Oral Abstracts - Monday

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Cardiovascular / Non-CPR/Non-Resuscitation

M01

A SIMPLIFIED APPROACH TO SCREEN FOR DIASTOLIC DYSFUNCTION USING LIMITED BEDSIDE ECHO

BY EMERGENCY PHYSICIANS

J. Colla 1, P. Kotini-Shah 1, M. Del Rios 1, J. Briller 1, M. Gustafsson 1, N. Patel 1, H. Prendergast 1

1

University Of Illinois At Chicago, Department Of Emergency Medicine, Chicago, Usa

Background: Early detection of diastolic dysfunction is important and has potential for reversal. Emergency physicians (EPs) are well positioned to identify patients at risk for diastolic dysfunction early in the disease process and can improve the cardiovascular health of patients. However, identification of diastolic dysfunction (DD) is complex, multifactorial, and is limited due to time constraints in the ED. We explored a simplified method that could aid in screening for DD. Objective: To determine the accuracy of using only tissue doppler imaging (TDI) measurements as a means to detect DD when compared to a board certified cardiologist as a gold standard.

Methods: A convenience sample of emergency department patients without signs or symptoms of heart failure were enrolled in a pilot study. Using limited bedside echo (LBE), TDI of the mitral annulus was recorded. The presence or absence of diastolic dysfunction was determined by the EP by taking the average peak velocities of the TDI septal (e’S )and lateral (e’L) measurements (e’A). If e’A was <9, then patient was considered to have LV diastolic dysfunction. A board certified cardiologist with ASE level III certification was given all data recorded from the LBE, regardless of the quality of images, to make a determination of diastolic dysfunction. The cardiologist read the study as either DD present, DD absent, or indeterminate. Indeterminates were classified as no DD. Results: 64 patients had LBEs performed. 17 studies were excluded due to incomplete data. 47 studies were sent to the cardiologist for reviews. Using (e’A), the sensitivity was 88.24% and specificity was 90.32%. The unweighted kappa score was 0.7753 (95% CI .589 to 0.9617). When the 7 indeterminates were excluded, 38 of out the 40 case were in agreement (kappa 0.896). The sensitivity remained the same and specificity increased to 100%.

Conclusions: Our data suggests that using average of the TDI (e’A) has good strength of agreement, sensitivity, and specificity at determining DD when compared to the cardiologist’s interpretation. This simplified approach can serve as a one-step method of screening for LV diastolic dysfunction at the bedside.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Cardiovascular / Non-CPR/Non-Resuscitation

M02

PAINLESS ACUTE AORTIC DISSECTION MAY PRESENT AS A STROKE; COULD WE IDENTIFY THE HIGH-RISK PATIENT?

Y. Huang 1, S.F. Sung 2, K.T. Liu 3

1

Department Of Emergency Medicine, Chiayi Christian Hospital, Chiayi City, Taiwan, 2 Division Of Neurology, Department Of Medicine, Chiayi Christian Hospital, Chiayi City, Taiwan, 3 Department Of Emergency Medicine, Kaohsiung Medical Unversity Hospital, Kaohsiung, Taiwan Background: To identify the independent predictors of a painless acute aortic dissection (AAD) in stroke patients who may be missed by current protocols.

Methods: In addition to our painless AAD patients who presented as a stroke, we searched the Medline and the Science Citation Index Expanded from 1981 until March 2015. Reported cases with sufficient information were included to improve the generalization. Another 200 consecutive cases of infarction stroke were enrolled as the control. We collect the demographics and related clinical information. Univariate analyses were done between the AAD and the control groups. Logistic regression was thereafter done for variables with significant differences to obtain the odds ratio (OR) and 95% confidence interval (CI).

Results: In this study, 47 painless AAD patients were enrolled. The AAD patients had a higher female percentage (p = 0.005), were younger (p < 0.001), and had less co-morbidity (p < 0.001). More AAD patients had syncope (p < 0.001). On hospital arrival, more AAD patients remained unconscious (p = 0.001), had lower blood pressure and slower heart rate (p < 0.001). Left-sided weakness was more common in AAD patients (70.2%)(p < 0.001). Peripheral pulses were evaluated in a small part of patients; however, some AAD patients were reported to have symmetrical pulses. Although not required in the current protocol, most of the patients received a chest X-ray (CXR) with a higher percentage of a widened mediastinum in AAD patients (p = 0.001).

AAD patients were brought to the hospital sooner (p < 0.001), were more likely to receive fibrinolytic therapy (p = 0.009). However, the mortality rate was higher in AAD patients (p < 0.001). The logistic regression analysis showed that hypotension (OR 48.86, 95% CI 5.70-420.28), bradycardia (OR 8.11, 95% CI 2.71-24.24), syncope (OR 5.27, 95% CI 1.88-14.76), left-sided weakness (OR 3.31, 95% CI 1.17-9.40), and a widened mediastinum on CXR (OR 3.03, 95% CI 1.06-8.64) were observed more frequently in AAD patients.

Conclusions: In stroke patients with hypotension, bradycardia, syncope, left-sided weakness, or a widened mediastinum, remember to rule out aortic dissection first.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Cardiovascular / Non-CPR/Non-Resuscitation

M03

ASSESSMENT OF AN EMERGENCY DEPARTMENT CHEST PAIN PATIENT COHORT AT LOW RISK FOR SIGNIFICANT ADVERSE EVENTS DURING ADMISSION FOR ACUTE CORONARY SYNDROME

J. Perkins 1, N. Voore 2, J. Patel 3, S. Sanna 4, E. Mann 2, A. Gozu 2

1

Virginia Tech Carilion School Of Medicine, Roanoke, Usa, 2 Medstar Franklin Square Hospital Center, Baltimore, Usa, 3 Virginia Commonwealth University School Of Medicine, Richmond, Usa, 4 University Of Maryland School Of Medicine, Baltimore, Usa Background: The American College of Cardiology (ACC) and the American Heart Association (AHA) have recommended telemetry monitoring for all admitted patients that will be evaluated for an acute coronary syndrome (ACS). This recommendation is not evidence based and leads to broad utilization of a costly resource.

Our purpose was to evaluate a cohort of chest pain patients felt to be at very low risk for significant adverse events (e.g. ventricular fibrillation (VF), ventricular tachycardia (VT), sudden cardiac death (SCD)) during inpatient admission. We hypothesized that this cohort would have few, if any; adverse events and the characteristics of this cohort could be used for future prospective studies.

Methods: All patients in an electronic medical record system aged 18-49 admitted from a community emergency department (ED) with a primary diagnosis of chest pain from January 1, 2009 through June 30, 2010 were retrospectively analyzed. Patients were excluded if they had an abnormal initial troponin-I level, a history of coronary artery disease (CAD), an initial electrocardiogram (ECG) suggestive or diagnostic of ischemia or dysrhythmia, or had no discharge summary available for review. All subjects were reviewed for occurrence of primary endpoints (VF, VT, SCD) and secondary endpoints (STEMI, NSTEMI or upgrade to a higher level of care). The data was analyzed using STATA 10.

Results: There were 1519 patients admitted for chest pain and 814 met the study inclusion criteria. None of the study patients suffered VF, VT, or SCD. Four patients were subsequently diagnosed with an NSTEMI while no patients had a STEMI or required upgrade to a higher level of care.

Conclusions: We conclude that our study cohort is a patient population at very low risk for ACS and may be suited for non-telemetry admission when admitted for chest pain. Using Medicare cost estimates for a 24-hour charge of telemetry (i.e. cost above med/surg bed) of $300 per patient per day; we calculate $244,200 could have been saved by admitting this patient cohort to a non-telemetry bed. Future prospective studies of patients at low risk for ACS may help stimulate ACC/AHA policy change.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Cardiovascular / Non-CPR/Non-Resuscitation

M04

THE RELATIVE STRENGTH OF ASSOCIATION OF CLINICAL FACTORS WITH QT PROLONGATION

K. Marill 1, E. Miller 2

1

University Of Pittsburgh Medical Center, Pittsburgh, Usa, 2 Massachusetts General Hospital, Boston, Usa

Background: A prolonged QT interval is associated with Torsades de Pointes and sudden death. objective was to quantitate the strength of association of factors thought to cause QT interval prolongation.

Our

Methods: A retrospective case series of ED patients was performed at an urban ED with annual volume 90,000.

Two groups of consecutive patients were enrolled with ECG characteristics: QTc>500 milliseconds and QTc<500 milliseconds. Automated ECG measurements were recorded after manual confirmation. The primary outcomes were the coefficients in a multivariate linear regression model with dependent variable QT interval, and independent variables listed in the Table. All included variables were retained in the SPSS model. Sample size was estimated to allow at least 25 subjects per model predictor variable. Abstraction reliability was assessed with a second blinded reviewer.

Results: Patients with QTc>500 msec and QTc<500 msec were included from 7/10/11 to 3/22/12, and from 8/17/11 to 8/19/11, respectively. Full data was available for 544 and 126 patients for a total of 670 included.

Abstraction reliability was excellent. A Loess curve of the model residuals after removal of the K term as a function of K suggested a linear spline function with a single knot at K=3.9 mmol/L (Figure). This was incorporated into the model. Model R2 was 0.72. Age, gender, antidysrhythmic and QT prolonging medicines, hour of ECG, RR interval, QRS interval, serum potassium (K) if less than 3.9, and serum calcium (Ca) were statistically significantly associated with QT interval (Table). There was an approximate 33 msec increase in QT interval per 1 mmol/L decrease in K below 3.9 mmol/L, and no significant association above this K level.

Sensitivity analysis obtained similar results when the heart rate dependence of QT duration effects was included either by adding individual interaction variables or modeling the corrected QT interval.

Conclusions: QT interval is most strongly associated with heart rate, antidysrhythmic or known QT prolonging therapy, and potassium when less than 3.9 mmol/L. These should be some of the primary factors to consider when diagnosing and treating a patient with marked prolonged QT interval at risk for TdP. <FILE IMAGE='174_20150603231313.jpg'>

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Cardiovascular / Non-CPR/Non-Resuscitation

M05

COMPARISON OF THE EFFECTIVENESS OF DILTIAZEM AND ATENOLOL IN THE MANAGEMENT OF RAPID VENTRICULAR RATE IN ATRIAL FIBRILLATION IN THE EMERGENCY DEPARTMENT

H. Ghazali 1, J. Essid, M. Gammoudi, R. Jabri, A. Yahmadi, S. Zelfani, M. Mguidich, M. Louhichi, S. Souissi

1

Regional Hospital, Emergency Department, Ben Arous, Tunisia

Background: Objective: Compare the effectiveness of oral Diltiazem60 with oral Atenolol50 for rate control in patients with acute symptomatic uncomplicated atrial fibrillation and rapid ventricular rate in emergency department for the initial 24-hours.

Methods: Prospective, randomized, double-blind over 3 years study. Inclusion: patients (age>= 18 years old) with symptomatic acute uncomplicated atrial fibrillation > 48 hours and rapid ventricular rate >120 bpm. Patients were randomly assigned to receive either oral Diltiazem60 or Atenolol50. Exclusion criteria: ventricular rate >200 bpm, pre-excitation syndrome, hypotension (systolic blood pressure <90 mmHg), acute ST-elevation myocardial infarction, congestive heart failure, temperature > 38.0°C, history of asthma or chronic obstructive pulmonary disease, allergy or contraindication to the study medications, use of antiarrhythmic and/or atrioventricular nodal blocking drug within last 4 hours, history of anemia (hemoglobin < 11. g/dL) and pregnancy. The study team monitored each subject’s systolic and diastolic blood pressures and heart rate every two hours. Primary end point: sustained ventricular rate control (<110 bpm) at rest and the delay to reach the target heart rate within 24 hours. Secondary end points: atrial fibrillation symptom improvement and length of hospitalization. Informed consent was obtained from all participants.

Results: Inclusion of 92 patients. Mean age: 61 ±14 years. Sex ratio: 0, 27. Diltiazem60 group n=46. Atenolol50 group n=46. Percentage of patients who achieved the target heart rate was higher in the Diltiazem60 group (45%) than the Atenolol50 group (37%) (p=0,04). The median time to ventricular rate control was significantly shorter in the Diltiazem60 group (4,4 ± 2,4 hours) compared with the Atenolol50 group (4,9± 2,8 hours, p =0,05).

The Diltiazem60 group had the lowest mean heart rate after 4 hours of drug administration (p= 0.05), and had the largest reduction in atrial fibrillation symptom frequency score (p=0, 02). Length of hospital stay was significantly shorter in the Diltiazem60 group (p=0.02). From a safety perspective, there was no difference between the two groups.

Conclusions: As compared with Atenolol50, Diltiazem60 is safe and more effective in achieving ventricular rate control in emergency department patients with acute atrial fibrillation.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Cardiovascular / Non-CPR/Non-Resuscitation

M06

PROGNOSTIC VALUE OF THE MAGNITUDE OF ST-SEGMENT DEPRESSION IN PATIENTS WITH NON-ST SEGMENT ELEVATION ACUTE CORONARY SYNDROMES ON SHORT-TERM MORTALITY

H. Ghazali 1, R. Jabri, M. Bayar, A. Yahmadi, G. Chaabeni, M. Chkir, A. Ben Yahya, S. Souissi

1

Regional Hospital, Emergency Department, Ben Arous, Tunisia

Background: Objective: Determine if the magnitude of ST-segment depression predicts short-term mortality in patients with non ST-segment elevation myocardial infarction.

Methods: Prospective observational study was conducted over two years. Patients were eligible for inclusion if the diagnosis of non ST-segment elevation myocardial infarction was made (based on anamnestic, clinical, electrocardiographic and biological criteria). The demographics, co-morbidities, clinical and biological data and in-hospital procedures were collected. The electrocardiogram ST-segment depression was categorized into three groups: Group (ST-segment depression < 1 mm), Group (ST-segment depression between 1 and 2 mm) and Group (ST-segment depression >2 mm). The prognosis was based on the evaluation of mortality at 6 months. Multivariate analysis by multiple logistic regressions was performed.

Results: Inclusion of 111 patients. Mean age: 63 Âą 10 years. Sex ratio: 1.52. Co-morbidities n (%): hypertension 66 (59), diabetes 51 (46), dyslipidemia 31 (28), coronary artery disease 42 (38). Mortality rate was 8%. An ST-segment depression was found in 51 patients (46%). Patients with ST segment depression were 2 times more likely to die within 6 months than patients with other electrical abnormalities (odds ratio adjusted =2.53, p = 0.02, 95% confidence interval: 1.6 to 10.2).

When categorized into three subgroups, the mortality rate was 4,5% for the group ST < 1mm (n=26), 0% for the group ST between 1 and 2 mm (n=16) and 4,5% for the third group ST > 2mm (n=9). After adjustment, patients with ST-segment depression > 2 mm had 3 times higher risk of death at 6 months than the group of patients with ST <1mm (odds ratio adjusted = 3.5, p <0.001, 95% confidence interval: 1.406 to 28.942).

Conclusions: This study shows that quantitative ST segment analysis is an important prognostic factor in non ST-segment elevation myocardial infarction.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Infectious Disease & Sepsis

M07

DIAGNOSTIC VALUE OF COMPUTED TOMOGRAPHY IN EMERGENCY DEPARTMENT PATIENTS WITH SUSPECTED PNEUMONIA

N. Hata 1, Y. Matsuoka 1, M. Sono 1, K. Ariyoshi 1

1

Kobe City Medical Center General Hospital, Kobe, Japan

Background: Chest radiography is the usual standard for diagnosing community-acquired pneumonia, while the use of computed tomography varies among clinicians and no guidelines provide clear recommendations. The aim of our study was to evaluate the effectiveness of computed tomography versus chest radiography for the diagnosis and treatment of pneumonia in emergency departments.

Methods: We retrospectively analyzed adult patients with symptoms suggestive of pneumonia who were evaluated with both chest radiography and computed tomography in an urban emergency department between April 2013 and March 2014 in Japan. We analyzed the differences in diagnosis and treatment strategy between chest radiography and computed tomography. We also evaluated the diagnostic value of chest radiography and computed tomography using the discharge diagnosis as the standard.

Results: A total of 394 patients were enrolled. Of them, 177 were diagnosed with pneumonia on chest radiography versus 254 on computed tomography. Of the 177 patients who were diagnosed with pneumonia on chest radiography, the diagnoses with computed tomography were the same in 148 patients (83.6%), but changed from pneumonia to other diagnoses in 23 patients (12.9%); interstitial lung disease in 5 patients, pulmonary hemorrhage in 4, malignancy in 3, and tuberculosis in 2. The treatment of nine patients (5.1%) who were diagnosed with pneumonia on both chest radiography and computed tomography was changed based on computed tomography findings such as pneumothorax and empyema. The sensitivity, specificity, and overall accuracy of chest radiography were 56.9% (95% confidence interval, 53.3–60.2%), 75.0% (68.9–80.4%), and 63.7% (59.2–67.8%), and those of computed tomography were 94.7% (92.2–96.5%), 85.8% (81.7–88.8%), and 91.4% (88.3–93.7%), respectively.

Conclusions: In emergency department patients with suspected pneumonia, chest radiography had poor sensitivity and specificity in diagnosing pneumonia, and its management based on chest radiography was changed in a significant number of cases as a result of computed tomography findings. The use of computed tomography appears to improve the quality of pneumonia treatment in emergency departments.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Infectious Disease & Sepsis

M08

PRESEPSIN USED FOR PATIENTS WITH SEPSIS IN EMERGENCY DEPARTMENT

T.O. Popa 1, D. Cimpoesu 1, P. Nedelea 2, M. Dumea 1, M. Corlade Andrei 1, A. Petris 1

1

Umf Gr.T.Popa Iasi, Iasi, Romania, 2 Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania

Background: Sepsis is a common syndrome and has devastating implications on health care systems worldwide. Biomarkers may have an important role to highlight the presence, absence or severity of sepsis.

Methods: Retrospective study was conducted on a group of 81 patients with suspected sepsis, presented in the Emergency Department - Emergency County Hospital St. Spiridon - Iasi between 01.09.2014 and 30.10.2014.

The statistical data obtained using SPSS software were interpreted, the ROC curve was calculated. The study aims was to establish the following: determining the validity of presepsin as a biological marker in sepsis diagnosis and prognosis; sepsis stadialization; intra-hospital mortality at 28 days.

Results: The mean age of patients was 64.52 years. Determination of presepsin sensitivity in sepsis early diagnosis was calculated by generating the ROC curve. AUC values obtained were: AUC = 0.709, with a standard error of 0.065 for predicting sepsis; AUC = 0.866, with a standard error of 0.080 for severe sepsis; AUC = 0.864, with a standard error of 0.053 in the presence of septic shock. Presepsin AUC value calculated for sensitivity in relationship to mortality is 0.764 with a standard error of 0.062.The average values of presepsin, related with severity of infection, obtained in this study is 544.39 ± 141.93 pg./ml in case of localized infection; 605.6 ± 59.55 pg./ ml in patients with systemic inflammatory response syndrome; 1283.21 ± 195.74 pg./ ml in patients diagnosed with sepsis; 4787.8 ± 1980.43pg./ml in patients presenting severe sepsis and 3734.88 ± 1732.41pg./ml in patients diagnosed with septic shock.

Conclusions: Presepsin level, measured by using quantitative dosage methods, may be helpful in staging patients diagnosed with sepsis and may be used as an indication for initiation of intensive therapy to prevent septic shock. Presepsinlevel can be used as an early marker of severe prognostic in septic patients.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Infectious Disease & Sepsis

M09

KNOWLEDGE AND PERCEPTIONS OF HIV PRE-EXPOSURE PROPHYLAXIS (PREP) AMONG PATIENTS

Y. Calderon 1, E. Cowan 1, D. Mercer 2, K. Chacon 1, J. Krauss 1, A. Rao 1, J. Leider 3

1

Department Of Emergency Medicine, Jacobi Medical Center, Bronx, Usa, 2 Albert Einstein College Of Medicine, Bronx, Usa, 3 Department Of Internal Medicine, Jacobi Medical Center, Bronx, Usa Background: The safety and efficacy of HIV Pre-Exposure Prophylaxis (PrEP) has been established in several high-risk populations, underscoring the importance of its integration into clinical practice. However, the implementation of PrEP as a population-level prevention strategy has not been demonstrated. Several questions remain, particularly the local communityâ&#x20AC;&#x2122;s knowledge and attitudes towards PrEP. This study assessed knowledge and willingness to take PrEP among patients tested for HIV in an emergency room setting Methods: A prospective, cross-sectional study was conducted on a convenience sample of patients aged 18-71 tested for HIV in an urban public hospital emergency room. Eligible participants completed anonymous written surveys about knowledge, attitudes, and interest in taking PrEP. Results: The study population (n=351) was 45.1% male, 43.2% Hispanic, and 39.4% Black. Mean age was 34.0 Âą 11.4. 24.6% do not have health insurance and 43.1% do not engage in regular medical care. As per CDC criterion, 33.3% of participants were high-risk for acquiring HIV. Risk factors were: inconsistent condom use with multiple sex partners (31.6%), injection drug use (0.6%), sex for commodities (1.1%), sex with an injection drug user (0.6%), or sex with an HIV-positive partner (1.5%). However, only 3.5% of the high-risk cohort believed they were at high-risk for acquiring HIV, and only 35.7% were worried about getting HIV. Most of the total participants had not previously heard of PrEP (79.5%), and more than half would not be interested in taking it even after learning more (58.9%). Common barriers cited include concerns over side effects (40.2%), having enough time for the appointments (44.4%), and concerns over friends and family knowing (45.0%).

Conclusions: Despite high-levels of risk, many patients are not self-aware of their risk and are uninterested in taking PrEP. Other perceived barriers included side effects, lack of time to attend appointments, and concerns over friends/family knowing. Programs addressing these barriers will be needed to increase knowledge and acceptability of PrEP among an urban community.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Infectious Disease & Sepsis

M10

PREPARING FOR EBOLA: READINESS OF A UK GENERAL HOSPITAL

P. Scolding 1, J. Ross 2, G. Kamaras 3

1

Luton And Dunstable University Hospital - Department Of Emergency Medicine, Luton, United Kingdom

Background: The Ebola virus (EV) outbreak of 2014-15 is the largest viral haemorrhagic fever (VHF) epidemic to date with over 26,000 confirmed cases. EV is highly infectious with a case fatality rate of more than 50%.

We aimed to find out how prepared a major UK Hospital Trust was to mount a safe VHF response.

Luton and Dunstable University Hospital is a general hospital serving a population of 400,000. It is close to a busy international airport. The Trust aimed to prepare all staff involved in VHF response by education and investing in materials and training for Personal Protective Equipment (PPE).

Methods: There was a 100% response rate in the 80 individuals surveyed. These included doctors, nurses, healthcare assistants, porters, biomedical scientists and clerical staff.

As well as exploring staff attitudes towards PPE, different exposure-prone procedures were outlined to test understanding of when to use VHF PPE. Knowledge on routes of EV transmission was also assessed.

Results: 71% of staff overall had received training in the management of VHF, including 79% of doctors and 67% of nurses.

95% of staff felt they knew what PPE entailed, and with the exception of clerical officers, staff felt confident in using PPE. 88% of doctors and 72% of nursing staff correctly identified indications for using PPE. The routes of transmission of EV were best understood by biomedical scientists. Doctors of all grades scored similarly, correctly discerning 3 out of the 5 routes by which EV is or is not transmitted. <FILE IMAGE='206_20150530210219.jpg'> Conclusions: 26% of staff involved in VHF response felt that they had not received training, 28% of nurses and 12% of doctors did not understand appropriate indications for PPE. This may be explained by the use of locum doctors and newly qualified nurses who did not receive training. These are likely to be recurring features in UK hospitals.

Overall senior doctors and nurses were well prepared in the use of PPE, and were therefore well placed to lead a response.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Public Health, Screening, and SBIRT

M11

IDENTIFYING ACUTE AND CHRONIC HIV INFECTION IN THE ED: DO 4TH GENERATION ASSAYS CHANGE THE GAME?

M. Menchine 1, S. Arora 1, K. Jacobson 1,2, I. Shulman 1

1

Keck School Of Medicine Of The University Of Southern California, Los Angeles, Usa, And Training Center, Los Angeles, Usa

2

Pacific Aids Education

Background: In 2006, the CDC recommended screening for HIV infection in all healthcare facilities including emergency departments (ED). To date, rapid, point-of-care testing by dedicated testing personnel has been the most common model for ED testing programs. Enthusiasm for this model has been hampered because it is labor intensive. New 4th generation HIV testing platforms (e.g. Abbott Architect Analyzer HIV Ag/Ab) can turnaround HIV tests in less than one hour with fewer resources. Further, this testing platform is able to detect early HIV infection 10-21 days post exposure when patients are highly infectious and may present to the ED with acute seroconversion syndrome. The goal of this investigation was to examine the impact of 4th generation testing on HIV screening and case-identification in an urban ED. Methods: Retrospective evaluation of the 'R/O HIV in the LAC+USC ED' program which offers non-targeted HIV screening to adult ED patients regardless of chief complaint. In July 2013, the 'R/O HIV' program converted from a dedicated-tester, point-of-care model to a lab-based model using 4th generation assays. We compare 1) the number of HIV tests performed 2) the number of new HIV diagnoses and 3) the number of new, acute HIV infections diagnosed in the 15 months before and after the conversion to the lab-based 4th generation testing model.

Results: HIV tests increased by 250% from 8,983 tests in the 15 months before to 22,593 after conversion to the lab-based, 4th generation testing platform. Similarly, the number of newly diagnosed HIV infections increased from 36 to 115 (319% increase). The overall prevalence of newly diagnosed HIV infection was 0.5%.

Fourteen of Acute HIV infection were diagnosed (12.2% of the total new diagnoses) in the 15 months following the conversion compared with 0 cases in the 15 months before. Individuals with Acute HIV infection were 93% male, 79% Latino/Hispanic and 21% Black. Median CD4 count among Acute infections was 430 cells/ul and median HIV viral load was 1.7 million copies/ml.

Conclusions: Conversion to a lab-based 4th generation substantially augmented HIV testing and case finding in an urban ED

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Innovations & new technologies

M12

IMPLEMENTATION OF A VIDEO MESSAGING INTERVENTION TO RE-ENGAGE HIGH-RISK HIV-NEGATIVE PATIENTS IN REPEAT TESTING

Y. Calderon 1, E. Cowan 1, C. Martinez 2, K. Chacon 1, J. Krauss 1, S. Rahman 1, A. Rao 1, J. Leider 3

1

Department Of Emergency Medicine, Jacobi Medical Center, Bronx, Usa, 2 Albert Einstein College Of Medicine, Bronx, Usa, 3 Department Of Internal Medicine, Jacobi Medical Center, Bronx, Usa Background: Testing negative for HIV often represents a missed opportunity for more targeted interventions for high-risk patients. The main objective of this study was to determine the acceptability of using video messages as a means of post-test counseling to educate high-risk individuals after they received an HIV test. The secondary objective was to assess the impact of the video-messages on re-testing for HIV in 3 months.

Methods: We conducted a 2-armed randomized controlled trial on a convenience sample of HIV-negative high-risk patients ages 18 and above in an urban emergency department. Participants were identified as high-risk through their responses to a pre-test questionnaire or by concurrent diagnosis of an STI. Participants were randomized to video intervention arm or to control/standard-of-care arm. Those in the video intervention arm received a series of 6 videos, one video every 2 weeks, each video focusing on a different HIV-related topic.

Results: 138 eligible patients were approached for the study, and 120 agreed to participate (87.0%).

Demographic characteristics of the participants were: 60.1% male, 43.0% Hispanic, and 40.2% Black. Mean age was 27.5 years Âą 8.2 years. Risk factors over the last three months: inconsistent condom use with multiple sex partners (51.7%), injection drug use (1.7%), sex for commodities (0.8%), sex with an injection drug user (4.2%), or sex with an HIV-positive partner (5.0%). Videos were viewed 171 times, with Acute HIV the most watched (75 views). 21 patients (12 control; 9 intervention) reported re-testing in 3 months and 7 patients (3 control; 4 intervention) reported not re-testing. We were unable to contact the remaining 92 participants to determine if they had re-tested.

Conclusions: Our study found video-messaging is an accepted method of conducting post-test counseling for high-risk patients, as the majority of high-risk patients were receptive to receiving the messages. The number of views indicates interest in post-test counseling videos. However, we were unable to determine the impact the videos had on patient re-testing in three months due to our limited ability to contact patients who did not return to our medical center for re-testing

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Biomarkers

M13

COMPARISONS OF THE MDRD, CKD-EPI AND REVISED LUND-MALMO STUDY EQUATIONS FOR THE ESTIMATION OF THE GLOMERULAR FILTRATION RATE IN THE GENERAL KOREAN POPULATION

M. Ji 1, Y. Lee 2, M. Hur 1, H. Kim 2, S. Di Somma 3

1

Konkuk University School Of Medicine, Seoul, South Korea, South Korea, 3 University Of Rome Sapienza, Rome, Italy

2

Korea Association Of Health Promotion, Seoul,

Background: The estimated glomerular filtration rate (eGFR) is the most commonly used index for the assessment of renal function. The Chronic Kidney Disease Epidemiology Collaboration equations based on serum creatinine (CKD-EPICr), cystatin C (CKD-EPICysC) or a combination of both (CKD-EPICr-CysC) and revised Lund-Malmo(LMrev) Study equation were recently evaluated. We compared them with the traditional Modification of Diet in Renal Disease (MDRD) Study equation regarding the prevalence of GFR category in the general Korean population.

Methods: The study population consisted of 20,552 individuals (age 50.5±12.5 years, 42.7% male) who received annual physical check-ups during the year of 2014. Among them, cystatin C measurements were performed in 1,482 participants. We conducted a retrospective analysis of medical records and laboratory data.

GFR was estimated using five equations (1 MDRD, 3 CKD-EPI and 1 LM) and the GFR categories were according to the Kidney Disease: Improving Global Outcomes 2012 guideline.

Results: Mean eGFR values were: eGFRMDRD 72.7±11.3, eGFRCKD-EPI CysC 104.7±18.0, eGFRCKD-EPI Cr-CysC 94.0±15.9, eGFRCKD-EPI Cr 80.6±14.0, and eGFRLM rev 74.0±11.1 mL/min/1.73 m2. Mean eGFR difference was highest in the CKD-EPICysC (31.2) compared to MDRD equation. CKD stage assignments considerably varied according to the equations used, especially for stage 1 and 2. The proportions of stage 1 were 6.4% (MDRD), 81.7% (CKD-EPICysC), 66.2% (CKD-EPICr-CysC), 25.6% (CKD-EPICr) and 6.0% (LMrev).

Concordance rate between MDRD and other equations were 91.6-95.4% when 60 mL/min/1.73 m2 was used for the decision criterion. Kappa agreement was poor in CKD-EPICysC equation (κ=0.259).

Conclusions: Our data suggest that there are remarkable differences in eGFR assessment depending on the equations, especially in normal or mildly decreased categories. Cystatin C-containing equations showed larger differences compared to MDRD equation.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Biomarkers

M14

PREDICTIVE VALUE OF NGAL FOR ACUTE KIDNEY INJURY AND IN-HOSPITAL MORTALITY IN ACUTE HEART FAILURE PATIENTS UNDERGOING HIGH DOSAGE OF DIURETIC THERAPY IN THE EMERGENCY ROOM

S. Navarin 1, S. Santarelli 1, L. Magrini 2, R. Marino 2, D. Volterra 1, C. Berardi 1, G. Zoccoli 1, P. Cardelli 3, G. Salerno 3, S. Di Somma 1, 2

1

Emergency Department, Faculty Of Medicine And Psychology, Sapienza University Of Rome, Sant'andrea Hospital, Rome, Italy, 2 Emergency Department, Sant'andrea Hospital, Rome, Italy, 3 Clinical And Molecular Medicine Department, Sapienza University Of Rome, Sant'andrea Hospital, Rome, Italy Background: Acute heart failure prevalence is increasing worldwide. Acute kidney injury complicates the clinical course of 30-50% of heart failure patients, leading to increased mortality and length of stay. Our aim was to investigate the impact of heart and kidney biomarkers in early detection of acute kidney injury in acute heart failure patients.

Methods: A prospective observational study on acute heart failure patients presenting to the emergency department. At arrival each patient received standard of care treatment according to current guidelines.

Routinary lab tests and NGAL were assessed at admission, while BNP (or NT-proBNP) were evaluated at admission and after 48 hours. Acute kidney injury was diagnosed as serum creatinine increase > 0.3 mg/dl within 48 hours after admission.

Results: Within 245 enrolled patients (44% male, mean age 78.4Âą9.5), 17.5% developed acute kidney injury.

BNP at 48 hours and NGAL at admission proved to predict in-hospital death (Area Under Curve for BNP 48hours: 0.68, p<0.03; for admission NGAL: 0.78, p<0.03). Acute heart failure patients with acute kidney injury showed higher in-hospital mortality rate (Area Under Curve: 0.66, p<0.008) and a trend of longer length of stay even if not statistically significant. The simultaneous presence of metabolic acidosis increased mortality prediction (Area Under Curve: 0.66, p<0.01). NGAL proved to be a strong predictor of acute kidney injury in patients who received a Furosemide dosage >135 mg within 24 hours after admission (Area Under Curve: 0.80, p<0.0001), and the strongest predictor of in-hospital mortality in patients who received a Furosemide dosage >180 mg within 24 hours (Area Under Curve: 1.0, p<0.0001).

Conclusions: Admission NGAL and BNP 48 hours after hospitalization blood values are good predictors for in-hospital death in patients hospitalized for acute heart failure. In patients treated with high dosage of Furosemide during the first 24 hours, NGAL showed to be the best predictor for the development of acute kidney injury and in-hospital mortality. At emergency department admission NGAL blood value could be considered as an indicator of ongoing kidney tubular damage for diuretic treatment decision making in acute heart failure patients.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Biomarkers

M15

SOLUBLE ST2 AND LEFT VENTRICULAR REMODELING IN PATIENTS WITH METABOLIC SYNDROME

V. Celic 1,2, A. Majstorovic 1, B. Pencic-Popovic 1,2, A. Sljivic 1, N. Lopez-Andres 3, I. Roy 4, E. Escribano 4, M. Beunza 4, A. Melero 3, F. Floridi 5, B. Zancla 6, G. Salerno 7, P. Cardelli 7, S. Di Somma 8

1

Clinical Hospital Centre Dr Dragisa Misovic-Dedinje, Belgrade, Serbia, 2 Faculty Of Medicine, Belgrade University, Belgrade, Serbia, 3 Miguel Servet Foundation-Navarrabiomed, Pamplona, Spain, 4 Complejo Hospitalario De Navarra, Pamplona, Spain, 5 School Of Medicine And Psychology La Sapienza University, Santandrea Hospital, Rome, Italy, 6 Emergency Medicine Department, Faculty Of Medicine And Psychology, Sapienza University, Santandrea Hospital, Rome, Italy, 7 Clinical And Molecular Medicine Department, School Of Medicine And Psychology La Sapienza University,santandrea Hospital, Rome, Italy, 8 Postgraduate School Of Emergency Medicine, La Sapienza University, Santandrea Hospital, Rome, Italy Background: Metabolic syndrome (MetS) has been linked to subclinical changes in cardiac structure and function, including left ventricular hypertrophy. One of the contributing factors is proinflammatory state. A biomarker that is of interest in relation to this is soluble ST2. The aim of our study was to determine the link between proinflammatory factors, namely ST2 and left ventricular remodeling in patients with MetS. Methods: The study included 180 subjects screened for MetS at university hospital centers in Serbia, Spain and Italy. Study inclusion criteria was MetS, diagnosed according to the new International Diabetes Federation definition, in subjects aged <65, with normal left ventricular ejection fraction (greater or equal to 50%). ST2 testing was performed using a quantitative monoclonal ELISA assay. Reference upper limits of normal left ventricular mass index were 95g/m2 in women and 115g/m2 in men, measured by echocardiography. Statistical analysis was done using statistical software SPSS17.

Results: There was the same proportion of men and women, aged 53±9 years, with waist circumference of 107±8cm in males and 100±10cm in females and at least two additional criteria for MetS. Mean concentration of ST2 was 27.35±15.74ng/mL (male 26.24±13.89ng/mL, female 28.73±17.81ng/mL). Results of echocardiographic examinations showed normal left ventricular ejecton fraction (60.56±6.61%), increased septal thickness (1.04±0.15cm), posterior wall thickness (1.03±0.14cm) and relative wall thickness (0.43±0.08cm). Left ventricular mass index was 90.63±20.90g/m2. Logistic regression determined that males with MetS were 2.51 times more likely to exhibit left ventricular hypertrophy, as were subjects with increased ST2 [Exp(B)=2.20, p=0.048] and increased systolic blood pressure [Exp(B)=1.02, p=0.05]. Mean concentrations of ST2 in the group with and without left ventricular hypertrophy were significantly different (32.18±16.88ng/mL vs. 25.94±15.19ng/mL, p=0.042). Receiver operating characteristic curve showed that ST2 has an ability to distinguish between groups with and without left ventricular hypertrophy (area under the curve 0.62, p=0.02).

Conclusions: Our study showed increased values of ST2 in patients with MetS. Concentration of ST2 correlated with left ventricular mass index. This could make ST2 possibly a very useful tool in early assessment of MetS patients and their overall prognosis.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Biomarkers

M16

PROGNOSTIC ROLE AND TEMPORAL PROFILE OF BIOMARKERS IN SEPSIS AND SEPTIC SHOCK.

U. Audisio 1, S. Battista, C. Galluzzo, M. Maggiorotto, M. Masoero, D. Forno, G. Mengozzi 2, M. Lucchiari, A.R. Vitale, F. Settanni

1

Città Della Salute E Della Scienza-Department Of Emergency Medicine, Turin, Italy, 2 Città Della Salute E Della Scienza-Clinical Biochemistry Laboratory, Turin, Italy Background: In this study we compared Copeptin, Galectin-3 and Presepsin with PCT as biomarkers of sepsis in the Emergency Department of “Città della Salute e della Scienza” University Hospital of Turin. We enrolled patients affected by SIRS with a suspicion of infection and patients with gastrointestinal bleeding as controls; diagnostic and prognostic efficacy (mortality at 7 and 30 days) of each biomarker were evaluated.

Methods: Fourty-two patients were included in the study: 12 with sepsis, 11 with severe sepsis, 8 with septic shock and 11 with gastrointestinal bleeding. Biomarkers and routine laboratory tests were assessed at the first medical evaluation (T0) and thereafter 24 (T1), 48 (T2), and 72 (T3) hours after admission; SAPS II and SOFA scores were calculated for all patients. In the control group American College of Surgeons and Blatchford scores were also determined. Definitive diagnosis and in-hospital survival rates at 7 and 30 days after enrollment were obtained through analysis of medical records.

Results: At T0 PCT proved to be the only diagnostic biomarker able to distinguish septic population from controls (p=0.025), and patients with severe sepsis from those with septic shock (p<0.05). Presepsin, Galectin-3 and Copeptin levels at T0 were not statistically different among the groups. Areas Under the Curve (AUC) of serial measurements for Galectin-3 and PCT showed significative differences among groups (p=0.045 and p=0.003, respectively). In particular, PCT levels decreased in subjects with severe sepsis and septic shock after T0, while it remained persistently low in patients with sepsis and in controls.

Copeptin concentration profile showed a trend in patient stratification on the basis of the severity of hemodynamic instability (p=0.08). None of the studied biomarkers had a significant prognostic role with respect to either 7-day or 30-day mortality.

No significant differences have been found for the other biomarkers, but this could be due to the small number of patients enrolled in the study. <FILE IMAGE='154_20150528183645.jpg'> Conclusions: This work confirmed the diagnostic value of PCT. Further studies are needed to investigate the potential role of Copeptin as biomarker of hemodynamic stress.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Biomarkers M17

HOW USED AND USEFUL ARE THE CARDIAC BIOMARKERS FOR EMERGENCY NON ISCHEMIC CARDIAC EVENTS CONFIRMATION? L.T. Rotaru 1, D. Cimpoesu 2

1

Medicine & Pharmacy University, County Emergency Hospital, Ed & Prehospital Care, Craiova, Romania, Medicine & Pharmacy University, County Emergency Hospital, Ed, Iasi, Romania

2

Background: Current use of cardiac biomarkers is carried out on 3 areas in ED: chest pain, shortness of breath, chronic heart faillure. There are, however, many other situations in which myocardial damage may occur and the changes in myocardial necrosis enzymes can be helpful for the EM physician.

Methods: The aim of this work are to identify those directions and conditions in which the determination of myocardial necrosis markers can provide tactical reasoning as important tools in myocardial types of injury evaluation.

We studyed 3261 patients in clinical situations likely myocardial injury generators received by ED-University Hospital Craiova between 2012-2014 .

Results: Only at 6,13% of patients with ACS necrosis biomarkers determination led relevant diagnostic clues to other diagnoses resources To 21,14% patients with severe sepsis, myocardial injury (based of the myocardial enzyme levels) occurred before installing other organ dysfunction In neonatal sepsis biomarkers development did not correlate with the severity and sepsis evolution.

Dynamic alteration in severe pancreatitis - observed to 8,73% of cases, and in crush syndrome in 2,1%.

9,11% of patients with severe carbon monoxide intoxication has CKMB transient alteration.

From 38,72% of patients with acute myocarditis cardiac biomarkers alteration - the first allarm signal 13,84% patients with severe thoracic blunt trauma - CK MB s-modified, and almost 17% percent of them, troponin I positive in dynamics Conclusions: 1.

The main utility of determination of myocardial necrosis enzymes appears to be ACS but early identification and tracking trends could be: • acute nonoclusive myocardial injury but ischemic mechanism (sepsis) • endotoxic injury (pancreatitis, electrocution, crush syndrome) • myocardial disfunction related to hypothermia / reheating or reperfusion syndrome, • cardiac contusion, myocarditis, hypoxic myocardial lesion (carbon monoxide).

2.

Other directions of use of biomarkers were found to be: • detection and risk stratification in acute heart failure – decision of management level • directing patient to advanced medical facilities 3.

Various tactical errors can diminish the value of these tests, related to the occurrence and persistence in circulation, interpretation of the clinical context, single marker determination or single determination.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Biomarkers

M18

UTILITY OF BIO-ADRENOMEDULLIN (BIO-ADM) AND PRO-ENKEPHALIN (PRO-ENK) PREDICTION OF IN-HOSPITAL MORTALITY IN PATIENTS WITH ACUTE HEART FAILURE

FOR

THE

S. Navarin 1, R. Marino 2, S. Santarelli 1, D. Volterra 1, B. De Berardinis 1, C. Berardi 1, G. Zoccoli 1, A. Bergmann 3, O. Hartmann 3, J. Struck 3, L. Magrini 2, S. Di Somma 1, 2

1

Emergency Department, Faculty Of Medicine And Psychology, Sapienza University, Sant'andrea Hospital, Rome, Italy, 2 Emergency Department, Sant'andrea Hospital, Rome, Italy, 3 Sphingotec Gmbh, Neuendorfstr.

15a, 16761, Hennigsdorf, Germany Background: Bio-Adrenomedullin (bio-ADM) and Pro-Enkephalin (pro-ENK) have already proved to be good predictors of short term mortality in patients with sepsis. No data are available so far on their predictive value for in-hospital mortality in patients with acute heart failure.

Methods: This was a prospective, observational trial conducted in intensive care unit. We enrolled patients admitted from the emergency department of Sant’Andrea hospital in Rome for acute heart failure. Clinical and laboratory data, bio-ADM and pro-ENK values were collected at arrival and patients were followed until hospital discharge.

Results: 209 patients with a final diagnosis of acute heart failure were recruited (44% male, mean age 78.4±9.5). Regarding patients’ characteristics we found out that 49.7% had prior history of heart failure, 58% had reduced systolic function, 17% presented with pulmonary edema, and 21% developed acute kidney injury, defined as serum creatinine increase by 0.3 mg/dl within 48 hours after hospitalization. Using Pearson’s analysis, a significant correlation was found between bio-ADM and inferior vena cava index (r=0.20, p=0.003), suggesting a potential role of bio-ADM in the detection of intravascular congestion, that is considered to be the main cause of re-hospitalization for acute heart failure patients. Moreover, admission pro-ENK significantly correlated at Pearson’s test with serum creatinine (r=0.56, p<0.0001) and chronic kidney disease (r=0.31, p<0.0001). This result seems to extend the already known role of pro-ENK for renal impairment identification to the heart failure condition. Finally, both analyzed biomarkers, bio-ADM and pro-ENK, proved their value in predicting in-hospital mortality in acute heart failure patients (bio-ADM: Area Under Curve=0.65, p=0.047; pro-ENK: Area Under Curve=0.73, p=0.0011).

Conclusions: Bio-ADM and pro-ENK are suitable biomarkers for risk prediction of in-hospital mortality in patients hospitalized for acute heart failure. The pathophysiological mechanism of the two biomarkers for the prediction of in-hospital death for acute heart failure patients seems to be linked to intravascular congestion for bio-ADM and to renal dysfunction for pro-ENK.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Metabolic and endocrine disorders

M19

ASSESSMENT OF FREQUENCY AND ASSOCIATED FACTORS OF HYPERNATREMIA IN PATIENTS WITH ISCHEMIC CEREBROVASCULAR ACCIDENT

V. Monsef Kasmaei 1, S.M. Zia Ziabari, P. Asadi, N. Gangii, O. Hedayati

1

Road Trauma Research Center, Guilan University Of Medical Sciences, Rasht, Iran

Background: Sodium ion electrolyte disturbance is one of the most common disorders during patients Hospitalization. This study Assesses the frequency and the associated factors of hypernatremia in patients with ischemic cerebrovascular accident admitted to Pour Sina hospital of Rasht located at the northern part of Iran, during August 20th of 2012 to September 20th of 2014.

Methods: This was a cross sectional planned study . Documents of patients with cerebral ischemic accident who were admitted to Pour Sina hospital during August 20th of 2012 to September 20th of 2014 were collected and information such as demographic data, the results of blood tests, paraclinc reports were included, the patient's condition upon admission, the state of consciousness during hospitalization according to Glasgow Coma Scale (GCS) on admission , during hospitalization and at the time of discharge were noted, the time and cause of death if patient was expired were derived and then SPSS version 20 was used for statistical analysis of data.

Results: In this study, 693 patients were enrolled, among whom 344 (49/64%) were male and 349 (50.36%) were female. The mean and standard deviation of their ages were 68 13. The study showed that the prevalence rate of hypernatremia in samples has been 12.8% with confidence interval of 95 %( 10.34-15.34).Also the study showed that 75.28% OF hypernatremic patients died. The confidence interval was 66 .14- 84.42.The mortality rate of patients without hypernatremia has been 17.1% and this difference was significant (p<0.0001).

Conclusions: This study reveals the importance of hypernatremia as an independent risk factor in the patients with ischemic cerebrovascular disorders which can increase the mortality rate of such patients. It is necessary to perform prompt electrolytes tests and determination and control of sodium level of the serum to reduce the mortality rate of patients with ischemic cerebrovascular accidents.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Neurologic / Psychiatric

M20

CLINICAL CHARACTERISTICS OF 372 CASES OF TRANSIENT GLOBAL AMNESIA IN THE EMERGENCY DEPARTMENT: A SINGLE CENTER STUDY

Y. Shin 1, S. Ahn 2, K.S. Lim

1

3

Asan Medical Center, Seoul, South Korea

Background: Transient global amnesia (TGA) is characterized by abrupt onset of antegrade amnesia usually seeking emergency care. We analyzed the clinical characteristics of TGA patients and the significance of diffusion weighted imaging (DWI) in the diagnosis of TGA. <FILE IMAGE='9_20150312153323.jpg'> Methods: Retrospective analysis was performed using electronic medical records of patients diagnosed as TGA in the emergency departments from January 2003 to December 2013. The patientâ&#x20AC;&#x2122;s clinical characteristics and precipitants were analyzed, and detection rate of hippocampal lesion was compared according to the time to DWI after symptom onset (< 6 h, 6~12 h, 12~24 h, and >24 h).

Results: Of 372 consecutive TGA patients studied, 27 had a positive DWI lesion in hippocampus.

Demographics and vascular risk profile were not significantly different between those in DWI (+) and DWI (-), and neither was duration of amnesia (p=0.076). However, the median time interval to DWI was significantly longer in DWI (+) than DWI (-) [7.5 (5.5~15.0) h vs. 6.0 (3.5~9.0) h, p=0.011]. In addition, the detection rate of hippocampal lesion increased with the time interval [0-6 h (4.1%), 6~12 h (10.7%), 12~24 h (11.1%), and >24 h (16.1%), p=0.004].

Conclusions: Positive hippocampal lesion on DWI can confirm the diagnosis of TGA; however, difference in lesion detectability in regard to time interval from symptom onset to DWI should be considered in diagnosis of TGA with DWI.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Neurologic / Psychiatric

M21

IS CT/CTA OR MRI BETTER FOR IMAGING TIA?

L. Cochon 1, T. Stead 2, L. Ganti 2, A.A. Baez 3

1

Universitat De Barcelona, Barcelona, Spain, 2 Usa, 3 Jackson Memorial Hospital, Miami, Usa

Background: Transient ischemic attack (TIA) is an important warning sign of stroke, with 12-20% of all ischemic strokes heralded by a TIA. Stroke is the number one cause of adult disability and the 3rd leading cause of death in North America, and thus imaging is usually performed in the emergency department setting, even when symptoms have completely resolved. There is debate, however, as to which imaging modality is most useful diagnostically.

Methods: ABCD2 score classified as low (0-3 points), intermediate (4-5 points), or high risk (6-7 points) associated with a certain percentage of subsequent risk of stroke at 2, 7 and 90 days. Bayesian statistical model was constructed starting with the ABCD2 score risk categories as the pretest probabilities. Sensitivity and specificity for CT/CTA and MRI were obtained from pooled data and used to calculate positive (+) and negative (-) likelihood ratios (LRs). The Bayesian nomogram was used to calculate the post-test probabilities.

Results: The (-)LRs for CT/CTA and MRI were -0.49, and -0.58. The (+)LRs were +2.09 and +1.32 respectively.

For risk of stroke at 2 days in patients with a low risk ABCD2 score, CT/CTA was clearly the diagnostic test of choice, with a relative gain of 100% for CT and 0% for MRI, for the ability of the imaging study to detect a stroke when one was present and to be negative when one was not.

The post test probability (relative and absolute gain) increased for (+)LRs and decreased for (-)LRs for every risk category at 2,7, and 90 days for both CT/CTA and MRI, except for MRI in low risk patients at 2 days Conclusions: Doing any imaging study, whether CT/CTA or MRI, improves the risk stratification of patients who present to the ED with TIA, except for MRI in the low risk group at 2 days. Across all risk categories (low, intermediate, high) at all endpoints (2 days, 7 days, and 90 days), CT/CTA performed equal or better than MRI.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Neurologic / Psychiatric

M22

ISCHEMIC PRECONDITIONING MAINTAINS IMMUNOREACTIVITIES OF GLUCOKINASE AND GLUCOKINASE REGULATORY PROTEIN IN NEURONS OF THE GERBIL HIPPOCAMPAL CA1 REGION FOLLOWING TRANSIENT CEREBRAL

J.H. Cho 1, C.W. Park 1, T.G. Ohk 1, Y.S. Kim 1, M.C. Shin 1, M.H. Won 2

1

Emergency Medicine, Kangwon National University, Chuncheonsi, South Korea, National Univeristy, Chuncheonsi, South Korea

2

Neuobiology, Kangwon

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Neurologic / Psychiatric

M23

HYDROQUINONE SHOWS NEUROPROTECTIVE POTENTIAL IN EXPERIMENTAL ISCHEMIC STROKE MODEL VIA ATTENUATION OF BLOOD-BRAIN BARRIER DISRUPTION

J.H. Cho 1, C.W. Park 1, T.G. Ohk 1, Y.S. Kim 1, M.C. Shin 1, M.H. Won 2

1

Emergency Medicine, Kangwon National University, Chuncheonsi, South Korea, National Univeristy, Chuncheonsi, South Korea

2

Neuobiology, Kangwon

Background: Hydroquinone (HQ), a major benzene metabolite, occurs naturally in various plants and food, and is also manufactured for commercial use. Although many studies have demonstrated the various biological effects of HQ, the neuroprotective effects of HQ following ischemic stroke have not been investigated.

Methods: Therefore, in this study, we first examined that the neuroprotective effects of HQ against ischemic damage in a focal cerebral ischemia rat model.

Results: It was proven that pre- and post-treatment with 100 mg/kg of HQ protects from ischemia-induced cerebral damage, which was confirmed by evaluation of neurological deficit, PET (Positron-emission tomography) and TTC (2,3,5-triphenyltetrazoliumchloride) staining. In addition, pre- and post-treatment with 100 mg/kg of HQ significantly attenuated ischemia-induced Evans blue dye extravasation, and significantly increased the immunoreactivities and protein levels of SMI-71 and glucose transporter-1 (GLUT-1), which were well-known as useful makers of endothelial cell, in ischemic cortex compared to vehicle-treated-group.

Conclusions: Briefly, these results indicate that pre- and post-treatment with HQ can protect from ischemic damage induced by transient focal cerebral ischemia, and the neuroprotective effects of HQ may be closely associated with the prevention of BBB disruption via increasing of SMI-71 and GLUT-1 expressions.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Substance abuse

M24

PROGNOSTIC VALUE OF THE SUICIDE INTENT SCALE IN SELF-POISONING PATIENTS IN THE EMERGENCY DEPARTMENT

R. Jebri 1, S. Souissi 1, R. Ben Kaddour 1, H. Ghazali 1, A. Yahmadi 1, W. Bousselmi 1, J. Essid 1, N. El Heni 1

1

Ben Arous Regional Hospital Emergency Department, Ben Arous, Tunisia

Background: Over the past 30 years, Beck's Suicide Intent Scale has been the prevailing psychometric scale for assessing suicide intent in suicide attempters (Freedenthal, 2008). It is recognized that this scale is predictive of recurrence of suicide attempt, but it is not known if it influence the prognostic of these patients. The objective of this study was to assess the prognostic value of the Suicide Intent Scale in patients self-poisoning patients seen in the emergency department.

Methods: It is a prospective observational study conducted over two years. All patients with self-poisoning admitted in the emergency department during the study period were included. The demographics, co-morbidities, clinical and biological data and in-hospital procedures were collected.

The suicide attempters were assessed with the Beck's Suicide Intent Scale. Receiver-operating characteristic curves and tables were created to establish the optimal cut-off values for this scale. Patients admitted in an intensive care unit were considered as having a poor outcome.

Results: During the study period, 228 patients were enrolled. Mean age 26 +/- 9 years, sex ratio at 0.2. sixty four patients (28%) had already committed suicide attempt. drug poisoning was found in 84% of cases, and pesticide poisoning in 14% of cases. fifty five patients (24%) were admitted in an intensive care unit. the prognostic value of the Suicide intent scale was demonstrated with a likelhood ratio to 14.7 (p = 0.000). A cut-off at 12 was predictive of intensive care unit admission and the Area Under Curve was 0.71 (p=0,000).

Conclusions: The measurement of suicidal intent scale in the assessment of self harm patients is beneficial for the evaluation of future suicide risk. It can also be a valuable tool to assess the short-term prognosis of these patients in the emergency department. A shorter version of the scale may offer a better predictive value

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Biomarkers

M25

IS THERE A RELATIONSHIP BETWEEN THE NT PRO BNP RATES AND THE ACUTE HEART FAILURE SYNDROMES IN THE EMERGENCY DEPARTMENT?

R. Jebri 1, O. Djebbi 1, M. Ben Lassoued 1, G. Ben Jrad 1, I. Guerbouj 1, H. Mahfoudhi 2, K. Lamine 1

1

Military Hospital Of Tunis Emergency Department, Tunis, Tunisia, Department, Tunis, Tunisia

2

Military Hospital Of Tunis Cardiology

Background: The Acute heart failure is a common disease in the emergency department. Making the accurate diagnosis can be a challenge for the emergency phycisian. The NT-proBNP dosage of is simple to perform but it does not completely waiver echocardiography. Echocardiography can determine the mechanism by diastolic heart failure, systolic dysfunction or right heart failure. The objective of this work is to study the relationship between the NT pro-BNP rates and the acute heart failure syndromes in the emergency.

Methods: A prospective descriptive study in the emergency department over a period of seven months. Were included all patients with the diagnosis of acute heart failure. All patients had NT pro BNP dosage and echocardiography within 24 hours. Were excluded patients who could not benefit from a dosage of NT pro-BNP or echocardiography and those in whom the diagnosis has been laid wrongly (NT pro-BNP <400). Were collected demographics, clinical and biological data, treatment and outcome Results: Sixty three patients were included. The mean age was 66.79 Âą 11 years. The sex ratio was 3. A history of cardiac failure was found in 70% of patients. Diastolic heart failure (clinical scenario 1) was found in 22% of cases, Systolic heart failure (clinical scenario 2) in 50% of cases, ischemic heart failure (clinical scenario 4) in 16%. Cardiogenic shock (clinical scenario 3) in 3% of cases, and right heart failure (clinical scenario 5) in 7% of cases. Eighteen patients, 23% NT pro-BNP in the gray zone. Table 1 reports the rate of NT pro-BNP and echocardiography data for the different clinical scenarios.

The hospitalization rate was 55%, 44% discharged home from the emergency department. The mortality rate at 6 months was 8%.<FILE IMAGE='214_20150531222411.jpg'> Conclusions: NT pro BNP highest rates were seen in patients with diastolic heart failure with a preserved ejection fraction. The lowest rates were observed in patients with an altered ejection fraction. A larger number of patients is needed to determine if the rate of NT pro BNP would alone predict the clinical scenario of heart failure without the use of ultrasound.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Biomarkers

M26

A ROLE FOR THE NOVEL CARDIAC BIO-MARKER ST2 FOR HEARTS IN SYSTEMIC INFLAMMATORY RESPONSE SYNDROME

H. Yang 1, M. Hur 1, S. Di Somma 2

1

Konkuk University Medical Center, Seoul, South Korea, 2 University La Sapienza Rome

Background: The possible role of ST2 as an early marker of cardiovascular diseases has been tested in heart failure and ischemic heart disease. However, the role of ST2 in systemic inflammatory response syndrome (SIRS) is not fully evaluated. <FILE IMAGE='225_20150531134446.jpg'> Methods: A total 132 patients (age 69±15 years, male 73) with SIRS underwent blood culture, blood tests [C-reactive protein (CRP), procalcitonin], and echocardiography. We excluded patients with acute coronary syndrome. The level of ST2 was measured from plasma samples using a Presage® ST2 Assay (Critical diagnostic). ST2 was compared with the cardiac systolic and diastolic filling parameters and sepsis markers as well.

Results: The echocardiogram revealed left ventricular (LV) ejection fraction (EF) of 63.0±11.3%, and tachycardia (> 90/min) in 94 (71%). Acute systolic heart failure (EF<40%) was demonstrated in 7 (5%) patients.

The LV filling pressure was elevated (E/e’>15) in 17 patients (13%), and the estimated resting pulmonary arterial systolic pressure (PASP) was high (>40 mmHg) in 22 (17%). The ST2 was not well-correlated with systolic function (EF), diastolic filling (E/e’) and PASP (r=0.016, p=0.859; r=-0.024, p=0.792; r=-0.063, p=0.479).

However, ST2 had a good positive correlation with CRP, and procalcitonin (r=0.270, p=0.002; r=0.370, p<0.001).

Patients with shock (n=40) had higher ST2, CRP, and procalcitonin than without (all, p<0.01). SOFA score showed a good correlation with ST2 (r=0.380, p<0.001), but not with procalcitonin (r=0.123, p=0.168). Finally, the 30-day mortality group (n=20) revealed higher ST2 (median 193.5 vs. 102.5 ng/ml, p=0.294).

Conclusions: Initial ST2 in patients with SIRS might have a role not in assessing LV systolic or diastolic function but as a bio-marker of inflammation or shock itself, and a better predictor of SOFA score than procalcitonin.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Cardiovascular / Non-CPR/Non-Resuscitation

M27

COMPARISON OF THE DIAMOND & FORRESTER SCORE AND DUKE CLINICAL SCORE TO SAFELY REDUCE STRESS UTILIZATION IN CHEST PAIN UNIT PATIENTS

A. Napoli 1

1

Brown University School Of Medicine, Providence, Usa

Background: Cardiology consensus guidelines recommend use of the Diamond & Forester (D&F) to assess the pretest probability of coronary artery disease (CAD) in symptomatic chest pain patients. However, recent work has suggested the Duke Clinical Score (DCS) may better predict obstructive CAD in low risk patients. Our objective was to examine if the DCS identified a greater proportion of low risk individuals while not affecting accuracy of identification of true positive stress tests.

Methods: A retrospective, observational trial of consecutive admitted CPU patients in a large-volume academic urban ED. Inclusion criteria were: age>18, AHA low/intermediate risk, nondynamic ECGs, and normal initial Troponin I. Exclusion criteria were: age>75 with CAD. A D&F score and a DCS for likelihood of CAD was calculated on each patient. Based on the score, patients were assigned a priori to low, intermediate, and high risk groups (<10%, 10-90%, >90% respectively). Acute coronary syndrome (ACS) was defined by ischemia on stress test, coronary artery occlusion of >=70% in at least one vessel, or elevations in troponin I consistent with consensus guidelines. A true positive stress test was defined by evidence of reversible ischemia and subsequent angiographic evidence of critical stenosis or a discharge diagnosis of ACS. T-tests and Pearson Chi-square tests were used for comparisons of demographics, cardiac comorbidities, and risk scores.

The primary outcome was analyzed using a Z-test for proportions (alpha=0.05, 2 tail).

Results: 1357 patients with index visits were enrolled. 57% of patients were stressed. Of those stressed, the mean age was 53 Âą 11, 51% were female.

The median D&F score was 27 (IQR 15-51), the median DCS score was 20 (IQR 8-20). More patients were identified as low risk using the DCS score 28% (95% CI 25-31) than the D&F score 16% (95% CI 14-19), p<0.05. No significant difference between TP stress test rates in the low risk group of either score was found, however TP stress rates were low (1.1%).

Conclusions: The DCS may identify a larger cohort of low pretest probability CPU patients in which stress testing may be obviated. Prospective validation is necessary.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Cardiovascular / Non-CPR/Non-Resuscitation

M28

INTER-RATER RELIABILITY OF THE DIAMOND & FORRESTER SCORE IN EMERGENCY DEPARTMENT CHEST PAIN OBSERVATION UNIT PATIENTS

A. Napoli 1

1

Brown University School Of Medicine, Providence, Usa

Background: Cardiology consensus guidelines recommend use of the Diamond & Forester (D&F) score in augmenting the decision to pursue stress testing. We have recently shown that it may have value in safely reducing stress utilization in an Emergency Department chest pain unit (CPU). However, full application necessitates demonstration of a good inter-rater reliability of the D&F score in the CPU setting. We hypothesized that D&F pretest probability would have good inter-rater reliability in CPU patients.

Methods: This was a chart review of randomly selected patients from a previously collected prospective observational trial of admitted CPU patients in a large-volume academic urban ED. Inclusion criteria were: age>18, AHA low/intermediate risk, nondynamic ECGs, and normal initial Troponin I. Exclusion criteria were: age>75 with CAD. A D&F score for likelihood of CAD was calculated on each patient by two trained chart abstractors using a standardized data abstraction instrument. Abstractors were trained to specifically categorize presenting symptoms as fitting one of three types of chest pain symptoms: Nonanginal, atypical, or anginal based on previously published pre-specified criteria. Approximately 20% of charts in a CPU registry were abstracted by two chart abstractors who were blind to each other’s categorization, the patient outcomes, and the study hypothesis. The primary outcome was the kappa statistic for agreement between the two raters.

Results: The charts of 705 random patients were reviewed. The mean age was 55.1 ± 11.8, 52% were female.

44% of patients received stress testing, and 2.4% of patients had acute coronary syndrome. The mean D&F score was 39 ± 24. There was good inter rater agreement of chest pain characteristics (kappa=0.77, 95% CI 0.72-0.81, p<0.01).

Conclusions: This study supports the use of the Diamond & Forrester score as a reliable indicator of pretest probability in CPU patients by demonstrating that there is good Inter-rater reliability. Prospective validation is necessary at the point of patient assessment, in conjunction with application of the D&F score to augment stress utilization decision making.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Cardiovascular / Non-CPR/Non-Resuscitation

M29

ACUTE CARE DIAGNOSTIC COLLABORATION: ASSESSMENT OF DIAGNOSTIC QUALITY OF TIMI VS. HEART RISK SCORE INTEGRATING CORONARY CT ANGIOGRAPHY IN A BAYESIAN STATISTICAL MODEL

L. Cochon 1, M. Supino 2, M. Caputo 3, A.A. Baez 2

1

Universitat De Barcelona, Barcelona, Spain, Ft. Lauderdale, Usa

2

Jackson Memorial Hospital, Miami, Usa,

3

Holy Cross Hospital,

Background: cardiac events are one of the leading causes of emergency department visits. Both Thrombolysis in myocardial infarction (TIMI) risk score and HEART score are used as integrated clinical assessment tools. The objective of this study was to asses the diagnostic accuracy of TIMI and HEART risk scores with the integration of coronary computed tomography angiography (CTA) using Bayesian statistical modeling.

Methods: TIMI and HEART score were used as tools for risk stratification of the patient population in low and moderate risk. TIMI risk score of 0-3 points was considered low, with a 13.3% risk of complications and 4-5 points was moderate with a 23.2% risk. HEART score of 0-3 points was considered low with a 1.7% risk and moderate 4-6 points with 16.6% risk. CTA was used as validation tool. Sensitivity and specificity for CTA was obtained from pooled meta analysis data and likelihood ratios (LR) were calculated. Percent risk from scoring system was used as pre test probability in Bayesian nomogram and LR were inserted to calculate post test probability. Absolute (ADG) and relative diagnostic gains (RDG) were then calculated.

Results: Low TIMI risk score and LR+ yielded a post test probability of 53%, ADG 39.8%, and RDG 301.5%.

Moderate TIMI score resulted in 69% post test probability, ADG 45.8% and RDG 197.4%. Using LR- for TIMI low risk post test probability of 1% and RDG 92.4%. Moderate risk had a post test probability of 2% and RDG 91.4% (Table 2). Low HEART risk score and LR+ yielded a post test probability 11%, ADG 9.3% and RDG 547.1%.

Moderate risk resulted in 59% post test probability, ADG 42.4%, RDG 255.4%. Using LR- low risk had no yield, while moderate risk had a RDG of 93.9%.

Conclusions: HEART risk score demonstrated superior diagnostic gain in both patient populations, low and moderate risk. Limitations include the retrospective nature of the study and the limited universe of subjects in the Meta analysis pool.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: International Emergency Medicine

M30

EMERGENCY MEDICAL SERVICES RESPONSE IN RURAL HAITI: A SINGLE AMBULANCE SERVICE MODEL

B. Nicholson 1, D. Dhindsa 2, J. Lovelady 2

1

Boston Medical Center - Department Of Emergency Medicine, Boston, Usa, University - Department Of Emergency Medicine, Richmond, Usa

2

Virginia Commonwealth

Background: Rural populations in Haiti have limited access to medical services and almost no access to EMS. An ambulance based at a rural clinic in Titanyen, Haiti and staffed with a paramedic and driver was initially placed into service to provide EMS care during transfers from the clinic to hospitals in Port-au-Prince. This operation was gradually expanded to meet the EMS scene response needs of the community. This review sought to determine the utility of an ambulance in rural Haiti for scene responses and to evaluate the mode of ambulance request in a region lacking an EMS system.

Methods: Design – Prospective, observational review of requests for an ambulance response in a rural region lacking an EMS system Setting – Ambulance based at a weekday, daytime only clinic in Titanyen, Haiti Participants/Subjects – Consecutive series of all patients for whom an EMS response was requested during the time periods of 11/22/2010 – 12/14/2010 and 3/28/2011 – 5/13/2011 Results: Between 11/22/2010 – 12/14/2010 and 3/28/2011 – 5/13/2011, an ambulance response was requested for 26 patients. Thirteen (50%) patients were transported to hospitals in Port-au-Prince, to the outpatient clinic in Titanyen, or a cholera treatment center. Four (15%) were declared dead at the scene. Eight (31%) were evaluated at a single scene and transferred in the requesting NGO’s 15-passenger van under the care of a two nurses. One (4%) patient was treated on scene and not transported. Activation of the EMS response was accomplished via three methods: a phone call from another NGO operating in the area (7, 54%); a religious leader (4, 31%); a bystander running to the clinic (2, 15%).

Conclusions: While the overall sample size was low, this pilot study demonstrates the feasibility of using EMS in rural Haiti to expand timely access to care. Through strong community relationships, NGOs and religious leaders in the region served as the primary means of entering patients into the EMS system and requesting an ambulance despite the lack of an organized EMS system. This study was limited due to a small sample size and limited timeframe.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Pre-Hospital / EMS / Out of Hospital

M31

EVALUATION OF THE CURRENT HELICOPTER EMERGENCY MEDICAL SERVICES DISPATCH CRITERIA AND REGISTRATION SYSTEM

N. Ter Bogt 1, R. Egberink 1, F. Van Eennaam 2, R. De Wit 1,3

1

Regional Network For Emergency Care, Acute Zorg Euregio, Enschede, Netherlands, 2 Ems-Dispatch Centre, Ambulance Oost, Hengelo, Netherlands, 3 Hospital, Medisch Spectrum Twente, Enschede, Netherlands Background: New Helicopter Emergency Medical Services (HEMS) dispatch criteria will be introduced in the Netherlands. One of the accompanying recommendations is to register whether and why (or why not) a HEMS was called and to describe the reasons for cancellations in all high priority ambulance rides who met the HEMS dispatch criteria. We performed baseline measurements to evaluate the current dispatch criteria (based on mechanism of injury (MOI)) and to oversee if the current registry of the EMS-dispatch centre is equipped to meet the new recommendations.

Methods: In the registration system of the EMS-dispatch centre in the Eastern part of the Netherlands all high priority ambulance rides following 112-emergency calls in the last six months of 2013 were analysed for the presence of an item of the dispatch criteria in the description of the call. The presence of an item means, that according to the current criteria a HEMS should have been deployed. In these cases it was investigated if the reasons (not) to call for a HEMS were registered. For all cancelled HEMS dispatches the reason for cancellation was collected.

Results: In 148 out of 4,000 emergency call descriptions an item of the dispatch criteria was found. This means that according to stringent use of the current criteria the percentage of HEMS dispatches should be 3.7%, while the actual percentage was much lower (n=34; 0.9%). Reasons (not) to call for a HEMS were not registered. The main reasons for cancellation were â&#x20AC;&#x2DC;not further specifiedâ&#x20AC;&#x2122; (8 out of 17), patient died (3 out of 17) or patient is stable (3 out of 17).

Conclusions: In our small sample adherence to the current dispatch criteria seems low. Apparently, employees of the EMS-dispatch centre already take other factors, like the physiological status of the patient, into account in their decision making to call a HEMS because dispatch criteria based on MOI usually will lead to overtriage.

Adjustments to the registration system will be necessary to meet the recommendations.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Pre-Hospital / EMS / Out of Hospital

M32

GOOD SAMARITAN ACTS BY EMERGENCY PHYSICIANS: A SURVEY OF FREQUENCY, LOCATIONS, AND UTILITY OF SUPPLIES AND MEDICATIONS

T. Burkholder 1, R. King 2

1

Denver Health - Department Of Emergency Medicine, Denver, Usa, Department Of Emergency Medicine, Aurora, Usa

2

University Of Colorado Denver -

Background: Physicians may be called upon in the event of an emergency outside of the hospital, with some citing an ethical imperative to act as a Good Samaritan. This is especially true for emergency physicians (EPs)â&#x20AC;&#x201D;with unique qualifications for rapidly triaging and stabilizing a diverse range of ill or injured patientsâ&#x20AC;&#x201D;who may even find that other physicians defer to them on scene. However, little is known about the frequency and locations of such Good Samaritan acts or which equipment and medications are most useful in these situations.

Objectives: 1.

To describe the (a) frequency and (b) locations of out-of-hospital emergencies in which EPs are called upon to provide Good Samaritan care.

2.

To determine which medications and supplies are most frequently useful to EPs during Good Samaritan events.

Methods: An electronic survey was emailed to a convenience sample of board certified or eligible EPs at six emergency departments in Colorado, USA. Respondents were asked about the number of times they provided Good Samaritan care, the locations where these events occurred, and the medications and supplies that would have been useful during their last Good Samaritan event. Data were analyzed using simple descriptive statistics reported by averages, medians, and confidence intervals where appropriate.

Results: A total of 90 emergency physicians responded. The EPs surveyed reported acting as Good Samaritans an average of 3.5 times (95% CI 2.4-4.9) every 5 years. However, the median reported frequency was 2.0 per 5 years. The proportion of Good Samaritan events occurring in each of the surveyed locations is reported in Figure 1. The most frequently desired supplies and medications are reported in Figures 2 and 3, respectively. <FILE IMAGE='120_20150530212601.jpg'> Conclusions: The prepared emergency physician can expect to provide Good Samaritan care multiple times during a career. There were a significant number of reported events in which certain supplies or medications would be useful. Keeping this in mind, emergency physicians may benefit from carrying a kit containing commonly used supplies and medications in situations where they are most likely to be called upon as Good Samaritans.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Pre-Hospital / EMS / Out of Hospital

M33

THE EFFECT OF EMERGENCY MEDICAL SERVICES USE ON HOSPITAL OUTCOMES OF HEMORRHAGIC STROKE ACCORDING TO LENGTH OF STAY AT EMERGENCY DEPARTMENT

S. Kim 1, S. Shin

1

Seoul National University Hospital, Seoul, South Korea

Background: Use of the emergency medical services (EMS) has been known to be related with shortening the symptom to definite care in hemorrhagic stroke. It is unclear, however, whether the use of EMS is associated with survival and disability after hemorrhagic stroke or not, according to length of stay (LOS) at emergency department (ED) as a proxy measure of door to definite care.

Methods: Patients with acute hemorrhagic stroke due to primary cause from 28 hospitals between 2008 to 2011 were analyzed, excluding patients discharged or transferred to other hospital at emergency department (ED), with symptom to ED arrival time longer than 3 hours, received thrombolysis or operation at prior hospital, less than 19 years old, with cardiac arrest at ED, 6 hours or longer of LOS, and unknown information of ambulance use and outcomes. Exposure variable was EMS use. End points were survival at discharge and worsened of disability measured by difference of modified Rankin Scale (W-mRS) more than 2 points between pre-event mRS and post-event mRS. Adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs) for outcomes were calculated, adjusting for potential confounders (demographic, SES, clinical symptom, co-morbidity, behavior, interhospital transfer, time of event) in the final model. ED LOS classified with early versus late by 120 min. was added to the final model for testing the interaction model.

Results: Total of 2,055 hemorrhagic stroke were analyzed, 76.4% were transported by EMS. 15.2% and 58.4% of these were dead and worsened in mRS at discharge. AOR (95% CI) was 0.560 (0.393-0.798) for death, and 0.599 (0.460-0.779) for W-mRS. The effect size, however, was different according to LOS at ED. AOR (95% CI) for death was 0.585 (0.325-1.056) in early LOS group while 0.521 (0.347-0.780) in late LOS group. AOR (95% CI) for W-mRS was 0.718 (0.466-1.109) in early LOS group while 0.617 (0.460-0.828) in late LOS group.

Conclusions: EMS transport was associated with lower hospital mortality and less worsening of disability. In particular, the patients group with late LOS at ED showed significant improvement of outcomes, not in early LOS group.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Pre-Hospital / EMS / Out of Hospital

M34

ACUTE CARE DIAGNOSTICS COLLABORATION: ASSESSMENT OF THE PREHOSPITAL SEPSIS PROJECT SCORE (PSP-S) INTEGRATED WITH PREHOSPITAL POINT OF CARE LACTATE IN A BAYESIAN CLINICAL DECISION M

L. Cochon 1, J.M. Nicolas 1, K. Schrank 2, A.A. Baez 2

1

Universitat De Barcelona, Barcelona, Spain, 2 Jackson Memorial Hospital, Miami, Usa

Background: Previous Prehospital Sepsis Project research demonstrated that shock index and respiratory rate are highly predictive of ICU admissions in sepsis. Objective to evaluate the integration of the prehospital sepsis score (PSP-S) and Point of Care Lactate in assisting prediction of severity of illness utilizing Bayesian statistical modeling.

Methods: The patient population was stratified based on the PSP-S: 1 point is low risk, 2 points is moderate risk, and 3-4 point is high risk. Sensitivity and specificity for prehospital lactate was obtained from pooled data and used to calculate likelihood ratio (LR). Percentage risk used as pretest probability and likelihood ratios for prehospital lactate were charted into the Bayesian nomogram to obtain posttest probabilities.

Results: Pooled data for prehospital point of care lactate demonstrated a sensitivity of 76% and a specificity of 55%, yielding a positive LR of 1.6 and negative LR of 0.44. Integration of the PSP-S and point of care Lactate was inserted in a Bayesian Nomogram for calculation of Post-Test probabilities. Using positive LR, posttest probability for low risk was 16% with an ADG of 6% and RDG of 160%. Moderate risk population yielded a posttest probability of 47%, ADG of 12.5% and RDG of 136.2%. High risk population resulted in a posttest probability of 72%, an ADG of 12% and RDG of 120% (Table-1). Low risk cohort and negative LR for prehospital lactate of 0.44 yielded a posttest probability of 5% and RDG of 50%. Moderate risk group had a posttest probability of 19% and RDG of 55.1%. Patients in the high risk population had a posttest probability of 40% and RDG of 66.7% (Table-2), these findings however did not yield statistically significant differences (P=0.887 for LR+ and 0.772 for LR-).

Conclusions: PSP Score can be clinically complemented with the use of prehospital point of care lactate. The greatest incremental gain was obtained for low PSP-S and a positive lactate, demonstrating the overall strong value of POC Lactate, with further validation this could serve as an interesting triage tool for EMS systems.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Administration, Health Policy, and Legislation

M35

X-RAY ORDERING AMONG EMERGENCY DEPARTMENT PHYSICIANS AS A FUNCTION OF THE PATIENT’S PRIMARY LANGUAGE

S. Bilal 1, D.C. Kuo, W.F. Peacock, M.T. Pillow

1

Baylor College Of Medicine - Section Of Emergency Medicine, Houston, Usa

Background: To evaluate the effects of a patient’s primary language on x-ray ordering by Emergency Department physicians Methods: This is a 15-month retrospective case-control study conducted at a Level 1 Trauma center in Houston, Texas, USA with an annual census >100,000. A convenience sample of patients presenting to the Emergency Department was abstracted from the electronic medical record. Patients’ were stratified based on triage level (1=highest, 5=lowest acuity) and language group divided into local (English) and non-local language speakers.

Race and primary language was self-identified. Patients were included if their age was >18, and had both their triage level and primary language recorded. X-ray ordering was defined as obtaining Ultrasound (US) and/or Computed Tomography (CT) imaging of any type while in the Emergency Department. Univariate analysis was performed, with results presented as proportions and 95% confidence intervals. Data from triage levels 1 and 5 were excluded as in these cohorts X-ray ordering practices were either performed by protocol (level 1), or was very rare (level 5).

Results: Overall, 1692 patients met the entry criteria and 659 were male. The primary language was 382 English, 674 Spanish, and 636 neither. Race was reported as 50.6% Latino, 35% Asian/Pacific Islanders, 5.9% African-American, 2.4% Caucasian, and 6.1% Other. X-ray ordering practices were similar in the higher acuity triage category (level 2) among local (n=20, [26.3%], 95%CI=16.9-37.7) vs. non-local language speakers (35, [24.6%], 95%CI=17.6-31.7). However, among the low acuity cohort (triage 4), 2 local language speakers (2.9%; 95%CI=0.34-10.1) vs. 14 non-local language speakers (18.2%; 95%CI=10.3-28.6) received imaging. Low acuity non-local language speaking patients were 500 times more likely to receive imaging than local language speakers Conclusions: Physicians ordered more imaging studies for non-local language speaking lower triage acuity patients. Mitigating the consequences of a lack of local language fluency could potentially have beneficial consequences for radiation exposure, cost, and Emergency Department operational throughput

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Administration, Health Policy, and Legislation

M36

EMERGENCY MEDICINE AND ACTIVE LABOR ACT VIOLATIONS 2002-15: REVIEW OF OFFICE OF INSPECTOR GENERAL PATIENT DUMPING SETTLEMENTS

M. Langdorf 1, N. Zuabi 1

1

University Of California, Irvine Department Of Emergency Medicine, Orange, Usa

Background: The Emergency Medicine and Active Labor Act (EMTALA) of 1986 was passed to prevent hospitals from “dumping” or refusing service to patients for financial reasons. The Office of the Inspector General (OIG) of the Department of Health and Human Services enforces the statute. Our objective was to determine the scope, cost and most common allegations leading to settlement of the OIG against hospitals and physicians for patient dumping.

Methods: Review of OIG patient dumping archive on May 2015, which includes cases of EMTALA allegations settled from 2002-2015 (https://oig.hhs.gov/fraud/enforcement/cmp/patient_dumping.asp).

Results: There were 192 settlement agreements (14 per year average for 4000+ hospitals in the USA). Fines against both hospitals and physicians totaled $6,357,000 (hospital and physician average $33,435 and $25,625 respectively). There were 184/192 (95.8%, $6,152,000) settlements involving hospitals and eight against physicians ($205,000). The most common settlements were for failing to screen 144/192 (75%) and stabilize 82/192 (42.7%) for emergency medical conditions. There were 22/192 (11.5%) cases where the hospital inappropriately transferred the patient and 22/192 (11.5%) cases where the hospital failed to transfer the patient.

Hospitals failed to accept an appropriate transfer in 25/192 (13.0%) of cases. Patients were turned away from hospitals for insurance/financial status in 30/192 (15.6%) of cases. There were 13/192 (6.8%) violations for patients in active labor. In 12/192 (6.3%) cases, the on-call physician refused to see the patient and in 28/192 (14.6%) cases, the patient was inappropriately discharged. Other settlements included hospital not accepting a referral 3/192 (1.6%), no accepting physician available 4/192 (2.1%), emergency department on diversion status 3/192 (1.6%), and hospital had capacity but still refused 4/192 (2.1%). Although loss of Medicare/Medicaid federal funding is an additional possible penalty for EMTALA violation, there were no disclosures of any revocation of federal reimbursement for hospitals. There was no information on EMTALA investigations that were not subject to settlement.

Conclusions: Most hospitals and physicians settled allegations of failing to provide screening and stabilization to patients with emergency medical conditions. The reason for patient “dumping” was due to insurance or financial status in 15.6% of settlements.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Administration, Health Policy, and Legislation

M37

STUDY OF RELATIONSHIP BETWEEN RESILIENCY AND JOB BOURNOUT&MENTAL HEALTH AMONG THE EMERGENCY DEPARTMENT PERSONNEL

S. Hosseini Kasnavieh 1, H. Basirghafouri, G. Masumi, M. Chardoli, M. Yasinzadeh, N. Tavakoli, H. Amiri

1

Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 2 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 3 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 4 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 5 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 6 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 7 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran Background: As examining the victims is important, the mental health of the emergency department personnel is of particular importance. The emergency personnel are exposed to the psychological trauma, harsh and abusive treatments and even physical damages by patients and their companions because of the low tolerance of patients and their companions and their problems.Today, the trend of violence in workplace is a global problem where the individual is abused, threaten or attacked although all organizations are involved with the risk of violence in workplace but it is more likely in medical centers Research conducted has shown that the prevalence of workplace violence against the emergency personnel has become a key concern for the system of providing emergency care and these personnel are exposed to violence in workplace more than other treatment groups Methods: The study is descriptive- cross â&#x20AC;&#x201C; sectional and was performed in emergency centers of Tehran hospitals .

All emergency personnel such as maids, assisting health workers, health workers, nurses, residents, and faculty, we were in the group. After providing a description of the questionnaires, the samples were given the questionnaires and they responded as the self-report.

Results: Overall, the findings showed high emotional exhaustion, (34.1% in frequency), depersonalization (23.2% in frequency) and personal failure(37.2% in frequency).The results indicated that there was a positivesignificant relationship between mental health and resiliency.AlsoThe relationship between burnout and resiliency was significant.There wasnot a significant difference between Male and Female students in resiliency Conclusions: Given the resiliency is one of the predictors of burnout and mental health; we recommend someworkshops to increase the resiliency-related skills of the nurses.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Administration, Health Policy, and Legislation

M38

HOSPITAL PERFORMANCE BASED ON PABON LASSO MODEL

S. Hosseini Kasnavieh 1, H. Basirghafouri, G. Masumi, M. Chardoli, M. Yasinzadeh, N. Tavakoli, H. Amiri

1

Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 2 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 3 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 4 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 5 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 6 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 7 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran Background: Background and Objectives: Hospital is the largest and most costly operating unit of healthcare system.

Provision of optimal care requires that hospital administrators identify hospital performance based on relevant indicators. This study used the Pabon Lasso analysis to assess the performance of hospitals and identify strategies towards an improved hospital performance.

Methods: This cross-sectional descriptive study involved all the eight general hospitals affiliated to Tehran University of Medical Sciences. Data on average length of stay, bed occupation and bed turnover rates were collected using questionnaire Results: The overall average length of stay, bed occupation and bed turnover rates were 4.78 days, 79.95% and 28.36, respectively. One hospital demonstrated inefficiency and under-utilization of resources by falling into Zone I, two hospitals located in Zone II, and five hospitals were placed in Zone IV. None of the hospitals were located in Zone III which represents a satisfactory level of efficiency.

Conclusions: The study showed the studied hospitals have generally low performance as indicated by Pabon Lasso analysis. The administrators should therefore seek a strategy for balancing average length of stay, bed occupation and bed turnover rates for an improved hospital performance.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Administration, Health Policy, and Legislation

M39

SURVEY ON PATIENT'S LENGTH OF STAY AND ITS EFFECTIVE PREDICTORS IN EMERGENCY DEPARTMENTS AT SELECTED HOSPITALS

S. Hosseini Kasnavieh 1, H. Basirghafouri, G. Masumi, M. Chardoli, M. Yasinzadeh, N. Tavakoli, H. Amiri

1

Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 2 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 3 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 4 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 5 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 6 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 7 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran Background: Background and Aim: Hospitals should be able to service their clients in less time and with best quality possible. Length of stay (LOS) in hospital is considered as a key performance indicator, especially in emergency department. In this study, timing analysis of LOS in the emergency department, to find some of the factors affecting the duration of the patients was performed Methods: Materials and Methods: This descriptive â&#x20AC;&#x201C;Analytical and cross sectional study was performed in the emergency departments of two teaching hospitals of Tehran University of Medical Sciences. 72 patient samples were included. The assessment tool with using a stopwatch to measure patient emergency start from the beginning until the patient into one of four conventional (transmission part, discharge, transfer to other centers ft) was removed from the emergency department. Data on both descriptive (mean and standard deviation) and analytical statistics (one way ANOVA, independent sample t-test and linear regression test) were analyzed with spssv19 software.

Results: Results: The average LOS of patients in hospitals was estimated at around 03:13 (SD=01:52). Patient variables marital status, day of week (holiday or regular day) and presentation (day or night) with the factors affecting the LOS were determined.

Conclusions: Time served in hospital emergency rooms was in appropriate level and items such as marital status, vacation week and time of day can be referred to as factors affecting the length of stay of patients involved. With regard to these health managers can rely on the results for the effective planning and management of hospital emergency departments.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Medical Education (Undergraduate, Graduate, and CPD)

M40

ONLINE LEARNING MODULE OBSERVATION UNIT PRACTICE

IS

KEY

FOR

IMPROVEMENT

TO

EMERGENCY

DEPARTMENT

I. Young 1, S. Lee 1

1

Winona Health, Winona, Usa, 2 Mayo Clinic Health System, Mankato, Usa

Background: Emergency department (ED) observation units have become a unique practice opportunity to ease and help with inpatient capacity and flow since the 90s in the United States. The Mayo Clinic Health System launched an ED observation unit in 2014. Substantial improvements and variations in clinical practice and level of comfort among ED providers were noticed. We aimed to study the effectiveness of newly developed educational modules that target emergency medicine providers.

Methods: Based on the review of existing literature and input from experts, we developed 20-minute online learning modules including pre-test, learning, and post-test modules using an online platform. The format consisted of Likert scale (1=least comfortable, 5=most comfortable), true or false, and multiple choice questions for the tests. The learning module contained slides, scripts, and figures describing inclusion, exclusion, and management strategy for commonly encountered events and conditions in the observation unit. A follow up survey was sent 2 months after the completion of the module. Participants were invited via e-mail to take the online module. The institutional review board granted exempted review. Pre- and post-test scores were evaluated with Wilcoxon Rank Sum Test and we reported the p-value. A p-value of less than 0.05 was considered significant. We described continuous variables with mean and standard deviation.

Results: A total of twenty-one participants completed the pre-test with a mean score of 63.8 +/- 19.3 and a total of fourteen participants completed the post-test with a mean score of 87.9 +/- 9.7, which was statistically significant (p=0.0001). A total of eight participants responded to the follow-up survey with a response rate of 57%. Responses demonstrated the level of provider comfort and skill in selection of observation (4.3 +/- 1.5), choice of stress test for chest pain (4.3 +/- 1.0), asthma management (4.1 +/- 1.0), and anaphylaxis care (4.1 +/1.4). Documentation remained efficient and high (4.3 +/- 0.9). All of the respondents and participants agreed that the module was helpful.

Conclusions: Online learning modules can be an effective learning tool to enhance the practice of observation medicine among emergency medicine providers.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Trauma

M41

CLINICAL DECISION RULE TO PREVENT UNNECESSARY CHEST X-RAY IN PATIENTS WITH BLUNT MULTIPLE TRAUMAS

M.M. Forouzanfar 1, S. Safari 1, N.S. Mahdavi 2, B. Hashemi 1, A. Baratloo 1, F. Rahmati 1

1

Emergency Department, Shohadaye Tajrish Hospital, Shahid Beheshti University Of Medical Sciences, Tehran, Iran, 2 Anesthesiologist And Intensive Care Specialist, Shahid Beheshti University Of Medical Sciences, Tehran, Iran Background: Since the diagnostic yield of chest X-ray (CXR) is not high enough, when it is ordered for all the multiple trauma patients, this study was aimed to evaluate the relationship between clinical and CXR findings in order to formulate a clinical decision rule to prevent unnecessary CXR in these patients.

Methods: Stable multiple blunt trauma patients referring to the ED were included. The clinical and radiographic findings of all the patients were collected and the relationships between these variables analysed. Finally, based on the regression coefficients () of the variables, the Thoracic Injury Ruleout Criteria (TIRC) were designed. β Results: A total of 2607 patients were included (males: 78.9%, mean age: 34.1 ± 15.0 years). Age over 60 (beta=0.8; 95% CI: 0.27–1.34; P = 0.003), crepitation (beta=4.33; 95% CI: 1.65–7.0; P < 0.001), loss of consciousness (beta=3.16; 95% CI: 2.44–3.88; P < 0.001), decrease in pulmonary sounds (beta=2.67; 95% CI: 1.73–3.6; P < 0.001), chest wall pain (beta=2.12; 95% CI: 1.63–2.61; P < 0.001) and tenderness (beta=1.78; 95% CI: 1.26–2.27; P < 0.001), dyspnea (beta=1.3; 95% CI: 0.41–2.18; P=0.004) and abrasion (beta=0.5; 95% CI: 0.22–0.83; P = 0.03) were independent factors predicting thoracic injury. CXR in stable conscious multiple blunt trauma patients under 60 years, without chest wall pain and tenderness, decrease in pulmonary sounds, crepitation, skin abrasion, and dyspnea did not provide any additional findings.

Conclusions: Based on TIRC, it seems that CXR in stable multiple blunt trauma patients who are conscious and under 60 and have no decrease in pulmonary sounds, no dyspnea, no thoracic skin abrasion, and no crepitation can be ignored.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Pre-Hospital / EMS / Out of Hospital

M42

THE EFFECT OF PREHOSPITAL HYPOXIA AND HYPOTENSION ON OUTCOME IN MAJOR TRAUMATIC BRAIN INJURY: A DEADLY COMBINATION

D. Spaite 1, C. Hu 1,2, B. Bobrow Denninghoff 1, U. Stolz 1

1, 3,

V. Chikani

1, 3,

B. Barnhart 1, D. Sherrill 2, J. Gaither 1, C. Viscusi 1, K.

1

Arizona Emergency Medicine Research Center, University Of Arizona, Phoenix, Usa, 2 College Of Public Health, University Of Arizona, Tucson, Usa, 3 Arizona Department Of Health Services, Phoenix, Usa Background: Hypoxia or hypotension occurring during the prehospital management of major traumatic brain injury-(TBI) reduces survival. However, little is known about the impact of both hypoxia and hypotension, occurring together. Only a handful of studies have evaluated the combination of prehospital hypoxia/hypotension in TBI and the largest of these only had 14 cases with both. Objective: To evaluate the associations between mortality and prehospital hypoxia and hypotension, both separately and in combination. <FILE IMAGE='146_20150529180940.jpg'> Methods: All moderate/severe TBI cases (Barell Matrix-Type-1 and/or International Classification of Disease-9 head-region severity >=3 and/or Abbreviated Injury Scale head-region severity >=3) in the Excellence in Prehospital Injury Care (EPIC) TBI Study (a statewide, before/after, controlled study of the impact of implementing the international prehospital TBI Treatment Guidelines-NIH/NINDS: 1R01NS071049) from 1/1/07-3/31/14 were evaluated [exclusions: age<10; death before ED arrival; prehospital oxygen saturation<11%; prehospital systolic blood pressure-(SBP)<40 or >200; missing saturation, SBP, or other risk factors (12.5% missing)]. The relationship between mortality and hypoxia (saturation<90) and/or hypotension (SBP<90) was assessed with crude and adjusted odds ratios using multivariable logistic regression, controlling for important confounders [Injury Severity Score, head region severity, injury type (blunt versus penetrating), age, sex, race, ethnicity, payor, inter-hospital transfer, and trauma center).

Results: 13,151 cases met inclusion criteria [Median age: 45 (Interquartile range: 26-64); Male: 68.6%]. 11,545 (87.8%) had no hypoxia/hypotension, 790 (6.0%) had hypoxia only, 604 (4.6%) had hypotension only, and 212 (1.6%) had both hypoxia and hypotension. The Figure shows the crude and adjusted odds ratios for death, comparing the latter three groups to the cohort with neither hypoxia nor hypotension.

Conclusions: In this very large analysis of major Traumatic Brain Injury, prehospital hypoxia and hypotension were associated with significantly increased mortality. However, the combination of hypoxia/hypotension together had a profoundly-negative effect on survival even after controlling for confounders. In fact, the adjusted odds ratio for death in patients with both hypoxia/hypotension was more than two times greater than for those with hypoxia or hypotension alone. Since the TBI Guidelines emphasize the prevention and treatment of hypoxia and hypotension, their implementation has the potential to significantly impact outcome.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Trauma

M43

COMPARISON OF FOUR SCORE COMA SCALE (FOUR SCALES) AND GLASGOW COMA SCALE (GCS) IN ANTICIPATION OF TRAUMATIC PATIENTâ&#x20AC;&#x2122;S OUTCOME

A. Baratloo 1, A. Rouhipour 2, M. Shokravi 1, B. Hashemi 1, S. Safari 1, F. Rahmati 1, M. Forouzanfar 1

1

Emergency Department, Shohadaye Tajrish Hospital, Shahid Beheshti University Of Medical Sciences, Tehran, Iran, 2 Pediatric Department, Valiasr Hospital, Ghazvin Medical University, Abyek, Iran Background: Full Outline of Unresponsiveness (FOUR score) has been designed in recent years to compensate the limitations of Glasgow Coma Scale (GCS). The present study was done with the aim of assessing the predictive value of GCS and FOUR score concerning the outcome of patients with multiple trauma referred to the emergency department.

Methods: This cross-sectional prospective study was performed on patients with multiple trauma referred to the emergency department. The assessment of GCS and FOUR score was done at the time of admission as well as 6 and 12 hours later. The predictive value of GCS and FOUR score in prediction of patients' outcome was evaluated by using Receiver Operating Characteristic (ROC) curve, sensitivity, specificity, and positive and negative predictive values. The outcome of patients was categorized in two groups, discharging of patients without lesion and presence of at least one lesion (motor disability, brain death, or death).

Results: Finally 89 patients were entered to the study. Sensitivity and specificity of GCS in prediction of undesirable outcome (motor disability, brain death, or death) were 84.2% and 88.6% at the time of admission, 89.5% and 95.4% after 6 hours, as well as 89.5% and 91.5% after 12 hours, respectively. These rates for FOUR score were 86.9% and 88.4% at the time of admission, 89.5% and 100% after 6 hours, as well as 89.5% and 94.4% after 12 hours, for sensitivity and specificity, respectively.

Conclusions: The findings of the present study show that GCS and FOUR score have a similar predictive value regarding the outcome of patients with multiple trauma referred to the emergency department.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Social role of emergency medicine

M44

THE IMPACT OF CYCLING RELATED INJURIES ON AN IRISH EMERGENCY DEPARTMENT

J. Foley 1, A. Kaskovagheorgescu 2, J. Ryan 1, D. Evoy 2

1

Department Of Emergency Medicine - St. Vincent's University Hospital, Dublin, Ireland, Surgery - St. Vincent's University Hospital, Dublin, Ireland

2

Department Of

Background: The Central Statistics Office Ireland (CSO) reported following the 2011 census that there was a 9.6% increase in the number of people cycling to work compared with 2006. This ultimately leads to a higher prevalence of injuries and hospital attendances. The Road Safety Authority of Ireland (RSA) estimates from their provisional report that there were 12 pedal cyclist fatalities on Irish roads in 2014. We hypothesise that the RSA are under-reporting the true number of bicycle related injuries in Ireland at present and that there is huge resource demands on emergency departments (EDs) and hospitals as a whole due to cycling injuries.

Methods: We used the ED Maxims © database to retrospectively review all cycling presentations to the ED in 2014. We searched for bike, cycling, bicycle in triage notes to identify patients that presented to the department following a bike-related incident. We also made use of Syngo © radiology database to access radiology reports for the same cohort of patients.

Results: From our review, we conclude that there were 534 cycling related injuries presenting to a suburban university teaching hospital emergency department (ED), accounting for over 1% of attendances for 2014.

There were 2 mortalities during this time period.

Admissions to hospital: 42 Orthopaedic OPD: 130 Transferred to another facility: 10 Observation in ED: 16 Return for ED review: 38 Discharge to GP: 272 Other: 26

Conclusions: From our review, it is clear that there is a massive effect on our ED in Dublin from cycling related injuries. The demand is reflected across the hospital with huge emphasis placed on radiology and orthopaedic clinics in particular. The number of patients requiring observation or review in the ED after a defined time period also places huge demands on the already busy department and medical and nursing staff. The number of cycling injuries is being under-reported by the RSA and that ED’s may provide a vector for guiding injury prevention strategies for what is now, an extremely popular means of transport and leisure activity in Ireland.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Trauma

M45

COMPARING THE INTERPRETATION OF TRAUMATIC CHEST X-RAY BY EMERGENCY MEDICINE SPECIALISTS AND RADIOLOGISTS

S. Safari 1, A. Baratloo 1, A. Rouhipour 2, B. Hashemi 1, A. Negida 3

1

Emergency Department, Shohadaye Tajrish Hospital, Shahid Beheshti University Of Medical Sciences, Tehran, Iran, 2 Pediatric Department, Valiasr Hospital, Ghazvin Medical University, Abyek, Iran, 3 Faculty Of Medicine, Zagazig University Of Medical Sciences, Zagazig, Egypt Background: Discrepancy between X-ray readings of emergency physicians (EPs) versus radiologists was reported between 0.95% and 16.8% in different studies. The discordance was even higher when specific studies such as chest X-rays (CXR) were probed. This prospective study was conducted to assess the discrepancies between emergency and radiology departments with respect to interpretation of the traumatic chest X-rays.

Methods: his prospective study was conducted in Shohadaye Tajrish Hospital, Tehran, Iran, from March to April 2014. Based on Advanced Trauma Life Support (ATLS) guidelines, plain chest radiography (CXR) was ordered for all patients in two standard views of posterior-anterior and lateral. All CXRs were interpreted by a corresponding emergency medicine specialist and a radiologist blind to the clinical findings of the patients.

Finally, the results of two interpretations were compared. Accuracy, sensitivity, specificity, and predictive values of traumatic CXR interpretation were calculated by EPs with 95% of confidence interval (CI).

Results: The evaluation of EPs was identical to that of the radiologists in 89.5% of the cases. Ninety-eight percent (98%) indicated total agreement and 1.5 percent total disagreement.

Conclusions: There is a high agreement between EPs and radiologists in CXR interpretations in Shohadaye Tajrish Hospital. Thus, EPs can substitute radiologists in the emergency department. More improvements are recommended to achieve the standard level of agreement.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015

Topic: Metabolic and endocrine disorders

M46

ASSESSMENT OF RELATION BETWEEN SERUM SODIUM LEVEL ABNORMALITIES AND MORTALITY IN PATIENTS WITH TRAUMATIC BRAIN INJURY

V. Monsef Kasmaei 1, S.M. Zia Ziabari, B. Zohrevandi, M. Abed Rad, S. Heidari Moghadam

1

Road Trauma Research Center, Guilan University Of Medical Sciences, Rasht, Iran

Background: Traumatic Brain Injury (TBI), which can cause serious physical, behavioral, cognitive and emotional damages, is considered a major concern of modern medicine. Extensive researches have been conducted regarding factors that influence the prognosis of patients with TBI. GCS (Glasgow Coma Score), pupil’s responsiveness and CT scan results are among these factors.

Methods: As a retrospective cohort, this study is based on the data drawn from 650 patients’ documents that are diagnosed with TBI with GCS smaller than or equal to 13, and those with GCS as big as 14 and 15 whose CT scan results are positive. All the data has been collected through HIS system of Pour Sina hospital of Rasht located at the northern part of Iran. Patients’ sodium, BUN and creatinine level for 14 days and survival status in 14th day of admission plus demographic data, the cause of trauma, CT scan results and prescribed serum were statistically analyzed. Patients classified in 2 groups including patients with serum sodium level disturbances and those with normal level of serum sodium in order to examine the effect of independent variables on survival, cox regression model was used .also for determination of survival rate and it’s differences among two groups Kaplan-mayer analysis and log-rank test were used respectively.

Results: The results of this study showed that the prevalence of sodium ion disturbances among patients with head trauma was 29.4% (n=191), among which hypernatremia prevalence was 16.6%(n=108) and hyponatremia was 10%(n=65) . In patients with normal sodium level and those with sodium ion disturbance, mortality was 5.7 %( n=26) and 39.8 %( n=76) respectively. The results from multi-variant cox regression model showed that serum sodium level (HR=0.33, CI=0.21-0.53), age(HR=0.01,CI=1.002-1.02) and BUN/Cr ratio are effective variables on patients survival.

Conclusions: Serum sodium level disturbances in patients with head trauma are highly prevalent and have independence impacts on patients’ mortality. With future surveys, sodium disturbance may be introduced as a risk factor of mortality in head trauma patients, thus physicians could better understand and treat this disorder.