1]. These changes can lead to a hypercoagulable state that can increase the risk of thrombosis [2,3]. DKA patients are managed with rapid fluid correction (5-8 litres over 24 hours) and insulin infusion. It is not known that how the initial insult and the effect of subsequent treatment changes the clot microstructure. This study aims to assess the effect of DKA and standard treatment on clot microstructure, and thereby quantify the thrombotic risk by using a new haemorheological biomarker, fractal dimension, Df [4].
Methodology: Adultpatients (>18yrs) with a diagnosis of diabetic ketoacidosis were recruited on admission to the Emergency Department of a large teaching hospital in Wales. Blood samples were taken at time 0, at 2-6 hours and at 24 hours post admission to determine the effect of treatment intervention. Rheological analysis was performed on whole, unadulterated blood to determine the fractal dimension (Df) of incipient clots. A healthy control group matched for gender and age was also recruited. This study had ethical approval from the South West Wales research ethics committee.
Results: 15 patients with diabetic ketoacidosis were recruited on admission to the Emergency Department of a large teaching hospital in Wales. 15 healthy volunteers were also recruited as a matched control. Mean Df in the healthy control group was 1.74 ± 0.03. An elevated Df of 1.78 ± 0.07 was observed in patients with DKA on admission. The mean pH on admission was 7.14 ± 0.13 and the lactate was 3.6 ± 2.0. Df changed significantly in response to standard treatment (intravenous fluids and insulin infusion) and was reduced to 1.68 ± 0.09 (2-6hrs), followed by 1.66 ± 0.08 at 24 hours (p < 0.01 One-way ANOVA). Df also correlated significantly with lactate and pH (Pearson correlation coefficient 0.479 and -0.675 respectively, p < 0.05).
Conclusion: Our study showed that the patients who were admitted with DKA had a tight fibrin clot structure resistant to fibrinolysis initially (as indicated by high Df). With standard treatment the clot structure had progressively weakened (as indicated by progressive and significantly low Df). This suggests that the risk of developing thrombotic events on DKA patients at admission to the Emergency Department is significantly high. However, this risk is negated by the standard treatment. This highlights the importance of early and appropriate treatment in patients with DKA. The new biomarker, fractal dimension (Df) could be used as a biomarker to quantify the thrombotic risk in DKA patients.
References:
1. Doi T, Sakurai M, Hamada K, Matsumoto K, Yanagisawa K, et al. (2004) Plasma volume and blood viscosity during 4 h sitting in a dry environment: effect of prehydration. Aviat Space Environ Med 75: 500–504.
2. Kelly J, Hunt BJ, Lewis RR, Swaminathan R, Moody a., et al. (2004) Dehydration and venous thromboembolism after acute stroke. QJM - Mon J Assoc Physicians 97: 293–296. doi:10.1093/qjmed/hch050.
3. Prandoni P (2006) Acquired risk factors of venous thromboembolism in medical patients. Pathophysiol Haemost Thromb 35: 128–132. doi:10.1182/asheducation-2005.1.458.
4. Evans P a, Hawkins K, Morris RHK, Thirumalai N, Munro R, et al. (2010) Gel point and fractal microstructure of incipient blood clots are significant new markers of hemostasis for healthy and anticoagulated blood. Blood 116: 3341–3346.
Gareth Richard DAVIES, Suresh PILLAI (Swansea, UK), Gavin MILLS, Keith MORRIS, Phylip Rhodri WILLIAMS, Phillip Adrian EVANS
11:00 - 12:30 #1423 - #1423 - Costs associated with emergency care and hospitalization for severe hypoglycemia in Italy.
#1423 - Costs associated with emergency care and hospitalization for severe hypoglycemia in Italy.
Background and aims: Severe hypoglycemia has been associated with several adverse clinical outcomes. As it often requires emergency care management and hospitalization, severe hypoglycemia also constitutes a major economic burden on healthcare systems. Using derived data from the HYPOglycemia Treatment in the Hospital Emergency System - Italian Study (HYPOTHESIS), we aimed to determine the direct cost burden resulting from the management of severe hypoglycemia among people with diabetes in Italy.
Methods: Data on all cases with an acceptance diagnosis of hypoglycemia between January 2011 and June 2012 were collected from 46 Emergency Departments (EDs) covering an area of approximately 12 million inhabitants. Information on patient characteristics, comorbidities, prescribed drugs, as well as information on disposition (referral to general practitioners or diabetes units; short-term (<24 h) intensive observation; admission to hospital wards) was collected through the ED medical records. Direct costs were defined as costs for the medical treatment of hypoglycemia, including emergency care services and hospitalization. Emergency care costs were computed by estimating the average cost per ambulance service, ED visit and short-term observation period. Hospitalization expenditure was estimated using the average hospitalization cost per patient with diabetes in a specific ward.
Results: A total of 3516 episodes of severe hypoglycemia occurred in subjects with diabetes. Median age was 76 years (range, <1-102), 50.5% of patients were males. Blood glucose at the time of event was recorded in 2314 cases (mean, 2.33 ± SD 1.22 mmol/L). Insulin was the only glucose-lowering treatment in 49.8% of cases; 31.4% of patients were treated by oral agents only and 15.1% were on combination treatment. A total of 2320 (65.9%) cases with diabetes were characterized by one or more comorbidities. Almost half cases (n = 1821, 51.8%) required the intervention of the emergency ambulance services. Following the ED visit, 1498 cases (42.7%) were sent home and referred for outpatient visits to their general practitioners/diabetes units; 604 cases (17.2%) received a short-term intensive observation; 1161 (33.1%) were admitted to hospital wards. Unit costs for emergency care management were estimated at €120 for an ambulance call, €18 for an ED visit, and €220 for a short intensive observation. Mean hospitalization cost was estimated to be €5317, highest for critical care departments (€7688) and lowest for endocrinology, diabetes and metabolism departments (€4164). Based upon the evidence collected in our study, in Italy (60 million inhabitants), approximately 12000 individuals with diabetes are thus expected to attend the EDs for a severe hypoglycemic event each year. From this base case assumption, total direct medical costs of hypoglycemia in patients with diabetes in Italy were estimated to exceed €20 million per year, with hospitalizations contributing to the most of the annual expenditure.
Conclusion: Severe hypoglycemia in patients with diabetes has a considerable impact on national resource utilization and constitutes a remarkable economic burden for national health systems. Measures to prevent hypoglycemia should be mandatory in future diabetes management programs considering its impact on patients and health spending.
Giacomo VERONESE (Milan, ITALY), Giulio MARCHESINI, Gabriele FORLANI, Stefania SARAGONI, Luca DEGLI ESPOSTI, Andrea FABBRI
11:00 - 12:30 #1450 - #1450 - Comparison of registered and published outcomes of randomized controlled trials in the field of emergency medicine.
#1450 - Comparison of registered and published outcomes of randomized controlled trials in the field of emergency medicine.
Background: The International Committee of Medical Journal Editors (ICMJE) requires registration of all clinical trials in a public registry, at or before the time of first patient enrolment. The appropriateness of trials registration and the risk of selective outcome reporting bias have been assessed in several medical fields but never in emergency medicine (EM). Our objectives were to assess the proportion of EM trials adequately registered and to compare registered outcomes with those in published articles.
Methods: We have searched MEDLINE via PubMed to identify all trials reporting randomized clinical trials in the field of EM, assessing a therapeutic intervention, published in 2013 & 2014, in the 6 general medicine journals (GMJ) and 10 EM journals with the highest impact factor (Journal Citation Reports, 2013). We defined trials as in the field of emergency medicine if patients were included in an emergency department or by emergency medical services. For each included trial report, if the trial registration number was not available, we have searched public registries for trials protocols; if not available we have contacted the corresponding authors. One of the investigators examined the selected journals instructions for authors about registration requirements. Two abstractors extracted trials data using a standardized data extraction form. Our main outcomes were primary outcomes discrepancies between protocols and published reports, and the proportion of trials registered before the trial start date.
Results: Our search identified 844 references; out of which 78 (9%) were in the field of EM. Forty five of them (58%) were published by EM journals. A total of 69 (88%) of the trials were registered; 53 (77%) on ClinicalTrials.gov, 9 (13%) on ISRCTN and 7 (10%) on regional registries. Among the included trials, 42 (54%) were appropriately registered. In 11 reports (14%), trial registration information was missing or erroneous, two (3%) trials were found by registry search.
Among all registered trials, 23 (33%) presented some discrepancies between the registered primary outcomes and the published primary outcome. A new primary outcome was introduced in 13 (19%) of the published articles (ie, article primary outcome does not appear on the register or a registered secondary outcome is reported as primary outcome in the article), the timing of outcome assessment differed between the article and the registry in 7 (10%) of them and in 4 (6%) the registered primary outcome was omitted in the published report. The proportion of registered trials was greater for trials published in journals requiring registration than for those in journals with no recommendations (94% vs 58%, p=0.003). Trials published in GMJ were more likely to be registered than those in EM journals (100% vs 80%, p=0.008).
Conclusion: Half of published clinical trials in the field of EM were appropriately registered. One third presented evidence of selective reporting of the primary outcomes. Our results are consistent with the results of similar trials in other medical fields. These discrepancies between registered and published outcomes may lead to biased trials and by extent to some waste of research.
Youri YORDANOV (Paris), Amélie BAILLY, Ariana BEHTASH, Anthony CHAUVIN, Dominique PATERON
11:00 - 12:30 #1931 - #1931 - Benign paroxysmal positional vertigo in emergency department: maneuver vs. medications: a randomized controlled trial.
#1931 - Benign paroxysmal positional vertigo in emergency department: maneuver vs. medications: a randomized controlled trial.
Introduction:
The Benin paroxysmal positional vertigo (BPPV) is a common pattern in emergency department (ED). Its management is not well codified. The N-acetyl leucine is commonly used in vertigo management in ED, but its mechanism of action remains poorly understood. The canal repositioning maneuver, effective and simple to implement, looks promising.
Objective: Our aim was to compare the efficacy of canal repositioning maneuver vs. N-acetyl leucine therapy in patients presenting to the ED with BPPV.
Methods: This was a prospective, single-blinded, randomized study comparing two groups of patients who presented to the ED with a diagnosis of BPPV. BPPV was diagnosed based on findings obtained from the Dix-Hallpike maneuver (DH) by a blinded physician assessor. The first group received N acetyl leucine and the second group received a canalith repositioning maneuver. The canalith repositioning maneuver was repeated, if necessary, during the ED visit to attempt full resolution of symptoms. The Visual Analogue Scale was used to measure symptom resolution two hours after treatment. Phone follow-up assessing any repeat ED visits and satisfaction with their treatment seven days after the emergency visit. Multivariate analysis by multiple logistic regression was performed.
Results: Thirty three patients were randomized; 16 to the standard treatment arm and 17 to the interventional arm. Mean age ± standard deviation of subjects randomized to receive maneuver and medication were 43 ± 12 years and 48 ± 14 years, respectively. There was no significant difference in mean ages between the two treatment arms (p = 0.264). Two hours after treatment, the symptoms between the groups showed no difference in measures of nausea and dizziness (p = 0.530). Both groups reported a good level of satisfaction, measured on a 0 - 10 scale. Satisfaction in subjects randomized to receive maneuver and medication was 6,7 ± 1.5 and 6,8 ± 1.4, respectively; there was no significant difference in satisfaction between the two arms (p = 0.933). Length of stay during the ED visit did not differ between the treatment groups (p = 0.06). Only adverse effect noted: a case of fright during the maneuver in one patient. None the patients returned to an ED for similar symptoms at seven days.
Conclusions: This study suggest that there is no difference in symptomatic resolution, ED length of stay, or patient satisfaction between standard medical care and canalith repositioning maneuver. Considering the cost savings and potential adverse reactions to medications, physicians should consider the canalith repositioning maneuver as a treatment option in emergency department.
Rania JEBRI (Ben Arous, TUNISIA), Anware YAHMADI, Soumaya MAHDHAOUI , Hanane GHAZALI, Chaabani GHZELA, Moez MOUGAIDA, Mohamed MGUIDICH, Sami SOUISSI
11:00 - 12:30 #2036 - #2036 - Efficacy and safety of pharmacological cardioversion for recent onset atrial fibrillation: a propensity score matching study to compare amiodarone vs 1C antiarrhythmic class drugs.
#2036 - Efficacy and safety of pharmacological cardioversion for recent onset atrial fibrillation: a propensity score matching study to compare amiodarone vs 1C antiarrhythmic class drugs.
Atrial fibrillation (AF) is the more frequently observed and treated between sustained cardiac arrhythmias in the Emergency Department (ED). The acute management of patients affected by recent–onset AF episodes (< 48 h) is still a matter of debate.
Aims: The aim of this study was to use a propensity score matching analysis to compare efficacy and safety between intravenously administered amiodarone to both propafenone and flecanide (1C antiarrhythmic class drugs) in the acute management of recent-onset AF in the ED. Primary endpoint was conversion to stable sinus rhythm within 12 hours after starting treatment, while secondary endpoint included time to conversion within 48 hours and adverse effects rate.
Methods: We retrospectively evaluated all episodes of recent–onset AF (< 48 h) that have been submitted to a pharmacological attempt of cardioversion that were observed in the ED of Verona AOUI Hospital (Italy) from January 2011 to December 2013. We recorded baseline clinical characteristics of all cases along with personal history of arrhythmias, acute past treatments and current chronic treatments, excluding those patients whose informations were incomplete. These clinical features have been used to create a propensity score matched population weighted to Cox regression, hence to obtain two treatment groups accurately matched. Then we analysed the differences between Amiodarone group and 1C antiarrhythmic class drugs group.
Results: A total number of 817 episodes of recent-onset AF with non-overlapping characteristics between the two groups of treatment (Amiodarone group = 406, 1C antiarrhythmic class group 411) were reviewed. After propensity score matching we obtained 358 events equally divided into these two groups: Amiodarone group = 179 and class IC antiarrhythmic drugs = 179 with baseline overlapping characteristic (basic characteristics had no statistically significant differences between groups). With this selection, comparison between the two treatment groups was not affected from remarkable differences, thus permitting an “equal” confrontation between these two groups. Median time of cardioversion for Amiodarone Group was 420 minutes (IC 95% 331,6 – 508,3), while in the 1C antiarrhythmic class group median time was 55 minutes (IC 95% 44,9 – 65,1) (p < 0,05). Cardioversion rates at 12 hours were respectively 53,1% (95/179 Amiodarone group) and 72,6% (130/179 Classe IC group) (p < 0,05). Cardioversion rates at 48 hours were 77,7% (139/179 Amiodarone group) and 86,1,% (154/179 Classe Ic group) (p < 0,05).
Adverse events for the two treatment groups were numerically irrelevant and equally distributed (p = NS).
Conclusions: Compared to amiodarone in a selected and propensity score matched population, intravenous administration of 1C antiarrhythmic class drugs proved to be more effective for cardioversion of recent-onset AF both at 12 hours and 48 hours from presentation, without any safety concern. Emergency Physician should consider the benefits of 1C antiarrhythmic class drugs when starting a farmacological rhythm control strategy, if no contraindications in the medical history of patients are detected.
Gianni TURCATO, Antonio BONORA (VERONA, ITALY), Gabriele TAIOLI, Stefania PUGLISI, Elena FRANCHI, Giorgio RICCI
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Oral Paper 2
Clinical Decision Guides / Biomarkers
Moderator: Cristian BOERIU (Assoc.Professor) (Targu Mures, ROMANIA)
11:00 - 12:30 #1162 - #1162 - Emergency research on incapable subjects: an international multicenter study.
#1162 - Emergency research on incapable subjects: an international multicenter study.
Emergency Research (ER) is the experimentation of new diagnostics/therapies for patients coming in emergency departments in critical condition, frequently incapable to consent, and with a not otherwise treatable disease. Today the debate is particularly focused on the issue of the participation of the incapable subjects in ER. Oviedo Convention and the Additional Protocol (2005) set up a safeguards system to ensure the protection of incompetent persons in clinical research. But the application of the Oviedo Convention in Europe has been quite “patchy”: most countries have ratified it, but in some cases the Convention was not ratified or the ratification process has never been completed. This main debate seems to have been solved by the adoption of the new European Regulation (EU) 536/2014, in which the provision for the carrying out of ER in subjects incapable to give IC is included in article 35.
In the USA the exception to informed consent was introduced in 1996 from FDA through the adoption of Regulation 21 GFR 50.24, updated in November 2014. Many studies have been conducted in American emergency departments where patients and legal authorized representative (LARs) had the possibility to exhibit their opinions in case of necessity of an ER.
In particular, after what was established by point d), art. 35 of the EU Regulation "the investigator certifies that he or she is not aware of any objections to participate in the clinical trial previously expressed by the subject" some dilemmas arise about ethical application of ER in incapable subjects. Therefore, we have designed the EROIS Study, an international multicenter study involving some centers in European countries and in USA.
Patients hospitalized for severe and acute diseases that in the future may be eligible for ER, their LARs, patient associations and healthy control subjects are included to investigate, through questionnaires, their perspectives about emergency research on incapable subjects. In particular four specific anonymous questionnaires, one for type of stakeholders, was designed with the aims to understand patients/LARs’ knowledge, awareness, choices, level of trust in the physicians-researchers/RECs, that will be involved in the application of the ER.
Preliminary application of EROIS Study involved at the “A. Gemelli” University Hospital in Rome was carried out on patients of Stroke Unit, Cardiology and Nephrology and Dialysis department; on LARs of these patients and on healthy persons in particular university students of health care degree courses. The early data of the EROIS in our center at the “A. Gemelli” UniversityHospital showed a poor knowledge about ER meaning and a differences of opinion between patients and LARs. Indeed only 15% know what is ER and regarding the trust on researchers and RECs the 37% of patients believe on them against the 49% of LARs which have trust on researchers and RECs.
EROIS preliminary data highlights the need to improve public knowledge and culture on Emergency Research in order to the correct implementation of the article35, point d) and to ensure the integral management of ER on patients incapable to give IC.
Emanuela MIDOLO (Rome, ITALY), Roberta MINACORI, Dario SACCHINI , Antonio G. SPAGNOLO
11:00 - 12:30 #1277 - #1277 - Thrombocytopenia as an independent predictor of mortality in the emergency department.
#1277 - Thrombocytopenia as an independent predictor of mortality in the emergency department.
Introduction
Thrombocytopenia, defined as platelet (PLT) count < 150x109/L, is a common finding in critically ill patients. In patients admitted to Intensive Care Units, thrombocytopenia represents a risk factor for acute bleeding, transfusion requirements, and higher mortality rate[1]. Nowadays, only few data are available about thrombocytopenia in the Emergency Department (ED) setting[2,3]. Aim of our study was to define the relationship between plt count at the admission in the ED and the in-hospital mortality risk.
Partecipants and methods
We retrospectively enrolled 1218 patients (830 males, 388 females; age 69 ± 17.7 SD) presenting with thrombocytopenia to the ED of "Città della Salute e della Scienza" Hospital of Torino in four non-consecutive months in 2012. No exclusion criteria were adopted. Preliminary data about this population concerning epidemiological details, bleeding frequency, and therapeutic strategies have been previously published[3].
Results
In our population, 12% of patients had severe thrombocytopenia, defined as PLT count < 50x109/L. In these patients, signs of minor and major bleedings and hypovolemia were more frequently present than in patients with less severe thrombocytopenia; moreover, patients with severe thrombocytopenia required more therapeutics interventions, and haematological consultations.
The in-hospital mortality rate in patients affected by severe thrombocytopenia was higher (19.7%) than in those with mild thrombocytopenia (8.6%). For every drop of 10x109/L in PLT count at the admission in the ED, indeed, the mortality odds increased of 12% (OR 0.988 - p < 0.001), even after adjusting for the major confounding factors, such as age, sex, comorbidities, admission category in the ED, and in-hospital length of stay. Furthermore, a drop in plt count at the admission of 10x109/L, even adjusting for several confounders, such as PT-INR, anticoagulant and antiplatelet medications, age, and sex, was associated with an increased probability of major bleeding of 16% (OR 0.984 - p < 0.001).
Finally, patients presenting to the ED with signs of major bleeding had an increased mortality risk of 87% compared to those without evidence of bleeding (OR 1.876 - p = 0.014).
Conclusions
This is the first study to assess the mortality risk in thrombocytopenic patients presenting to the ED. Thrombocytopenia could represent a helpful and important prognostic tool for the ED physician. Our findings may stimulate further prospective research studies.
References
1. Williamson DR, Lesur O, Tetrault JP, et al; Thrombocytopenia in the critically ill: prevalence, incidence, risk factors, and clinical outcomes. Can J Anaesth, 2013; 60(7): 641-51.
2. Howell MD, Powers RD; Utility of thrombocytopenia as a marker for heparin allergy in adult ED patients. Am J Emerg Med, 2006; 24(3): 268-70.
3. Turvani F, Pigozzi L, Barutta L, et al; Bleeding prevalence and transfusion requirement in patients with thrombocytopenia in the emergency department. Clin Chem Lab Med, 2014; 52(10): 1485-8.
Acknowledgments
The study was designed according to the Helsinki Declaration, and approved by the local Ethical Committee.
The authors disclose any financial competing interests.
Luca PIGOZZI, Luca PIGOZZI (Torino, ITALY), Fabrizio TURVANI, Emanuele PIVETTA, Giuseppe MONTRUCCHIO, Corrado MOIRAGHI, Enrico LUPIA
11:00 - 12:30 #1414 - #1414 - Comparison between the protocol used for mild traumatic brain injury patients in Verona and previously validated clinical decision rules and international guidelines.
#1414 - Comparison between the protocol used for mild traumatic brain injury patients in Verona and previously validated clinical decision rules and international guidelines.
Mild traumatic brain injury (mTBI) is a major concern for modern Health Systems because of its high incidence, subtle clinical presentation, and potential long-term disabilities. Our local protocol defines mTBI according to GCS, to clinical presentation and according to some pre-traumatic and post-traumatic risk factors, pointing out specific criteria that patients should meet before taking a head CT. It also proposes clinical stratification into three evolutive risk classes (low, medium and high risk mTBI), according to risk factors and clinical criteria previuosly collected. After patient’s evaluation, physicians should decide if the patients has to undertake Head CT scan or not.
Aims: Thanks to the “duplex nature” of our protocol, that can work both as a decision making tool that as a clinical stratification tool, we could compared its performance to other internationally validated clinical decision rules and to recently pubblished international guidelines. To our knowledge, this is the first paper that aims to do so.
Methods: We conducted a retrospective analysis of charts gathered during a six months period to determine clinical presentation, instrumental findings and outcome in 1246 consecutive ED patients who underwent head CT scan because of a mTBI in AOUI - Verona.
Results: Patients inappropriately submitted to CT (thus not presenting any risk factor or clinical finding that would mandate taking scans) were 9,2% of the totality , defining an overall 90,8% adhesion rate to our protocol. Sensibility of our protocol was 97,4% and specificity 10,4 %. First of all, we tested our protocol’s performance compared to the most notorious clinical decision rules: the Canadian CT Head Rule established a sensibility of 86,4% with a specificity of 40,1%, while the New Orleans Criteria proved respectively 98,3% sensibility and 6,4% specificity. These findings are in accordance with the few previous studies that directly compared this two rules outside the settings in which they were developed. Since guidelines provide clinical stratification of patient’s risk, by analysing ROC curves we could compare our protocol both to the NICE Head Injury guideline 2014 and to the Scandinavian Head Injury Management Guideline 2014: our protocol proved AUC = 0,74 while Scandinavian had AUC = 0,69 and NICE demonstrated AUC = 0,68 (p was <0,001 for all three).
Conclusions: Our protocol proved good performances, both as a decision-making tool (compared to NOC and CCHR) that as a clinical stratification tool (compared to NICE 2014 and Scandinavian guidelines 2014). It only missed a few patients, and none of them had neurosurgical complications. This results are statistically significant, and consistent with a very sensitive tool, unfortunately with low specifity that is mostly due to the high number of CT requested. Additional tools are needed to obtain a more accurate selection of patients, in order to increase the specificity of our protocol without decreasing its sensitivity. Biomarkers could serve this purpose, if integrated into an effective clinical decision and stratification support tool as our protocol is.
Gianni TURCATO, Gabriele TAIOLI (Verona, ITALY), Antonio BONORA, Eleonora ZACCARIA, Giuseppe BARTUCCI, Simone PECORARO, Massimo ZANNONI, Giorgio RICCI
11:00 - 12:30 #1540 - #1540 - Physical stress echocardiography in the evaluation of patients presenting to the Emergency Department with Chest Pain.
#1540 - Physical stress echocardiography in the evaluation of patients presenting to the Emergency Department with Chest Pain.
Introduction: We compared the ECG exercise test and physical stress-echocardiography (ESE) diagnostic performance, in order to identify patients who were more likely to take advantage from the use of an imaging modality in a group of subjects presenting to the Emergency Department with chest pain.
Methods: Between 2008, June15 and 2013, December31, 612 patients with an episode of spontaneous chest pain or angina equivalent, non diagnostic ECG and negative cardiac necrosis markers were evaluated with ESE. Patients with inducible ischemia were admitted for further diagnostic assessment. Patients with a negative exam were discharged and later contacted by telephone in July 2014, to investigate the occurrence of new cardiac events.
Results: ESE demonstrated inducible ischemia in 104 patients, was negative in 488 and inconclusive in 20. Eighty (77%) patients with a positive test underwent coronary angiography: critical coronary stenoses have been evidenced in 68/80 (85%) patients; a percutaneous revascularization procedure has been performed in 39/80 (49%) patients. Among patients with a negative test, one only patient reported an ACS within one month (cumulative 1-month incidence of new events 1/612, 0.2%). We compared ECG exercise test and ESE results: among patients with a negative test, 38 (8%) demonstrated ECG modification or symptoms, but ESE was considered negative due to the absence of new asynergic areas at peak-exercise echocardiography. We compared the 38 patients with false positive test and the 450 patients with negative exercise ECG: the only significant difference was a more advanced age in the first group (65±13 vs 60±13 years, p=0.044) compared with the other subjects. Gender distribution (male gender, 61 vs 66%), prevalence of arterial hypertension (50 vs 55%), diabetes (13 vs 10%) and history of known CAD (26 vs 20%), baseline LV EF (63±12 vs 62±11%) and FPR score (3.0±1.6 vs 2.7±1.6, all p=NS) were similar in both groups.
We also compared exercise ECG and Str-T results among the 68 patients with a positive Str-t who showed critical coronary stenoses at coronary angiography: up to 32% of these patients did not show any symptom or ECG modification and were identified only for the development of new asynergic areas at peak stress echocardiography. Patients with symptoms and ECG modifications were significantly younger than patients with a negative exercise ECG (68±9 vs 72±6 years, p=0.016); we did not evidence any significant difference between the two groups in terms of gender distribution (male gender, 76 vs 73%), prevalence of arterial hypertension (63 vs 82%), diabetes (9 vs 18%) and history of known CAD (35 vs 55%), baseline LV EF (62±9 vs 59±9%) and FPR score (3.7±1.6 vs 3.4±1.5, all p=NS). Overall ESE prevented unnecessary further diagnostic assessment in 38 (6%) subjects and avoided a missed diagnosis of CAD in 23 (4%) patients.
Conclusions: ESE demonstrated an incremental diagnostic value over ECG exercise test, especially among elderly patients.
Margherita LUZZI, Chiara DONNINI (SESTO FIORENTINO-FIRENZE, ), Barbara RINALDI, Francesca INNOCENTI, Riccardo PINI
11:00 - 12:30 #1588 - #1588 - Outcomes of Emergency Severity Index (ESI) Triage Scoring With Seven Vital Findings Instead of Three.
#1588 - Outcomes of Emergency Severity Index (ESI) Triage Scoring With Seven Vital Findings Instead of Three.
Introduction: ESI triage system has been first applied by Wuerz et al. in USA in 2000. It is different from complaint-dependent classification methods and treatment priority of the patient is determined according to the sources to be consumed and vital signs. These vital signs for adults have 3 parameters including respiratory rate (RR), pulse (p) and oxygen saturation (SaO2).
Objectives: In the present study, we practiced ESI triage system with 7 vital signs including arterial blood pressure (BP), p, RR, SaO2, body temperature (BT), blood glucose (BG) and shock index (SI) instead of 3 vital findings, and we called this method is modified ESI (mESI). Results were compared with determine whether differences in efficacy and safety between the ESI with mESI.
Method: The present study was conducted prospectively and included the patients over 18 years of age with categories 3, 4 and 5 according to ESI triage score who referred Emergency Department Clinic of Konya Training and Research Hospital between 08.00 a.m. and 04.00 p.m. and September, 1st, 2014 and October, 1st, 2014. Patients with category 1 and 2 according to ESI triage scoring, all trauma patients and brought to the emergency room with ambulance were excluded. All of our patients have evaluated by the same three triage officer in our triage unit (triage officers consists of nurses, paramedics and emergency medical technicians and all received the education of ESI triage system ) and after looking their 7 vital signs , they all recorded according to ESI and mESI.
Results: Totally 4536 patients were involved into the study. Mean age of the patients was 36.4 (18-81). Number of male patients was detected 2143 (47.2%) whereas female patients was 2393 (52.7%). The most common complaints for referral to emergency department were throat pain (1560 patients-34.4%), headache (503 patients-11.1%) and abdominal pain (412 patients-9.1%).The most common diagnosis was upper respiratory tract infection in 1871 patients (41%). The other common diagnoses included myalgia in 545 812%) patients, acute gastroenteritis in 244 (5.4%) patients, acute bronchitis in 225 (5%) patients. 4271 (94.2%) of our patients were examined and treated as outpatients although 265 (5.8%) patients were hospitalized. In terms of identifying patients who need to be hospitalized between ESI with mESI , the ESI was detected statistically significant and effective according to mESI. ( ROC curve: area under the curve mESI:0.69, %95 confidence interval (Cl):0.66 – 0.71; ESI:0.753, %95 confidence interval (Cl):0.73 – 0.77; p ≤ 0.001 ) There are also statistically significant positive correlation was found between the 2 scoring system. ( cc:0.55, p ≤ 0.001 )
Conclusion: ESI triage system in three vital signs are sufficient and reliable method used to separate the 2 categories of patients only with 3.category. Searching more vital signs or searching vital signs for all patients with 3, 4 and 5 categories is unnecessary and time-consuming method.
Yahya Kemal GÜNAYDIN (Ankara, TURKEY), Kamil KOKULU, Ahmet CAGLAR, Can Gökay YILDIZ, Zerrin Defne DÜNDAR, Nazire Belgin AKILLI, Ramazan KÖYLÜ, Başar CANDER
11:00 - 12:30 #1759 - #1759 - CT pulmonary angiography for the exclusion of pulmonary embolism in a general hospital: is it overused?
#1759 - CT pulmonary angiography for the exclusion of pulmonary embolism in a general hospital: is it overused?
CT pulmonary angiography for the exclusion of pulmonary embolism in a general hospital: is it overused?
A. Klijn1, S. van der Voort2,,F. Roodheuvel1, D. Linzel1, E. Bierdrager3, B. van der Maat4, M. ten Wolde2
Departments of Emergency Medicine 1, Internal Medicine 2, Radiology 3en Pulmonary Medicine 4, Flevohospital, Almere, the Netherlands
Background. In patients presenting with chest pain, pulmonary embolism is frequently considered in the differential diagnosis. The use of CTPA is guided by algorithms consisting of a decision rule (mainly the Wells rule) and D-dimer blood test. In spite of these algorithms, performance of a computed tomography pulmonary angiography (CTPA) to exclude the diagnosis of a pulmonary embolism (PE) seems the rule rather than the exception. This should be avoided because of long term complications due to radiation harm, irrelevant incidental findings, contrast induced nephropathy and unnecessary high charges. When these algorithms are inadequately used or passed by, CTPA could be overused. Aim. The aim of this study is to compare the percentage pulmonary embolism as final diagnosis after CTPA with the results expected in earlier studies using Wells criteria based algorithms. Subsequently, we investigated whether the algorithms were adequately used, and if not, whether a low percentage of positive CPTA could be due to no or inadequate use of the Wells score. Methods. All CTPA’s performed to exclude pulmonary embolism, between January 1st and March 1st 2013, were reviewed. Given a short amount of time these were the only data available. Additionally, clinical data were retrieved by review of medical records, containing the Wells criteria (hemoptysis, immobilization, signs of a deep vein thrombosis, deep vein thrombosis in patient history, heart rate>100, malignancy and PE is most likely diagnosis), way of referral, symptoms of dyspnea and pain related to breathing, D-dimer results. Results. CTPA’s of 90 patients were available. In 13 of these CTPA’s, PE was the final diagnosis (14.4%). In 26 (28.9%) of the cases no D-dimer was determined, which was justified in 8 (30.8%) of this cases because of a high Wells score. In only 4 (15%) PE was the final diagnosis. In 12 (46.1%) of the cases it was unclear whether D-dimer should have been determined or not, because not all Wells criteria were noted. Summary/conclusions. In contrast to earlier studies, in daily clinical practice in a general hospital, in only 14.4% of patients with suspected pulmonary embolism undergoing CTPA, pulmonary embolism was the final diagnosis. This is probably due to inappropriate use of current decision rules and D-dimer testing. In spite of the small database, the results were very surprising. There is a new protocol being used in the ER, containing three criteria and D-dimer to diminish CTPA’s in excluding PE. Results will follow in the near future.
Adinda KLIJN (Hoorn, THE NETHERLANDS), Sanne VAN DER VOORT, Floris ROODHEUVEL, Durk LINZEL, Edwin BIERDRAGER, Bas VAN DER MAAT, Marije TEN WOLDE
11:00 - 12:30 #1807 - #1807 - Use of the clinical decision rule for pulmonary embolism in a tertiary care facility in the Netherlands.
#1807 - Use of the clinical decision rule for pulmonary embolism in a tertiary care facility in the Netherlands.
Background For the diagnosis of pulmonary embolism (PE) doctors frequently use a clinical decision rule (CDR) comprising the Wells score for PE with or without D-dimer assessment. Literature suggests this CDR is often used in the wrong way or even not at all. It is unclear if there is a difference in usage between ‘regular patients’ and ‘tertiary patients’, and especially if the CDR is applicable in larger populations with, for example, hemato-oncologic diseases. This could affect outcome and have implications for current practice. Since the UMCG is a tertiary care facility and referral centre for, amongst others, patients with rare hematologic or oncologic diseases and transplanted patients (‘tertiary patients’), population differs from populations described in the literature. This setting allows to assess the use of the CDR for PE in a tertiary care facility and to compare this use in tertiary patients with other patient categories.
Method All patients that presented to the emergency department in 2014 in whom the diagnosis PE was considered were included. Data about Wells score for PE, D-dimer, diagnostic imaging and patient history was extracted from medical records. This data was then analyzed to assess the use of the CDR. To determine if the CDR was used we applied a ‘benefit of the doubt’ method, meaning that we assumed it was used when the Wells score was either documented or could be calculated with information from the medical record. The percentage of patients with the diagnosis PE was calculated for each possible outcome of the CDR (high/low Wells score and normal/elevated D-dimer) and compared with percentages found in the literature. We used the Chi2 to determine whether differences were statistically significant.
Results Of the 240 patients in whom the diagnosis PE was considered, 49 were considered to be tertiary patients. The Wells score was documented in 117 patients overall. In 102 patients it was possible to calculate the Wells score with documented Wells items from the medical records. The CDR was used correctly in 189 patients overall, respectively in 156 out of the 191 regular patients (82%) and in 33 out of the 49 tertiary patients (67%) (p=0.029). The most documented reasons for disregarding the CDR were use of the age-adjusted D-dimer, risk of developing contrast nephropathy with CTA and lack of clinical consequence in demonstrating the existence of PE.
Conclusion Preliminary results suggest the correct use of the CDR was significantly less in tertiary patients (67 vs 82%). Analyses on the entire studypopulation will show if and how this affects the outcome of diagnostic imaging.
These are preliminary results. We expect to include a total of 800-1000 patients within the next month. Analyses on the presence of PE for each outcome of the CDR in regular and tertiary patients and subgroup analyses of the correct use of the CDR for different populations will follow in the entire study population.
Final results will guide recommendations for further, prospective research and possibly have direct implications for current practice.
Rosa S IMMINK (GRONINGEN, THE NETHERLANDS), Jan C TER MAATEN
11:00 - 12:30 #845 - #845 - Community-acquired pneumonia in the emergency department: an Italian survey - work in progress.
#845 - Community-acquired pneumonia in the emergency department: an Italian survey - work in progress.
INTRODUCTION: The optimal management of Community-Acquired Pneumonia (CAP) in Emergency Departments (EDs) is pivotal for the right access to hospital resources and to ensure proper management for every patient. Despite a relevant body of significant literature, several unresolved questions remain, namely related to the best definition of clinical severity, the most appropriate criteria for patient allocation, the value and usefulness of immediate microbiological tests and diagnosis, and the criteria for different treatment choices
MATERIALS AND METHODS: Prospective, multicentre cohort study, enrolling, for a period of 24 consecutive months, all CAP cases referred to 9 different EDs in Italian hospitals. For every included patient demographics and clinical data were recorded, and clinical severity was defined using and comparing three different well-known and widely used predictive rules
RESULTS: Of 1214 enrolled patients, 844 were admitted to hospital. Of these, the mean age was 64 years, and only 56.9% were over 65 years old. Nearly 50% of patients admitted had low scores of severity (as resulted by celinical severity system scores), but over 70% had one or more comorbidities. Overall mortality was 8.5%. Streptococcus pneumoniae was the most frequent etiological agent, but, globally, the yield of microbiological work up was scant (16%)
CONCLUSIONS: In a real-life study condition, predictive rules, who are known to be very attractive for prognosis, are not useful for clinicians in deciding on admission of a patient with CAP, mainly when compared with assessment of comorbidities and welfare conditions
Rodolfo FERRARI (Bologna, ITALY), Mario CAVAZZA, Daniela AGOSTINELLI, Sara TEDESCHI, Fabio TUMIETTO, Pierluigi VIALE
11:00 - 12:30 #903 - #903 - The importance of cytokines level in predicting the outcome of acute pancreatitis.
#903 - The importance of cytokines level in predicting the outcome of acute pancreatitis.
Background/introduction: Acute pancreatitis (AP) is a common potentially lethal acute inflammatory process with a highly variable clinical course. AP progresses to a severe form in approximately 10-20 % of patients resulting in systemic inflammatory response syndrome, multiple organ failure and a prolonged hospitalization with significant morbidity and mortality. The aim of this study was to analyze if early changes in the serum concentrations of cytokines in peripheral blood of patients with acute pancreatitis can predict the outcome of this disease, especially in those patients who had lethal outcome.
Participants and method: We have conducted a prospective study which included 52 subjects who were admitted in Clinical Center Kragujevac, Serbia from October 2011 to July 2013. Serum levels of cytokines were measured using sensitive enzyme-linked immunosorbent assay (ELISA) kits. In all analyses level of statistical significance was set at alpha value of 0.05. The statistical analyses were performed using SPSS 13.0 software.
Results: The study enrolled 52 patients who were divided in interstitial form of acute pancreatitis (IAP) (65.38 % of patients) and necrotic acute pancreatitis (NAP) (34.62 % of patients) group. Serum levels of interleukins (IL) 6, 8 and 10, together with tumor necrosis factor (TNF)-alfa were determined on the 1st and 3rd day of hospitalization. Significantly higher values of IL-6, IL-8 and IL-10 were found on day 1 and 3 in NAP than in IAP. IL-6 was significantly higher on both days of measurement, while IL-10 on the first day and IL-8 on the third day were significantly higher in the group of patients who did not survive in comparison with patients who had interstitial form of AP.
Discussion/conclusion: Acute pancreatitis is no more considered only as a disease of the pancreas because there is strong evidence for systemic effects of the disease. We showed that early changes in serum cytokine profile could distinguish NAP from IAP and could also indicate lethal outcome. In the clinical setting, early diagnosis and, if possible, assessment of the prognosis of AP is a major interest for the clinician. Indeed, early aggressive treatment in patients who will develop necrotizing form of the disease could potentially change the outcome. In conclusion, the data from this study showed that immune suppression and excessive immune stimulation in the first three days after admission could indicate the development of NAP and potentially lethal outcome.
References:
- Kylanpaa ML, Repo H, Puolakkainen PA. Inflammation and immunosuppression in severe acute pancreatitis. World J Gastroenterol 2010; 16: 2867-2872
- Panek J, Kusnierz-Cabala B, Dolecki M, Pietron J. Serum proinflammatory cytokine levels and white blood cell differential count in patients with different degrees of severity of acute alcoholic pancreatitis. Pol Przeglad Chirur 2012; 84: 230-237
- Li JP, Yang J, Huang JR, et al. Immunosuppression and the infection in patients with early SAP. Frontiers in Bioscience 2013; 18: 892-900
Acknowledgements:This study was partially financed by grant No III41010 given by Serbian Ministry of Education, and by the project No 13/11 of Faculty of Medical Sciences, University of Kragujevac, Serbia.
Marko SPASIC (Kragujevac, SERBIA), Irena KOSTIC , Bojan STOJANOVIC, Milena JURISEVIC, Dragce RADOVANOVIC, Dragan CANOVIC, Srdjan STEFANOVIC, Slobodan JANKOVIC
11:00 - 12:30 #948 - #948 - Heart rate as a marker of disease severity in a paediatric emergency department.
#948 - Heart rate as a marker of disease severity in a paediatric emergency department.
Background
Heart rate is a central component of many triage systems and early warning scores. It is heavily weighted as an indicator of the severity of the patient’s illness in some systems. The majority of these systems included heart rate as a result of clinical consensus, rather than from a strong evidence base; the value of heart rate alone in triage systems and early warning scores has not been reliably validated.
Objective
To determine whether heart rate alone is a reliable marker for severity of disease in a population presenting to a paediatric emergency department.
Methods
A prospective observational study was conducted in a paediatric emergency department with the heart rates and ages of patients with non-traumatic presentations being recorded at attendance. Abnormal heart rate was investigated as a prognostic indicator for severe disease. An abnormal heart rate was defined using the current Advanced Paediatric Life Support (APLS) reference ranges and those of a recent meta-analysis reviewing normal age-specific paediatric heart rate by Fleming et al. (2011). The need for hospital admission for inpatient treatment was used as a surrogate outcome measure for severe disease. Data from 540 children were analysed after the application of relevant exclusion criteria. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and the area under the receiver operating characteristic (AUROC) curve were calculated.
Results
Abnormal heart rate as determined by the APLS reference ranges had sensitivity = 0.52, specificity = 0.65, PPV = 0.28 and NPV = 0.83 for predicting admission. The 1%-99% centile ranges of the meta-analysis showed sensitivity = 0.44, specificity = 0.72, PPV = 0.29 and NPV = 0.83. The 10%-90% centile ranges of the meta-analysis showed sensitivity = 0.64, specificity = 0.48, PPV = 0.25 and NPV = 0.83. The 25%-75% centile ranges showed sensitivity = 0.84, specificity = 0.32, PPV = 0.25 and NPV = 0.88. The AUROC curve of data plotted using the meta-analysis cut-off centiles was 0.61 units squared.
Conclusions
The results of this study indicate that the sensitivity and specificity of heart rate alone limits its use as a reliable predictor of disease severity. It is important to emphasise that heart rate does have a valuable role to play within clinical assessment of presenting patients. However, relevant literature and the results of this study do not support the current weighting of heart rate within some early warning scores and triage systems.
Megan BREW (Edinburgh, UK), Bethan COLLIER, Angus GANE, Mark HANNEN, Sam LOVE, Anne MONEY, Gregor CAMPBELL-HEWSON
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Congress Closing Ceremony
Moderator: Wilhelm BEHRINGER (Director) (Jena, GERMANY)
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EuSEM 2012 took place at the Congress Centre within the Susesi Luxury Resort. The Susesi is a five-star 550-room hotel in Belek with all the services and amenities you could wish for - restaurants, bars, sports and spa facilities.
THURSDAY, 4 OCTOBER 2012 10:40 - 11:30 Room Istanbul 1
FRIDAY, 5 OCTOBER 2012 10:40 - 11:30 Room Istanbul 1 
Plenary Session 1
Plenary Session 2
Plenary Session 7
September 29, 2014 - 09:00:00 / 09:45:00 - Zuiveringshal West
September 29, 2014 - 10:45:00 / 12:30:00 - Zuiveringshal West
September 30, 2014 - 09:00:00 / 09:30:00 - Zuiveringshal West
October 1, 2014 - 09:30 / 11:00 - Zuiveringshal West
MONDAY, 12 OCTOBER 2015 8:30 - 9:00 AUDITORIUM AGNELLI
TUESDAY, 13 OCTOBER 2015 8:30 - 9:00 AUDITORIUM AGNELLI
Its location at the heart of Vienna is another unique selling proposition. Cultural institutions – like museums, the Staatsoper and theatres – as well as certain universities are all conveniently situated within a few minutes’ walking distance. 
Monday 25 September
Sunday 24 September
Monday 25 September
Tuesday 26 September
Tuesday 26 September
