Poster Abstracts - Tuesday by American Academy of Emergency Medicine

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

T129

A CASE OF UNUSUAL ARM SWELLING IN A YOUNG MAN

J. Ashkar 1

Emergency Medicine Department, Hadera, Israel, Emergency Medicine Department, Hadera, Israel

Emergency Medicine Department, Hadera, Israel,

Background: MD Jalal Ashkar, MD Pavel Peschansky, MD Margarita Medvedovsky, MD Igor Tulchinsky, The Emergency Department Hillel yaffe Medical Center, Hadera Israel Spontaneous thrombosis of the veins draining the upper extremity was postulated by Sir James Paget in 1875 as a cause of acute pain and swelling of the arm, but von Schroetter, in 1884, was the first to relate the clinical syndrome to thrombotic occlusion of the axillary and subclavian veins . It was not until 1949 when Hughes, in a review of 320 patients, recognized this disease process as a unique disorder and named it Paget- Schroetter syndrome. Methods: Although rare (1%to 2% of all cases of deep venous thrombosis), this disease cause significant disability in a predominantly young, healthy, active patient population. Moreover, there have been several reports documenting a significant incidence of disability, ranging from 25%to 75%, in untreated patients who develop chronic upper extremity venous hypertension and /or recurrent venous thrombosis. Results: We report this case of effort thrombosis of the upper extremity (Paget- Schroetter syndrome) caused by hypertrophied muscles. This unusual cause of extrinsic venous compression and intimal injury leading to thrombosis was treated with good outcome. Conclusions: We report this case of effort thrombosis of the upper extremity (Paget- Schroetter syndrome) caused by hypertrophied muscles. This unusual cause of extrinsic venous compression and intimal injury leading to thrombosis was treated with good outcome.

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

T130

PROGNOSTIC VALUE OF TREATMENT SETTING IN CANCER PATIENTS WITH PULMONARY EMBOLISM: COMPARISON WITH THE PULMONARY EMBOLISM SEVERITY INDEX

Y. Kim 1, S. Ahn 1, W. Kim 1, K. Lim 1, Y. Lee 1

Asan Medical Center, University Of Ulsan, College Of Medicine, Department Of Emergency Medicine, Seoul, South Korea Background: Active cancer is a poor prognostic factor for survival after pulmonary embolism (PE). This retrospective cohort study was performed to investigate how accurately the pulmonary embolism severity index (PESI) predicts 30 day mortality in patients with active cancer. Whether the treatment setting (palliative vs. curative) could predict mortality in these patients was also investigated. Methods: All consecutive patients with active cancer and PE who visited the emergency department of Asan Medical Center in January 2007–June 2014 were identified. The covariates for predicting 30 day mortality were PESI classification (low vs. high risk), treatment setting (curative vs. palliative), brain natriuretic peptide >=150 ng/L, troponin I >=0.10 ng/mL, and right ventricular dysfunction on echocardiography. Cox proportional hazards regression analysis was used to assess the association between treatment setting and 30 day mortality. Results: PESI classification and 30 day mortality did not associate significantly. The discriminatory power of the PESI (expressed as the area under the receiver operating curve) was 0.565 [95% confidence intervals (CI): 0.453–0.677]. When multivariate Cox models were adjusted for the PESI, treatment setting, BNP >=150 ng/L, troponin I >=0.10 ng/mL, and right ventricle dysfunction, palliative treatment setting associated with an increased risk of 30day mortality regardless of PESI classification (adjusted HR: 4.59, 95% CI: 2.11–9.98) (Figure1). In the curative treatment group, the patients with low-and high-risk PESI scores did not differ significantly in terms of overall duration of survival (P=0.396). This was also observed for the palliative group (P=0.174). However, in the low-risk PESI group, the patients receiving curative treatment had significantly longer durations of survival than the patients receiving palliative treatment (P=0.012). This difference was also observed for the high-risk PESI group (P<0.001) (Figure 2). Treatment setting predicted mortality 30 days, 3 months, and 6 months after PE presentation better than PESI (Table 1).<FILE IMAGE='5_20150311030405.jpg'> Conclusions: PESI did not accurately predict mortality in patients with active cancer. Treatment setting was the most important determinant of clinical outcome in these patients. When stratifying patients with active cancer and PE, palliative treatment setting should be considered, as it is predictive of high mortality.

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

T131

RIFLE CLASSIFICATION IN CRITICALLY PATIENTS WITH EARLY ACUTE KIDNEY INJURY TERTIARY HOSPITAL, THAILAND.

AT A

W. Phonburee 1, P. Suwaratchai 1, K. Sae Lao 2, C. Boonsri 1

Sunpasitthiprasong Hospital, Ubonratchathani, Thailand, Bangkok, Thailand

National Institute For Emergency Medicine,

Background: Acute kidney injury (AKI) is a common life-threatening condition in critically ill patients. The presence of AKI defined either as changes in creatinine, decrease in urine output, or the need of renal replacement therapy (RRT) has been associated with high mortality rates and length of stay (LOS) Objective: To evaluate the incidence, levels of severity and outcomes associated with acute kidney injury (AKI) in critically ill patients. Methods: Methods: Retrospective cohort study between April to September 2014, Four hundreds and eight critically ill patients admitted at tertiary hospital, were assessed using the RIFLE criteria. Demographic data, mortality and LOS were also collected. Results: In a cohort of hospitalized patients at a tertiary hospital in Thailand, 21.8 % of all admitted critically ill patients had AKI. Among AKI patients stratified by RIFLE (Risk of renal failure, Injury to the kidney, Failure of kidney function ) class R (Risk) comprised 9.5%, while I (Injury) and F (Failure) were, 4.9.% and 5.9 %.Median LOS was 9 days Conclusion: Critically patients with AKI is common clinical problem and high mortality rates and long LOS . Results: Results: In a cohort of hospitalized patients at a tertiary hospital in Thailand, 21.8 % of all admitted critically ill patients had AKI. Among AKI patients stratified by RIFLE (Risk of renal failure, Injury to the kidney, Failure of kidney function ) class R (Risk) comprised 9.5%, while I (Injury) and F (Failure) were, 4.9.% and 5.9 %.Median LOS was 9 days Conclusions: Conclusion: Critically patients with AKI is common clinical problem and high mortality rates and long LOS .

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

T132

SERIAL MEASUREMENT OF THERAPEUTIC INTERVENTION SCORING SYSTEM-76 (TISS-76) IN THE EMERGENCY INTENSIVE CARE ROOM.

I. Makki 1, R. Ammar 1, Z. Guermazi 1, S. Othmani 1, F. Riahi 1, M. Boussen 1, K. Mallouche 1, M. Ben Cheikh 1

Service Des Urgences Chu Mongi Slim, La Marsa, Tunisia

Background: The aim of the study was to assess the use of the Therapeutic Intervention Scoring System-76 (TISS-28) in emergency intensive care unit patients and the relationship of the score to the diagnosis , severity of illness, and outcome in these patients. Methods: Materials and Methods Prospectively collected data from all patients admitted to the emergency intensive care unit between December, 2014, and April , 2015. Results: Results A total of 66 patients were admitted during the study period, 60% male; mean age, 61 + 20 years), Transport was provided by medical transport in only 3% of cases, 50% of patients directly consult the emergency department using their own means of transport. Patients were admitted in emergency intensive care room for: respiratory distress (43,8%), neurological distress (19,7%), trauma (13,6%), seizure (9%) ... The average ED stay was about 103+ 48h (whether 4 to 5 days), cumulating 286 observation days. TISS-76 score on the day of emergency intensive care unit admission were 31.7 Âą 14.9 ( 75,8% class III and IV ) The highest admission TISS-76 was observed in elderly (p=0,03), diabetics (p=0,02), patients with more than 4 comorbidities (p=0,01), trauma patients, who required vasoactive drugs (p=0,02) and mechanical ventilation (p<0,01), 19 patients died in t he emergency room, Therapeutic Intervention Scoring System-76 was correlated with the risk of death (p=0,01). Conclusions: Conclusions There are marked variations in TISS-76 scores according to the type of pathology . Therapeutic Intervention Scoring System-76 correlates with the age, the severity of illness and outcome in these patients. The workload is very important in this emergency department requiring a greater number of medical and paramedical staff.

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

T133

STREPTOCOCCAL TOXIC SHOCK SYNDROME IN NECROTIZING FASCITIS IN A HEALTHY WOMAN

M. Marini 1

Universita' Degli Studi Di Brescia, Brescia, Italy

Background: Septic shock in a healthy patient has a limited number of causes; streptococcal toxic shock syndrome is one of the most frequent; its suspicious is necessary in patient with skin wound evolving rapidly in necrotizing fasciitis. Methods: A woman aged 62 came to the emergency department complaining sever pain in left cervical region with contracture of the trapezium muscle; she had no significant anamnestic disease; two days before she underwent an ambulatory abscission of a sebaceous cyst on the left shoulder. Her blood pressure at admission was 90/60mmHg, heart rate was 113 bpm, temperature was 35.8째, and erythema in the skin around the recent surgical wound. At laboratory examination WBC were 3.05 x10^3/uL, lactates were 8.3 mmol/L, Creatinine was2.33mg/L, arterial blood gas showed metabolic acidosis.The woman was recovered in intensive care for septic shock. A broad spectrum antibiotic therapy and fluid challenge were started, nevertheless the woman became anuric and the skin lesion was extending from the shoulder to the left arm and leg, right breast and the left abdominal skin. A CT of the shoulder showed air bubbles in the supraspinatus muscle. Both blood and skin wound culture showed infection from a Group A streptococcus (S. Pyogenes). The woman was intubated and supported with CVVH; immunoglobulins were administered Supportive care with amine and blood and fresh plasma transfusion were performed . She was evaluated from plastic surgeon for skin wounds that were evolving in a wide region of eschar. On day 19 the woman underwent a first escarectomia; VAC therapy of the skin wound was started .On day 36 the patient was transferred to plastic surgery department where another intervention of escarectomia, necrosectomy and a reconstructive intervention were performed.

Results: The patient was dismissed after 83 days of recovery and sent to neuromotor rehabilitation center. Conclusions: Necrotizing fasciitis is a challenge for emergency department physician as late diagnosis is about the 60-85% of the whole case; more instrument to predict the evolution of a patient coming with skin wound and clinical signs of SIRS need to be developed

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

T134

RECOGNITION AND TREATMENT OF HEREDITARY ANGIOEDEMA IN EMERGENCY DEPARTMENTS.

S. Leone 1, G. Cremonesi 2, F. Catalani 1, D. Pierluigi 1

Accident & Emergency Dept., Galliera Hospital, Genoa, Italy, University Of Genoa, Genoa, Italy

Post-Graduate School In Emergency Medicine,

Background: Angioedema is a common presentation in emergency departments (EDs) and can be fatal if swelling obstructs the airways. In Italy 0.37% of all ED visits are related to angioedema. Angioedema can be either histamine or bradykinin mediated. Histamine-mediated angioedema is the most common form, often triggered by allergens, whereas bradykinin-mediated angioedema is much less common and can be either hereditary or acquired. Bradykinin-mediated angioedema can result from many causes, including hereditary defects in the C1 esterase inhibitor (C1-INH), as a side effect of angiotensin-converting enzyme inhibitors (ACEis), or from an acquired deficiency in C1-INH. Due to the increased use of ACEi in recent decades, ACEi-induced angioedema is becoming increasingly more common, so it is essential that ED staff are able to accurately diagnose this condition.

Methods: Therefore, prompt diagnosis and correct treatment is vital. Some parameters must be considered to identify the kind of angioedema. Urticaria does not occur with bradykinin-mediated angioedema. Histamine-mediated angioedema can occur quickly (within an hour of exposure to allergens), whereas bradykinin-mediated angioedema usually develops over several hours. Bradykinin-mediated attacks tend to be more severe and persistent than histamine-mediated angioedema, lasting up to 7 days in some cases, and are also more likely to have abdominal involvement. Diagnosis of hereditary or acquired angioedema can be confirmed with blood tests. Results: Angioedema without previous diagnostic definition should be treated with standard therapy. If the patient does not respond to standard therapy it must be considered the use of specific drugs for forms of hereditary angioedema. Berinertﾂｮ is a plasma-derived C1-INH on the market at present. General concern over transmission of blood-borne infections, inevitable when using human plasma窶電erived products, needs to be taken into account. Icatibant (Firazyrﾂｮ), a synthetic decapeptide containing five nonproteinogenic amino acids, is a stable, selective bradykinin B2 receptor antagonist . It is given subcutaneously with a single injection of 30 mg. No relevant safety concerns have risen with the use of icatibant. <FILE IMAGE='359_20150715135314.jpg'> Conclusions: Emergency medicine doctors should familiarize themselves with these, and hospitals should ensure that adequate procedures are in place for the management of angioedema.

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

T135

ACUTE RHABDOMIOLISYS IN HEALTHY WOMAN: A CASE REPORT

T. Ciarambino, L. Sena, T. Battista, I. Cortile, E. Lo Priore, M. Giordano

Dept Of Medical, Surgery, Neurological, Metabolic And Geriatrics Disease-Emergency Medicine Second University Of Naples, Naples, Italy, 2 Dept Of Medical, Surgery, Neurological, Metabolic And Geriatrics, Naples, Italy, 3 Dept Of Medical, Surgery, Neurological, Metabolic And Geriatrics, Naples, Italy, 4 Dept Of Medical, Surgery, Neurological, Metabolic And Geriatrics, Naples, Italy, 5 Dept Of Medical, Surgery, Neurological, Metabolic And Geriatrics, Naples, Italy, 6 Dept Of Medical, Surgery, Neurological, Metabolic And Geriatrics, Naples, Italy Background: Cytomegalovirus infection is common in cardiac transplant patients and it occasionally induces critical renal failure, acute respiratory and peripheral muscle paralysis. Methods: A 42 year old woman presented with muscle paralysis, muscle weakness and fever. Results: On admission, neurological examination showed proximal and distal weakness in the leg. Serum CPK and serum myoglobina level were markedly increased (5600 UI/L and 5197 UI/L, respectively). There was no sign of renal failure. Nerve conduction study was negative. Serological studies for virus titers showed antibody IgM-cytomegalovirus (CMV). She begins immediately antibiotic-therapy with piperacillina-tazobactam (4.5 gr ev TID) and levofloxacina (500 mg ev QD). Laboratory findings showed a leukocytosis on complete blood count. Blood chemistry examination showed an elevation of AST (120 UI), ALT (155 UI), a markedly increased of serum CPK (5600 UI) and myoglobina (5197 UI). The blood culture and urinalysis was negative. There were no other serological abnormalities suggesting autoimmune or metabolic or electrolyte disorders. The chest X-ray was normal. ECG showed sinus tachycardia. There was no significant elevation of serum antibodies against viruses. On the 6th days of admission, the serum IgM antibody for CMV titer was positive (enzyme immunoassay) and we interrupted immediately antibiotic therapy. In the next days, the myalgia, serum CPK and myoglobina values and fever gradually worsened, and the muscle weakness was extended until the impossibility to walk. On the 8th days of admission, high dose methylprednisolone (1 gr/day TID) was administered intravenously. The myalgia, muscle weakness, fever was gradually improved. The serum CPK and myoglobin a was normalized on the 14th day and she was discharged from the hospital. Conclusions: In the present case, we investigated all possible causes of rhabdomiolisys. In our patient, the nerve conduction study excluded other causes of proximal and distal muscle paralisys. This data was supported by the increase of CMV-IgM and after IgG titers. Clinicians should be more aware of CMV infections as a cause of acute and reversibile proximal and distal muscle paralisys induced by rhabdomiolisys.

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

T136

ELECTROLYTE DISORDERS IN EMERGENCY DEPARTMENT

T. Ciarambino, S. Pascarella, L. Catalano, A. Di Sette, F. Schettino, V. Latini, G. Sansone, M. Giordano, M. Giordano

Dept Of Medical, Surgery, Neurological, Metabolic And Geriatrics Disease-Emergency Medicine Second University Of Naples, Naples, Italy, 2 Dept Of Medical, Surgery, Neurological, Metabolic And Geriatrics, Naples, Italy, 3 Dept Of Medical, Surgery, Neurological, Metabolic And Geriatrics, Naples, Italy, 4 Dept Of Medical, Surgery, Neurological, Metabolic And Geriatrics, Naples, Italy, 5 Dept Of Medical, Surgery, Neurological, Metabolic And Geriatrics, Naples, Italy, 6 Dept Of Medical, Surgery, Neurological, Metabolic And Geriatrics, Naples, Italy, 7 Dept Of Medical, Surgery, Neurological, Metabolic And Geriatrics, Naples, Italy, 8 Dept Of Medical, Surgery, Neurological, Metabolic And Geriatrics, Naples, Italy, 9 Dept Of Medical, Surgery, Neurological, Metabolic And Geriatrics, Naples, Italy Background: Electrolyte disorders in acute patients are considered as a medical emergency. The management of these disorders can be achieved through the implementation of various interventions Methods: In this study, all emergency room patients, between Genuary to December 2014, were enrolled in the Emergency Department at the Hospital of Marcianise, Italy. A multivariable logistic regression model was performed to assess the association between cardiovascular diseases and electrolyte disorders. Results: A total of 32850 patients (16490 M and 16360 W) with mean age 55Âą15 yrs were screened for the study. In particular, 24820 had mean age < 65 yrs and 8840 had mean age > 65 yrs. A total of 18.150 patients had code red at the admission and were included into the analysis. In particular, between code red, we observed, 31% of the patients in the morning, 29% in the afternoon and 40% in the night (p <0.005 vs night). However, we observed that cardiovascular diseases occur most commonly in all months, followed by pulmonary disease and neurological disease. In particular, at the admission, in over 65 yrs, 60% had polmunary disease compared to 39% in under 65 yrs (p <0.005). However, 56% of over 65 yrs had electrolyte disorders compared to 44% in under 65 yrs (p<0.005). Hyponatremia (61%) and hyperkalemia (81%) occur most commonly in the elderly patients, compared to young patients (38% and 17%, respectively, p <0.005). Hypokalemia represents an electrolyte disorders most commonly in the young compared to elderly people (65% vs 35%, respectively, p<0.005). To this regard we observed an crucial relationship between electrolyte disorders (hyponatremia and hyperkalemia) and cardiovascular disease in elderly people. Conclusions: The study does demonstrate a possible association between cardiovascular disease and electrolyte disorders, measured upon admission in the emergency department and early in-hospital mortality.

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

T137

ECHOGRAPHY IN EMERGENCY-URGENCY: A MODEL OF TRAINING PROCESS WITH IMPACT ASSESSMENT.

F. Formisano 1, E. Montibello 1, G. Massa 1, C. Ferraiuolo 1

Public Health Authority Of The Northern Province Of Naples, Naples, Italy

Background: The Echographic Simulator, recently acquired, has enabled the training of emergency physicians effectively and rapidly, offering the opportunity to learn in a simulated environment. The training modules of the software, including clinical cases, allow to improve the skills of interpretation of sonographic images, in a rapid way and with full satisfaction of the participants on the effectiveness of the training. Methods: The training path of the Course Echography in Emergency-Urgency: Eco-Fast, has been planned in three steps: (Trauma) , (no trauma), from January to June, and (upgrade with field training) from September to December 2015. The course is intended for 120 emergency physicians working in hospital emergency rooms and Territorial Emergency. The field training involves the use of portable ultrasound scanners in emergency rooms with Tutoring and second opinion in short deferred and in real time. According to the Quality Manual ECM that indicates the impact assessment as the Standard of Quality of Education, we have defined a methodology for impact assessment understood as assessing the transfer of learning in behaviors applied to professional practice. Results: To the measurement of satisfaction and learning at the end of the course we also added the measurement of skills and competencies acquired in professional practice through the use of a Virtual Community active in the four months of UPGRADE of the Course. The upgrade to the emergency department offers the opportunity to learn on the field and on the jobs the use of the ultrasound to support clinical diagnosis with the supervision of a tutor. THE VIRTUAL COMMUNITY through an animator on-line offers the opportunity to assess the impact of the course on the job by measuring the effectiveness of the echographic simulator training. Conclusions: The Impact assessment allows to detect how much the use of a Ultrasound simulator has improved the diagnostic capability of the emergency physicians with the aid of ultrasound in emergency-urgency and how it has encouraged the adoption of appropriate behavior in emergency.

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

T138

THE ASSOCIATION BETWEEN EMERGENCY DEPARTMENT QUALITY INDICATORS AND CLINICAL OUTCOMES FOR SEVERE SEPSIS AND SEPTIC SHOCK

C. Dymond 1, L. Seoane 2, Q. Luo 3, J. Greenslade 4, J. Lipman 5, J. Baker 6, J. Williams 7

University Of Queensland-Ochsner Clinical School, New Orleans, Usa, 2 Ochsner Clinical Foundation, New Orleans, Usa, 3 Ochsner Clinical Foundation, New Orleans, Usa, 4 Queensland University Of Technology, Brisbane, Australia, 5 University Of Queensland-Royal Brisbane Women's Hospital, Brisbane, Australia, 6 Ochsner Clinical Foundation, New Orleans, Usa, 7 University Of Queensland- Royal Brisbane Women's Hospital Emergency Department, Brisbane, Australia Background: The Society of Critical Care Medicine treatment guidelines for the management of severe sepsis and septic Shock (SS&SH) call for bundled processes of care (prOC). We evaluated the association of emergency department (ED) prOC with physiologic improvement and mortality. Methods: We conducted a retrospective sub-analysis of 250 patients with SS&SH from a prospective cohort of 9,717 patients admitted with infection to a tertiary referral hospital during a 3-year period. Five internal quality prOC were evaluated: prOC1, blood cultures before antibiotics; prOC2, empiric antibiotics started within 2 hours; prOC3, at least 2.5 liters of crystalloids within first 6 hours; prOC4, norepinephrine infusion for septic shock (SH) in ED; prOC5, central venous access in the ED for patients with SH. Physiologic improvement was defined as decreased APACHE II score and decreased lactic acid (LA) levels from ED to intensive care unit (ICU) admission. Multivariate logistic regression modeling was used to determine the impact of each prOC on 30and 90day all cause mortality, adjusting for age, comorbidities, and organ dysfunction. Results: The cohort had a median age of 56.5 (17-90), median APACHE II of 19 (2-44), median lactate of 3 mmol/L (0.442). Shock was present in 47%, bacteremia in 40% of patients. Thirty-day mortality was 11% and 90day mortality 14%. Compliance with prOC2, prOC3, prOC4, and prOC5 were associated with improved APACHE II scores and decreased LA levels. Cumulative compliance with prOC was associated with reductions in APACHE II scores and LA levels. Multivariate logistic regression analysis revealed prOC4 was associated with reduced mortality at 30 days (0.747, CI 0.62-0.91, P=0.003) and 90 days (0.754, CI 0.61-0.93, P=0.008). Conclusions: In SS&SH patients, antibiotics in the first 2 hours, and infusion of 2.5L of crystalloids were associated with greater reductions in APACHE II score and LA level between ED and ICU. In patients with SH, central venous access and norepinephrine in the ED were associated with greater reductions in APACHE II and lactate. Starting norepinephrine in the ED was the only prOC associated with decreased 30 and 90day mortality.

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

T139

A RARE ADMISSION TO EMERGENCY DEPARTMENT WITH POSTICTAL CONSCIOUSNESS AFTER TONIC-CLONIC SEIZURE; BRAIN EDEMA DUE TO WATER INTOXICATION

G. Akgul Karadana 1, C. Aktas 1, A.G. Aydin 1, O. Dikme 1, E. Musalar 1, E. Ars

Koc University Hospital Emergency Department, Istanbul, Turkey

Background: Seizure is a common disorder for emergency department (ED) admissions. Many differential diagnosis should be considered for patients presenting to emergency department with seizure. In this case report we present a patient who brought to ED with seizure. Methods: A 28 year old woman who came to Turkey from Japan for touristic purpose brought to emergency department by ambulance with loss of conciousness after tonic-clonic seizure. Her past medical history was unknown. In her admission she had poor general condition with loss of conciousness, flexor response to painful stimuli, dilated pupils. Her vital signs were SKB: 110/60 mmHg, P: 100/ min.,T:36.4 C째 , RR:12/min., SO2:66. Her bedside blood glucose level was 150 mg/dl. She was entubated due to apneic breathing. There was metabolic acidosis with normal anion gap on her arteriel blood gase test. Her laboratory results; complete blood count, liver and kidney tests were normal. Electrolyte levels were Na:107 mmol/L, Ca:7,68 mg/dl, CI: 79 mmol/l. Brain CT was reported as brain edema with effacement on her bilateral sulcal and cerebral gyral structures. She was started fluid resuscitation and internated to intensive care unit. Intensive care unit treatments were fluid resuscitation with NaHCO3 combination, antibiotics (sulbactam-ampicillin), acetylcysteine, furosemide, dexamethasone and esomeprazole. Results: She could be extubated after a day. When her consciousness improved, she announced 19 liters water intake for fear of food poisining. Thus, hyponatremia and brain edema was depended to excessive water intake. She was discharged a week later when her consciousness and electrolyte levels improved. Conclusions: Hyponatremia due to excessive water intake (hypervolemic hyponatremia) is a rare reason of seizures. Metabolic disorders must be kept in mind for patients presenting to the emergency department with seizure.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Shock and Critical Care T140 CALCULATION OF THE RESIDUAL BLOOD VOLUME AFTER ACUTE, NON-ONGOING HEMORRHAGE USING SERIAL HEMATOCRIT MEASUREMENTS AND THE VOLUME OF ISOTONIC FLUID INFUSED S. Chon 1, W.S. Oh 1

H.H. Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, United Arab Emirates, 2 Seoul National University Hospital, Seoul, South Korea, 3 Kangwon National University College Of Medicine, Chuncheon, South Korea Background: The cornerstone in the initial management of hemorrhagic shock is damage control resuscitation, characterized by cautious isotonic fluid resuscitation and adequate transfusion strategy until definitive hemostasis. The residual blood volume (BV) is a reasonable parameter to guide the management. Clinicians generally perform subsequent Hct measurements after infusion of certain amounts of isotonic solutions during the initial management of hemorrhagic shock. We hypothesized that the Hct values and isotonic solution infusion volume could be used to calculate the residual BV after acute, non-ongoing hemorrhage. <FILE IMAGE='280_20150614122950.jpg'> Methods: When patients with hemorrhagic shock present to ED (stage 1), the standard management consists of obtaining blood samples including the initial Hct, rapid infusion of 1 to 2 L of isotonic solutions before possible transfusion, and immediate hemostasis. Usually, clinicians check subsequent Hct values (stage 2), while loading the isotonic solution. Using the designation of subscript of 1 and 2, we can define the BV, PV, and Hct at each time point. Conceptually, the isotonic solution is distributed to the extracellular fluid compartments, which comprise the interstitial fluid compartment and the PV, without entering the intracellular compartments. If the fraction of isotonic solution distribution into the PV is k (where 0<k<1), infusion of N(mL) of isotonic solution will add k*N to the PV. Then, PV2=PV1+k*N _(1) For non-ongoing hemorrhage, the RBCV remains unchanged. RBCV1=RBCV2 _(2) Therefore, BV2=RBCV2+PV2 [by definition] =RBCV1+(PV1+k*N) [incorporating (1) and (2)] =(RBCV1+PV1)+k*N = BV1+k*N _(3) [by definition] Meanwhile, RBCV1=BV1*Hct1 _(4) [by definition] RBCV2=BV2*Hct2 [by definition] =(BV1+k*N)*Hct2 _(5) [incorporating (3)] If we incorporate (4) and (5) into (2), which assumes non-sustained hemorrhage, then BV1*Hct1=(BV1+k*N)*Hct2 Results: Then, BV1 = (k*N) / [(Hct1/Hct2) â&#x20AC;&#x201C;1] (N (mL) is the infused isotonic solution volume, determined by the clinician, and the Hct1 and Hct2 values are serial measurements.) Conclusions: We suggest that the residual BV after acute, non-ongoing hemorrhagic shock in patients can be calculated using 0.25N/[(Hct1/Hct2)â&#x20AC;&#x201C;1], where Hct1 and Hct2 are the initial and subsequent hematocrits, respectively, and N is the volume of isotonic solution infused between these time points.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Shock and Critical Care

T141

THE ASSOCIATION OF OBESITY AND APPROPRIATE FLUID RESUSCITATION ON INTUBATED SEPTIC PATIENTS IN AN URBAN EMERGENCY DEPARTMENT

A. Ajani 1, C. Courage 1, L. Giesler 1, S. Wilson 1, R. Sherwin 1

Wayne State University/detroit Medical Center - Department Of Emergency Medicine, Detroit, Usa

Background: Septic patients are often volume depleted with inadequate end organ perfusion and appropriate weight based fluid resuscitation is a core element to improving outcomes. Current data are conflicting regarding the effect of obesity on mortality in sepsis. We hypothesized that obese septic patients receive less fluid resuscitation (based on mL/kg) than non-obese septic patients. Methods: A post-hoc analysis of an existing database of mechanically ventilated patients presenting in severe sepsis or septic shock was performed at Detroit Medical Center Emergency Departments from January 2008 â&#x20AC;&#x201C; December 2012. Patients were excluded if they were < 18 years old, admission weights were not available, or received palliative care within 48 hours of admission. Patients were divided into two groups: those with BMI > 30 and those with BMI < 30. We investigated whether patients with BMI > 30 received equal fluid administered per kilogram body weight, mortality, lactate clearance. Results: Obese and non-obese cohorts has similar ages, severe sepsis:septic shock proportion, lactate levels and SOFA scores. Compared to non-obese patients, obese patients were more likely to be female (61% v 30%; p<0.01), have ESRD (30% v 8%; p=0.036). There were no significant differences in ICU length of stay, hospital length of stay, ventilator days or in-hospital mortality. Overall, obese patients received significantly less weight based fluid resuscitation in the ED than non-obese patients (29 v 46; p<0.01). Prior to vasopressors, obese patients received half the IV fluids per kg (mL/kg) than non-obese patients (34 v 68 mL/kg; p=0.04). In univariate analysis, WBC, SOFA score, lactate, pulmonary source of infection and achieving a MAP of 65mmHg at 6 hours were associated with in-hospital mortality. In multivariate regression analysis predicting hospital mortality only lactate (OR 1.11; 95% CI 1.01 - 1.25) and SOFA (OR 1.25; 95% CI 1.05 â&#x20AC;&#x201C; 1.50) score remained significant. Conclusions: This study suggests that obese septic patients receive less fluid based on mL/kg than non-obese patients. The subsequent impact on mortality and patient outcomes is still debatable, however. Further study is required to determine the significance of these findings.

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

T142

OMAN DISASTER AND EMERGENCY ASSOCIATION: NATIONAL ACHEIVENT

D. Al Rahbi 1

Nahdha Hospital, Muscat, Oman

Background: Oman Disaster and Emergency Association This newly formed organization was formed to organize the volunteer work during disasters and emergencies. It is one of the NGO and what is special for this is that the members are from all citizens and expatriates who wants to give help during difficult time where works cannot be organized. Board of directors formed and the number of members is increasing. ODEA organized Oman International Conference on Emergency Medicine 2014 with great success and introduced the concept of Disaster Medicine to the county and planned to be a major subject in the education and training of medical students and doctors during their specializations. <FILE IMAGE='175_20150529085424.png'> Methods: FORMATION OF ADMINISTRATION BOARD AND GET ALL OFFICIAL PAPER WORKS. Results: NON Conclusions: ODEA FORMATION

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

T143

CAN SALT TRIAGE BE APPLIED IN CHEMICAL MASS CASUALTY INCIDENTS?

S. Chen 1, I. Yeh 1, F. Kuo 1, Y. Liu 1, P. Cheng 1, Y. Shih 1, Y. Hsiao 1, S. Chen 1

Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Background: SALT Triage was developed as a national all hazards mass casualty initial triage standard for all patients in United Stated of America. Currently, it's accuracy and time interval has not be assessed in any chemical mass casualty simulation. We tried to evaluate the accuracy of SALT Triage in chemical mass casualty incidents. Methods: 125 physicians, nurses and paramedics participated in one of two chemical disaster training courses in the Kaohsiung-Ping tong region. After a 30 minute lecture about SALT Triage participants enrolled in a simulated triage exercise as 24 actors and one mannequin were utilized to create a chemical incident scenario. The triage intervals were secretly recorded by fifteen victims and then SALT Triage experiences were assessed by pre and post-drill surveys. Results: The data samples consisted of a total 3125 triage observations. Accuracy was 65% (SD±16; range: 30%-100%). The over-triage rate was 27% and the under-triage rate was 8%. We observed that 79.6% of participants (SD±4.7; range: 74-83) over-triage minimal category victims manifested chemical exposure of eyes or airways. The average triage interval was 15 seconds (SD±2; range: 12-19). After the drill, different learning factors such as easy to understand and easy to remember were asked to participants and the result showed 7.4/10 (SD±1.79; range: 2-10) and 7.3/10 (SD±1.75; range: 2-10) respectively. Moreover, the confidence rate to use SALT triage increased from 5.6/10 to 6.78/10 (p<0.001) and participants felt the ease of triage application increased from 6.4/10 to 7.28/10 (p=0.003). Conclusions: Due to it’s ease of understanding and the ability by professionals to recall the SALT triage protocol, it showed a good acceptability with participants involved in the exercise. Therefore, educational planners will feel more confident to generally implement this evaluative tool in regional training courses. Over-triage of victims will represent to the practitioner better insight in the delayed aggravation of chemical injuries, and therefore most of the common triage pitfalls. We conclude that SALT triage is an accurate, faster and easier triage tool to be implemented in chemical mass casualty incidents.

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

T144

DISTURBANCES IN THE EARLY PERIOD OF EMERGENCY DEPARTMENT OPERATIONS DURING CHEMICAL DISASTERS

F. Kuo 1, I. Yeh 1, P. Cheng 1, S. Chen 1, Y. Hsiao 1, K. Liu 1, Y. Shih 1, S. Chen 1, Y. Liu 1

Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Background: Emergency departments cannot neglect the safety of existing patients when preparing for incoming victims of a chemical disaster. Our aim is to show the pitfalls of a chemical disaster plan that can disrupt the continuity of operations in the ER. <FILE IMAGE='177_20150529200249.jpg'> Methods: A total of 8 hospitals participated in a yearly unannounced drill during two successive years. A cardiac arrest victim was followed by an unknown number of casualties at each hospital at the beginning of the drill. Quantitative variation of emergency department nurses and their relationships with existing victims were recorded to objectively analyze the internal equilibrium of the department. Required times to activate intra-hospital assistance were also recorded. Results: Participant hospitals used different percentages of emergency department nurses to form a pre-design response team (table 1). The increase of this percentage produced a proportional increase of nurse-patient ratio in emergency rooms (fifty percent caused a twofold rising) that would be unsafe for existing patients (table 2). The combination of relocating nurseâ&#x20AC;&#x2122;s percentage and the pre-drill nurse-patient ratio caused the highest nurse-patient ratio in regional hospitals (table 3). Of interest, due to high nurse-patient ratio with no activation of assistance that was perceived as a dangerous environment (table 2), drill assessment officers twice suspended the drill in regional hospitals. Mean assistance activation times for local, regional and medical center hospitals were 1.7 minutes, 3.25 minutes and 7.03 minutes respectively. Conclusions: Other than victim quantity and severity, the high nurse-patient ratio is an essential indicator for activation of intra-hospital assistance to prevent emergency department equilibrium problems during the early stages of chemical disaster response. The percentage of emergency nurses joining response teams will determine the increased proportion of nurse-patient ratio before the arrival of victims. Therefore, chemical disaster planning must properly adjust this percentage in order to rapidly activate the appropriate quantity of intra-hospital assistance, especially in regional hospitals, who face the highest risk of chaos. Routine activation of intra-hospital assistance is an excellent feature for local hospitals and will allow a rapid mobilization of assistance personnel to overcome an imminent deficit.

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

T145

MOBILE PHONE APP AS AN RAPID TRIAGE TOOL IN MASS CASUALTY INCIDENTS

K. Tsai 1

Far Eastern Memorial Hospital, New Taipei City, Taiwan

Background: Triage is the most essential task to do when mass casualty events happened. The traditional tagging system is always criticized about the lack of effectiveness and timeliness. Moreover, the real time victim list could not also be obtained immediately and automatically by the paper tagging system. A new triage system is necessary to improve this in such a digital era. Methods: A three step triage system was designed for this purpose. An APP on Android platform which could be performed on many smart mobile phones was developed. When applying, first we have to attach a premade plastic tag with a barcode on it to the victim’s wrist or ankle. First, activate the APP to scan the barcode to make a temporary identity. In step 2, we activate the camera to take a photo of the victim. In step 3, we have to select a grade of this victim based on the triage principle, which is categorized into 4 colors. After the step 3, we complete the whole process of one victim. Then we can rapidly move on to the next one. A drill was conducted for the verification of this application. Results: In the drill, the system could be run without any difficulty. All the data collected by the APP were immediately uploaded to the cloud as an encrypted file. Any site which was authorized to access the cloud could get the summary of these data at the same time even in a remote distance. The average triage time per victim is 56.5 seconds initially. After repeated practice, the average triage time could be as short as 30.5±2.6 seconds. Compared to the traditional triage tagging system, 28.6±2.9 seconds, the P value is >0.05. Conclusions: The APP triage system is a new workable and convenient way for the rapid disposition and documentation in the situation of mass casualty. It is better in real time data collection, which makes the real time decision making possible. However, the system is web dependent. If the web were out of signal, the system could only work partially.

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

T146

A SURVEY OF U.K. EMERGENCY PHYSICIANSâ&#x20AC;&#x2122; KNOWLEDGE OF CHEMICAL WARFARE AGENTS

P. Moore 1, M. Byers 2, T. Joy 2, A. Weaver 3, G. Grier 3

Insitute Of Pre-Hospital Medicine, London, United Kingdom, United Kingdom

Barts And The London Medical School, London,

Background: In August 2014 the national security threat level was increased from substantial to severe, indicating that a terrorist attack on the United Kingdom remains likely. Many of the chemical warfare agents have specific toxidromes, and recognition is time sensitive. There are learning objectives within the College of Emergency Medicine (CEM) examination curriculum covering chemical, biological, radiological and nuclear (CBRN) medicine. However the clinicians in the emergency department (ED) who are at the front line for triage and diagnosis, may not be wholly familiar with these toxidromes. This article explores the difference between expected knowledge and actual knowledge levels amongst ED staff. Methods: Questionnaires were distributed via Twitter and personal emails targeting Emergency Medicine (EM) doctors. The internet-based survey was anonymous, making follow up of non-responders was not possible. Responders were asked to answer ten multiple-choice questions on the diagnosis and management of chemical agent poisoning. The CEM curriculum was used regarding expected knowledge of CBRN medicine. Results: 304 healthcare professional responded to the survey, of which 242 met the inclusion criteria. EM doctors at grade ST4 and above, (K), were expected to have knowledge regarding chemical warfare agents, all other doctors were not expected to (DK). The mean scores of (K) physicians and (DK) physicians were 44.0% and 36.8% respectively. (K) Physicians scored higher than (DK) physicians, this difference was statistically significant p=0.01, 95% CI [3.1, 11.4]. Conclusions: When tested on their knowledge of chemical emergencies senior EM physicians scored higher than doctors of other specialities, however their average score was still less than 45%. These findings indicate the need for further training and education surrounding CBRN medicine.

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

T147

DEVELOPMENT OF DISASTER MEDICAL SKILL COMPETENCY TRAINING (DISCO) COURSEâ&#x20AC;&#x201C; A PILOT STUDY

S. Kim 1, J. Noh 1, M. Choa 1, H.S. Chung 1,2, I. Park

1 2

1,2

Center For Disaster Relief Training And Research, Yonsei University Severance Hospital, Seoul, South Korea, Department Of Emergency Medicine, College Of Medicine, Yonsei University, Seoul, South Korea

Background: Skills competency is an important aspect of a healthcare provider responding to a disaster situation. However, there are no program which focuses on skill competency training. Therefore, we developed a core competency-based, standardized skill training program. The aim of this study was to develop and implement a competency-based and skill specific training program focusing on prehospital disaster response situation and to evaluate the effectiveness of the program through self-confidence and knowledge of clinical skills. Methods: The developed the training courses included airway management, wound management, ultrasound application and simulation session. Training for medical procedures in extreme environment were included in each session. To identify the difference in knowledge and self-confidence before and after training, all participants responded to the survey with a Likert scale. A descriptive analysis was performed to determine the general characteristics of subjects and the level of awareness of the importance of clinical skill in disaster response. Wilcoxon signed rank test was used to compare the knowledge and self-confidence level on pre- and post-training. Results: A total of 62 participants attended 4 courses with each course participants comprising from 13 to 18. The mean score of awareness of importance of skill in disaster response was 3.63 to 4.0 out of 5. The score differences in pre- and post-training scores of confidence for skill was 1.57 to 2.98 and differences in knowledge was 1.74 to 2.7. The simulation course showed the biggest difference. Conclusions: The level of awareness of importance of medical skill in disaster response was moderate. The trainees assessed the DISCO course as effective and this study showed the feasibility of educating medical skills performed in extreme environment.

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

T148

HYPOTHETICAL DISASTER RESPONSE DANGERS DURING THE KAOHSIUNG GAS EXPLOSION DISASTER

P. Cheng 1, I. Yeh 1, F. Kuo 1, C. Chang 1, Y. Shih 1, Y. Hsiao 1, Y. Liu 1, K. Liu 1, S. Chen 1, S. Chen 1

Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan

Background: After the explosion of subterranean propane gas pipelines on 31 July 2014 at 23:55, chemical mass casualties immediately crowded into regional emergency rooms. Our purpose is to describe and analyze center-based hospital response dealing with this magnitude of chemical disaster. <FILE IMAGE='314_20150626082508.jpg'> Methods: Kaohsiung Medical University Hospital is the closest center-base hospital to the explosion accident. We retrospectively reviewed victim charts and emergency room monitors to record substantial issues about hospital response. Results: Hospital emergency department received alert calls from emergency and rescue command center at 00:02 AM. The first victim arrived by ambulance at Kaohsiung Medical University Hospital after 13 minutes of the explosion and the major influx of victims occurred during the period 60 to 90 minutes afterward (20/40 victims) (figure 1). During the first hours, 76.7 % of victims needed ambulatory assistance to arrive at ER and only 23.3 % of victims were brought by family members. The level one and level two hospital disaster assistance plan were activated at 00:43 AM and 01:15 AM respectively when the incoming of mass casualties became imminent. A total of 160 physicians-nurses-technicians-secretaries were mobilized in order to resuscitate 40 victims (table 1) in different medical conditions such as emergency room resuscitation, personal patient data collection, family support, radiological evaluation, surgical treatment and intensive care unit management. Victims initial triage categories, emergency room dispositions and clinical outcomes are described in figure 2. Conclusions: Reflecting from this experience, misinterpretation of verbal information became a danger in disaster magnitude recognition and may also complicate hospital disaster preparedness. Moreover, being prepared before the influx of disaster victims is crucial for preparation of an organized disaster response management team. Therefore, adding visual information such as television news channels would be helpful for correct information interpretation. Emergency medical technicians would be the most effective way for the safety dispatch of victims when the disaster compromises local infrastructures. An emergency room response may be important but not sufficient to improve patient outcome. Therefore, an effective response plan should support rapid surgical intervention follow up by immediate intensive medical care.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Disease and Injury Prevention

T149

EVALUATION OF THORACIC AND LUMBAR SPINE INJURIES DURING SPORTS ACTIVITY IN YOUNG ATHLETES

N. Syrmos 1, A. Mylonas 2, G. Gavridakis 3, V. Valadakis 1, K. Grigoriou 1, D. Arvanitakis 1

Neurosurgical Department-Venizeleio General Hospita, Heraklion, Crete, Neurosurgical Department-Venizeleio General Hospit, Greece, 2. Department Of Sports Science, Aristotelian University Of Thessaloniki, Thessaloniki,macedonia,greece, . Department Of Sports Science, Aristotelian Unive, Greece, 3 Ct-Scan Department -Venizeleio General Hospita, Heraklion, Crete, Ct-Scan Department -Venizeleio General Hospita, He, Greece Background: Evaluation of thoracic and lumbar spine injuries during sports activity in young athletes Nikolaos Syrmos1,2 , Argyrios Mylonas2, Georgios Gavridakis3 ,Vasilios Valadakis1,Kostantinos Grigoriou1 , Dimitrios Arvanitakis1 1. Neurosurgical Department-Venizeleio General Hospita, Heraklion, Crete 2. Department of Sports Science, Aristotelian University of Thessaloniki, Thessaloniki,Macedonia,Greece 3. Ct-Scan Department -Venizeleio General Hospita, Heraklion, Crete

In this study conducted over a 5 year period (2006-2007-2008-2009-2010) in our Department, we studied all young athletes (<30 years) with lumbar and thoracic spine injuries were admitted to our neurosurgery unit. Methods: 80 patients were included in the study. Of these males were 70, and females were 10, All young athletes underwent standard clinical examination, spine radiography and 20 of them CT or MRI control. Results: Patients with negative findings on spine radiography and a normal neurological examination were discharged. Patients with positive findings were treated either medically or surgically as deemed necessary. Conclusions: Appropriate evaluation and accurate management, are necessary conditions for good results

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Disease and Injury Prevention

T150

EVALUATION OF CERVICAL SPINE INJURIES DURING SPORTS ACTIVITY IN YOUNG ATHLETES

N. Syrmos 1, A. Mylonas 2, G. Gavridakis 3, V. Valadakis 1, K. Grigoriou 1, D. Arvanitakis 1

. Neurosurgical Department-Venizeleio General Hospita, Heraklion, Crete,. Neurosurgical Department-Venizeleio General Hosp, Greece, 2 Department Of Sports Science, Aristotelian University Of Thessaloniki, Thessaloniki,macedonia,greece, Department Of Sports Science, Aristotelian Univers, Greece, 3 Ct-Scan Department -Venizeleio General Hospita, Heraklion, Crete, Ct-Scan Department -Venizeleio General Hospita, He, Greece Background: Evaluation of cervical spine injuries during sports activity in young athletes Nikolaos Syrmos1,2 , Argyrios Mylonas2, Georgios Gavridakis3 ,Vasilios Valadakis1,Kostantinos Grigoriou1 , Dimitrios Arvanitakis1 1. Neurosurgical Department-Venizeleio General Hospita, Heraklion, Crete 2. Department of Sports Science, Aristotelian University of Thessaloniki, Thessaloniki,Macedonia,Greece 3. Ct-Scan Department -Venizeleio General Hospita, Heraklion, Crete

Background In this study conducted over a 5 year period (2006, 2007, 2008, 2009, 2010) in our Department, we studied all young athletes (<30 years) with cervical spine injuries were admitted to our neurosurgery unit. 60 patients were included in the study. Methods: Of these males were (40) 66,7% , and females were (20 ) 33,3 %, Results: All young athletes underwent standard clinical examination, spine radiography and 15 of them CT or MRI control. Patients with negative findings on cervical spine radiography and a normal neurological examination were discharged. Conclusions: Patients with positive findings were treated either medically or surgically as deemed necessary. Appropriate evaluation and accurate management, are necessary conditions for good results

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Disease and Injury Prevention

T151

INVESTIGATION OF SELF-HARM ACTION BY THE AGE OF YOUNGER THAN 20 YEARS OLD IN 2012-2014 OF OUR HOSPITAL

S. Sugita 1, Y. Ooya 1, A. Nakano 1, M. Nemoto 1

Saitama Medical University International Medical Center, Hidaka, Japan

Background: The suicidal acts increased year by year in Japan. The Number of suicides in Japan was 25,427 in 2014 and it was the world 9th place. We studied the self-harm action of the age of younger than 20 years old patients. METHODS: This is retrospective study. The age of younger than 20 years old patients who came to our hospital as a result of self-harm actions in 2012-2014 were investigated. Methods: This is retrospective study. The age of younger than 20 years old patients who came to our hospital as a result of self-harm actions in 2012-2014 were investigated. Results: Total patients were 17. The possession rate of the psychiatric disease was 35% (6), and no underlying disease was 65% (11). The methods of self-harm actions were taking over dose medicines (9,53%), jumping from a high place or in at the running train (7, 41%), hanging (1, 6%). Death case was only one, and it was hanging. In the group of the age of 11-15 years, the most frequency methods were jumping which has been thought high lethality, generally. Conclusions: The most frequency methods were taking over dose medicines. In the group of age 11-15 years, the most frequency methods were jumping. And furthermore, there was no underlying disease in 65% of case and they did self-harm act suddenly. For prevention of self-harm act in the age of younger than 20 years patients, it is important for noticing the omen early at same time increasing vigilance against sudden actions.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Disease and Injury Prevention

T152

DEALING WITH DOMESTIC INJURIES AT EMERGENCY DEPARTMENTS: THE OLDEST REGION IN ITALY

EVIDENCE FROM LIGURIA,

L. Leporatti 1, P. Cremonesi 2, A. Schena 2, G. Cremonesi 3, S. Leone 2, F. Zanella 4, M. Montefiori 1

Dept. Of Economics, Genoa, Italy, 2 Accident & Emergency Dept, Galliera Hospital, Genoa, Italy, 3 Post-Graduate School In Emergency Medicine, University Of Genoa, Genoa, Italy, 4 Telecommunications And Informatics Dept, Galliera Hospital, Genoa, Italy Background: The aim of this study is to analyze the characteristics of patients who accessed to the Emergency Department of E.O. Galliera, Genoa, Italy, in 2014, after being victim of a domestic accident. Accesses are analyzed in terms of: demographic characteristics of patients; features connected to the accident; clinical condition of the patient. Methods: To ease the interpretation and comparison of results we make use of the European Injuries DataBase (IBD) which represents a standardized source of cross-national data on injuries treated in emergency departments located in 26 countries joining the program. This work focuses on domestic accidents contained in the dataset SINIACA for the period 2013-2014; we will make use of descriptive statistics able to contextualize the case of Galliera Hospital in the national and European environment. Results: During the period 2013-2014, the number of accesses to E.O. Galliera for domestic accidents accounted to 4,110. From a demographic point of view women tend to accesses more often than men (64% versus 36%) and they generally tend to be victims of accidents while doing households (45%) or walking (27%). Domestic accidents tend to take place more often in the kitchen (37%), in the bedroom (12%) and in the bathroom (10%). As expected, age plays a key role: the average age of patients accessing for domestic accidents was 62 years old in the period 2013-2014, with women being generally older than men (on average 65). In 2014, people aged more than 65 and more than 85 represented, respectively the 51% and the 16% of accesses for domestic violence. Conclusions: Results show older people to be over-represented among victims of domestic injures; this should be considered when setting prevention policies aiming at reducing their impact. Special interest should be put in the study of Liguria which, in the next decades, will be particularly affected by a progressive aging of the population. This fact will make necessary the adoption of best practices aimed at promoting a safe life at home for vulnerable individuals (older) and at reducing costs of treatments connected to the use of emergency services.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Disease and Injury Prevention

T153

THE EVALUATION OF NEEDLESTICK INJURIES AMONG HEALTHCARE WORKERS IN AN UNIVERSITY HOSPITAL

A. Nazli, H. Kahraman, D. Gokengin, A.C. Buke

Ege University Medical Faculty Department Of Infectious Diseases And Clinical Microbiology, Bornova, Izmir, Turkey Background: The aim of this study was to assess the needlestick injuries and the implementations after injuries occur among HCWs at Ege University Hospital in Izmir, Turkey. Methods: The study was carried out between December 2008 and February 2009. A questionnaire including 24 questions was asked and responds were recorded. Results: Eight hundred ninety one HCWs responded to the questionnaire. Out of 891, 402 (45%) were nurses, 258 (29%) were caregivers, 94 (11%) were cleaning staff, 93 (10%) technicians, and 44 (5%) were other HCWs. The mean ages of respondents were 35.05 Âą 8.45 and 70% were female. The number of HCWs who didnâ&#x20AC;&#x2122;t received an education program about needlestick injuries were 579 (65%). Serological tests of 669 (75%) HCWs were not evaluated before they started to work. Only 214 (24%) HCWs received the hepatitis B vaccine before they started to work. The group with highest vaccination rate to hepatitis B was nurses (35%). In two hundred thirty two HCWs, needlestick injuries were reported during the work. Forty one percent of them were studying less than one year in the institution. Syringes needles, lancet and hollow-bore needles were the causes of needlestick injuries in 68%, 17% and 5% respectively. The majority of needlestick injuries occurred in emergency room, patient rooms, the operatin rooms and critical care units. The injuries occurred while HCWs drawing blood (36%), administering injections (28%), recapping needles (21%) and handling trash and dirty linens (15%). Serological examinations were performed in 28/232 (12%) HCWs after needlestick injuries occurred. Fifteen HCWs received Hepatitis B vaccine, two received both hepatitis B vaccine and hepatitis B hyper immunoglobulin, and one received only hepatitis B hyper immunoglobulin. Only 79% of the injured HCWs educated about needlestick injuries after injuries occurred. A hundred sixteen HCWs stated that they have injured more than once. Conclusions: It is found that needlestick injuries is common in HCWs working at Ege University Hospital. Use of safety and bioengineering needles will be the best solutions to prevent needlestick injuries with education of HCWs.

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

T154

THE ACCURACY OF PAIN MEASUREMENT IN DIAGNOSIS OF SCAPHOID BONE FRACTURES IN PATIENTS

M. Sharifi 1, S. Hashemian 1, H. Saeidian 2, B. Rezvani Kakhki 1

Emergency Medicine Reasearch Center, Faculty Of Medicine, Mashhad University Of Medical Sciences, Mashhad, Iran, 2 Departement Of Emergency Medicine, Faculty Of Medicione, Kerman University Of Medical Sciences, Kerman, Iran Background: Scaphoid fracture is the most common fracture among the bones of the wrist. Plain radiography has a sensitivity of 59 to 79 percent for the diagnosis of scaphoid fracture after injury. Casting is done to avoid complications in patients with suspected fractures with normal radiography. MRI (the gold standard for diagnosis) has a sensitivity of 100% and a specificity of 99%. To avoid unnecessary casting and high costs, we decided to offer a way more efficient than radiography and less costly than MRI. Methods: In the present study, 175 patients with suspected scaphoid fracture along with snuff box tenderness and normal radiography were enrolled in the study. On arrival, patientsâ&#x20AC;&#x2122; pain score were determined using visual analog scale method with anatomical snuffbox tenderness and then MRI was performed on the patientsâ&#x20AC;&#x2122; wrist and the results were recorded for patient in the check list. The data was then aggregated and analyzed. Results: The result of MRI for fracture was negative for 90.9% and positive for 9.1%. The mean pain score was 7.3 in negative MRI group and 8.75 in positive MRI group, considering a significant difference. Roc-curve graph showed that the sensitivity and specificity will be 87% and 57%, respectively for scores 7.5 and higher and 75% and 72%, respectively for scores 8.5 and higher Conclusions: It seems that although this method, beside other criteria in the diagnosis of fractures, can be useful in future studies, it would not be helpful in fracture detection.

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

T155

DISLOCATION OF PROXIMAL INTERPHALANGEAL JOINT OF THE SECOND TOE: A CASE REPORT

C. Ertan 1, F.S. Akgun 2, S. Sanel 3, H. Yildiz 3

Izmir University, Faculty Of Medicine, Department Of Emergency Medicine, Izmir, Turkey, 2 Maltepe University, Faculty Of Medicine, Department Of Emergency Medicine,, Istanbul, Turkey, 3 Maltepe University, Faculty Of Medicine, Department Of Orthopedics And Traumatology, Istanbul, Turkey Background: Interphalangeal joint dislocations of toes are relatively rare and can generally be treated by closed reduction. <FILE IMAGE='358_20150630130012.jpg'> Methods: We present a case of a persistent proximal interphalangeal joint dislocation of the second toe. Results: A 17-year-old student sustained a left foot injury on landing during playing volleyball. He complained of pain and deformity over the left second toe. The patient was wearing a pair of sport shoes at the time of injury. He was admitted to the Emergency Department of Maltepe University by ambulance. He was diagnosed with a left second toe proximal interphalangeal joint dislocation. On admission to the orthopedics ward, the physical examination revealed marked swelling over the left second toe, with dorsal subluxation of the PIPJ. The subdermal venous plexus refill time was normal, and no neurologic deficit was detected. The radiographs demonstrated a dorsolateral dislocation of the PIPJ of the left second toe without any associated fracture. Closed reduction was performed. The joint was successfully reduced. He was able to perform full weight bearing walking without pain. Radiographs of his left second toe showed good alignment with congruent PIPJs. Conclusions: Dislocation of the interphalangeal joint of the toe is an uncommon injury; the great toe is more commonly involved than the lesser toes. Reduction is usually accomplished through manual traction with or without digital block anesthesia and the irreducible dislocation is rare. After closed reduction, these dislocations are usually stable.

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

T156

SUDDENLY I TURNED INTO POPEYE

E. Tosun, R. Ak, E. Unal Akoglu, T. Cimilli Ozturk, O. Ecmel Onur

Fatih Sultan Mehmet Education And Research Hospital, Istanbul, Turkey

Background: The figures demonstrate â&#x20AC;&#x153;Popeye signâ&#x20AC;?, which is diagnostic in proximal biceps tendon rupture. The purpose of this case is to show that careful inspection is an important part of physical examination and prevents loss of time. <FILE IMAGE='209_20150709171521.jpg'> Methods: A 46-year-old man presented to emergency department with his right upper arm swelling and pain. He reported that he was lifting up a sofa when he felt pain in his right upper arm and two hours later he noticed the swelling. In his medical history there was no other medical problem. But he was a smoker. On physical examination; deformity of the right upper arm (Figure 1) which was significantly different from the left (Figure2), minimal pain, no numbness and no tenderness was detected. His pulses were intact. He had full range of motion at the shoulder and elbow. Orthopedics was consulted. Results: 1 Conclusions: The Popeye sign is a deformity in biceps, is typical for diagnosis. Traumatic ruptures usually occur in young population as a result of acute strain on the tendon; whereas individuals aged between 40-60 with chronic tendon strain problems are at the highest risk population for tendon rupture. Other risk factors are chronic diseases like diabetes, chronic kidney disease, rheumatoid arthritis, chronic steroid use, smoking, systemic lupus erythematosus, fluoroquinolone use. The diagnosis is usually clinical. Because of that the physical examination involving inspection of both upper arms to evaluate for asymmetry, deformity and neurovascular impairment plays an important role. Plain radiography is useless but helps to rule out other bony injuries. Ultrasound is becoming a reliable diagnostic tool for tendon ruptures. MRI is the gold standart. This pathology effected rarely daily activity. In the emergency department the treatment bases on resting the affected joint, analgesia, anti-inflammatories with non-steroidal anti-inflammatory drugs, controlling swelling with cold modalities (eg, cold packs, ice massage, hydrotherapy). Rehabilitation should begin immediately during conservative management of the biceps rupture, after a complete examination of the limb to identify coexisting injuries or complicating factors that may affect treatment.

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

T157

FAT PAD SIGN

R. Ak, F. Doganay, E. Unal Akoglu, O. Ecmel Onur, T. Cimilli Ozturk

Fatih Sultan Mehmet Education And Research Hospital, Istanbul, Turkey

Background: Fat pad sign was first described by Norell in 1954, refers the radiologic visualization of the elbow fatty tissue on X-ray. Normally a lucency is visualized along the anterior surface of the distal humerus and no lucency is visualized along the posterior surface. An elevated anterior lucency and/or a visible posterior lucency on a lateral elbow X-ray, flexed at 90Â°, is described as a positive fat pad sign. In children, a posterior fat pad sign suggests a condylar fracture of the humerus. In adults it mostly suggests a radial head fracture. Here we report two cases of elbow trauma, one of them is an occult fracture that can be missed out easily if X-ray findings are not evaluated carefully. <FILE IMAGE='209_20150705155612.jpg'> Methods: Case 1: A thirty two years old male, presented to the emergency department with the complaint of elbow pain after falling on elbow in a football match. Swelling was noticed but overall elbow examination was limited because of severe pain. X-ray demonstrated a positive fat pad sign and a radial head fracture (Figure 1). The patient was discharged with splint. Case 2 : A thirteen years old child presented to the emergency department with the complaint of elbow pain after falling on elbow while playing in school. There was swelling and 2x2 cm ecchymosis in physical examination. X-ray demonstrated a positive fat pad sign but no fracture line was detected (Figure 2). Computed tomography (CT) of elbow was performed and a linear, non-displaced medial epicondyle fracture of humerus was determined. The patient was discharged with splint. Results: 1 Conclusions: Fat pad sign can be the herald of occult fractures, that can be determined by CT or MR Imaging. Oâ&#x20AC;&#x2122;Dwyer and et. suggest advanced imaging modalities are necessary in the presence of fat pad sign after recent trauma history as in our second case. Eckert and et. suggest that if there is a fat pad sign advanced radiographs should be performed and ultrasound (US) also can be used as a diagnostic tool especially in children.

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

T158

“FLIPPING” THE ADVANCED CARDIAC LIFE SUPPORT CLASSROOM WITH TEAM BASED LEARNING: COMPARISON OF COGNITIVE TESTING PERFORMANCE

M. Osborn 1, C. Anderson 1, R. Navarro 1, J. Yanuck 1, S. Strom 2, C. Mccoy 1, J. Youm 3, C. Ricks 2, M. Ypma-Wong 3, N. Zuabi 1, M. Langdorf 1

University Of California, Irvine School Of Medicine, Department Of Emergency Medicine, Irvine, Usa, 2 University Of California, Irvine School Of Medicine, Department Of Anesthesiology And Perioperative Care, Irvine, Usa, 3 University Of California, Irvine School Of Medicine, Instructional Technologies Group, Irvine, Usa Background: Advanced Cardiac Life Support (ACLS) is required for PGY-1 positions, so schools train students toward the end of clinical years. The “flipped classroom” (FC) provides content via podcasts, with class time for integration and discussion. In Team Based Learning (TBL), small groups collaborate to solve clinical problems. The objective was to see if test results were similar for ACLS course taught with FC/TBL vs. lecture based (LB) historical control. Methods: We taught final-year students 2010 ACLS in a FC/TBL model in 2015, compared to controls of three classes in LB format (2012-14). There were 27.5 scheduled hours in the FC/TBL model (TBL 10.5, podcasts 9, small-group, simulation 8 hours), and 20 hours (12 lecture, simulation 8 hours) in LB format. The TBL covered 13 cardiac- and peri-arrest cases; the LB format had none. We used 7 simulation cases for both formats. One instructor delivered the same content by lecture (2012-14) or podcast (2015). Testing was constant: 50-question multiple choice (MC), 20 question rhythm matching, and 7 fill-in-the-blank cases. Results: 354 students took the course (259 in LB format 2012-14, and 95 in FC/TBL format 2015). Two of three tests had statistical improvement for the FC/TBL format. For all tests, median scores increased from 93.5% (IQR 90.6, 95.4) to 95.1% (92.8, 96.7, p = .0001 by Kruskal-Wallis rank test). For the 7 case fill-in-the-blank, scores improved: 94.1% correct for LB (89.6, 97.2) to 96.6% for FC/TBL (92.4, 99.20 p = .0001). For the 50 question MC, scores improved: 88% correct for LB (84, 92) to 90% for FC/TBL (86, 94, p = .0002). For the 20 rhythm test, students did well (median 100% both formats). More students failed one test with LB vs. FC/TBL (24.7% vs. 14.7%), and two or three components (8.1% vs. 3.2%). Conversely, 82.1% passed all three with FC/TBL vs. 67.2% with LB. Conclusions: A “flipped classroom”/Team Based Learning format for ACLS marginally improved written test results for final-year medical students over traditional lecture based format.

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

T159

DIAGNOSTIC VALUE OF BARIUM MEAL AND ENDOSCOPY METHOD IN DIAGNOS OF UPPER GASTROINTESTINAL DISEASE

S. Esfandiari 1

Shiraz University Of Medical Science, Shiraz, Iran

Background: The upper gastrointestinal disease is the one of common disease in people find the accurate and the correct method to earlier diagnos of this problem is nessesary.in this search we want to comparisation that which method of barium meal and endoscopy have more value in diagnosed upper gastro intestinal disease Methods: At first we consider 60 outpatient with GI problems refered to hospitls emam hossin during 3 month.then these patients under tooke barium meal method after 6-8 hours fast and after 24 hours endoscopy and biopsy (if ulcer vissulised)was performed on these patient. In this situation endoscopyist have no information about barium meal result.barium meal result was disscused by at least 3 radiologists and endoscopic method was performed by one endoscopist. (before performed the barium meal and endoscopy method patient was fast). Results: diagnose of esophageal disease barium meal method have a diagnosis value the same as endoscopy in diagnos 80 % of esophageal cancers and polips but in esophagits and candidyasis endoscopy was value better rather than barium.Barium meal of 60% was reported normal by 3 radiologists have a gastric ulcer in endoscopic method and have cancer in biopsy. Barium meal of 65% and 50% and 100%was reported normal by 3 radiologists have a gastrit and polyp and gastric varic respectivly in endoscopic method. Barium meal of 9% was reported normal by 3 radiologists have a deodenit and erosion in endoscopic method in deodenom. barium meal method have a better diagnostic value rather than endoscopy in diagnos of duodenal diverticul in diagnose of deodenom disease.. Conclusions: attention this search endoscopy method have more diagnosis value in diagnosis of esophagit and esophagit candidyazis and gastrit and gastric cancer and ulcer and gastric varic and deodenitis rather than barium meal. in deodenom barium meal method have a better diagnostic value rather than endoscopy in diagnos of duodenal diverticul

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

T160

DIFFICULT AIRWAY TRAINING IN EMERGENCY MEDICINE

J. Nelson 1, R. Nelson 2, W. Paolo 3

Suny Upstate Medical University, Syracuse, Usa, 2 University Of Pennsylvania, Philadelphia, Usa

Background: Endotracheal intubation is a key emergency medicine skill, however few studies have addressed training and the achievement of resident proficiency associated with the difficult airway. Our aim was to quantify resident exposure to difficult airway training and the advanced airway techniques. Methods: A ten-question survey was sent, using the Council of Residency Directors list serve, to residency programs directors between September 2013 and October 2013. The dissemination of the survey was left to the discretion of program directors. The response rate was calculated using the number of programs with at least one respondent and their associated compliment of residents reported at www.ama-assn.org. Results: Residents were surveyed (n=1,856) with 207 respondents (response rate 11%) representing 48 residencies. Twenty six percent (n=55) were PGY1, 40% (n=86) were PGY2, 26% (n=55) were PGY3 and 8% (n=18) were PGY4. The majority of intubations were by orotracheal laryngoscopy 62.87 % (n=8810). The 2nd and 3rd were video assisted intubations 18.33 % (n=2568) and supraglottic devices 8.27% (n=1159), followed by bougie guided 7.44% (n=1043), nasal tracheal 1.26% (n=176), awake intubation 1.1% (n=154), needle cricothyrotomy 0.15 % (n=21) and surgical cricothyrotomy 0.58% (n=81). The reported average of didactic difficult airway training was 10.87 hours and 10.5 hours of clinical skills lab training. Ninety eight percent (n= 209) received training in screening for the difficult airway patient but 39% (n=84) utilized routine airway assessment tools before intubation. Training in the indications and methodology of awake intubations was noted in 63% (n=132). A majority, 97% (n=207), received training stressing the importance of a plan after a failed airway attempt. Algorithms used routinely for difficult airway management were reported 46% (n=48) of the time. Conclusions: Although there is a significant impact of recall bias on these data, it appears that the perception of the average emergency medicine resident is that the majority of intubation training is by direct laryngoscopy. Adjunct methods of intubation (bougie assisted, video assisted devices etc.) are prevalent but constitute a small percentage of intubations performed. It may be beneficial to develop routine airway assessments and intubation algorithms for trainees.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Education T161 IS IT COST EFFECTIVE TO DISTRIBUTE EDUCATIONAL VIDEOS OF INJURY PREVENTION IN THE EMERGENCY ROOM?

K. Nibhanipudi 1 1

Nymc, Metropolitan Hospital Center,emergency Medicine Dept., Scarsdale, Usa

Background: Objective: To determine the cost-effectiveness to video demonstration in the emergency room regarding injury prevention, Hypothesis: It is not cost effective to distribute videos of injury prevention compared to demonstration of the videos in Emergency room. Methods: Methods: A total number of 140 parents were registered. The group were subdivided into two parts group A and group B. Group A, consisting of 70 people received educational videos of injury prevention, one for each member. The same group was also given a questionnaire to be completed after viewing the video. The group members were requested to mail their responses after they viewed the video at home in a preaddressed stamped envelope that were provided to them. The second Group B, also consisting of 70 members, were requested to view the video of the injury prevention in the pediatric emergency room as they were waiting to be seen. These parents of Group B, were given the same questionnaire as the members of group A and requested to answer the questions and return the questionnaire before they left the emergency room. The contents of the video were as follows: 1.never shake the baby 2. Night time bath.3. Baby left alone in the car 4.Leaving the window open 5. Prevention of crib death 6. Hidden dangers such as electric outlets, cleaners, disposing plastics and proper usage of car seats. Results: Results: In the first group, group (A), only two of the 70 subjects returned the questionnaire (2.9% response rate). In the second group of people, those viewed the video in the emergency room, all of the parents answered and returned the questionnaire; response rate was 100%. This difference is statistically significant and the p-value by the two sample t-test method is <0.0001. Conclusions: Conclusions: It is not cost effective to distribute the educational videos of injury prevention to the parents to take home for viewing. The method of showing the videos as they are waiting in the emergency room is more efficacious and least expensive.

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

T162

MULTISOURCE FEEDBACK IN EMERGENCY RESIDENTS’ EDUCATION

A. Parlak 1, Y. Eyi 2, I. Arziman 3, O. Sezer 3

President Guard Regimen - Department Of Family Medicine, Ankara, Turkey, 2 President Guard Regimen Department Of Emergency Medicine, Ankara, Turkey, 3 Gulhane Military Medical Academy - Department Of Emergency Medicine, Ankara, Turkey Background: As many medical education programs shift from time-based to competency-based requirements for emergency medicine resident promotion, it is crucial that core competencies can be assessed in an accurate and comprehensive way. Methods: Results: Currently, there are several methods for evaluating an emergency medicine residents’ awareness of best-practice competencies, such as multiple choice tests and objective standardized clinical examinations. However, in addition, evaluation tools must be developed to assess the extent to which emergency residents carry out these behaviors on a daily basis. Many different skills and attributes of clinical supervisors are relevant to the discussion. Some, such as training qualifications and continuing professional development will be matters of record that need not be assessed by colleagues. Other attributes are more subjective and must be assessed by feedback from colleagues; these include overall competence, standards of supervision, quality of feedback provision, responsiveness and accessibility. With this in mind, a multisource feedback focuses on educational aspects of a trainer’s work can be envisaged. Conclusions: Assessment is an essential step in the curricular development process. An evaluation method is important for the improvement of the quality of learning among emergency medicine residents; however, such method is rare. Concern about the inability of monitored examinations to assess the full spectrum of clinical competence, including humanistic quality, knowledge, and communication skills, stimulated the introduction of the patient and peer assessment module.

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

T163

FORMATIVE ASSESSMENT IN EMERGENCY MEDICINE RESIDENTSâ&#x20AC;&#x2122; EDUCATION

A. Parlak 1, Y. Eyi 2, I. Arziman 3, O. Sezer 3

President Guard Regimen - Department Of Family Medicine, Ankara, Turkey, 2 President Guard Regimen Department Of Emergency Medicine, Ankara, Turkey, 3 Gulhane Military Medical Academy - Department Of Emergency Medicine, Ankara, Turkey Background: An important aspect of curricular reform is the assurance of quality in all curricular activities, including assessment, with ultimate benefits to the stakeholders emergency medicine residents and community at large. It is globally accepted that the role of assessment is not simply to assess a emergency medicine residents on preset criteria and make a judgment but also to facilitate his learning through a continuous process of feedback and at the same time provide him/her the opportunity to improve. Methods: Results: The concept of feedback in formative assessment has been accepted and embraced across educational institutes to a certain extent, as evidenced by literature. Evidences suggest that quality feedback is not only just an essential component but also a central feature of formative assessment. If formative assessment and feedback is well planned and conducted in assessment practice, effective learning can be facilitated in everyday learning activity. Over the past two decades, there has been a shift in the way academic members write about emergency medicine residents learning in postgraduate education. Instead of characterizing it as a simple acquisition process based on knowledge transmission, learning is now more commonly conceptualized as a process whereby emergency medicine residents actively construct their own knowledge and skills. Conclusions: Educators and learners are challenged to foster using a reflective skills toolkit with technical skills for reflective professionalism within clinical encounters for competent and compassionate patient-centered health care. Effective implementation of formative assessment as a vehicle for fostering reflective capacity through evaluation/interpretation of clinical experience can help meet this challenge.

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

T164

A BLENDED, SIMULATION-BASED CURRICULUM FOR CONTINUOUS PROFESSIONAL DEVELOPMENT OF EMERGENCY MEDICINE PHYSICIANS IN A MULTI-CENTER PRACTICE GROUP

P. Nemes 1, M. Cassara, M. Guttenburg, J. Phillip, J. D'angelo

North Shore-Lij Health System, Manhasset, Usa

Background: Maintaining evidence-based knowledge and competency with high risk, low frequency procedures, as required for credentialing, represent significant challenges for Emergency Medicine physicians (EMP). An additional concern is that EMPs are a heterogeneous group that includes clinicians, educators, researchers, and academic practitioners, that serve diverse patient populations in a variety of practice environments, and therefore has different continuous professional development (CPD) needs. Innovative CPD programs engaging asynchronous and synchronous instructional strategies that incorporate principles of adult learning are becoming more common. Simulation is routinely used in these programs for the deliberate practice of psychomotor, teamwork and communication skills. In the North Shore-LIJ Health-System, we have developed and are currently implementing an evidence-based curriculum incorporating principles of andragogy and utilizing blended â&#x20AC;&#x153;flipped classroomâ&#x20AC;? approach with simulation to target the CPD needs of our large group of EMPs. Methods: The curriculum has been designed using the Kerns six-step model, beginning with a needs assessment and learner gap analysis. Content selected for the CPD program includes essentials of critical care resuscitation (adult and pediatric), airway management, stroke, sepsis, and technical skills for EMP. Instructional materials have been developed by internal subspecialty experts using published evidence-based guidelines. The web-based portion consists of five slide-based narrated modules with embedded pictures and videos. The modules are accessible from any computer with an internet connection. The simulation portion includes six high technology mannequin and standardized patient scenarios of critical acuity along with a cadaveric technical skills laboratory focused on low frequency, high consequence procedures (advanced airway, thoracic, central venous access-associated, cardiovascular, and ophthalmologic/ENT-associated). Results:Conclusions: Based on preliminary surveys, evidence-based reviews and prior experience with resident education, we propose a novel curriculum that will serve as an efficient, cost-effective method of CPD for EMPs in a large, heterogeneous health system. This program will also be suitable for meeting the ongoing needs of hospital credentialing and regulatory requirements.

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

T165

5-YEAR TREND OF REPORTING ADVERSE DRUG REACTION: AN ITALIAN GENERAL PRACTICE EXPERIENCE

S. Leone 1, G. Cremonesi 2, F. Catalani 1, P. Cremonesi 1

Accident & Emergency Dept., Galliera Hospital, Genoa, Italy, University Of Genoa, Genoa, Italy

Post-Graduate School In Emergency Medicine,

Background: Adverse Drug Reactions (ADRs) underreporting is a serious drawback of the pharmacovigilance system. Spontaneous reporting of ADRs is a valid instrument to enhance pharmacovigilance. Objectives: to avoid prescribing again to patients the drug that caused them the ADRs, toevaluate spontaneous reporting of ADRs by patients to their General Practitioner (GP); to investigate the most involved Anatomical Therapeutic Chemical (ATC) classes in ADR signaling; to focus on sex-related differences in reporting ADRs; to propose suggestions to increase awareness about the issue. Methods: All ADRs reports collected by an Italian GP, during a period of five years, had been recorded by himself into his own array of records and then evaluated. The database of case histories in which data were filed allows data mining through queries formulated in SQL (Structured Query Language). We analyzed the numbers of prescriptions for each class of every ATC group in order to demonstrate the most involved ATC classes in ADR signaling. Results: We observed a total of 1278 ADRs for 11596 medical acts (11.02 ADRs per 100 consultations); four ATC groups (N, J, C, M) were responsible for the majority of ADR reports. Women had a higher reporting aptitude than men; 58% of women versus 38.9% of men has done at least one ADR report. Conclusions: The autonomous attention of the GP has led to more knowledge about the issue, the importance of reporting ADRs has been stressed in his local community, and, therefore, he has definitely changed the quality of life of his patients. Our study demonstrates that a close collaboration between GPs, patients and Pharmacovigilance Authorities may lead to a better pharmacovigilance practice, and may provide useful data about reporting trend and about unknown drug adverse reactions. We suggest to offer GPs some training courses to raise awareness to the problem of underreporting.

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

T166

PORTFOLIOS IN EMERGENCY MEDICINE RESIDENTS’ EDUCATION

A. Parlak 1, Y. Eyi 2, I. Arziman 3, M. Erkencigil 3

President Guard Regimen - Department Of Family Medicine, Ankara, Turkey, 2 President Guard Regimen Department Of Emergency Medicine, Ankara, Turkey, 3 Gulhane School Of Medicine - Department Of Emergency Medicine, Ankara, Turkey Background: Recent moves towards competency-based medical education and an increased emphasis on reflective practice have led to an expansion in the use of portfolios in emergency medicine resident education for the health professions. There has been widespread adoption for training, continuing professional development and most recently, revalidation across the postgraduate medical education. Methods: Results: The value of professional portfolios has been documented in professions such as art, architecture, and photography. However, until the last decade or so, we seldom saw the use of portfolios in the field of healthcare. Portfolios are an essential tool for demonstrating professional accomplishments and documenting professional growth in a variety of professions. It is for this reason that academic members have pushed the use of portfolios to promote and display the professional growth and development of emergency medicine residents’ education. A variety of teaching strategies such as teaching portfolios have therefore become necessary to improve emergency medicine residents’ education with the current emphasis on high educational standards. The maintenance of high standards in emergency medicine residents’ requires medical educators to develop a critical approach to their teaching. It also requests academic members to reflect upon their own teaching styles and to analyze and challenge the structures that contra in the development of teaching styles that facilitates the use of appropriate teaching pedagogical techniques. Conclusions: Portfolios have been claimed to support competence based emergency medicine residents’ education as they support the longitudinal recording of evidence of experience and achievements, feedback received, and future plans.

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

T167

FUTURE’S EMERGENCY MEDICINE RESIDENTS’ EDUCATION

A. Parlak 1, Y. Eyi 2, I. Arziman 3, M. Erkencigil 3

President Guard Regimen - Department Of Family Medicine, Ankara, Turkey, 2 President Guard Regimen Department Of Emergency Medicine, Ankara, Turkey, 3 Gulhane Military Medical Academy - Department Of Emergency Medicine, Ankara, Turkey Background: The emergency medicine residents’ education enterprise is just beginning to venture beyond its traditional emphasis on conveying diagnosis and treatment skills, to meaningfully integrating these new elements into clinical curricula. Methods: Results: A select number of undergraduate programs, medical schools, and residency programs have begun to emphasize the importance of quality improvement methods and interdisciplinary teamwork. These pioneering programs are leading the way, proactively developing a foundation for the dramatic change needed in emergency medicine residents’ education. In addition to notable schools and residency programs responsible for the accreditation of residency programs in several countries, have begun to outline detailed expectations for systematic change through its next accreditation system, which emphasizes the achievement of concrete milestones for each of six core competencies (Patient care, medical knowledge, professionalism, systems-based practice, practice-based learning, interpersonal and communication skills). Conclusions: Systems-based practice and practice-based learning and improvement requirements are both included in next accreditation system as necessary components to residency programs. As these changes indicate, the time has come to align the goals and outcomes of emergency medicine residents’ education with the needs and direction of the nation’s healthcare system and workforce.

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

T168

EMERGENCY RESIDENT ORIENTATION: GETTING THE DISORIENTED RESIDENT ORIENTED

C. Calandrella 1, M. Cassara, M. Nelson

North Shore University Hospital Hofstra School Of Medicine Department Of Emergency Medicine Manhasset New York, Manhasset, Usa Background: Although the Model of the Clinical Practice of Emergency Medicine (EM) forms the basis for all EM curricula, there is no universally accepted and validated orientation curriculum for effectively orienting new EM residents. We describe the implementation of our Orientation Program curriculum for preparing new EM residents for actual patient care activities. Methods: Our program begins with BLS, ACLS, PALS, ATLS, and TeamSTEPPS, followed by a four-week intensive “boot camp” style introduction to EM. This four-week intensive incorporates several androgogies and focuses on areas of special interest to new EM residents as identified on previous program evaluations. The Orientation Program provides multiple opportunities for active and vicarious learning using facilitated, deliberate practice and engaging small-group activities, supplemented by clinical shadowing. Highlights include a cadaver-based technical skills laboratory of high acuity, high consequence procedures; standardized patient and high-technology mannequin-based simulation sessions emphasizing team-based interpersonal and communication skills, patient centered communication, and patient safety-centric content; facilitated discussions and lectures hosted by content experts; and, participation in a regional EM conference to foster team building and professional identity formation among new EM residents. To evaluate the efficacy of our Orientation Program, we surveyed all participants in the past three years using electronic questionnaires. Responses to items were provided using a five-point bipolar Likert scale. An optional comment section was included at the end of the questionnaire. Results: 31 evaluations were disseminated. 25 completed evaluations were returned for analysis (81% response rate). All residents (25/25) responding indicated that they “strongly agreed/agreed” that the cadaver-based technical skills sessions prepared them well for actual patient care activities. Clinical shadowing and the foundational AHA/ACS coursework were the next highest rated activities (96% and 92%). Only 24% (6/25) residents indicated that they “strongly agreed/agreed” that the TeamSTEPPS portion was helpful. Content expert lectures/discussions were described as useful in understanding the available subspecialty services and appropriateness of consultation for improving patient care. Conclusions: Our residents appear to benefit from a month long orientation program integrating procedural labs, simulation, facilitated discussions, lectures and clinical shadow shifts to ease their transition into residency.

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

T169

COMBINING SIMULATION, FEEDBACK AND COACHING TO IMPROVE PROFESSIONAL PERFORMANCE OF RESUSCITATION SKILLS OF PREHOSPITAL CARE PERSONNEL

A. Batt 1,2, A. Al-Hajeri 1, D. Lonergan 1, B. Haskins 1,3, F. Cummins 1,3,4

National Ambulance Llc, Abu Dhabi, United Arab Emirates, 2 Centre For Prehospital Research, University Of Limerick, Limerick, Ireland, 3 Charles Sturt University, Nsw, Australia, 4 Graduate Entry Medical School, University Of Limerick, Limerick, Ireland Background: Cardiopulmonary resuscitation (CPR) skills are taught to a standard level using the American Heart Association (AHA) Basic Life Support (BLS) for Healthcare Providers course. This course does not address the environmental, human factor and team dynamics that need to be addressed by staff in prehospital resuscitation events. We hypothesized this deficit could be addressed through a short period of coaching, focusing on team dynamics, high performance CPR provision and rapid feedback to participants. Aim: To determine if intensive coaching techniques incorporating immersive simulation and performance feedback can improve professional performance standards in resuscitation skills amongst prehospital care personnel. Methods: Participants (n=16) were a mix of BLS and Advanced Life Support (ALS) level clinicians, placed in teams of two (1 BLS and 1 ALS clinician per team) and all had current AHA BLS certification. Baseline BLS performance was assessed in an immersive setting using the Ambu Cardiac Care Trainer simulator (Ambu GmbH, Hesse, Germany) to provide BLS metrics. Participants were then facilitated with a team coaching session focusing on teamwork and high-performance CPR. Participants were then re-assessed to determine if there was any improvement in BLS metrics. Results: All areas of BLS quality assessed improved after the coaching intervention. Mean compression rate improved from 118 bpm (SD 9.19) pre-intervention to 126 bpm (SD 6.29) post-intervention. Compression fraction improved from 40.37 % (SD 3.85) to 56 % (SD 3.81) post-intervention. Mean compression depth improved from 52.25mm (SD 7.18) to 57.37mm (SD 5.42). Hands off time reduced from a mean of 7.12 secs (SD 2.79) to 2.87 secs (SD 1.12) and time to first shock reduced from 85.37 secs (SD 35.88) to 47.5 secs (SD 9.3). Conclusions: This proof-of-concept study demonstrates that immersive simulation combined with coaching on high-performance CPR components results in improved BLS quality provision by mixed BLS and ALS provider teams. The most important improvements from this study were the reduction in hands off time and the increase in compression fraction. Follow-up with these providers in 3 months, and a larger implementation of this study are planned for the near future.

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

T170

THE ASSESSMENT OF EMERGENCY MEDICAL PERSONNEL’S COMPETENCY: EMERGENCY CENTER IN YAOUNDE, CAMEROON

K. Sun 1, S. Shin 1, C. Kim 2, D. Wi 3, K. Bae 1, Y. Jung 1

Seoul National University Hospital, Seoul, South Korea, 2 Konkuk University School Of Medicine Chungju Hospital, Chungju, South Korea, 3 Wonkwang University Hospital, Gunpo, South Korea Background: In Africa, there is a growing demand to the emergency medical services (EMS) due to increasing trend of injury patients. However, the disease burden caused by injury is increasing because the systematic EMS is not appointed well. Therefore, establishing a standardized training program and competency development plan are urgently needed. Methods: Data source came from the report of [The professional personnel training project based on Cameroon emergency medical needs and competency assessment]. The study was conducted in Yaounde, Cameroon. Inclusion criteria were doctors and nurses in Emergency Center in Yaounde. Main exposure or intervention were doctor's position (whether specialist or not), nurse's career, self-rated competency assessment survey (SR), and scenario-based competency assessment (SB). Main outcome was competency score. Variables were age, sex, doctor's position, specialty, occupational category, and career. Descriptive analysis was conducted with Weighted Kappa and Student-t test, significance level p<0.05. Results: The response rate of SR was doctor 82.6% (19/23) and nurse 77.1 %(27/35). The doctor's average age was 33 years old (6 males and 13 females, 9 general physicians (GP), 10 specialists) and nurse's was 36.5 years old (5 males and 22 females, 21 nurses, 3 assistant nurses) The nurse’s average career of ED was 12.8 months and the average clinical career was 71.7 months. Both of them in SR showed the highest competency in infectious disease (doctor: 4.6±0.3, nurse:4.1±0.7). Specialist showed better competency in cardiovascular,renal and genitourinary,musculoskeletal,resuscitation,environmental injuries,CPR skills,and procedure(p<0.05). GP showed better competency in OBGY,infectious disease,ENT,psychiatric and behavior(p<0.05). If compared by dividing the nurse career for >1 year and <1 year,it did not show a statistically significant difference in all categories except for BLS algorithm. The inter-rater reliability on 6 doctors in SB was a Weighted Kappa 0.88, and for 6 nurses was a 0.84. Agreement rate between SR and SB scores of doctors was 59.5% (nurses 60.5%),the under-estimation rate was 15.5%(0.9%),and the over-estimation rate was 25%(38.6%). Conclusions: Doctors and nurses in Emergency Center were relatively highly appreciated their personal competencies. To establish an EMS training program and competency development plan, it is required means that we can objectively assess the competency.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Academics / Resident Education

T171

VIEWS OF EMERGENCY PHYSICIANS WORKING IN TURKEY REGARDING USE OF ANALGESICS IN PATIENTS WITH ACUTE ABDOMINAL PAIN AND FACTORS AFFECTING USE OF ANALGESICS

O. Ozen 1, S. Kiyan 2

Ege University Emergency Department, Izmir, Turkey, 2 Ege University Emergency Department, Izmir, Turkey

Background: Use of narcotic analgesics in patients with acute abdominal pain does not cause delayed misdiagnosis, increases patient comfort and does not suppresses physical examination. Methods: The cross-sectional study was performed between November 15, 2013 and January 25, 2014 by conducting a questionnaire to EM physicians working in University Hospitals, Education and Research Hospitals of the Ministry of Health, State Hospitals and private hospitals in Turkey. Results: A total of 803 questionnaires (participation rate: 47%) were completed. 59,3% (n = 470) of the participants were research assistants. 49.5% of the participants reported that analgesic drugs suppressed physical examination findings. They reported that 90% of patients always and often requested analgesics. They reported that 34.6% of surgery consultant physicians rarel recommended the use of analgesics, while 28.7% never recommended, and that there was no common policy established together with surgical departments (79.1%). According to the comparison between the EM specialists and residents, residents in the group who stated that they would never use analgesics were higher than specialists in number (p = 0.002); residents reported that they administered analgesics upon surgical intervention decision, while specialists reported that they administered analgesics after patient's examination and treatment plan (p = 0.021); residents reported that analgesics suppressed physical examination findings, while specialists reported that analgesics clarified physical examination findings (p <0.0001); residents reported that they did not administer analgesics before examination by surgeon, while specialists reported otherwise (p = 0.0001). Senior residents (> 24 months) reported that they administered analgesics often' comparing to junior residents (p = 0.034) and that junior residents believed that the use of analgesics would suppress physical examination findings at a higher percentage (p = 0.002). Conclusions: The rates of use of analgesics in patients with acute abdominal pain by EM physicians are very low. The rates of use of analgesics by EM residents are much lower compared to EM specialists and they highly believe that analgesic drugs suppress physical examination findings. Residents tend to administer analgesic drugs at a later stage.

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

T172

LEARNING ASSESSMENT EFAST BY EMERGENCIES DOCTORS : A PROSPECTIVE STUDY

C. Jebali 1, N. Ibn Hassine 1, M. Omri 1, H. Kraiem 1, A. Jaoudi 1, N. Chbili 1, M.N. Karoui 1

Samu 03 Sahloul, Sousse, Tunisia

Background: Rapid learning EFAST technique (Focused Assessment with Sonography Extended for Trauma) by emergency has been validated for many years. But no studies have evaluated the training workshops of the emergency. Methods: Our study was a prospective observational two periods: - The first period (P1: before training) for questions on radiological semiology, false positives, false negatives, the benefits of EFAST and analysis of ultrasound images according to normal and pathological EFAST technical pre and post-test. - The second after a week of learning (P2) with the same questions and the same images of P1. The results were analyzed by SPSS 17.0 Results: During the training we recorded thirty five learners. These learners were divided into three groups led by three assistants in emergency medicine. Learners were trained by 6 residents in emergency medicine, 28 public health doctors and a liberal doctor. At the workshop we privilege of giving much more time probe in hand at the learner. During P1 all learners completed questionnaires pre and post-test. No learner has correctly answered all the questions of pre-test while 91.5% (n = 32) answered all post test questions. In the P2: only 83% (n = 29) of students answered the questionnaires with a rate of correct answers 86% (n = 25). Conclusions: Despite the short study period, our technical EFAST learning at the workshops seem to have a good rate integration. It seems opportune to make an assessment at the sickbed have to conclude on such a training strategy.

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

T173

A NEW SIMULATION MODEL TO ASSESS COMPETENCY IN SLIT LAMP EDUCATION

P. Rega 1, V. Kazan 1

University Of Toledo College Of Medicine, Emergency Medicine, Toledo, Usa

Background: The proper use of a slit lamp is important in Emergency Medicine. A practical, easily reproducible, and economical model to assess slit lamp competency objectively has been a goal in the education of both Emergency Medicine residents and multidisciplinary healthcare students. Design and Method: Therefore, the authors created an ocular image on paper upon which arrows, non-discernible to the naked eye, were printed. This image was then attached to the slit lamp’s chin/forehead rests. An Internal Review Board-approved pilot study evaluated this model. After a brief training session all the students (10/10; 100%) felt the model was useful to assess competency. A minority (20%) felt the model required better standardization. Therefore, a more standardized model has been the current goal. <FILE IMAGE='46_20150625182717.JPG'> Methods: A relevant literature search revealed one model (Cassara, et al; Academic Emergency Medicine, 2011) that could be modified to improve the authors’ initial concept. The new model was developed and re-appraised. Results: The model consists of: 1) a disposable cup; 2) Two 1-cm-diameter corks; 3) Pins; and 4) Two paper circles mimicking eyes. The “eyes” are divided into four quadrants. Into those quadrants, four arrows (Calibri-1) are printed randomly pointing in different directions. The “eyes” are pinned onto the two corks. These corks are taped to the bottom of the up-ended cup. This unit is secured to the slit lamp’s chin rest. Once training is completed, the students are asked to locate and identify the images and copy them for the educator’s evaluation. Each “eye” could be rotated to change the arrows’ orientation for multiple students’ evaluation. An eye patch could be worn by the student to assess the capability of getting each eye into focus. With this latest iteration, both students (4/4) and faculty (2) felt that it accurately and objectively assessed competency. Conclusions: A new slit lamp educational model has been developed to assess learner’s slit lamp competency in a manner that is economical, easily constructed and low maintenance. Additional studies with regard to residents’ education are being developed.

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

T174

SISTEMATIC EVALUATION OF THE INTERVENTION IN THE MYOCARDIAL INFARCTION WITH S-T ELEVATION BY PRIMARY CARE PHYSICIANS IN A SIMULATED CLINICAL SCENARIO

A. Casal Sánchez 1, A. Rodriguez Núñez 2, L. Sánchez Santos 1, J.A. Iglesias Vázquez 1

Emergencies Medical System Of Galicia 061, Santiago, Spain, Universitary Hospital, Santiago, Spain

Intensive And Crtical Pediatric Care Service.

Background: Assess the knowledge and skills of the primary care physicians to recognize the critical condition of a simulated patient with hemodynamic instability due to a myocardial infarction with ST-elevation (STEMI), and to provide the initial treatment. Methods: A simulated clinical scenario of a STEMI was designed and performed with the Laerdal Simman 3G human simulator system. Forty two (42) emergency teams developed the scenario. Each scenario was recorded and assessed. Results: 100% of rhythms were recognized adequately (mean time: 9,6 sec). Time to first shock: 63 seconds. Time between shocks: 2minutes 10 seconds. Median dosage was 200 Jl. Mean time to start chest compressions: 30 seconds, (37,9% < 12 seconds). 30/2 sequence: 83.3%. Compressions depth: 35,72 mm, rate: 108.6/ min. Hands on: 76%. Sequence of drugs (0-1-2 score) based on ERC recommendations was: 1.46. Troubles in Defibrillator management were detected in 9.6% of the shocks, mainly in relation with pressure applied to paddles (41%) or technical/acknowledge of defibrillator (41,9%). Conclusions: To improve the prognosis of sudden cardiac death, the precocious recognition and defibrillation as well as a high-quality cardiopulmonary resuscitation (CPR) are essential. In our study, the physicians recognized immediately the critical condition (mean time 9,6 seconds), but showed lacks of ability to provide precocious defibrillation (mean time 63 seconds), and a high-quality CPR. According to this data, the aim of the training programs should be the improvement in providing precocious defibrillation, and an early and high-quality CPR. In addition, the new training programs must be addressed to strengthen both the team and patient safety, and the trainees must learned to choose always the most secure and effective techniques to provide the adequate treatment.

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

T175

ASSESSMENT OF TEAMWORK IN SUDDEN CARDIAC ARREST BY MEANS OF HIGH-FIDELITY SIMULATION

A. Casal Sanchez 1, A. Rodriguez Núñez 2, L. Sánchez Santos 1, J. Antonio Iglessias Vázquez 1

Emergencies Medical System Galicia 061, Santiago, Spain, Universitary Hospital Of Santiago, Santiago, Spain

Pediatric Critical and Intensive Care Service.

Background: Teamwork and communication failure are leading causes of patient safety incidents. Leadership and effective communication under stress represent critical skills for optimal patient care. We assessed the teamwork abilities of primary care professionals (PCP) in case of simulated sudden cardiac arrest (CA). Methods: A high-fidelity simulation standardized clinical scenario of a CA with a shockable rhythm was designed. Laerdal SimMan 3G® system and Advanced Video System® were used to run and record the scenario in coursed for PCP. The Mayo high performance teamwork scale with item scores: 0- never, rarely, 1inconsistently, 2- consistently, was applied. Results: Sixty-six emergency teams (crew: 3-4) were included. Items and mean scores were: Leader clearly recognized: 1.47. The team leader assures balance between command authority and participation: 1.21. Each team member (TM) demonstrates understanding of his/her role: 1.48. The team prompts each other to attend to all significant clinical indicators: 1.09. They verbalize their activities aloud: 0.81. TM repeat back or paraphrase instructions: 0.51. TM refers to established protocols and checklists: 0.78. All TM are involved: 1.78. Disagreements among TM are well addressed: 1.12. When appropriate, roles are shifted: 1.11. When directions are unclear, TM acknowledge their lack of understanding and ask for clarification: 0.93. TM acknowledge statements directed at avoiding errors: 1.05. TM call attention to actions that they feel could cause errors or complications: 1.03. TM respond to potential errors: 0.88. TM ask each other for assistance during periods of task overload: 1.09. Total score: 15.65 (Max: 32, min: 0). Conclusions: Teamwork can be qualitative and quantitatively assessed by means of recorded high-fidelity simulation scenarios. The main detected weakness in our study was communication between TM, as well as their fear to express opinions or warnings during simulated care performance. Teamwork and safety culture must be included as a priority during simulation-based training.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: International Emergency Medicine

T176

NON-TRAUMATIC FOREARM HEMATOMA AND COMPARTMENT SYNDROME

M. Korcak 1, B. Taskin 1, O. Ecmel 1, A. Denizbasi 1

Marmara Univbersity Pendik Education And Research Hospital,department Of Emergency Medicine, Istanbul, Turkey Background: Acute compartment syndrome (ACS) most often develops soon after significant trauma, particularly involving long bone fractures. But especially in patients undergoing anticoagulant therapy, atypical presentations without trauma may occur. We describe a rare case of an acute compartment syndrome of the forearm without trauma in a patient with warfarin therapy and optimal value of INR. <FILE IMAGE='42_20150407165250.JPG'> Methods: A 52-years-old man admitted to Emergency Department(ED) with right forearm deep ache,burning pain and paresthesias. His complaints were started 1.5 hours before he admitted to ED. He has no trauma history with his forearm. And also there is no medical history except mitral valve replacement (MVR).He was assuming warfarin for 5 years after MVR. The result of international normalized ratio (INR) value was in normal range (INR1.6).Approximately 6.5x3 cm dimensional hematoma was detected in his flexor digitorum muscles fascia by superficial tissue ultrasound examination. In upper extremity computed tomography (CT) angiography, there was a tightness in his right distal radial arterial vessel surface. We had diagnosis of ACS with our clinical signs, physical examinations and radiological tests. The patient was consulted to the orthopedics. The hematoma was removed after the fasciotomy. (Figure 1, 2) Results: The forearm has four compartments;the deep and the superficial volar, the dorsal and the lateral compartment. The deep volar compartment usually develops the highest interstitial pressures with ACS of the forearm and thus the flexor digitorum profundus and the flexor pollicis longus muscles are most often affected [5].The most frequent reason of volar compartment is trauma. Non traumatic reasons are the less frequently cause of ACS. Conclusions: We confirmed our diagnosis by ultrasound and CT angiography. But the important clues to the development of ACS include rapid progression of symptoms and signs over a few hours. The volar hematoma was the reason of ACS in our case and under the warfarin but normal INR values. Fasciotomy is the definitive treatment for ACS in the great majority cases. In patients with warfarin therapy, the risk of development of compartment syndrome should be always considered despite normal INR values in spite of no trauma history.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: International Emergency Medicine

T177

UTILITY OF A BEDSIDE POCKET-SIZED ULTRASOUND DEVICE TO PROMPTLY MANAGE ABDOMINAL PAIN IN THE EMERGENCY DEPARTMENT

C. Bongiovanni 1, L. Magrini 1, B. De Berardinis 1, C.S. Gori 1, R. Marino 1, S. Di Somma 1

Sapienza University, Sant'andrea Hospital, Rome, Italy

Background: Ultrasound techniques in Emergency Department provide the possibility to rapidly evaluate critically ill patients and to screen their need for hospitalization and /or immediate therapeutical decisions. The aim of this study was to demonstrate the utility of a new bedside pocket-sized ultrasound device (Vscan) to promptly manage patients referring to Emergency Department for abdominal pain, distinguishing different levels of emergency/urgency in order to improve their outcome and cost related efficacy. Methods: We enrolled 230 patients (M/F= 50/50%; 51.81±17.82 years) referring to Sant’Andrea Hospital Emergency Department for acute abdominal pain. Patients were triaged according to their symptoms. Bedside ultrasound examination was immediately performed by trained residents at patient’s arrival in Emergency Department for 5 main signs presence: abdominal free fluid, abdominal aorta aneurism, hydroureteronephrosis, urine acute retention, gallbladder-biliary tract disease. Immediately after, traditional abdominal diagnostic imaging (X-rays, computed tomography, ultrasound) were performed on the basis of emergency physician assessment. The results of bedside ultrasound examination were blinded to radiologists. Results: In 76.9% of patients bedside ultrasound showed pathological findings (55.6% hydroureteronephrosis, 14.7% gallbladder-biliary tract disease, 3.9% free fluid in abdomen, 3.04% abdominal aorta aneurism, 1.7% acute urinary retention). In the whole group of 230 patients, traditional imaging recorded pathological findings as follows: traditional ultrasound 76.09%, computed tomography 28.26%, and X-ray 5.91%. The global agreement between routine radiology imaging and bedside ultrasound was higher for computed tomography than for traditional ultrasound. Moreover, patients were divided into 3 subgroups: hepatic/gallbladder disease, urinary disease and abdominal aorta disease. The higher concordance between bedside ultrasound and traditional imaging (K= 0.64) was found in the first subgroup. In these patients a high statistically significant correlation between bedside ultrasound and both computed tomography (r=0.65; p=0.0006) and traditional ultrasound (r=0.65; p<0.0001) were shown. Conclusions: In patients presenting to the Emergency Department with abdominal pain, when compared to traditional radiology imaging, a bedside pocket-sized ultrasound device assessment could represent a reliable tool for emergency physician to reduce time to clinical decision making, favorably impacting patient outcome and cost related consequence by avoiding some redundant, unnecessary traditional radiological exams.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: International Emergency Medicine

T178

HYPOTHERMIA IN POST-RESUSCITATION PERIOD (COOLING THERAPY)

V. Nikovic 1

Emergency Department Montenegro, Podgorica, Montenegro

Background: SUMMARY Introduction Pulmonary embolism as a possible cause of acute heart failure is a potentially fatal condition that can cause death in all age groups. Patients successfully resuscitated after cardiac arrest have a high risk of increased mortality and their poor long-term outcome is often associated with severe neurological complications. Methods: Case Outline: This is a case report of a 67-year-old man after a successful cardiopulmonary resuscitation (CPR) which was followed by therapeutic hypothermia (TH). The patient visited the dermatological outpatients’ department with clinical presentation of pain and swelling of the right leg, shortness of breath and chest pain. Results: During examination the patient lost consciousness, stopped breathing and had cardiac arrest. ECG was done which registered asystole. We began CPR. After 59 minutes of resuscitation return of heartbeat was achieved. The patient was transported to the Emergency Department. On admission, after computerized tomography (CT) of the chest confirmed massivepulmonary embolism (PE), the patient was administered thrombolytic therapy with Metalyse (tenecteplase) and anticoagulation therapy (heparin). After stabilization, therapeutic hypothermia was applied. Combination of EMCOOLSpad on the chest and abdomen and cold Ringer lactate 500 ml at 4°C was flushed. Temperature was decreased to 33°C and kept stabile for 24 hours. After eight days the patient was conscious with aminimal neurological deficit. Conclusions: Conclusion: As shown in this case report, and according to therich experience elsewhere, cooling therapy after out-of-hospital cardiac arrest and successful CRP may be useful in preventing neurological complications. Keywords: pulmonary embolism; acute cardiac arrest; cardiopulmonaryresuscitation; post-resuscitation period; hypothermia;neurological outcome

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: International Emergency Medicine

T179

METFOMIN OVERDOSE: IS EMERGENCY DIALYSIS TREATMENT ALWAYS RECOMMANDED?

E. Lainu 1, B.K. Guglielmana 2, L. Pagani 1, S. Marra 1, F.G. Panizzardi 1, M. Bonzano 1, I.F. Ceresa 2, G. Ricevuti 1, M.A. Bressan 2

University Of Pavia - School Of Emergency Medicine, Pavia, Italy, Of Emergency, Pavia, Italy

Irccs Policlinico San Matteo - Department

Background: Metformin is an oral anti-hyperglycaemic drug, widely prescribed as first-line therapy for type II diabetes mellitus [1]. The main glucose lowering effects of metformin occur through decreased hepatic glucose output and enhanced peripheral glucose uptake [2]. Its mechanism of action involves dose-dependent inhibition of complex 1 of the mitochondrial respiratory chain, resulting in increased production and decreased clearance of hepatic lactate [1][3]. Although metformin overdose is relatively uncommon, its sever toxicity results in the form of hyperlactataemia, with or without lactic acidosis, considered a pathological extension of its cellular effects [4][5]; gastrointestinal symptoms, bradycardia, hypotension, altered state of consciousness can occur, as well. Methods: C.T., woman, 75 years old. Past medical history: type II diabetes mellitus, hypertension. As the patient reaches the Emergency Department, she appeared agitated, presenting signs of dehydration, reporting diarrhoea for six days; serum metformin: 12.8 mcg/ml (therapeutic range: 0.5-2.5 mcg/ml). The patient was put on medication: 7000 ml of crystalloids were overall administered, during about 20 hours of observation, resulting in progressive improvement both of the state of consciousness and of the blood tests values, especially lactacidemia, serum creatinine and acid-base balance status. The administration of furosemide, moreover, aided the pickup of the diuresis (See Tables below for the evolution of the parameters over time). Objectively, the patient did not present either pulmonary rales at the auscultation of the thorax or any signs of volemic overload; the lung ultrasonography did not show any B-line. <FILE IMAGE='389_20150712162019.jpg'> Results: The patient at admission presented a clinical picture of metabolic acidosis with an effective respiratory compensation. Conclusions: In the specific case, emergency dialysis was not recommended,as the patient presented neither worsening metabolic acidosis nor hyperkalaemia. Moreover, metformin is mainly renally eliminated: during continuous veno-venous haemodialysis, clearance rate is estimated around only 50 mL/min, versus 400 mL/min in the presence of normal renal function [6]. The ability of renal replacement therapy to contribute significantly to lactate clearance also appears limited (<3% of total plasma lactate clearance) [7]. The clinical picture of our patient cleared up, therefore, thanks only to the administration of crystalloids and to the stimulation of diuresis through furosemide.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: International Emergency Medicine

T180

UTILITY OF THORAX COMPUTERIZED TOMOGRAPHY FOR DYSPNE PATIENTS AT AN EMERGENCY SERVICE IN A SUBURBAN HOSPITAL

S. Korkut 1, A. Denizbasi 2, O. Onur 2, S. Eroglu 2, H. Akoglu 2, E. Salcin 2, O.H. Kasikci 1

Sultanbeyli State Hospital, Istanbul, Turkey, Turkey

Marmara Un. Department Of Emergency Medicine, Istanbul,

Background: Objective: The aim of this study is to evaluate the utility and appropriateness of thorax computerized tomography in dyspnea patients presenting to a suburban hospital. Accuracy of the initial diagnosis by the emergency physicians are discussed. Methods: Design and method: This is a retrospective analysis of thorax tomographies of patients admitted to the emergency service of Sultanbeyli State Hospital in Istanbul between November 2014- February 2015. This is a suburban State Hospital which has emergency physicians working at the emergency. In this study 440 patients who underwent thorax computerized tomography with the presenting complaint of dyspne and chest pain, and who were evaluated by the emergency physicians were included. These patients were treated at the emergency service and their final tomography reports were completed afterwards by the radiology. The treating emergency physician who ordered tomography were not informed about the final diagnosis at the time being. The statistical analysis was made by SPSS 13. Results: Result: Total 440 patients (191 female and 249 male) were included in the study. The concordance of initial and final diagnosis were compared. The final diagnosis was confirmed by the radiology in 131 patients of total 440 patients. The final diagnosis was confirmed by the radiology in 45/ 191 female patients and 83/ 249 male patients. The most frequent final diagnosis of the dyspnea patients were classified as bronchial and fibrotic degenerations such as observed in COPD (n: 64), parenchymal diseases due to infection or tuberculosis (n: 35), mass lesions (n: 21), and aortic lesions (n: 40), which accompany parenchymal lung lesions in 50% of the cases. Conclusions: Conclusion: The tomography rates were higher for the male gender (p> 0.05) whereas there was no significant difference between the correlation of the initial and final diagnosis of the dyspnea patients. The male dominance is due to distribution of the cigarette smoking habits in two gender.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: International Emergency Medicine

T181

CROSS SECTIONAL STUDY IN EMERGENCY CENTER IN QUELIMANE PROVINCIAL HOSPITAL, CITY OF QUELIMANE, PROVINCE OF ZAMBEZIA, MOZAMBIQUE

J.Y. Choi 1, H. Kim 1, K.H. Kim 1, J.S. Park 1, D.W. Shin 1, W.C. Jeon 1, H.J. Kim 1, J.M. Park 1, B.T. Caetano 2

Department Of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea, Provincial Hospital, Quelimane, Mozambique

Quelimane

Background: Developed countries have committed capital to build a hospital for health care development in developing countries of Africa. However, there have been many frustrations to build hospital and operate emergency center because it is more difficult to determine the medical situation of local area. We found limited data about epidemiology and medical resources. The aim of this study is to survey characteristics of patients visited in emergency center and propose the emergency medical system that can provide emergency medical services needed in province of Zambezia, Mozambique. Methods: We investigated the patients who visited the emergency center of Quelimane Provincial Hospital (QPH), in Mozambique for 2 weeks (from Dec-1, 2014 to Dec-14, 2014). Simple X-ray study, hemoglobin, malaria Ag, malaria Ab, HIV Ab, urine analysis and blood sugar test were available in emergency center of QPH, but CT and MRI scan could not be performed. There were the six general physicians in this emergency center.We investigated demography, chief complaints, transfer methods, X-ray examination, blood examination, urine examination, diagnosis, hospitalization and treatment of patient in emergency center in QPH. Results: Total 4485 patientsâ&#x20AC;&#x2122; data were collected whose average age was 25.7Âą16.2 years old and males to females ratio was 1:0.87. The proportion of children below 14 years was 24.0%. Most patients (90.1%) visited emergency center on foot. Disease and injury related diagnosis ratio were 90.3% and 9.7%. Among the disease related diagnosis, infective, respiratory and gastrointestinal disease were 35.6%, 10.7% and 10.2%, respectively. One physician in emergency center confronted average 106.8 patients per duty. Conclusions: Multilateral approach is important in developing emergency center. Patient transport system is necessary for the prehospital management. Considering the prevalence rate, it is necessary to focus the medical resources to infectious disease. It is also important to develop and manage human resources in the long term point of view.

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

T182

ADHERENCE TO THE COLLEGE OF EMERGENCY MEDICINE 'FITTING CHILD' GUIDELINES AT THE COUNTESS OF CHESTER HOSPITAL

A. Williams 1, P. Pureti 1

Emergency Department, Countess Of Chester Hospital, Chester, United Kingdom

Background: Seizures occur with a frequency of 425/100,000 per year in children under 13years of age, and 879/100,000 in children under 5. The â&#x20AC;&#x2DC;fitting childâ&#x20AC;&#x2122; therefore represents a common cause of paediatric Emergency Department attendances. Methods: This project was part of a national CEM audit. It involved a retrospective review of up to 50 patients between the age of 0 and 15 (inclusive), presenting to the ED with seizures between 01/08/14 and 31/01/15. The audit excluded children over the age of 15 and those with a known history of seizures who had a personalized written management plan. Case notes, usually hard copies but electronic case notes where appropriate, were reviewed and a pre-designed data collection tool was completed for each case. The data was then analysed. It will later be compared to national data when available. Results: 49 patients were identified as meeting the inclusion criteria. The majority of patients (45%) were aged 1-2years, with a male preponderance (67%). Only 3 children (0.06%) were still fitting on arrival, and of these, all were managed according to APLS guidelines. Only 22% had a full eyewitness history documented, with 18% having no eye witness history documented at all. Most of the seizures (45%) lasted less than 5minutes, although the duration was not recorded in 12 patients. 96% of patients had a temperature recorded, and in 66% of these cases, the temperature was less than 37.8 degrees Celsius. Importantly, Glasgow Coma Scale (GCS) or AVPU and blood glucose measurement were not recorded in 33% of patient notes. The most common diagnosis made was one of epilepsy (29%), with febrile convulsion and afebrile seizure of unknown aetiology diagnosed in 24% each. One case was attributed to infection. With respect to disposal, 3 patients were discharged from the Emergency department, 2 were admitted to PICU with the remainder admitted to paediatrics. Conclusions: Documentation of febrile convulsions is poor in terms of history and observations. Emphasis needs to be placed on the importance of recording blood glucose and GCS at the bedside.

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

T183

PREVALENCE OF CELIAC ANTIBODIES IN CHILDREN WITH NEUROLOGIC DISORDERS

S. Esfandiari 1, S. Inallu, M. Haghighat, M. Dehghani, M. Kalantari Meibodi

Shiraz University Of Medical Science -Shiraz-Iran, Shiraz, Iran

Background: Neurologic complications are a recognized but unusual manifestation of celiac disease (CD) in adults and children. The use of specific CD antibodies in screening has revealed the frequency of CD among symptom-free individuals to be high. We investigated the yield of screening for CD in children with common neurologic disorders Methods: One hundred, 1-18 years of age, were included in the study: autism (6%), learning disorders (9%), mental retardation (13%), epilepsy (25%), development delay (31%), ataxia (11%), peripheral neuropathy (6%), ADHD (22%) and, chronic diarrhea (4%). Positive (IgA Anti TTG Ab ) was as evident in 1 child (1%) in the study group compared with 30 children (2%) in the control group (1500 children) The study was approved by the University ethics committee. IgA Anti TTG Ab and Total IgA Ab were checked for the patients. The patients that their parents were not pleased to take blood or intestinal biopsy from them were excluded from the study. Control group containing 1500 children also were checked for anti TTG to determine the prevalence of CD and compare with study group. Results: Among children with development delay, one child (3.2%) was anti-TTG positive for CD. However, in all children, negative IgA Anti TTG antibodies were observed. Intestinal biopsy also showed no pathological changes. Contrary to studies performed in adults, these results did not demonstrate any relationship between common neurologic disorders without a specific diagnosis with unknown cause during childhood and CD Mean age was 7.51Âą 4.57 that was from 1 year to 17 years old. The BMI of the children ranged from 11.63 to 27.55 with the mean and standard deviation of 16.75Âą 3.245. Among 100 children referred for neurological, 6 children (6%) had autism, 9 children (9%) learning disorders, 13 children (13%) mental retardation, 25 children (25%) epilepsy, 31 children (31%) development delay, 11 children (11%) ataxia. Six children (6%) showed peripheral neuropathy, 22 children (22%) ADHD and, 4 children (4%) chronic diarrhea. Conclusions: Thus screening for CD does not need to be routinely included in the diagnostic evaluation of children with neurological disorders.

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

T184

PREVALENCE OF VITAMIN A DEFECINCY ANDCORILATION WITHININCHILDRENBETWEEN6 MONTH-7 YEARS IN SHIRAZIRAN

A. Jangjou 1, M. Kadivar 1

Shiraz University Of Medical Science Medical, Shiraz, Iran

Background: Malnutrition problem is the most important problem in countries .in iran lack of vitamin a is very important problem specific in children Methods: In this study serum sample and retinol serom was measured by advanced apparatus named HPLC and result were found from about 313 children who were in the age range 6 months to 7 years randomly Results: 1 % of samples had serum retinol less than standard (level 2 m per dl) From which none of them had the level below 10 m per dnifestation caused by vitamin a deficiency was seen in those who had serum retinol below standard Conclusions: There was direct poor relationship between child nutrition and serum retinol level No significant relationship between the ages of child. And serum retinol and vitamin a no relationship between diarrhea and respiratory infection but if there are back ground risk factor in child there are significant relation with low serum retinol and clinical symptom

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

T185

REMOVAL OF BLUNT ESOPHAGEAL FOREIGN BODY USING FOLEY CATHETER IN CHILDREN

J. Lee 1, W. Jeon 1, J. Lee 2

Ajou University School Of Medicine, Suwon, South Korea, 2 Inje Univeristy, Ilsan Paik Hospital, Goyang, South Korea Background: Foreign body ingestion is a common cause of visiting emergency department in children. Removal of esophageal foreign body was usually done by endoscopy. Since 1966, after Bigler introduced Foley catheter technique for esophageal foreign body, many studies were done about the technique but only a few reported about the technique in Korea. This study reports 10 year experience of a single center in Korea. Methods: A retrospective chart review of patients who were removed of esophageal foreign body by Foley catheter between March 2005 and February 2015 was done. Their clinical characteristics and outcomes were evaluated. Results: A total of 73 patients were removed of esophageal foreign body using Foley catheter. In 67 cases (91.8%), foreign body removal was successful. 6 failed case were removed by esophagoscopy or endoscopy. Mean age was 3.73 years. Most common foreign body was a coin (80.8%). Foreign bodies were lodged at upper esophagus level most frequently (79.5%), 12.3% at middle esophagus and 6.8% at lower esophagus. During the removal procedure, 43.8% of patients were sedated and 95.9% of cases were used with a fluoroscopy. There were no positive correlation between success and sedation (p=0.54) or using a fluoroscopy (p=0.23). In 69 cases (94.5%), there were no serious complication. Complications were observed such as vomiting, fever, esophageal ulceration for each one patient. Only 1 patient complained fever and esophageal ulceration. In cases with button battery ingestion, serious complications such as fever or esophageal ulceration were occurred. Conclusions: Removal of blunt esophageal foreign body using Foley catheter in children is useful and relatively safe method. But a patient ingested button battery is required more attention trying Foley catheter removal.

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

T186

THE TRENDS OF RADIOLOGIC IMAGING UTILIZATION IN AN EMERGENCY DEPARTMENT AT TERTIARY HOSPITAL FROM 2000 TO 2014 IN KOREA

I. Chang 1, J. Jung 2, J. Jung 1, D. Kim 1, H. Kwak 1

Seoul National University Hospital, Seoul, South Korea, Seongnam, South Korea

Bundang Seoul National University Hospital,

Background: We wanted to evaluate the trends of Computed Tomography use in pediatric emergency department comparing with adult emergency department and access the change of ultrasonography use in pediatric emergency department. Methods: We obtained the electronic medical data of patients who had visited the emergency department from January 2000 to December 2014. We analyzed not only the change of computed tomography use according to the anatomical region, but also the change of ultrasonography use with ratio of computed tomography use compared with ultrasonography in each year. Patients group was categorized into four age groups (Infants: 0-2 years, children: 3-12 years, adolescents: 12-17 years, adults: > 17 years). Results: Computed tomography scan ratio per 1,000 emergency department visit in adult group steadily increased from 167.7 in 2000 to 384.9 in 2009, but from 2010 (384.6) to 2014 (342.5) the ratio was decreasing slightly. In case of pediatric patients, computed tomography scan ratio per 1,000 emergency department visit steadily dropped since 2008 (106.8), reached 36.8 in 2014. In all pediatric group, the trend of brain/head/neck computed tomography scan ratio showed the remarkable drop since 2007 (78.5), reached 19.4 in 2014 especially infant and children group. The ultrasonography/computed tomography ratio increased since 2007 in infant (1.18), children (0.56) and all pediatric group (0.71) and in a case of adolescent group, the ratio increased since 2011 (0.28). The ultrasonography/computed tomography ratio of abdomen/genitourinary region in infant (8.15), children (1.58), all pediatric group (2.27) showed the rise fashion from 2007. Conclusions: Computed tomography use in pediatric patients has decreased since 2007. Adult computed tomography use increased steadily and decreased slightly. There was remarkable decrease of brain/head/neck computed tomography use in children. The ultrasonography/computed tomography ratio in all pediatric groups showed the increase trend. The ultrasonography/computed tomography ratio of abdomen/genitourinary region in infant, children, all pediatric group increased since 2007.

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

T187

TRACHEOSTOMY IN CASE OF FOREIGN BODY ASPIRATION IN CHILDREN

M. Alsoodany 1, M. Alsoodany 1

Olv Hospital, Aalst, Belgium

Background: Aspiration of foreign bodies results in significant morbidity and mortality in children. It may lead to asphyxia may rapidly cause death. Majority of foreign body aspiration are under the age of 3 years. The incidence rate was 0.5 deaths per 100,000 population aged 0-4 years. The spectrum of presentation varies widely from sudden death due to complete respiratory obstruction to accidental finding during routine investigation. <FILE IMAGE='85_20150518155056.png'> Methods: Clinical presentation: A 19-month-old girl, previously healthy, was founded unconscious on the floor in the day-nursery. She was reanimated first by the nanny and then by the medical emergency team. She had asystole, ventilation was very difficult. In the hospital reanimation continued longer than one hour until she had ROSC. During the intubation a thumbtack between the vocal cord was seen, but it was difficult to remove. The thumbtack was pushed deeply with the endotracheal tube. The patient was ventilated, supported with Noradrnaline infusion and then transferred to the intensive care. Patient passed away in the same day. Technical exams: Chest X ray shows the thumbtack at the end of the endotracheal tube obliterating the entrance of the right bronchus. Results: Litterature keypoints: Once a bronchial foreign body is identified, rigid bronchoscopy is almost always successful in retrieving the aspirated object. An urgent tracheostomy should be performed to secure the airway in some patients if severe upper airway obstruction is present before bronchoscopy is undertaken. Conclusions: Aspiration of a foreign body is a potentially lethal events. A common problem is delayed diagnosis. When a severe airway compromise is encountered, it demands immediate laryngoscopy, intubation and then bronchoscopy. Tracheostomy has to be done immediately in case of severe hypoxia, difficult ventilation and too sharp FBs that it can injure the airway or too large to pass through the subglottic region.

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

T188

BEDSIDE ULTRASOUND FOR ENDOTRACHEAL TUBE VERIFICATION IN PEDIATRIC EMERGENCY DEPARTMENT AND INTENSIVE CARE UNIT PATIENTS: A SYSTEMATIC REVIEW AND META-ANALYSIS

M. Lin 1, K. Gurley 1, M. Yitshak-Sade 2, B. Hoffmann 1

Beth Israel Deaconess Medical Center, Department Of Emergency Medicine, Boston, Usa, 2 Clinical Research Center, Soroka University Medical Center; Faculty Of Health Sciences, Ben Gurion University, Beersheba, Israel Background: Accidental esophageal intubation can be a dangerous complication of endotracheal intubation, and bedside ultrasound has been proposed as a method of quickly and accurately identifying tube placement. Recent studies in adults have found it to be accurate, but only a few studies have examined its use in children. Methods: We performed a systematic review and meta-analysis using both OVID MEDLINE and EMBASE for all available articles pertaining to use of bedside neck or lung/diaphragm ultrasound for confirmation of endotracheal tube placement in children through December 2014. Included studies were evaluated using the Quality Assessment of Diagnostic Accuracy Studies statement (QUADAS). We then performed random effect meta-analyses to determine pooled sensitivities and specificities. Results: A total of 5 papers: 2 studies using neck ultrasound, 2 using lung/diaphragmatic ultrasound and 1 with both, met our inclusion criteria. In total there were 91 intubations evaluated using tracheal or neck ultrasound and 212 intubations evaluated using diaphragmatic or pleural sliding. The pooled sensitivity of trans-tracheal ultrasound for intubation for all included studies was 0.95 [95%CI 0.85-0.98] with a specificity of 0.87 [95%CI: 0.53-0.97] For lung ultrasound, the pooled sensitivity for tracheal placement versus esophageal placement was 0.99 [95%CI 0.96-1]. Pooled specificity was unable to be calculated as only one study had esophageal intubations. When assessing the appropriate depth for tracheal intubations using lung ultrasound, the pooled sensitivity was 0.96 [95%CI: 0.84-0.99], with a specificity of 0.70 [95%CI: 0.24-0.92], and a positive predictive value of 0.94 [95%CI: 0.81-0.99]. Conclusions: Our pooled analysis showed excellent sensitivity and moderate specificity for bedside ultrasound in determining correct endotracheal tube placement. Neck and lung/diaphragm ultrasound can be a useful tool in confirming endotracheal tube placement in critically ill pediatric patients.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Paediatrics T189 SEVERE AND OCCULT INJURIES TO TODDLERS WHO TUMBLE DOWN STEPS R. Cook 1 1

Richard Tramontina and Ruth Pauline Cook Foundation, Hershey, USA

Background: When toddlers (children 1-4) fall down steps, some tend to bounce in a tumble, a series of essentially falls from the height of each stair, and are thus often spared serious injury, at least relative to the large numbers of times children fall down steps. We reviewed the data from children who fell down steps and were treated in Pennsylvania trauma centers 1987 - 2000. The biomechanical mechanism of injury of the series of free falls from each step is different from those of free falls off of the sides of the staircase, being pushed or carried, or riding a tricycle or baby walker down the stairs, and were therefore excluded, though are in themselves, interesting. Methods: Data was obtained from the Pennsylvania Trauma Systems Foundation (PTSF) database, the repository for all Pennsylvania trauma centers. We evaluated date on all children from 1987 thru 2000 (toddlers, age 1-4) who had fallen down steps, including all with e codes 880.9, as well as a focused review of all with E code 887 and 888, as well as a free text search on causes of injury for all E880 thru 888 (stair, step, tumble), which yielded 565 entries. Excluding duplicates, clear cut non-tumblers, and those on whom the data was incomplete or ambiguous, resulted in 301 toddlers 1-4 who had appeared to have tumbled down steps. Results: Superficial or no injuries: 22 Spinal cord injury: 0 Cervical spine fxr: 0 Major Brain Injury (EDH, SDH, SAH, contusion, laceration): 59 Concussion: 48 Intracranial/CHI non-specific: 44 Eye Injuries: 1 Facial Bone Fractures: 15 Skull Fractures: 112 - dome: 81 - basilar: 29 - unspecified: 2 Orthopedic: - femur: 30 - lower leg: 1 - humerus: 25 - forearm: 5 - clavicle: 4 Hemo/PTX and renal: 1 Pulmonary contusion and brain: 1 Abdominal Organs: 4 - kidney gr 4 lac; kidney; liver contusion; duodenal hematoma Discharged - to home: 278 - to rehab center: 4 Deaths: 6 Conclusions: Severe, and occult, injuries can occur to toddlers who tumble down steps. Head, including brain, injuries predominated in our study.

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

T190

DIABETES IN THE EMERGENCY DEPARTMENT: CLINICAL PRESENTATION OF TYPE 1 DIABETES IN CHILDREN.

M. Bohane 1, N. Mcgrath, C. Mcdonnell, N. Murphy

Department Of Diabetes And Endocrinology, Children's University Hospital, Temple St., Dublin, Ireland

Background: The worldwide incidence of type 1 diabetes mellitus in children is rising by about 3.9% per year while concurrently the age at presentation is falling. Our objective was to review the clinical presentation of children with newly diagnosed T1DM presenting to a paediatric Emergency Department. Methods: A retrospective review was undertaken of incident cases of T1DM presenting to the Emergency Department of the Childrenâ&#x20AC;&#x2122;s University Hospital between 2004-2014. Data collected included: clinical characteristics on presentation, occurrence and severity of diabetic ketoacidosis (DKA), Intensive Care Unit (ICU) admission and complications, and family history. Outcomes were analysed in subgroups according to age at presentation: 0-1.99 years old, 2-6.99 years old, and > 7 years old. Results: Three hundred and sixty-seven children (51% female) presented with T1DM, 29 aged 0-1.99 years, 113 aged 2-6.99 years, and 225 aged > 7 years. Children presenting to the ED were managed in line with the ISPAD Clinical Practice Consensus Guidelines 2014. Mean (SD) age at diagnosis was 8.3 (4.0) years. Ninety-three per cent presented with classical symptoms (polyuria, polydipsia, and weight loss). The median duration of symptoms prior to presentation was 14 days (range 0-365 days). Twenty-seven per cent of children had a positive family history of T1DM in a first- or seconddegree relative. Data was available on 325/367 (89%) regarding DKA presentation. Thirty-four per cent of the cohort presented in DKA â&#x20AC;&#x201C; 44% mild (pH<7.3), 24% moderate (pH<7.2), and 32% severe (pH<7.1). Overall, 38% of children with DKA were admitted to the ICU with the 0-1.99 years age group accounting for 56% of these admissions. A greater incidence of DKA (46%) was observed in the youngest age group and overall the incidence of DKA increased during the study period. Despite adherence to recommended guidelines, two children developed cerebral oedema early in their ED course which required treatment with mannitol. Both recovered fully. Conclusions: The incidence of DKA at diagnosis remains high, particularly in the youngest age group. Greater awareness of the changing pattern of T1DM disease onset is critical to early recognition and prevention of severe complications.

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

T191

THROMBOLYSIS WITH ALTEPLASE FOR ACUTE ISCHEMIC STROKE: AN ASSESSMENT OF THE ROMANIAN NATIONAL PROGRAM OF FIBRINOLYSIS IN STROKE CONDUCTED IN EMERGENCY CLINICAL COUNTY HOSPITAL OF T

V. Gavrila 1, M. Simu 2, A. Carstea 1, R. Vorovenci 2

Emergency Department, Clinical Emergency County Hospital, Timisoara, Romania, Emergency County Hospital, Timisoara, Romania

Neurology Clinic, Clinical

Background: Intravenous (IV) thrombolysis with tissue plasminogen activator (rt-PA) within 4,5 hours of symptoms onset is the standard of care in the treatment of acute ischemic stroke in current clinical practice. Despite these guidelines, many practitioners remain hesitant to use it, partly because of concern about causing intracerebral hemorrhage. On the other side, thrombolysis has several limitations such as a short time window and this narrow window for treatment leads to a small proportion of eligible patients to be treated. At Clinical County Hospital of Timisoara, thrombolytic therapy with intravenous rt-PA (alteplase/Actilyse) for acute ischemic stroke was introduced in 2013. Methods: 45 patients were recruited between January 2013 and January 2015 for this prospective, open, monitored, observational, nonrandomized study. We compare the baseline characteristics, treatment delay, rate of symptomatic intracerebral hemorrhage and functional outcome at 3 months after treatment between patients enrolled in Romanian National Program of Fibrinolysis in Stroke conducted in Emergency Clinical County Hospital of Timisoara, Romania and the Safe Implementation of Thrombolysis in Stroke - Monitoring Study (SITS-MOST). Data are presented as mean +/- standard deviation or percentage. Results: The mean age of patients included in this analysis was 65,51 years +/- 14.32 (range 32-87) vs.71years in SITS-MOST register, of whom 64,4% were men (vs. 56,2%). They presented with a mean baseline NIHSS of 14,93 +/- 4,54 (range 7-23) vs. 11 in SITS-MOST register and received intravenous thrombolysis after 156 min +/- 38,77 (range 75-250) from stroke onset vs. 150 min. in SITS-MOST register. In 9 cases thrombolysis was followed by intracerebral hemorrhage (17.8%), of which 4 cases were symptomatic (8.9% vs. 6.5% in SITS-MOST register). Mortality at 3 months was 20% (8 cases) vs. 14, 6% in SITS-MOST register. Conclusions: We found a higher rate of mortality at 3 months, explainable, perhaps, by lower experience and reduced group of patients. Despite the higher mortality rates at 3 months, all the primary and secondary outcome results are in line with the rates in clinical trial experience of intravenous thrombolysis.

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

T192

QUALITY OF SLEEP MENINGIOMAS

AND

COGNITIVE

PERFORMANCE

PATIENTS WITH

PRE-OPERATIVE

V. Giannouli, N. Syrmos

School Of Medicine, Aristotle University Of Thessaloniki, Greece, Thessaloniki, Greece

Background: Quality of sleep and cognitive performance in patients with pre-operative meningiomas Vaitsa Giannouli & Nikolaos Syrmos School of Medicine, Aristotle University of Thessaloniki, Greece Our aim in undertaking this study was to examine if pre-operative patients with meningiomas show differences in their reported quality of sleep when compared with healthy controls and patients with other types of chronic diseases. Methods: Twenty-three pre-operative patients (11 females, 12 males) with meningiomas in various brain regions (8 right, 7 left and 8 bilateral,) and of various sizes participated in the study. Their mean age was 58.60 years (SD = 12.26, range 31-77), level of education 9.47 years (SD = 3.82) and time since the first signs of possible brain disease (headaches, fatigue, fainting) were 4.21 years (SD = 2.19). A control group of 20 healthy participants with similar demographics was examined (mean age = 59.25, mean education = 11 years) and a group of 19 patients with different types of chronic diseases were also examined (mean age = 62.10, mean education = 12 years). All three groups of participants completed the Pittsburgh Sleep Quality Index and a battery of neuropsychological tests concerning mainly: verbal memory [word list learning: immediate recall, delayed recall and recognition; story learning: immediate and delayed recall], working memory (Digit Span backward), verbal fluency (semantic and phonological) and visual memory (Rey-Osterrieth Complex Figure Test immediate recall, delayed recall and recognition). Results: Results revealed that pre-operative patients suffering from meningiomas reported more problems with the overall quality of sleep when compared with patients who suffer from other types of chronic diseases and healthy controls. Conclusions: The sleep problems correlated strongly with the cognitive performance not only for the group of pre-operative patients with meningiomas, but also for the group of patients with other chronic diseases. Future studies should clarify the possible factors that affect and differentiate the patients with meningiomas.

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

T193

ANXIETY IN PRE-OPERATIVE PATIENTS WITH MENINGIOMAS

V. Giannouli, N. Syrmos

School Of Medicine, Aristotle University Of Thessaloniki, Greece, School Of Medicine, Aristotle University Of Thessa, Greece, 2 School Of Medicine, Aristotle University Of Thessaloniki, Greece, School Of Medicine, Aristotle University Of Thessa, Greece Background: Anxiety in pre-operative patients with meningiomas Vaitsa Giannouli & Nikolaos Syrmos School of Medicine, Aristotle University of Thessaloniki, Greece Our aim in undertaking this study was to examine if pre-operative patients with meningiomas show differences in their anxiety when compared with healthy controls and patients with other types of chronic diseases. Methods: Twenty-three pre-operative patients (11 females, 12 males) with meningiomas in various brain regions (8 right, 7 left and 8 bilateral,) and of various sizes participated in the study. Their mean age was 58.60 years (SD = 12.26, range 31-77), level of education 9.47 years (SD = 3.82) and time since the first signs of possible brain disease (headaches, fatigue, fainting) were 4.21 years (SD = 2.19). A control group of 20 healthy participants with similar demographics was examined (mean age = 59.25, mean education = 11 years) and a group of 19 patients with different types of chronic diseases were also examined (mean age = 62.10, mean education = 12 years). All three groups of participants completed the State-Trait Anxiety Inventory. Results: Results revealed that pre-operative patients suffering from meningiomas reported more state anxiety when compared with patients who suffer from other types of chronic diseases and healthy controls. No statistically significant differences were found for the three groups when trait anxiety was examined. Conclusions: Future studies should clarify the possible factors that affect and differentiate the patients with meningiomas.

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

T194

EFFECTS OF LONG-TERM EXERCISE ON MEMORY RECOVERY IN THE AGED GERBIL HIPPOCAMPUS AFTER TRANSIENT CEREBRAL ISCHEMIA

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

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

Neuobiology, Kangwon

Background: Therapeutic exercise is an integral component of rehabilitation of patients with stroke. Although the high prevalence of cerebral ischemia in the elderly population, the mechanisms linking restorative exercise to memory recovery from ischemic stroke have not completely understood in aged animals. In this study, we investigated effects of long-term exercise on neuronal death and memory recovery in the aged gerbil hippocampus after transient cerebral ischemia. We also investigated changes in gliosis, ischemia-induced myelin repair, microvessels, neurogenesis, and growth factors immunoreactivity in the hippocampus to study possible mechanisms of restorative exercise in memory recovery. Methods: The gerbils were divided into four groups (n = 12 in each group): 1) the sham-operated group (Sham), 2) 4 weeks sedentary group following ischemia (SD4), 3) 1 week treadmill group following ischemia (TR1) and 4) 4 weeks treadmill group following ischemia (TR4). Treadmill exercise was stared at 5 days after ischemia/reperfusion (I/R) and lasted for 1 or 4 weeks, and the animals were sacrificed 31 days after ischemia. Results: In this study, 4 weeks of treadmill exercise facilitated memory recovery despite neuronal damage in the CA1 region after I/R. On the other hand, the long-term treadmill exercise alleviated the increased gliosis in the CA1 region, and increased the myelin repairing and microvessels in the CA1 region and DG, and enhanced the ischemia-induced cell proliferation, neuroblast differentiation, neuronal maturation of the newly generated cells, and BDNF expression in the ischemic DG of the aged gerbil. Conclusions: These results suggest that, in the aged gerbil, long-term treadmill exercise after ischemic stroke could restore the impaired short-term memory function through the cumulative effects of multiple neurorestorative processes.

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

T195

NEUROPROTECTIVE EFFECTS OF NOVEL ANTIEPILEPTIC DRUG LACOSAMIDE VIA DECREASING GLIAL ACTIVATION IN THE HIPPOCAMPUS OF A GERBIL MODEL OF ISCHEMIC STROKE

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

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

Neuobiology, Kangwon

Background: Lacosamide, a novel antiepileptic drug, has been discovered to have some beneficial effects beyond its effectiveness. Methods: In the present study, we examined the neuroprotective effect of lacosamide against ischemic damage in the hippocampal CA1 region following 5 min of transient cerebral ischemia in gerbils using H & E staining, NeuN immunohistochemistry and F-J B staining. Results: The results showed that pre- and post-treatment with 25 mg/kg lacosamide significantly protected neuronal death from transient cerebral ischemic injury. Many H&E positive cells, NeuN-immunoreactive neurons and a few number of F-J B-positive cells were found in the stratum pyramidale of the CA1 region in the lacosamide-treated-ischemia-operated groups compared with those in the vehicle-treated-ischemia-operated group. In addition, the treatment with 25 mg/kg lacosamide markedly attenuated the activation of astrocytes and microglia in the ischemic CA1 region. Conclusions: In brief, these results indicate that both pre- and post-treatment with lacosamide can protect CA1 pyramidal neurons from transient cerebral ischemic injury in the hippocampus and the neuroprotective effect of lacosamide may be related with decreasing the activation of glial cells in the ischemic CA1 region.

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

T196

ISCHEMIC PRECONDITIONING INDUCES NEUROPROTECTION CAUSE BY A TRANSIENT GLOBAL ISCHEMIA VIA MAINTAINING THE EXPRESSION OF P63

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

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

Neuobiology, Kangwon

Background: p63 is a transcription factor of p53 gene family, which are involved in development, differentiation and cell response to stress; however, their roles in ischemic preconditioning (IPC) in the brain are not clear. In the present study, we investigated the effect of IPC on p63 immunoreactivity caused by transient cerebral ischemia, which was induced by 5 min of transient ischemia, in gerbils, and IPC was induced by subjecting the gerbils to 2 min of ischemia followed by 1 day of recovery. Methods: The animals were randomly assigned to 4 groups (sham-operated-group, ischemia-operated-group, IPC plus (+)-sham-operated-group and IPC+ischemia-operated-group). Results: The number of viable neurons in the stratum pyramidale of the hippocampal CA1 region (CA1) was significantly increased by IPC+ischemia-operated-group compared with that in the ischemia-operated-group 5 days after ischemic insult. We found that strong p63 immunoreactivity was detected in the CA1 pyramidal neurons in the sham-operated-group, and the immunoreactivity was decreased with time after ischemia-reperfusion. In addition, strong p63 immunoreactivity was newly expressed in the microglial cells of the CA1 region from 2 days after ischemia-reperfusion. In all the IPC+sham-operated-group, p63 immunoreactivity in the CA1 pyramidal neurons was similar to that in the sham-operated-group, and the immunoreactivity was well maintained in the IPC+ischemia-operated-groups after cerebral ischemia. Conclusions: In brief, our present findings showed that IPC dramatically protected the reduction of p63 immunoreactivity in the pyramidal neurons of the CA1 region after ischemia-reperfusion, and this result suggests that the expression of p63 may be necessary for the neurons to survive after transient cerebral ischemia.

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

T197

IMPACT OF HYPERTHERMIA BEFORE AND DURING ISCHEMIA-REPERFUSION ON NEURONAL DAMAGE AND GLIOSIS IN THE GERBIL HIPPOCAMPUS INDUCED BY TRANSIENT CEREBRAL ISCHEMIA

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

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

Neuobiology, Kangwon

Background: Hyperthermia can exacerbate the brain damage produced by ischemia. In the present study, we investigated effects of hyperthermia before and during ischemia-reperfusion on neuronal damage and glial changes in the gerbil hippocampus following transient cerebral ischemia using by cresyl violet staining, NeuN immunohistochemistry and Fluoro-Jade B histofluorescence staining. Methods: The animals were randomly assigned to 4 groups: (1) sham-operated animals with normothermia (normothermia+sham group); (2) ischemia-operated animals with normothermia (normothermia+ischemia group); (3) sham-operated animals with hyperthermia (hyperthermia+sham group); and (4) ischemia-operated animals with hyperthermia (hyperthermia+ischemia group). Hyperthermia (39.5 Âą 0.2ÂşC) was induced by exposing the gerbils to a heating pad connected to a rectal thermistor for 30 min before and during ischemia-reperfusion. Results: In the normothermia+ischemia groups, a significant delayed neuronal death was observed in the stratum pyramidale (SP) of the hippocampal CA1 region (CA1) 5 days after ischemia-reperfusion. In the hyperthermia+ischemia groups, neuronal death in the SP of the CA1 occurred at 1 day post-ischemia, and neuronal death was observed in the SP of the CA2/3 region at 2 days post-ischemia. In addition, we examined activations of astrocytes and microglia using immunohistochemistry for anti-glial fibrillary acidic protein (GFAP) and anti- ionized calcium-binding adapter molecule 1 (Iba-1). GFAP-positive astrocytes and Iba-1-positive microglia in the ischemic hippocampus were activated much earlier and much more accelerated in the hyperthermia+ischemia groups than those in the normothermia+ischemia groups. Conclusions: Based on our findings, we suggest that experimentally hyperthermic pre-condition before cerebral ischemic insult produces more extensive neuronal damage and glial activation in the ischemic hippocampus.

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

T198

REPORT OF NINETEEN CEREBRAL VEIN THROMBOSIS DEPARTMENT A CASE SERIES AND LITERATURE REVIEW

REFERRALS

EMERGENCY

A. Baratloo 1, A. Rouhipour 2, F. Rahmati 1, S. Safari 1, H. Delavar Kasmaei 3, B. Hashemi 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 Neurology Department, Shohadaye Tajrish Hospital, Shahid Beheshti University Of Medical Sciences, Tehran, Iran Background: Risk factors, diagnosis, treatment and outcome of patients with cerebral venous thrombosis (CVT) have always been challenging. The present study aimed to report on the characteristics of CVT in the patients referring to the emergency unit of a teaching hospital to review and add to the current knowledge on this topic. Methods: This was a retrospective cross sectional study, which consisted of a series of 19 patients admitted to the emergency department during one year with the diagnosis of CVT. The required data were extracted from existing reports in the case files via manual-searching. All patients were re-evaluated prospectively with the goal of outcome assessment. Results: This study included 19 patients with CVT. Mean age of the cases was 38.7 Âą 8.8 years (range 22 to 62 years) and they were predominantly women (84.2%). The most common chief complaint at presentation was headaches, observed in 15 (78.9%) of the patients either solely or accompanied with other symptoms. Use of oral contraceptive pills (OCPs) was reported in more than half of the cases. The outcome was favorable in 18 (94.7%) of the cases and only one patient, despite appropriate five months of remedial measures, still suffered from visual disturbance. Conclusions: Although many risk factors for CVT have been identified thus far, it seems that there are different patterns of frequency among ethnic groups. Thus, an inter-racial comparison study is still needed. Likewise, with attention to the lack of proper studies and strong evidence regarding treatment options, conducting a multicenter prolonged study with a large sample size is apparently required

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

T199

SERUM CONCENTRATION OF IONIZED MAGNESIUM AS AN INDEPENDENT RISK FACTOR IN MIGRAINE ATTACKS: A MATCHED CASE-CONTROL STUDY

S. Asgarzadeh 1, S. Safari 1, M. Yeusefifard 2

Shahid Beheshti University Of Medical Sciences, Tehran, Iran, Tehran, Iran

Tehran University Of Medical Sciences,

Background: There is controversy over the role of magnesium in the etiology of migraine headaches. Therefore, an attempt was made in the present study to evaluate and compare serum levels of magnesium between healthy subjects and those with migraine headaches during migraine attacks and between attacks in order to evaluate the role of magnesium in the etiology of migraine headaches. Methods: Forty patients with migraine headaches and 40 healthy individuals were enrolled in this matched case-control study. Demographic data, history of background medical conditions such as malnutrition, digestive system disorders, a history of smoking, drug abuse, a history of the use of medications and other exclusion criteria were questioned and recorded at baseline. The pain scores of the patients were measured and recorded based on a 10-cm VAS. Subsequently, blood samples were collected from the subjects at 8-10 in the morning and serum levels of magnesium were determined. ANOVA, chi-squared test and conditional logistic regression were used for data analysis. Results: There were no significant differences in demographic data between the two groups. There were significant differences in magnesium serum levels between the three groups (1.09±0.2 mg/dL during migraine headaches; 1.95±0.3 mg/dL between the attacks; and 1.3±0.4 mh/dL in the control group in the control group; P<0.0001). Conditional logistic regression showed that when serum levels of magnesium reach blow the normal level, the odds of acute migraine headaches increase up to 35.3% (OR=35.3; 95% CI: 12.4-95.2; P=0.001). It should be pointed out that the odds in patients who are not in the acute attack phase is 6.9 folds higher (OR=6.9; 95% CI: 1.3-2.1; P=0.02). Conclusions: The serum level of magnesium is an independent factor for migraine headaches and patients with migraine have lower serum levels of magnesium during the migraine attacks and between the attacks compared to healthy individuals.

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

T200

COMPARISON OF THERAPEUTIC EFFECTS OF MAGNESIUM SULFATE DEXAMETHASONE/METOCLOPRAMIDE ON ALLEVIATING ACUTE MIGRAINE HEADACHE

VS.

S. Asgarzadeh 1, M. Moallem 1, V. Nikmanesh 1

Shahid Beheshti University Of Medical Sciences, Tehran, Iran

Background: There is controversy about the efficacy of currently used treatment modalities to alleviate migraine headaches. Objective: We aimed to evaluate and compare the effects of magnesium sulfate and combined use of dexamethasone/metoclopramide on relieving acute migraine headache. Methods: We randomly divided 70 patients who had been referred to an emergency department, into two equal treatment groups with the two treatment plans, and analyzed pain severity at baseline using a numeric rating scale (NRS). We gave dexamethasone/metoclopramide to one group and magnesium sulfate to the other group, and evaluated pain severity at 20 min and at 1- and 2-h intervals after infusion. Finally, we used repeated-measure and two-way analysis of variance for intra- and inter-group evaluations of pain severity and complications, respectively. Results: We found no significant differences in demographic data and pain severity at baseline (8.2 vs. 8.0) between the two groups (p< 0.05). In the dexamethasone/metoclopramide group, pain severity (mean ± standard deviation) was 7.4 ± 1.4 (p= 0.36), 6.0 ± 2.4, and 2.5 ± 2.9 (p< 0.0001) at 20-min, 1-h, and 2-h intervals after treatment, respectively, with statistically significant differences between the baseline values and 1-h and 2-h interval values. Administration of magnesium sulfate was associated with decreased pain severity at the three intervals (5.2 ± 1.7, 2.3 ± 1.9, and 1.3 ± 0.66, respectively), exhibiting significant differences compared to baseline values and the corresponding time intervals in the dexamethasone/metoclopramide group (p< 0.0001). Conclusions: According to the results, magnesium sulfate was a more effective and fast-acting medication compared to a combination of dexamethasone/metoclopramide for the treatment of acute migraine headaches.

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

T201

ACUTE SPONTANEUS CERVICAL EPIDURAL HEMATOMA MIMICKING AORTIC DISSECTION

C. Yildirim 1, G. Pamukcu Gunaydin 1, I. Erkan Aydin 2, G. Kurtoglu Celik 1, A. Ozhasenekler 2

Ataturk Training And Research Hoispital, Ankara, Turkey, 2 Yildirim Bayezit University Medical School, Ankara, Turkey Background: Spontaneous cervical epidural hematoma (SCEH) is defined as an epidural hematoma that does not have a known etiological reason. Patients usually complain of acute neck pain or interscapular pain. SCEH is an important and urgent cause of spinal cord pressure. Early diagnosis and treatment are essential for a good prognosis. We present a patient with interscapular pain initially mistaken for aortic dissection. <FILE IMAGE='364_20150630215013.jpg'> Methods: 38 year old male patient was admitted to our emergency department with sudden severe back pain. He had no history of chronic diseases or drug use. His vital signs were: heart rate: 75/min, blood pressure: 150/90 mmHg, body temperature: 36.7 C, respiratory rate: 18 /min. His ECG was normal sinus rhytm. There was no laboratory abnormalities. A thoracoabdominal computed tomography angiography was performed with prediagnosis of aortic dissection. There was no aneursym or dissection at CT scan. Patientâ&#x20AC;&#x2122;s pain worsened and spreaded to his neck. While he was observed in the emergency department ascendan hemiplegia and paresthesia developed. Brain and whole spinal MRI scan was performed and it revealed cervical epidural hematoma that extends through C4-6 vertebrae posteriorly. Patient was consuted with neurosurgery and underwent surgery. Results: Conclusions: Although SCEH is a rare condition, it can cause severe morbidity and mortality. Early diagnosis and treatment are crucial for the best outcomes. Since SCEH can imitate different pathologies such as aortic dissection or stroke emergency physicians should be aware of these presentations.

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

T202

UTILITY OF INTRAVENOUS KETAMINE FOR DECREASE OF SUICIDAL IDEATION IN EMERGENCY DEPARTMENT PATIENTS

P. Kashani 1, S. Yoosefian 2, A. Afshar 3

Shahidbeheshti University, Tehran, Iran

Background: Suicidal ideation is problem in the Emergency Department (ED) that often complicated patient disposition. It has been shown that ketamine has antidepressant and anti-suicidal effects. We examined the effects of a single intravenous boluse of ketamine on patients with suicidal ideations in ED. Methods: Forty-four subjects with suicidal ideations, received 0.2 mg/kg of ketamine. Scale for suicidal ideation (SSI) and Montgomery Abserg depression Rating Scale (MADRS) were evaluated before and 40, 80 and 120 minutes after drug intervention. The results were compared using the paired t-test and patients were followed up 10 days after ED admission for remnant suicide ideation. Results: SSI and MADRS scores significantly dropped after ketamine injection (p<0.05); the SSI score before and after 20, 40, and 80 minutes of ketamine injection were 23±6, 16±5, 14±4 and 13±4 respectively. The MADRS scores were 38±2, 25.6±7, 23.5±6 and 22±6 at the same time intervals. Twenty four percent of patients were hospitalized, 31% had been given drug and 12% were discharged. 62% of patients had suicidal ideations after ten days of admission in ED. Conclusions: Ketamine is a good choice for fast decrease of suicidal ideations in ED patients. Further studies are needed to determine the optimal dose of ketamine for different patients.

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

T203

THE DIAGNOSTIC VALUE OF CYCLOPHILIN A IN ACUTE ISCHEMIC STROKE

Y. Karaca 1, O. Tatli 1, U. Eryigit 2, A. Sahin 1, N. Aksut 3, A. Mentese 4, D. Us Altay 4, N. Beslioglu 5, M. Karatas 6, A. Orem 4

Karadeniz Technical University, Faculty Of Medicine, Department Of Emergency Medicine, Trabzon, Turkey, 2 Diyarbakir Selahaddin Eyyubi State Hospital, Department Of Emergency Medicine, Diyarbakir, Turkey, 3 Manisa State Hospital,department Of Emergency Medicine, Manisa, Turkey, 4 Karadeniz Technical University, Faculty Of Medicine, Department Of Biochemistry, Trabzon, Turkey, 5 Kanuni Training And Research Hospital, Department Of Emergency Medicine, Trabzon, Turkey, 6 Recep Tayyip Erdogan University, Faculty Of Medicine, Department Of Pulmonary Medicine, Rize, Turkey Background: Early diagnosis and treatment of patients presenting to the emergency department with stroke can significantly reduce mortality and morbidity associated with this disease. The purpose of this clinical study was to investigate the diagnostic value of serum cyclophilin A in patients presenting to the emergency department with symptoms of acute ischemic stroke. Methods: One hundred fourteen patients diagnosed with acute ischemic stroke between October 2013 and October 2014 and a control group of sixty six healthy volunteers were included in the study. Patient and control group cyclophilin A values were compared. Cyclophilin A levels of serum were determined by using an enzyme-linked immunosorbent assay (ELISA). Results: Mean ages were 68.2Âą15.3 in the patient group and 61.7Âą9.7 in the control group (p<0.05). Median cyclophilin A level in the patient group measured at time of presentation was 13.47 (11.97-17.92) ng/mL, and the median value in the control group was 11.54 (8.48-16.22) ng/mL. Patient group cyclophilin A values were significantly higher than those of the control group (p<0.05). Conclusions: Plasma cyclophilin A levels in patients with acute ischemic stroke were significantly higher compared with the control group. We concluded that, when supported by studies involving larger studies, cyclophilin A can assist in the early diagnosis of patients with ischemic stroke.

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

T204

BASILAR ARTERY THROMBOSIS AFTER MINOR WHIPLASH INJURY

G. D'antuono 1, M.S. Cotelli 2, P. Malamani 1, C. Sepe 2, M. Soccio 2, M. Turla 2, G. Ricevuti 1

UniversitĂ Degli Studi Di Pavia, Pv, Italy, 2 Ospedale Di Esine, Esine, Italy

Background: Whiplash injuries are generally seen after rear-end car collision. Traumas in which the victim's head swings backward followed by a forward flexion generally cause occipito-nucal pain due to local damage of ligaments and muscles, severe headhache, neck stiffness, anxiety, irritability and dizziness, which may subside for several months or even became chronic. Sometimes, however, complications can be life -threatening. Methods: We report the case of a 50 years-old Caucasian woman who was involved in a minor whiplash injury and underwent ocular symptoms (scotomas and torsional nystagmus) with subjective dizziness for which she was repeatedly admittted to the Emergency Department in the following two months. A brain CT showed an acute ischemic stroke in right cerebellar hemisphere. A few days later general conditions worsened and she developed bulbar symptoms together and left hemiparesis. She was admitted to Intensive Care Unit. Results: An acute proximal basilar artery thrombosis after basilar dissection was found at angiography but mechanical intra-arterial thrombolisis was unsuccessful. Our patient developed a Locked-in Syndrome and died in a month due to central hyperthermia and respiratory failure. Conclusions: Retrospectively, if the reported symptoms should have been promptly recognized as posterior circulation transient ischemic attacks, our patient might have benefited from anticoagulation therapy with better clinical outcome (Virktup et al 1995). We think also that it is important to find preociously signs or symptoms of central nervous system involvement in patients involved in whiplash injury even if not recently happened and neuroimaging exams should be promptly performed in Emergency Department

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

T205

IMPLEMENTATION OF A RAPID HIV TESTING PROGRAM IN PSYCHIATRIC INPATIENT WARDS

M. Popiel 1, V. Duvvi 1, A. Turkieh 1, E. Cowan 2, Y. Calderon 2, C. Umfrid 1, K. Chacon 2, J. Krauss 2, A. Rao 2, J. Leider 3

Albert Einstein College Of Medicine, Bronx, USA, 2 Department Of Emergency Medicine, Jacobi Medical Center, Bronx, USA, 3 Department Of Internal Medicine, Jacobi Medical Center, Bronx, USA Background: New York State law mandates the offer of HIV testing to every patient aged 13-64. However, acute mental health admittances into the psychiatric emergency room can be difficult settings in which to conduct HIV screening. Because individuals with mental illness have higher rates of HIV infection, routine testing of stabilized patients in psychiatric inpatient wards could be beneficial. This study sought to assess the implementation of a rapid HIV testing program in this nontraditional setting. Methods: This prospective, descriptive study was conducted in a psychiatric inpatient ward over 23 days. Public Health Advocates (PHAs) recruited a convenience sample of patients, deemed to have capacity to consent by a team of physicians, for HIV testing. PHAs collected demographic characteristics and risk factors during counseling sessions. Chart reviews were conducted to assess psychiatric diagnoses and sexual/drug abuse history. Rates of test acceptances were tracked during the last nine days of the study. Results: 405 patients were tested for HIV. Demographic characteristics of the participants were: 59.5% male, 43.0% Hispanic, and 40.2% Black. Mean age was 37.9 Âą 13.0 years. 38.0% did not engage in regular medical care. As per CDC criterion, 26.4% of participants were high-risk for acquiring HIV. Risk factors were: multiple sex partners (22.2%), injection drug use (4.9%), sex for commodities (4.9%), sex with an injection drug user (3.2%), or sex with an HIV-positive partner (1.5%). Psychiatric diagnoses were: Schizophrenic/Psychotic/Affective (65.2%), Depression (15.6%), and Bipolar (13.8%). Drug abuse was noted in 33.1% of cases, and 7.4% reported sexual abuse history. One patient was confirmed HIV positive and linked to outpatient HIV care. In the last nine days of study, 294 of 394 consentable patients were offered the HIV test (74.6%), of which 185 accepted (62.9%). Conclusions: A rapid HIV testing program with multidisciplinary staff buy-in can test a large number of patients in a psychiatric inpatient ward. Expansion of HIV screening initiatives to nontraditional settings can increase access to testing for high-risk populations that may not otherwise engage in primary care, especially those that cannot consent while admitted in a psychiatric emergency room.

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

T206

IS IT DEPRESSION OR FRONTAL LOBE SYNDROME?

F. Doganay, R. Ak, E. Unal Akoglu, T. Cimilli Ozturk, O. Ecmel Onur

Fatih Sultan Mehmet Education And Research Hospital, Istanbul, Turkey

Background: The frontal lobe is the largest lobe in the brain, yet it is often not specifically evaluated in routine neurologic examinations. Frontal lobe syndrome (FLS) occurs as a result of the damage in prefrontal area due to various reasons. Symptoms seen in the prefrontal cortex damages vary depending on the lesion size and location. Personality changes, aboulia, apathy, dysfunction in planning and sequencing functions can be seen in the lesions of part of dorsolateral prefrontal cortex.We report the case of a patient, in whom have acute depressive symptoms and have a frontal lobe tumor, and the absence of neurological signs. <FILE IMAGE='209_20150716125349.jpg'> Methods: A 57 year-old man was admitted to our emergency deparment complaining of amnesia and depressive symptoms for a week. His family emphasised that previously he had funny and cheerful personality. Vital signs were as follows: 36,2Â°C, blood pressure: 125/60 mmHg, pulse:71 beats per minute, sp02:%99. His medical history regarding psychiatric and other medical conditions was unremarkable. Physical examination was normal. His Hamilton Depression Rating Scale (HAM-D) score was 39 which meaning of very severe deprression. Laboratory testing include coagulation panel, hemogram, serum electrolyts and other biochemistry markers were normal. The computed tomography (CT) scan showed a 69x60 mm sized lesion at left frontal with associated edema and 16 mm shift of the midline structures (Figure 1). The Lesionâ&#x20AC;&#x2122;s MRI T2 scan was seems like Glioblastome Multiforme (Figure 2). The patient underwent neurosurgical treatment. After the surgery his symptoms were regressed rapidly. Results: 1 Conclusions: Brain tumors may present multiple psychiatric symptoms such as mood alteration, anxiety, delirious state or amnesia. The physicians must be alert for cognitive symptoms and not to be opinionated because of the frontal lobe syndrome.

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

T207

NEUROGENIC PULMONARY EDEMA

F. Doganay, R. Ak, E. Unal Akoglu, T. Cimilli Ozturk, O. Ecmel Onur

Fatih Sultan Mehmet Education And Research Hospital, Istanbul, Turkey

Background: Neurogenic pulmonary edema (NPE) is an increase in pulmonary interstitial and alveolar fluid that is due to an acute central nervous system injury. But it is underdiagnosed although it may course mortally if it is not treated early.The primary precipitants of NPE are epileptic seizures, traumatic brain injury, and cerebral hemorrhages. NPE characteristically presents within minutes to hours of a severe central nervous system insult. Dyspnea is the most common symptom. The physical examination generally reveals tachypnea, tachycardia, and basillary rales. Chest radiographs typically shows bilateral alveolar filling. We reported a case of NPE, develop after spontan subarachnoid hemorrhage (SAH). <FILE IMAGE='209_20150709172331.jpg'> Methods: A 82-year-old man presented to emergency department (ED) with fatigue and headache. His symptoms began about 5 hours ago. His Glascow Coma Scale (GCS) was 15; blood pressure was 170/90 mmHg, pulse rate was 78 bpm, oxygen saturation 98%, body temperature was 36,4째C. His physical examination, electrocardiography and laboratory results were normal. He sent to computed tomography (CT) of brain. His CT scan in ED revealed diffuse subarachnoid hemorrhage (Fig 1). After an hour in his follow-ups, dyspnea was added to his symptoms suddenly and bibasillary crepitant rales began. His new oxygen saturation measured 88%. After supportive treatment, he sent to thorax CT. Thorax CT revealed pulmonary edema (Fig 2). During the supportive treatment his GCS score fell to 8. After endotracheal intubation, the patient transported to intensive care unit for further therapy and follow-up. Results: 1 Conclusions: NPE is a clinical diagnosis based upon the occurrence of pulmonary edema in the appropriate setting and in the absence of a more likely alternative cause. The clinical findings of NPE may be confused with aspiration pneumonitis. Emergency physicians should remember NPE when neurologic patients suddenly become dyspneic. The mortality rate is high, but surviving patients usually recover very quickly.

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

T208

TRANSIENT ISCHEMIC ATTACK VERSUS TRANSIENT ISCHEMIC ATTACK MIMICS: USE OF COMPLETE BLOOD COUNT FOR DIFFERENTIAL DIAGNOSIS

N. Salman 1, A. Bayramoglu 2

Etimesgut Military Hospital Department Of Emergency Medicine, Ankara, Turkey, Faculty Department Of Emergency Medicine, Erzurum, Turkey

Ataturk University Medical

Background: The transient ischemic attack (TIA) is an acute loss of cerebral or ocular function with symptoms lasting up to 24 hours and of presumed ischemic origin. Early detection and management is important because the patients with a TIA have a high-risk of stroke within the first three months. However the clinical diagnosis of TIA is based on clinical examination, studies have been researched auxiliary methods for differential diagnosis. We aimed to investigate the efficacy of values for components of Complete Blood Count (CBC) in differential diagnosis of the TIA and the TIA mimics. <FILE IMAGE='49_20150515221017.jpg'> Methods: A retrospective case control study. Patients admitted to emergency department and hospitalized with a diagnosis of TIA in Ataturk University Training Hospital Neurology Clinic between the years 2012 and 2014 were recruited to study. These patients of which the initial diagnosis were TIA divided into two groups according to their final diagnosis: TIA group and TIA-mimic group. Venous blood samples were obtained from patients for CBC within the first 30 minutes of the admission to neurology department. Results: During two years, 2733 patients admitted to emergency department and hospitalized with the diagnosis of TIA. 1401 of them excluded because of incomplete or missing data. After diagnostic processes, 420 patients diagnosed with TIA and 912 patients diagnosed with TIA mimics. We detected that that five variables of CBC (white blood cell, red blood cell, mean platelet volume, mean corpuscular hemoglobin concentration, neutrophil to lymphocytes ratio) are predictors of TIA at differentiation with TIA mimic (Table). Conclusions: We propose that CBC is an auxiliary method for the differential diagnosis of TIA. Moreover, age and the gender are demographic predictors as compatible with prior studies at TIA diagnosis.

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

T209

DID THE WALKING DEAD APPEAR AT A DANCE EVENT?

S. Calle 1, L. Patteet 2,3, K.E. Maudens 2, S.M.R. Wille 4, P. Blanckaert 5, H. Neels 2,3, P.A.A. Calle 1,6

Ghent University - Faculty Of Medicine And Health Sciences, Ghent, Belgium, 2 University Of Antwerp Toxicological Centre, Wilrijk, Belgium, 3 Zna Stuivenberg - Laboratory For Tdm And Toxicology, Antwerp, Belgium, 4 Federal Public Service Justice - National Institute Of Criminalistics And Criminology, Brussels, Belgium, 5 Scientific Institute Of Public Health (wiv-Isp) - Belgian Early Warning System Drugs, Brussels, Belgium, 6 Maria Middelares General Hospital - Emergency Department, Ghent, Belgium Background: Substances sold as party drugs may be inactive, contaminated or may contain a different ingredient. Obviously, these phenomena increase the chances of a wrong or delayed therapy. We report 3 cases of clozapine intoxication at a dance event with 30,000 attendants. This neuroleptic drug is mainly prescribed for treatment-resistant schizophrenia. In clozapine-naive subjects bradycardia, syncope and asystole for 30 seconds has been reported with a 25 mg dose. Methods: This report is part of a prospective study approved by the local ethics committee. At the on-site medical station clinical data and blood samples were collected from 45 intoxicated patients. Results: Case 1 was brought comatose to the medical station. Upon clinical evaluation he became agitated. Systolic blood pressure was 131 mmHg, pulse rate 130 bpm, body temperature 36.7 °C and glycaemia 170 mg/dL. A pill was found in his pockets, later to be identified as Leponex® 100 mg (clozapine). He was administered diazepam intravenously. Within 3 hours he suffered from obstructive breathing and bradycardia, necessitating intubation for 8 hours. The blood ethanol concentration was 1.1 g/L, and urine toxicology screening was positive for cannabis. Two more patients presented with syncope and altered mental status for 1 and 3 hours, respectively. Routine toxicology detected ethanol (0.73 g/L) and cannabis in case 2, and ethanol (0.69 g/L) and MDMA (635 ng/mL) in case 3. The advanced toxicological analysis revealed the presence of clozapine (244, 73 and 95 ng/mL) and its metabolite norclozapine (59, 29 and 9 ng/mL). The elevated clozapine:norclozapine ratios were indicative for acute overdose in clozapine-naive subjects. Only case 1 could be contacted. He denied clozapine therapy. Interestingly, in the television series The Walking Dead, a murder with clozapine was covered up as a therapeutic error. This episode was aired only 6 days before the dance event… Conclusions: First, conscientious monitoring of vital signs until full recovery is indicated. Second, routine drug screening may be unable to detect the toxic agent(s) involved. Consequently advanced toxicological analysis is indicated whenever life-threatening and/or unusual symptoms are observed.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Substance abuse T210 ACUTE ALCOHOL INTOXICATION IN THE ED NOT JUST ADOLESCENT BINGING? E. Mcguckin 1, S. Mcgovern 1

Ulster Hospital - Department Of Emergency Medicine, Dundonald, Northern Ireland, United Kingdom

Background: Alcohol misuse is a major cause of attendance to the ED, 35% in some studies. Our aim was to quantify the proportion of Ulster Hospital’s ED visits linked to alcohol ingestion, examine these patient’s profiles that might better inform public health strategy. Methods: Attendances over 17-23/11/14 were examined. All initial ED and ambulance records were searched for evidence of alcohol ingestion. Prior attendances assessed through on-line electronic records. Results: 1571 patients presented to the ED. Alcohol related attendance was evident in 4.6% (n=72). Of these 73.6% male, 26.4% female, average age 42 years (median=42). 63% attended previously with alcohol ingestion, averaging 7 within 2014 (range 0–49). Sunday morning (00:00-05:59) showed highest proportion of alcohol related attendance when 37%. 60% of these patients presented via ambulance. 11% required police involvement, 28% self-presented, 1% referred via GP. Those with police or ambulance involvement, pre hospital location was home addresses in 80%, 20% public areas. 78% of cases presented with acute alcohol intoxication (n=56). Cases involving acts or threats of deliberate self-harm found in 39%(n=28), medically unwell 31%(n=22), injury 24%(n=17) and detox requests 6.9%(n=5). Total number of hospital admissions from the ED was 461. Alcohol attendances accounted for 17 , 3.7% of total admission. 47% of alcohol related attenders were discharged, 24% medical/surgical admission, 21% left before treatment and 8% admitted to ED observation ward. Length of stay of 1-3 days seen in 78%. 13% were greater than one week, longest being 39 days. Alcohol ingestion accounted for 51.7% of all left before been seen patients. Conclusions: This study indicates our alcohol intoxication attendance is low. Most involve males, highest proportion occurring early Sunday morning. An average age of 42 years is older than expected and for many, a repeat attendance. Many are brought from home, require ambulance and police intervention and ultimately leave before been attended to. The ED seems an appropriate place to test interventions at reducing alcohol intake however this study demonstrates alcohol ingestion and the ED is not just an adolescent problem on a night out.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Metabolic and endocrine disorders

T211

POSTPARTUM COMA DUE TO ISOLATED HYPERAMMONEMIA: A PATIENT WITH UREA CYCLE DEFECT

A.A. Akpinar 1, N.R. Disel 1, E.C. Direk 1, A. Sebe 1, M.T. Ilginer 2, S. Bicakci 3

Cukurova University Faculty Of Medicine, Department Of Emergency Medicine, Adana, Turkey, 2 Cukurova University Faculty Of Medicine, Department Of Anesthesiology, Adana, Turkey, 3 Cukurova University Faculty Of Medicine, Department Of Neurology, Adana, Turkey Background: Introduction: Here we present a patient with seizures and coma secondary to isolated hyperammonemia on fifth postpartum day. Methods: Case Presentation: A-23-year old woman was transferred to emergency clinic after giving birth to a healthy baby in a vaginal delivery. She was diagnosed as eclampsia because of seizures started on the fifth day postpartum. Her initial Glasgow Coma Scale score was 8 (E2V2M4) and vitals were as follows: blood pressure, 100/60 mmHg; pulse rate, 120/min; temperature, 37.8 oC and pulse O2 saturation, 91%. She was not diagnosed seizure disorder or pre-eclampsia during pregnancy and she was known to be healthy in her medical history. Her laboratory and imaging evaluations were performed to exclude central nervous system diseases like hemorrhage, infection and stroke. Her cerebral CT scan, MRI and lumbar punction revealed nothing pathological. Her hemogram and biochemistry were also in normal limits except ammonia which was 321 mg/dL. Her liver functions, hepatitis markers and abdominal ultrasonography were all normal and chronic or acute hepatic insufficiency and hepatitis were all excluded. She was hospitalized in intensive care unit, received sodium benzoate, and undergone hemodialysis. She died on the 14th day despite all supportive care measures and ammonia-lowering treatment. Results: Discussion: Urea cycle defects are rarely seen disorders. The lack or insufficiency of these enzymes causes fatal encephalopathy due to hyperammonemia. The reasons of coma in postpartum patients are eclampsia, Hellp Syndrome, thromboembolia, hemorrhage and septicemia. Although it is rarely seen, hyperammonemia in previously healthy young adult females is another reason of coma. Metabolic diseases are usually diagnosed in early years of life. Healthy individuals with ornithine transcarbamylase (OTC) deficiency experience hyperammonemia following prolonged catabolic situations like surgery and delivery. Most of the cases of hyperammonemia due to OTC deficiency reported in the literature are postpartum women with coma. Conclusions: Hyperammonemia should be kept in mind as a reason of coma in postpartum women. Early diagnose and initiation of ammonia-lowering treatment may be life-saving.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Internal Medicine (General), Nephrology, and Endocrine

T213

COMPLETE BLOOD CELL AS PREDICTIVE MARKER FOR ACUTE KIDNEY INJURY IN CHILDREN.

A. Pakniyat 1, P. Yousefichaijan 2, A. Eghbali 3, M. Rafiei 4, H. Taherahma 5

Student Committee Research,emergency Medicine Department , Arak University Of Medical Sciences, Arak, Iran., Arak, Iran, 2 Associate Professor Of Pediatric Nephrology, Arak University Of Medical Sciences, Arak, Iran., Arak, Iran, 3 Assistant Professor Of Pediatric Hematology , Arak University Of Medical Sciences, Arak, Iran., Arak, Iran, 4 Associated Professor Of Biostatistics., Arak University Of Medical Sciences, Arak, Iran., Arak, Iran, 5 Assistant Professor Of Pediatric. Arak University Of Medical Sciences, Arak, Iran., Arak, Iran Background: Acute kidney injury (AKI) is a clinical syndrome in which a sudden deterioration in renal function results in the inability of the kidneys to maintain fluid and electrolyte homeostasis. AKI occurs in 2-3% of children admitted to pediatric emergency centers and in as many as 8% of infants in neonatal intensive care units. A classification system has been proposed to standardize the definition of acute kidney injury in adults. These criteria of risk, injury, failure, loss, and end-stage renal disease were given the acronym of RIFLE. Our goal was to study the complete blood cell as a predictor of prognosis of AKI in children. Mean platelet volume (MPV) as part of the CBC , is a machine-calculated measurement of the average size of platelets found in blood .Since the average platelet size is larger when the body is producing increased numbers of platelets, the MPV test results can be used to make inferences about platelet production in bone marrow or platelet destruction problems. Methods: in a prospective study 206 patients with AKI who admitted to Amirkabir emergency department, were investigated. The complete blood count, erythrocyte sedimentation rate, serum C-reactive protein and electrolytes of patients were measured and compared.All patients have been follow up for 6 months. Results: The patients were 59 (risk group), 57 (injury group), 46 (failure group), 43 (loss group) and 1(ESRD group). The MPV values were low in loss (p=0.0012) and failure (p < 0.005). The sensitivity and specificity of the MPV for the diagnosis of loss and failure were higher than those of the other inflammation markers. MPV < 8.2 fL was significantly associated with poor prognosis in renal functions.other CBC parameter such as White blood cell,Hemoglobin ,etc didn't show significant relation with that. Conclusions: The MPV is a fast and reliable measurement with considerable predictive value for predict of prognosis in acute kidney injury.A multicenter study with a larger sample size is suggested to investigate the correlation between MPV and AKI.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Internal Medicine (General), Nephrology, and Endocrine

T214

THE UTILITY TO DOSE BLOOD MAGNESIUM VALUE IN THE EMERGENCY DEPARTMENT

G. D'antuono 1, C. Sepe 2, P. Malamani 1, D. Polonioli 2, M. Soccio 2, G. Ricevuti 1

UniversitĂ Degli Studi Di Pavia, Pv, Italy, 2 Ospedale Di Esine, Esine, Italy

Background: Hypomagnesemia remain quite prevalent, particularly in patients in intensive care units and in multimorbidity patients afferent to the emergency department, and may have important clinical consequences. Magnesium should be measured in clinical circumstances in which a risk for magnesium deficiency exists and appropriately corrected when found. Methods: A 76 years old patient with diabetes mellitus, COPD gold III stadium, heart failure in NYHA III class, bipolar syndrome, hemiplegia, in polytherapy and addicted to alcohol was admitted to the Emergency Department with dyspnea, behavioral abnormalities, fatigue, lethargy, lack of appetite, bilateral lower arms paresthesia, muscles cramps and frequent myoclonus. Results: The ABG analysis showed PH 7.495, pCO2 41.2 mm Hg, pO2 147.4 mm Hg, HCO 31 mmol / L , ca2 ++ 0.54 mmol/L. Blood analysis showed no particular abnormalities: only CK was 2920 u / L. The chest radiography was negative for pneumonia, pleural effusion or heart failure. During the anamnesis we discovered a history of hypocalcemia unresponsive to calcium therapy. For these reason, blood magnesium and parathormone were dosed and their value were respectively 0.4 mg/dl (normal values 1.6 to 2.3 mg/dl) and 6 pg/ml (normal values 11 to 67 pg/ml). The patient was hospitalized and treated with magnesium, calcium and calcitriol with benefit and resolution of symptoms and diagnosis hypoparathyroidism caused by severe hypomagnesemia Conclusions: We conclude that hypomagnesemia continues to be an underestimated diagnosis especially in Emergency Departments beacause of non-specific symptoms (lethargy, weakness, personality changes) and may lead to serious consequences if unrecognized. Blood magnesium value should be routinely measured when there is a finding of hypocalcemia.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Hematological and oncological disorders

T216

PROSPECTIVE ASSESSMENT OF TRANSFUSION PRACTICE AMONG EMERGENCY ROOM NURSES

C. Jebali 1, N. Ibn Hassine 1, F. Mani 2, N. Chebili 2, L. Boukadida 1, A. Haj Ali 2, M.N. Karoui 2, A. Zorgati 1, R. Boukef 1

Emergency Department Of Sahloul, Sousse, Tunisia, 2 Samu 03 Of Sahloul, Sousse, Tunisia

Background: transfusion, even in difficult emergency conditions, nevertheless requires rigorous implementation by following to the letter the rules of good transfusion practices to ensure optimal blood transfusion safety. This requires adequate blood safety basic knowledge, a continuous and repeated training so that the transfusion act is set in the rules of art. No studies have evaluated the knowledge and skills of paramedics in our emergency department. Methods: Our study was prospective, descriptive, mono centric conducted during a period a period 11 weeks. The tool used was a questionnaire containing 21 items in the form of multiple choice questions which were distributed in connection with the three stages of the transfusion (pre-transfusion, per-transfusion and post-transfusion). The collection of information was carried out by two senior technician in emergency medicine, volunteering and respecting anonymity. All paramedics working in our emergency department outside the administrative were included. Outcome measures were adherence to transfusion good practice include taking the correct answers. Results: thirty nine (93%) nurses have participated to study. Only 31 % have appropriate knowledge and practice with no negative consequences for the patient safety. In our sample, poor knowledge and practice concerned mainly pre-transfusion compatibility check when receiving blood units (62%); delay in preservation of blood unit in the ward (65%); and recognition of abnormal reactions after transfusion (46%). These results showed on which topics the teaching program should emphasize so as to improve the quality of blood transfusion in the medical centers according to legal obligations. Conclusions: These results showed on which topics the teaching program should emphasize so as to improve the quality of blood transfusion in the medical centers according to legal obligations.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Hematological and oncological disorders

T217

IMPACT OF TIME TO ANTIBIOTICS ON OUTCOMES IN CHEMOTHERAPY INDUCED FEBRILE NEUTROPENIA

J. Shin 1, S. Ahn 1, B. Ko 1, W. Kim 1, K. Lim 1, Y. Lee 1

Asan Medical Center, University Of Ulsan, College Of Medicine, Department Of Emergency Medicine, Seoul, South Korea Background: Clinical practice guidelines recommend administration of broad-spectrum antibiotics as soon as possible, ideally within an hour, after fever is documented in patients with febrile neutropenia (FN). However, this recommendation is primarily based on expert opinion and evidence from the studies regarding diverse patients with severe sepsis or septic shock. The goal of this study was to determine the relationship between time to antibiotics administration and patient’s outcome in FN. We also tried to find out the relationship between time to antibiotics and mortality rates in subgroup patients with severe sepsis or septic shock, and bacteremias. Methods: From the Neutropenic Fever Registry, we analyzed consecutive 1001 FN episodes diagnosed from November 1, 2011 to August 31, 2014. Timing cutoffs for antibiotics included: <=1 hr vs. >1 hr; <=2 hrs vs. >2 hrs; <=3 hrs vs. >3 hrs; and <=4 hrs vs. >4 hrs. Multivariable logistic regression was used to adjust for potential confounding in the association between timing intervals and outcomes of FN episodes. Results: The median length of time from triage to antibiotics was 140 min (interquartile range, 110 – 180 min). In each time cutoff, time from triage to administration of antibiotics was not significantly associated with outcomes of FN after adjusting for potential confounders. Antibiotics timing were not significantly associated with complication rates in overall episodes (Table 1). We couldn’t found significant relationship between antibiotics timing and mortality in episodes with severe sepsis or septic shock (Table 2), and episodes with bacteremias (Table 3).Procalcitonin concentration and the Multinational Association for Supportive Care (MASCC) risk-index score were found to be more crucial determinant of outcomes in patients with FN.<FILE IMAGE='5_20150311022553.jpg'> Conclusions: Our study could not provide sufficient evidence to establish a benefit in outcomes from antibiotics administration in less than 1 or 2 hrs from ED arrival. Time to antibiotic administration was not a major factor in outcomes of FN.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Hematological and oncological disorders

T218

SICKLE CELL PATIENTS EXPERIENCE DELAY IN ANALGESIC ADMINISTRATION WITH RESPECT TO NATIONAL GUIDELINES DESPITE SEVERITY OF PRESENTATION

I. Agu 1, S. Brown, L. Hsu, T. Vandenhoek, S. Heinert, J. Lowe, J. Colla

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

Background: Objective: (1.) To determine if door to analgesic (DTA) times for sickle cell disease (SCD) patients presenting to an urban tertiary emergency department (ED) are prolonged compared to the national guidelines of 60 minutes (2.) To compare DTA times of sickle cell pain crisis to that of renal colic, another painful disease without reproducible tenderness or outward signs of trauma. Methods: The electronic medical record was queried for adult patients (patients > 18) presenting to a single urban tertiary ED from 1 June 2013 to 31 May 2014 using all ICD 9 codes for sickle cell disease with crisis. A similar query was made using ICD 9 codes for renal colic. Patients not receiving analgesic medicine were excluded from the queries. DTA administration time was determined using the difference from patient registration time to the time analgesic order was noted as completed by the nurse. In order to control for severity of presentation, patients were separated into subgroups based on the Emergency Severity Index (ESI) levels as recorded by the triage note. Results: Our query identified 272 patient visits to the ED for SCD and 53 visits for renal colic. The mean DTA times for SCD patients were higher than national recommendations despite ESI levels. The mean DTA time for all SCD patients was 129.2 minutes (SD = 75.9), compared to 97.7 minutes (SD = 88.0) for all renal colic patients, a difference of 31.5 minutes (p = 0.0077). Conclusions: SCD patients presenting to a single urban tertiary care center did not meet the national guideline requirement of 60 minutes for DTA, as recommended by both the National Heart Lung and Blood Institute and American Society of Hematology. In fact regardless of the ESI triage level, analgesia was not administered within the 60 minute timeframe. Furthermore, patients presenting to the ED with renal colic had significantly shorter time to analgesia than SCD patients presenting with pain crisis. There is significant scope for improvement in timely administration of pain medication for SCD patients presenting with vasocclusive pain crisis.

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

T219

IDIOPATHIC ACUTE PANCREATITIS IN PREGNANCY

R. Ak, F. Doganay, T. Cimilli Ozturk, O. Ecmel Onur, E. Unal Akoglu

Fatih Sultan Mehmet Education And Research Hospital, Istanbul, Turkey

Background: Acute pancreatitis in pregnancy occurs infrequently and has a reported incidence of approximately 1 in 1000 to 3 in 10000 births. More than 50% of cases in pregnancy are diagnosed in third trimester. Acute pancreatitis in pregnancy might have a lethal effect on both the mother and the fetus. Methods: A previously healthy 36-year-old multiparous woman (gravida 3, para 2) was admitted at 25 wk of gestation with severe epigastric pain radiating to her back. Vital signs were as follows: 36째C, blood pressure: 107/65 mmHg, pulse: 96 beats per minute, sp02:%98. Physical examination revealed epigastric tenderness and a gravid uterus. Initial laboratory testing showed a white blood cell count of 11500, glucose was 106 mg/dL, LDH was 203U/L, AST was 28 U/L, serum amylase level was 1190 IU/L and lipase level was >500 IU/L. Triglyceride level was normal. Abdominal ultrasound revealed no definite evidence of intra- or extra-hepatic ductal dilatation and the gallbladder and pancreas was unremarkable. The diagnosis was acute pancreatitis. She was managed with intravenous fluids, analgesics and by nil per oral. We monitored the fetus using the non-stress test based on amniotic fluid volume. The results were satisfactory for gestational age. The mother improved with supportive treatment within two days. Serum amylase and lipase levels dropped to 64 IU/L and 46 IU/L, respectively, on the 6th hospital day. The patient was discharged on the 6th hospital day in good health. Results: 1 Conclusions: The initial management of acute pancreatitis in pregnancy does not vary from nonpregnant state. It consists of fluid restoration, oxygen, analgesics, and cessation of oral feeding to suppress exocrine function of pancreas, thereby preventing autodigestion of pancreas. A multidisciplinary approach is vital in the management.

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

T220

COULD SMOKERSâ&#x20AC;&#x2122; SOCIO-DEMOGRAPHIC AND HOUSING FACTORS AFFECT AND INFLUENCE THE CHOICE BETWEEN SMOKING CESSATION THERAPIES?

S. Leone 1, G. Cremonesi 2, M. Greco 1, D. Pierluigi 1

Accident & Emergency Dept., Galliera Hospital, Genoa, Italy, University Of Genoa, Genoa, Italy

Post-Graduate School In Emergency Medicine,

Background: The published data suggest that interventions which combine pharmacotherapy and behavioral support increase success rates of smoking cessation compared to minimal intervention or usual care; however, a standardized behavioral psychotherapy programme has not been assessed yet. Our main aim was to assess if socio-demographic and housing characteristics of smokers attending an Italian smoking cessation centre, could have influenced the choice between varenicline therapy and psychological support only. Our secondary aims were: i) to evaluate the 6-month abstinence rates (ARs), confirmed by comparing exhaled air carbon monoxide concentrations, in smokers according to whether they took varenicline or received only psychological support; ii) to assess the most frequently reported adverse drug reactions (ADRs) by the varenicline group, mainly focusing on psychiatric events; iii) to evaluate the differences between men and women with regard to specific varenicline-related ADRs. Methods: 144 smokers were enrolled; all of them received the same psychological support programme. They were evaluated by a team of clinical experts, who advised them to opt for either one quitting method or the other; then the smokers chose themselves a treatment option of either varenicline plus psychotherapy (VAR: 78 patients) or psychotherapy alone (PSY: 64 patients). Results: Socio-demographic and psychological characteristics of patients have significantly influenced the treatment choice; the 6-month ARs were 35.9% versus 10.9% (p<0.01) in those using varenicline versus psychotherapy, respectively; 57.7% of the patients reported at least one adverse event. Conclusions: The analysis of socio-demographic factors and psychological characteristics of patients seems to be necessary to offer them the most effective therapy in order to achieve good abstinence rates. Therefore, this study confirms the data about the efficacy and safety of varenicline. Our screening methods and exclusion criteria seem to be valid aids to achieving good therapeutic outcomes with a low risk of occurrence of severe psychiatric events.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Therapies for Acute Diseases

T221

REVIEWING THE IMPLEMENTATION OF PACKING IN PENETRATING ABDOMINAL TRAUMA

S. Kaymak 1, A. Unlu 1, R. Senocak 1, E. Lapsekili 1, M. Yilmaz 1, A.K. Coskun 1, N. Zeybek 1

Gmma Department Of General Surgery, Ankara, Turkey

Background: Most of penetrating abdominal injury occurs with gunshot or stab. Damage control surgery becomes more common than before with a wide variety of techniques including hepatic packing,managing gastrointestinal lacerations with stapler,ligation of vascular injury and packing the other bleeding area. We aimed to find the prevalence and the reasons for packing in this study. <FILE IMAGE='331_20150629221405.png'> Methods: We analyzed the data of patients with abdominal trauma retrospectively for the 5 year period. We took the data of patients who underwent damage control surgery and performed packing. Results: There were 100 patients admitted our clinic with penetrating abdominal trauma. 19 of them was performed packing. All of the patients were male and injuried with high-energy trauma.All of the patients were performed a first-surgery in other hospitals and the referred to our clinic. The major reason of packing arranged as follows: 7 to liver injury, 4 to unstable retroperitoneal hematoma, 4 to pelvic hemorrhage and 4 to bleeding site at psoas neighborhood (Table 1). All of the patients had multiple organ injury.Packing was performed due to solid organ injury in 7 patients and vascular injury in 12 patients. All of patients were re-operated for unpacking at postoperative first or second day. None of the patients faced postoperative complications associated with packing process. Mortality was not seen in any of cases. Conclusions: It is not able to perform a controlled surgical procedures to the patients with penetrating abdominal trauma especially if there is life-threatening hemorrhage and multisystemic severe injury.Packing must be kept in mind is such of these cases.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T222

EPIDEMIOLOGY, AGE EFFECTS, AND CLINICAL OUTCOMES OF POISONING PATIENTS

S. Jeong 1, K. Ahn 2, K. Song 1, Y. Ro 2, S. Shin 1, K. Hong 3

Seoul National University Hospital - Department Of Emergency Medicine, Seoul, South Korea, 2 Seoul National University Hospital Biomedical Research Institute - Laboratory Of Emergency Medical Services, Seoul, South Korea, 3 Seoul National University Boramae Medical Center - Department Of Emergency Medicine, Seoul, South Korea Background: Poisoning is one of the injury mechanisms inducing high mortality. Aims of this study were to describe the epidemiology of poisoning, and to identify age effects on clinical outcomes. Methods: An observational study was conducted using ED injury in-depth surveillance. Eligibility was poisoning patients who visited six urban tertiary hospitalsâ&#x20AC;&#x2122; ED from 2010 to 2012. We excluded the patients with unknown survival outcomes after ED treatment. Endpoints were mortality in ED and hospital. We tested age trends on survival outcomes. Results: Total of 5416 poisoning patients, 3031 (56.0 %) were female and 2669 (49.3%) used EMS. Anti-psychotic drug was a leading cause of substance (30.5%), followed by artificial substance (21.2%). Insecticides (8.7%), herbicides (6.2%), painkiller (8.6%), and gas poisoning (12.3%) were identified. Among them, 2772 (51.2 %) used substances with self-injury intention, and 1234 (22.8%) consumed alcohol. Admission rate was 28.5% and mortality rate in ED and ward were 2.2% and 1.6%. By age group, teenage used painkiller (37.1%), and elderly used herbicides and insecticides (32.2% in 60-69 and 38.7% in over 70) (p-value <0.01). Teenage (60.8%) and mid-old age (61.9% for 30-39, 61.4% for 40-49) groups had more self-injury intention (p-value <0.01). Mortality in ED and ward were increased by age (6.0% and 5.5% for 60-69 and 7.2% and 9.0% for over 70, respectively) (both p-for-trend <0.01). Conclusions: Poisoning induced mortality was increased by age. It may be affected by not only natural age effect but also poisoning substances, which elderly more likely to use fatal substances like herbicides.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T223

OUTCOMES FOLLOWING NERVE AGENT EXPOSURE REPORTED IN THE TOXIC REGISTRY (2010-2013)

B. Hatten 1, J. Westphalen 2, E. Schwarz 3, P. Wax 4, J. Brent 1, On Behalf Of Toxic 5

Section Of Medical Toxicology, Department Of Emergency Medicine, University Of Colorado School Of Medicine, Aurora, Co, Usa, 2 Denver Health Residency In Emergency Medicine, Denver Health Medical Center, Denver, Co, Usa, 3 Division Of Emergency Medicine Washington University School Of Medicine, St. Louis, Mo, Usa, 4 Department Of Emergency Medicine, University Of Texas-Southwestern, Dallas, Tx, Usa, 5 Toxicology Investigators Consortium, American College Of Medical Toxicology Background: Since 2010, the Toxicology Investigators Consortium (ToxIC) Registry records in a standardized fashion all clinical consults seen by an international multi-center network of medical toxicologists. In recent years, the United States Department of Defense, the Food and Drug Administration, the Department of Health and Human Services, and the Centers for Disease Control have developed lists of chemicals that are considered potential threat agents. Nerve agents are of interest. Methods: The Registry was queried from 2010-2013 for cases entered with an exposure to a nerve agent. Cases recorded as no or chronic exposure, no signs/symptoms, and signs/symptoms unlikely toxin-related were excluded. Sites reporting exposure to an organophosphate pesticide or a carbamate, a patient exhibiting a cholinergic toxidrome, or treatment with 2-PAM were contacted for a case abstraction. Results: 33 cases of nerve agent exposure from 16 sites were identified. 8 cases from 7 sites were abstracted and available for analysis. 3/8 patients were female. 4/8 patients were under 18 years of age (3/4 pediatric patients < 13 years). Agents identified include: 5 organophosphate pesticides (Chlorpyrifos-1, Diazinon-1, Dimethoate-1, unidentified organophosphate pesticide-2) and 3 carbamates (Aldicarb-1, Pyridostigmine-2). 2/8 patients presented with a Glasgow Coma Score of 3 with the remainder at 14-15. 3/8 of patients required intubation. 7 patients were admitted, and 4/7 admissions were to the intensive care unit. Median hospital length of stay for admitted patients was 4 days (range 1 to 38 days). Confirmatory testing was inconsistent with red blood cell cholinesterase activity in 1 case, pseudocholinesterase level in 1 case, plasma cholinesterase in 1 case, urine organophosphate screen in 1 case, and no agent directed testing in 4 cases. 7/8 patients survived. 4 of 8 patients received atropine. Following atropine, all 4 patients then received oxime therapy (pralidoxime-3, obidoxime-1). 1 patient seized and was treated with benzodiazepines. Conclusions: Medical toxicologists encounter a wide variety of nerve agents. Most patients require admission and many are critically ill. Treatment regimens vary but half of cases examined received atropine/oxime therapy. 1 death was reported in this case series.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T224

PREDICTION OF THE SEVERITY OF ESOPHAGEAL INJURY FOLLOWING CAUSTIC INGESTION.

J. Juengsiragulwit 1

Emergency Department Of Chulalongkorn Hospital, Bangkok, Thailand

Background: Evaluation of the severity of esophageal injury following caustic ingestion is useful in management plan and providing the tendency of esophageal stricture. Esophagoduodenoscopy (EGD) is a gold standard to assess the severity of esophageal injury but it is quite expensive and complicated in process. In a resource-poor environment and experience practitioners, the surrogate factors may be substituted for EGD. Methods: Prospective analytic design. Patient with caustic ingestion who came to the ED of the Chulalongkorn Hospital during January 2008 to October 2009. All patients were taken their histories and physical examination, and blood sampling at the ED. EGD was performed within 6-24 hrs. Clinical presentation, investigation and finding from EGD were obtained and analysed to look for factors influencing on the severity of esophageal injury following caustic ingestion. Results: There were 45 patients with caustic ingestion enrolled in this study. One patient was died, one patient had esophageal stricture in the first month after caustic ingestion. There were 15 patients with high grade of esophageal injury (33.3%). We found that some factors may help us to classify the severity of esophageal injury significantly as follows the lesion in oral mucosa (86.7% and 40.0%; p = 0.003), abdominal pain (66.7% and 33.3%; p = 0.034), white blood cell count (13,606 ± 5,286.04 and 8,078 ± 2,348.16; p < 0.001), neutrophil count (10,529 ± 5,183.62 and 5,526 ± 2,235.78; p < 0.001) and HCO3 (18.86 ± 4.58 and 22.30 ± 3.08). We also analyzed these factors by binary logistic regression method found that patient with white blood cell count more than 10,000 cell/mm3 had high grade of esophageal injury risk. (p = 0.014, OR 7.43, 95%CI = 1.50-36.64). Conclusions: White blood cell count more than 10,000 cell/mm3 associated with high grade of esophageal injury finding from EGD in patient with caustic ingestion, however it cannot be substituted for EGD in the present. Further studies are needed.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T225

DEVELOPING A PRACTICAL HOSPITAL RESUSCITATION ALGORITHM FOR CARDIAC ARREST VICTIMS IN CHEMICAL HAZARD CONTAMINATION

I. Yeh 1, K. Liu 1, F. Kuo 1, P. Cheng 1, Y. Hsiao 1, S. Chen 1, Y. Liu 1, G. Chen 1, Y. Shih 1, S. Chen 1

Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Background: The effective resuscitation of contaminated cardiac arrest victims depends on the precise coordination between resuscitation and decontamination procedures. The lack of an resuscitation guide for this purpose created a need for us to develop a clinical algorithm useful in the resuscitation of contaminated cardiac arrest victims. <FILE IMAGE='100_20150519171650.jpg'> Methods: Based on advanced cardiovascular life support algorithms, advanced trauma life support and advanced hazard life support, the hospital's chemical disaster preparedness committee performed a systematic literary analysis to include those relevant resuscitation maneuvers that can be performed using personal protective equipment. Additionally, live trials were utilized to adjust those procedures and develop a practical and feasible algorithm. The algorithm was then assessed by completing pre and post simulated exercise surveys utilizing time intervals to record the exercise. Prior to simulation participants attended a 30 minutes training course to learn about the algorithm. Results: The resulting algorithm consisted of a simple flow diagram detailing the sequential steps to follow. A concise figure like algorithm was also created to supplement all information regarding the responder's position, functions and equipment used. Ninety-two physicians and nurses participated in the simulated exercise. The mean resuscitation-decontamination interval was 122.77 seconds (SD Âą30.81; range: 71.7-167.72). Competences of contaminated victims resuscitation increased from 2.54/5 to 4.28/5 (p<0.001). Participants found the algorithm practical (4.27/5), appropriate (4.26/5), fluent (4.29/5), easy to learn (4.23/5), and easy to memorize (4.35/5). Overall, they felt it would be useful to implement this algorithm in their future practices (4.14/5). Conclusions: Correct resuscitation of contaminated cardiac arrest victims represents the integration of a broad diversity of medical disciplines that may be aggravated when secondary contamination is another limitation to be consider. The creation of a simple standardized algorithm would improve not only the learning and recall of steps but would also assist in upgrading contaminated victims resuscitation in clinical practices. Moreover, the use of different demonstration modalities may enhance the perception and interpretation of information by the health provider. Future research is required to evaluate outcomes during actual situations.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T226

THE DANGERS OF PRE-HOSPITAL COOLING. A CASE REPORT OF AFTERDROP IN A PATIENT WITH EXERTIONAL HEAT STROKE

A. Whitford 1, T. Stewart 1

University Of Texas Health Science Center, San Antonio, Usa

Background: Objective Exertional heat stroke is a potentially life threatening disease with varying clinical presentation and severity. Given the severe morbidity that may accompany the disease the immediate management often times begins in the pre-hospital setting. It is important not only to have a comprehensive understanding of the pre-hospital cooling methods in addition to hospital management strategies, but an understanding of their potential complications as well. Methods: A 32 year old male presented with progressive confusion, nausea, non-bloody emesis, and ataxia. Initial presentation was concerning for exertional heat stroke as the patient was recorded in the field to have a temperature of 42.1 degrees Celsius (106.2 degrees Fahrenheit). Upon arrival to the Emergency Department the patient was found to have a core body temperature of 38.1 degrees C (100.6 degrees F). All active cooling measures were terminated and active rewarming was initiated. Despite adequate resuscitation and rapid identification of the patient’s overcorrection in core body temperature, the lowest recorded temperature was 36.0 degrees C (96.8 degrees F). Results: Patients who undergo active cooling via medical resuscitation efforts or passive cooling via environmental processes are at risk for a physiologic phenomena termed afterdrop. Afterdrop is the process by which previously vasoconstriced peripheral blood vessels, a protective mechanism to divert warm blood to the bodies core, dilate after rewarming techniques are started. This subsequent vasodilatation causes a sudden return of cold, deoxygenated, low pH, lactic acid rich blood to return to the patient’s core circulation. This may result in prolonged hypothermia, in addition to cardiac dysrhythmias, despite implementation of adequate passive rewarming techniques if active core rewarming techniques are not simultaneously implemented. Conclusions: This case represents the dangers associated with exertional heat stroke, the over correction of core body temperature, and the potentially lethal complication of after drop. Although this patient’s clinical outcome was good, the event could have caused serious morbidity or potentially could have been lethal.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T227

ACUTE RESPIRATORY FAILURE DUE TO FATAL ACUTE COPPER SULFATE POISONING; A CASE REPORT

G. Kim

National Health Insurance Service Ilsan Hospital, Goyang-Si, South Korea

Background: Copper sulfate is a copper compound used widely in the chemical and agriculture industries. Most Intoxication occurs in developing countries of Southeast Asia particularly India, but rarely occurs in Western countries. The early symptoms of intoxication are nausea, vomiting, diarrhea, and abdominal cramps. The most distinguishable clue is bluish vomiting. The clinical signs of copper sulfate intoxication can vary according to the amount ingested. Methods: Results: A 75-year-old man came to our emergency room because he had taken approximately 250 ml copper sulfate per oral 8 hours ago to commit suicide. His past medical and surgical histories were unremarkable. Glasgow Coma Scale (GCS) score was 14 (E3V5M6) and vital signs were blood pressure 173/111 mmHg, pulse rate 24 bpm, respiration rate 24 bpm and body temperature 36.1 celcius. Arterial blood gas analysis (ABGa) showed mild hypoxemia (pH 7.27, PaCO2 46.4 mmHg, PaO2 60.7 mmHg, HCO3- 20.6 mmol/L) and just improved after 4 L/min oxygen supply via nasal cannulae. Laboratory tests showed an elevated serum copper 634.7 µg/mL (normal range 75-145 µg/mL) initially and 731.0 µg/mL 4 hours later. Other laboratory tests and chest CT scan showed no clinical siginificance. We did not do gastric lavage nor give activated charcoal. 3 hours later, the patient's mental status showed sudden deterioration (GCS 12, E3V4M5) and ABGa showed hypercarbia (pH 7.038, PaCO2 85.2 mmHg, PaO2 76.8 mmHg, HCO3- 21.8 mmol/L). After we intubated him, He was arrested with pulseless electrical activity (P.E.A.). His spontaneous circulation returned after 8 minutes CPR. However, 22 minutes later, he was arrested again with slow rate P.E.A. and returned after 3 minutes CPR. The family did not want additional resuscitation, so that he died 5 hours after ED visit. Conclusions: In our knowledge, early deaths are the consequence of shock, while late mortality is related to renal and hepatic failure. However, as this case shows, consideration of early definite airway preservation is reasonable in a case of supposed copper sulfate intoxication, because the patients can show rapid deterioration even when serious clinical manifestation are not presented initially.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T230

ALCOHOL INTOXICATION PATIENTS IN THE EMERGENCY DEPARTMENT: WHAT TO DO?

J. Ashkar 1

Emergeny Medicine Department, Hadera, Israel, Emergency Medicine Department, Hadera, Israel

Emergency Medicine Department, Hadera, Israel,

Background: J.Ashkar M.D., P.Pechansky M.D., M. Medvedovsky M.D. The Emergency Department, Hillel Yaffe Medical Center Hadera, Israel Alcoholism is a wide â&#x20AC;&#x201C; spread medical and social problem in the Western world. It is the leading pathology of addiction. In Israel, there are more than 50,000 patients suffering from alcoholism. The Hillel Yaffe Emergency Department treats more than 400 alcohols Intoxicated patients per year, who with a variety of emergency conditions. Of these, the most dramatic are trauma case, including victims of traffic accidents and violence, different cardiac arrhythmias electrolyte and glucose metabolism disturbances, etc. According to our statistics, these patients are comprised of about 90% males and 10% females. Methods: We have observed that there are two age peaks: the first is between the ages 15-20 and the second is age 30-55. We have created a unique protocol for treatment of unconscious/ confused patients including those who are alcohol intoxicated that has guided the emergency physician. After emergency treatment, approximately 25% are hospitalized and 75% are released. The management of these patients in the Emergency Department requires a multidisciplinary approach including: emergency physicians, a trauma team, cardiologists, intensive care specialists and social workers. Results: We present a unique protocol in our poster presentation and we emphasize the most important points of reference for treating these Alcohol Intoxicated patients. Conclusions: We present a unique protocol in our poster presentation and we emphasize the most important points of reference for treating these Alcohol Intoxicated patients.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T231

A CASE OF DISTURBANCE OF CONSCIOUSNESS BY DEXTROMETHORPHAN (DXM) OVERDOSE

H. Yoshioka 1, M. Morohara 1, N. Kiriu 1, K. Maebashi 2, K. Iwadate 2, H. Yanagisawa 3, H. Kato 1

National Hospital Organization Disaster Medical Center, Department Of Critical Care Medicine And Trauma, Tokyo, Japan, Tokyo, Japan, 2 The Jikei University School Of Medicine, Department Of Forensic Medicine, Tokyo, Japan, Tokyo, Japan, 3 The Jikei University School Of Medicine, Department Of Public Health And Environmental Medicine,tokyo, Japan, Tokyo, Japan Background: We report a case of disturbance of consciousness by Dextromethorphan (DXM) overdose. Methods: A 59-year-old man, prescribed Dextromethorphan (DXM) for bronchitis, swallowed 400 tablets with the intention of committing suicide. After 1 to 2 hours had elapsed, his family discovered him in a state of disturbance of consciousness, and he was transported to our critical care center. Results: On admission, disturbance of consciousness, shock and bradypnea were observed, so tracheal intubation and artificial respiration were immediately performed. Moreover, there was no response to transfusion, we were able to maintain blood pressure by administering vasopressor. After admission to the ICU, direct hemoperfusion (DHP), and continuous hemodiafiltration (CHDF) were performed, and on Day 2, a total of 9.6 mg of Naloxone was administered. On Day 3, the ability to breathe on his own was observed, and gradually improvement in consciousness was seen, so on Day 6, the respirator was removed. On Day 12, he was discharged with no aftereffects. When he was admitted the blood concentration of DXM was 9.34 µg/ml, and it took 30 hours for him to come out of the coma concentration. Conclusions: DXM is a cough medicine that is frequently used in all over the world. However, there are few reports of overdose, and there have been no cases worldwide such as our case involving 6000 mg overdose. The treatment concentrations are set at 0.01 to 0.04 µg/ml, the toxic concentration 0.1 µg/ml, and the coma-death concentration 3 µg/ml or more, and in our case, at the time of admission, the coma-death concentration had been exceeded to a significant extent. There were no specific treatment methods and symptomatic treatment was the mainstay in this case. In our case also, DHP and CHDF were carried out, but no clear decrease in the toxic concentration was observed. On the other hand, there were reported cases of Naloxone administration in the recovery from respiration and central nervous system problems, and in our case also, its usefulness was indicated because an improvement in spontaneous respiration was observed.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T232

SCORPION STING IN PREGNANCY

S. Sari Gokay 1, T. Celik 1, H.L. Yilmaz 1, R. Kilic 1

Cukurova University Medical Faculty, Department Of Pediatric Emergency Medicine, Adana, Turkey

Background: Scorpion stings in pregnancy are rarely encountered in the pediatric emergency department. Post-sting clinical manifestations range from mild localized skin erythema to life-threatening systemic reaction. We present a case of scorpion sting in a 17 years old, 35 weeks pregnant female evaluated in our emergency department. Methods: A case report Results: The patient presented to our emergency department with localized skin irritation at the site of the sting. No symptoms of systemic involvement were noted in the ED and the patient was admitted to the hospital for further evaluation. No anti-venom was administered during hospitalization and the patient was discharged home in good condition and no adverse effects were noted on the unborn fetus. Conclusions: In pregnant patients with scorpion sting and localized skin irritation following scorpion sting anti-venom may be safely withheld. Decisions regarding the use of anti-venom in pregnant women should be carefully considered given the limited information on the safety profile of anti-venom in these patients and effect on the unborn fetus.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T233

INITIAL SERUM AMMONIA AS A PREDICTOR OF NEUROLOGIC COMPLICATIONS IN PATIENTS WITH ACUTE GLUFOSINATE POISONING

S.J. Kim 1, D.K. Lee 1, H. Youk 1, O.H. Kim 1, J. Go 1, T.H. Kim 2, K.C. Cha 1, K.H. Lee 1, S.O. Hwang 1, Y.S. Cha 1

Wonju College Of Medicine, Yonsei University, Wonju, South Korea, Busan, South Korea

Busan Baik Hospital, Inje University,

Background: Glufosinate poisoning can cause neurologic complications that may be difficult to treat due to delayed manifestation. Studies assessing possible predictors of complications are lacking. Although serum ammonia level is a probable predictor of severe neurotoxicity, it has only been assessed via case reports. Therefore, we investigated factors that predict neurologic complications in acute glufosinate-poisoned patients. Methods: We conducted a retrospective review of 45 consecutive glufosinate poisoning cases that were diagnosed in the emergency department of Wonju Severance Christian Hospital between May 2007 and July 2014. The patients with Glasgow Coma Scale (GCS)<8, seizure, and amnesia, were defined to a neurologic complication group. Results: The neurologic complication group (29 patients, 64.4%) included GCS<8 (27 patients, 60.0%), seizure (23 patients, 51.1%), amnesia (5 patients, 11.1%), respectively. The non-neurologic complications were respiratory failure (14 patients, 31.1%), intubation and ventilator care (23 patients, 51.1%), shock (2 patients, 4.4%), pneumonia (16 patients, 35.6%), acute kidney injury (10 patients, 22.2%), and death (4 patients, 8.9%), respectively. GCS<8, seizure, respiratory failure, and intubation and ventilator care appeared with latent periods within 14 hrs, 34 hrs, 14 hrs, and 48 hrs, respectively. Initial serum ammonia was a predictor of neurologic complications [odds ratio 1.039, 95% confidence interval (1.001-1.078), p=0.046 and area under the curve 0.742]. <FILE IMAGE='311_20150623132618.png'> Conclusions: Neurologic complications developed in 64.4% of patients with acute glufosinate poisoning. The most common complication was GCS<8. Initial serum ammonia level was a predictor of neurologic complications that can be readily assessed in the ED

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T234

DISCHARGE OR OBSERVE?: ENCEPHALOPATHY

DELAYED

PRESENTATION

VALPROIC

ACID

INDUCED

B. Sonmez 1, M. Baba, H.M. Yuzbasi, U. Bal, B. Esfer

Ankara Numune Training And Research Hospital, Department Of Emergency, Ankara, Turkey

Background: Valproic acid acute overdose is a frequency assending drug intoxication. Central nervous system depression ranging from lethargy to coma is the most frequent symptom and can be also due to hyperammonemia. This is a case report of valproate-related hyperammonemic encephalopathy after ingestion of 15 gr valproic acid. Methods: Results: A 36-year-old female patient with a history of epilepsy was referred to our emergency department (ED) 8 hours after intentional ingestion of her own 30 long-acting valproic acid (VPA) tablets. A single dose of 60 mg activated charcoal was given in the ED of other hospital she referred from. On arrival; she was alert with a GCS of 15, a blood pressure of 148/89 mm/Hg, a heart rate of 73 bpm, a body temperature of 36, a glucose level of 132, an initial ECG with no any toxicology-spesific findings. Laboratory results were all within normal ranges. VPA level could not be determined due to the lack of VPA measurement in ED institutionally. A supportive therapeutic approach was considered. During observation in ED, fluctuations in patient’s mental status including lethargy, confusion, stupor were arised. A total of 10 mg intravenous naloxane was applied to reverse the central nervous system (CNS) effects of valproat but no any clinical improvement was observed so a cranial computed tomography (CT) with a serum ammonia level measurement were performed. No any intracranial pathology was detected on CT. Ammonia level was determined as 253 µg/l (upper limit was 90 µg/l). Patient was diagnosed as valproate-related hyperammonemic encephalopathy. L-carnitine was not available and a single session of haemodialysis were performed. Serum ammonia and VPA levels were determined as 29 µg/l and 50.6ug/ml (institutional toxic serum concentration was 120ug/ml), respectively. Patient was hospitalized by intensive care unit (ICU). Conclusions: Valproate-related hyperammonemic encephalopathy is a delayed presentation of valproic acid acute intoxication so prolonged observation of asymptomatic VPA acute overdose patient is appropriate approach and serum ammonia level measurement should be kept in mind with CNS symptoms.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T235

PREVALENCE OF ANALYTICALLY CONFIRMED INTOXICATIONS BY NEW PSYCHO-TOXIC SUBSTANCES IN ITALY: DATA FROM PAVIA POISON CENTRE AND NATIONAL EARLY WARNING SYSTEM

A. Schicchi 1, D. Lonati 1, V.M. Petrolini 1, E. Buscaglia 1, S. Vecchio 1, A. Giampreti 1, O. Maystrova 1, M. Crevani 1, P. Papa 2, T. Coccini 3, G. Ricevuti 4, P. Richelmi 5, C.A. Locatelli 1

Poison Control Centre, National Toxicology Information Centre, Irccs Maugeri Foundation, Pavia, Italy, 2 Laboratory Of Analytical Toxicology, Clinical Chemistry Service, Irccs Policlinico San Matteo Foundation, Pavia, Italy, 3 Laboratory Of Clinical Toxicology, Irccs Salvatore Maugeri Foundation, Pavia, Italy, 4 Residency School Of Emergency Medicine, Department Of Internal Medicine, University Of Pavia, Pavia, Italy, 5 Residency School Of Clinical Toxicology, University Of Pavia, Pavia, Italy Background: Prevalence and severity of patients admitted to the emergency departments (EDs) for new psychoactive and toxic substances (NPTS) is generally unknown and in most cases the standard toxicological screening results negative. The underestimation of this phenomenon could have direct implication on early diagnosis and clinical management. A study was conducted through the national EDs network referring to the Pavia Poison Centre (PPC) in order to evaluate the clinical features and the prevalence of analytically confirmed NPTS intoxications. Methods: All consecutive cases referred to the PPC (Jan 2010-Oct 2014) for suspected/confirmed substances of abuse poisoning were evaluated (n=8.457); cases (n=2.605) presenting history for NPTS or atypical-clinical pictures after old/classical drug abuse were included. Cases were assessed for: age, history, acute clinical manifestations, evolution and toxico-analytical investigations. Cocaine, opiates, cannabis, amphetamine/methamphetamine were defined â&#x20AC;&#x153;old drugsâ&#x20AC;?. Ethanol intoxication and body-packers were excluded. Results: Among 2.605 cases of substances of abuse intoxication, 913/2.605 (35%) met the inclusion criteria. In 324/913 (35%) NPTS were declared; 33% of patient was unable to report the taken substances. The most common clinical manifestations were agitation (43%), tachycardia (35%), hallucinations (23%), mydriasis (21%), gastrointestinal discomfort (17%), drowsiness (17%), mental confusion (15%), coma (14%), seizures (5%) and hyperthermia (4%); 18 fatal cases were registered. Laboratory investigations were performed in 93% of cases; 86% of biological samples/products were delivered to PPC by courier (non-urgent analysis) and 14% were urgent analysis. The NPTS identified were: MDMA (80 cases), ketamine (59), synthetic-cannabinoids (24), methoxetamine (24), caffeine (17), atropine-scopolamine (16), synthetic-cathinones (13), 2C-series (10), GHB/GBL (6), PMA/PMMA (5), benzofurans (3), armine/dimetyltriptamine (2), psilocin/psilocybin (1) and mitragynine (1) Conclusions: The clinico-toxicological evaluation of identified lab-confirmed NPTS intoxications permits regulatory actions by the Department for Antidrug Policies (DPA) and Ministry of Health aimed at prevention and control, such as the inclusion of the NPTS in the list of controlled substances (excluding analogues, 22 new molecules has been controlled from 2010). Acknowledgements: Study carried out with the support of DPA Presidency of the Council of Ministers.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T236

MUSHROOMS POISONING IN ITALY: A TWO-YEAR CASE SERIES (2012-2013) OF THE PAVIA NATIONAL POISON CENTRE.

M. Crevani 1, S. Vecchio 1, A. Giampreti 1, V.M. Petrolini 1, D. Lonati 1, F. Chiara 1, A. Schicchi 1, M. Garbi 1, T. Coccini 2, G. Ricevuti 3, P. Richelmi 4, C.A. Locatelli 1

Poison Control Centre And National Toxicology Information Centre, Toxicology Unit, Irccs Fondazione Salvatore Maugeri, Pavia, Italy, 2 Toxicology Unit, Laboratory Of Clinical & Experimental Toxicology And Poison Control Center, Irccs Maugeri Foundation, Pavia, Italy, 3 Residency School Of Emergency Medecine, Department Of Internal Medecine, University Of Pavia, Pavia, Italy, 4 Residency School Of Clinical Toxicology, University Of Pavia, Pavia, Italy Background: Mushroom poisoning is a major health risk in many countries. At present, the exact incidence of mushroom poisonings in Italy cannot be precisely estimated. The aim of this study is to describe mushrooms poisoning in Italy managed by the Pavia Poison Centre, with particular regards to the mushroom species involved, the patientsâ&#x20AC;&#x2122; clinical course and outcome, and the critical issues in the diagnosis and treatment of these poisonings. Methods: A retrospective review of all cases of mushrooms poisoning referred to Pavia Poison Centre over a 2-year period (2012-2013) was conducted. The included cases were assessed for age, sex, circumstances of exposure, mushroom species involved, clinical picture, latency of symptoms, hospital stay, urine alpha-amanitin detection and outcome. Wild mushrooms not subject to mycological control before ingestion are considered in this study not controlled, whereas those purchased in a shop or consumed at restaurant are referred as controlled Results: During the study period, 1881 cases distributed all over Italy were included (males 48%; average age 45 Âą 20.6 years). Not controlled mushrooms were ingested in 85% of cases (1599/1881). Boletus edulis, genus Agaricus and Armillaria mellea have been the most frequent species referred by patients. Armillaria mellea, Entoloma lividum, Omphalotus olearius and the genera Amanita, Boletus, Clitocybe were the most frequently identified by mycologists at hospital admission. Mortality rate was 0.26%. Six patients (0.31%) required liver transplantation. Ninety-six patients (6%) developed liver damage, all after ingestion of not controlled mushrooms. Most of these patients (82%) manifested gastrointestinal symptoms after at least 6 hours from mushrooms ingestion. Alpha-amanitin in urine resulted positive in all fatal cases, in 62.5% of cases who develop liver damage and in 25.6% of cases with long latency over 6 hours from the meal. Conclusions: Mushrooms poisoning may represent a real life-threatening clinical condition that may require early and specific approach. Latency over 6 hours from meal may represent a predicting factor for severe poisoning. Mycological identification and urine alpha-amanitin are crucial for the management but present some limitations. The interaction of multiple professional figures (emergency physician, clinical toxicologist, mycologist) is needed

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T237

EPIDEMIOLOGY AND CLINICAL CHARACTERISTICS OF HYDROFLUORIC ACID (HF) EXPOSURES: A 6 YEARSâ&#x20AC;&#x2122; EXPERIENCE OF PAVIA POISON CONTROL CENTRE

M. Crevani 1, S. Vecchio 1, A. Giampreti 1, V.M. Petrolini 1, D. Lonati 1, F. Chiara 1, E. Cortini 1, M. Garbi 1, G. Ricevuti 2, P. Richelmi 3, C.A. Locatelli 1

Poison Control Centre And National Toxicology Information Centre, Toxicology Unit, Irccs Fondazione Salvatore Maugeri, Pavia, Italy, 2 Residency School Of Emergency Medecine, Department Of Internal Medecine, University Of Pavia, Pavia, Italy, 3 Residency School Of Clinical Toxicology, University Of Pavia, Pavia, Italy Background: Hydrofluoric acid (HF) is a weak acid, widely used as a rust remover. Poisoning usually occurs after dermal exposure; ingestions are reported. HF penetrates tissues deeply, causing delayed local/systemic effects (hypocalcemia, hypomagnesemia, local bone demineralization). Methods: Retrospective case review of HF exposures from Jan-2007 to Sept-2013. Cases were assessed for: demographic/clinical data, modality of exposure, time to ED-presentation (for domestic exposure), and treatment/outcome. Results: 164 cases were evaluated (84% age >18 ys) and divided in group-A (n=135, domestic exposure) and group-B (n=19, occupational). Group-A: Twenty-six (19%) accidental exposure involved patients <18 years (n=20 <3 years; n=3 3-6 years; n=3 10-18 years). In patients <6 years (14%) the modality of accidental-exposures were ingestion/oral mucosa (57%) and dermal/ocular contact (43%). In adults (n=109) accidental and intentional exposure were registered in 94 and 15 cases, respectively. Accidental exposure involved mainly dermal/eyes (84/94; 89%), ingestion (9 cases) and inhalation (1 case). In dermal/eyes accidental exposure (n=84) ED evaluation was performed within 12 hours in 49 cases (58%), 12-24 hours in 13 cases (16%) and >24 hours in 22 cases (26%). Selected cases were hospitalized for at least 24 hours to rule out systemic hypocalcemia and follow-upped for weeks until healing. No systemic effects and sequelae were noticed. Intentional exposures were characterized by ingestion (14/15) and by dermal/intramuscular injection (1 case). Two lethal cases were registered in intentional ingestion. All exposures regarded domestic products (HF<15%). Group-B: 29 cases were registered (n=23 dermal/ocular, n=6 inhalation) involving products with HF<15% (n=8), 15-30% (n=2) and >30% (n=16); in 4 cases nitric and sulphuric acid were also present. Inhalation exposure was related to respiratory symptoms requiring symptomatic and antidotal (nebulization calcium gluconate) treatment. Two cases required hand plastic evaluation/reconstruction. No lethal cases were documented. Dermal exposure in group-A and group-B were treated with prolonged topical antidote (calcium gel) associated to onychectomy/plastic surgery in selected cases. Conclusions: Serious morbidity and death are documented. Main factors influencing clinical manifestations are concentration, modality of exposure/contact/time/volume, body surface area involved, and association with other caustics. Antidotal treatment with topical calcium gluconate is effective and permits an ambulatory management.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T238

ACUTE INTOXICATIONS BY SYNTHETIC CANNABINOIDS IN THE EMERGENCY SYSTEM: THE ITALIAN CASES SERIES.

A. Schicchi 1, V. Petrolini 1, D. Lonati 1, A. Giampreti 1, S. Vecchio 1, F. Chiara 1, E. Cortini 1, M. Crevani 1, G. Scaravaggi 1, E. Buscaglia 1, P. Papa 2, T. Coccini 3, G. Ricevuti 4, P. Richelmi 5, C.A. Locatelli 1

Poison Control Centre, National Toxicology Information Centre, Irccs Maugeri Foundation, Pavia, Italy, 2 Laboratory Of Analytical Toxicology, Clinical Chemistry Service, Irccs Policlinico San Matteo Foundation, Pavia, Italy, 3 Toxicology Unit, Laboratory Of Clinical & Experimental Toxicology And Poison Control Center, Irccs Maugeri Foundation, Pavia, Italy, 4 Residency School Of Emergency Medecine, Department Of Internal Medecine, University Of Pavia, Pavia, Italy, 5 Residency School Of Clinical Toxicology, University Of Pavia, Pavia, Italy Background: Synthetic cannabinoids (SC) represents approximately 30% of new psychoactive substances (NPS) signaled in the last years. This study take into consideration the clinical manifestations of intoxicated patients by SC at Emergency Department (EDs) admission. Methods: All cases evaluated by EDs network and followed by Pavia Poison Control Centre during a two-year period (January 2010â&#x20AC;&#x201C;December 2012) are included. Symptomatic patients with referred/suspected abuse of SC were included. Demographic data, clinical course and laboratory results (biological sample/consumed substance) were collected. Results: 40 patients (14-55 years) with acute SC intoxications were analyzed. Cases were collected on all national territory. SC were mainly assumed (90%) by smoking and product(s) have bought online in 45% of cases. Advanced laboratory investigations analysis (in order to detect the specific SC) were performed in 32/40 cases (80%). The clinical considerations and the correlation between clinical manifestations and specific SC were performed in the subgroup of patients (21/32) resulted positive for SCs in serum. Main clinical manifestations were: tachycardia >100 bpm (13/21), mydriasis (12/21), anxiousness/agitation (9/21), gastrointestinal symptoms (5/21), hypertension (4/21), hallucinations (3/21); seizures were observed in 5% of cases. No lethal cases were registered. SC identified in serum sample were: JWH-122 (10 cases), JWH-018 (4 cases), JWH-250/JWH-122 (3 cases), JWH-073 (1 case), MAM-2201 (1 case), JWH-018/JWH-122 (1 case), JWH-018/JWH-122/JWH-073 (1 case). Conclusions: SC acute intoxications are an important and confirmed problem in the Italian emergency setting. Clinical diagnosis is difficult and usual screening performed in ED (and for THC) results negative. The Emergency physician plays a key role in making clinical suspicion of SC acute intoxication in order to proceed with second level analysis necessaries to confirm the abuse. According to emerging medical reports, a close monitoring for functional and toxic damages is necessary.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T239

THE POSSIBILITY OF ICHTHYOOTOXICITY FROM REPORT AND LITERATURE REVIEW

WHITING FISH: DIAGNOSTIC CHALLENGE, CASE

A. Sahin 1, Y. Karaca 1, O. Asik 1, S. Arslan 2, S. Turedi 1

Karadeniz Technical University, Faculty Of Medicine, Department Of Emergency Medicine, Trabzon, Turkey, Karadeniz Technical University, Faculty Of Medicine, Department Of Otorhinolaryngology, Trabzon, Turkey

Background: Merlangius merlangus, in the family Gadidae, commonly known as whiting, is an important seafood in the Black Sea region and there is no case report about its toxic effects in the literature. The aim of this case is to report the diagnostic difficulties encountered in a case of seafood poisoning caused by Whiting fish. Methods: We provide a literature review and present the clinical findings, and pertinent laboratory data in a patient with seafood poisoning caused by Whiting fish. Results: A 22-year-old-man, with no medical history and was not on any medications or supplements, presented to emergency department with dizziness, tinnitus, confusion, nausea and vomiting 1 hour after eating whiting fish a restaurant. The patient was hypotensive (75/54 mmHg) and bradycardic (45 bpm). Pupils were dilated, Glasgow Coma Score (GCS) was 14 and IR +/+. Muscle power, light touch and pain sensation in the patientâ&#x20AC;&#x2122;s four limbs were normal. Electrocardiogram (ECG) showed sinus bradycardia. Seven minutes after the administration of atropine and saline, the patientâ&#x20AC;&#x2122;s pulse rate increased to 81 bpm and his blood pressure increased to 118/73 mmHg. Laboratory tests, including a complete blood cell count, metabolic profile, liver function tests, and neuroimaging tests (brain CT and MRI) were normal. All symptoms except dizziness and tinnitus improved, and the patient was admitted to ward for further investigation and monitoring. MRI of ear was normal and severe hearing loss was detected in left ear. Blood analysis was negative for heavy metals (lead, mercury, cadmium) and autoantibodies (ANA, AMA, ASMA, LKM, Anti-ds-DNA). After 7 days, the patient was discharged without any symptoms except hearing loss. Conclusions: This is the first case report the possibility of ichthyootoxicity from Whiting fish in the Black Sea region. Clinicians should be made aware of the risks from seafood poisoning.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T240

DO GRAYANOTOXIN LEVELS IN BLOOD, URINE AND HONEY AFFECT CLINICAL OVERVIEW? A DESCRIPTIVE STUDY

A. Sahin 1, A. Aygun, A. Gunduz, S. Turedi, S. Turkmen, Y. Karaca, A.F. Ayaz, S.Y. Ahn, S. Kim

Karadeniz Technical University, Faculty Of Medicine, Department Of Emergency Medicine, Trabzon, Turkey, 2 Karadeniz Technical University, Faculty Of Science, Department Of Biology, Trabzon, Turkey, 3 Daejeon Institute, National Forensic Service, Daejeon, South Korea Background: ‘Mad honey’ poisoning is a form of intoxication occurring in the Black Sea region. The purpose of this study was to investigate grayanotoxins (GTXs) levels in blood and urine and in honey consumed by patients with mad honey intoxication and to determine whether or not an association exists with clinical status. There are no previous studies showing either toxin levels in honey or the levels of this toxin in patients intoxicated by this natural product. Methods: 25 cases of mad honey intoxication were included in the study. Mad honey, blood and urine samples were obtained from patients intoxicated with GTXs between September 2013 and October 2014. GTXs levels in patients’ blood and urine and in the honey they had consumed were examined simultaneously. GTX 1 and GTX 3 were analyzed on LC-MS/MS systems. Results: The most common symptoms of the patients enrolled in the study were dizziness and nausea. Mean time to symptom onset was 1.79 hours. Comparison of blood, urine and honey GTX 1 and GTX 3 levels between patients with systolic blood pressure below 90 mmHg revealed no significant differences. Level of GTX 3 in blood were significantly higher in patients with heart rates below 50/min compared to those with heart rates above 50/min (p: 0.000). Conclusions: This is a descriptive study and the first to determine grayanotoxin levels in specimens from human body fluids. Large series studies are now needed to provide statistical evidence whether or not a relation exists between levels of toxins in human body fluids and clinical status.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T241

VENOM INDUCED COAGULOPATHY IN VIPERA BERUS ENVENOMING: CASE REPORT AND REVIEW OF LITERATURE

Z. Krejzar 1, I. Zykova 1, D. Morman 1

Regional Hospital - Department Of Anesthesia And Intensive Care Medicine, Liberec, Czech Republic

Background: Coagulopathy can result from snakebite envenoming by Viperid snake, certain Elapids and a few Colubrid snakes. Venom-induced consuption coagulopathy (VIC) caused by procoagulant toxins and resulting in broad spectrum factor deficiencies is the commonest one. Several other types of coagulopathy were described. Vipera berus (Common viper) is widely distributed and causes most of snakebites in Europe. Diverse composition of common European viper venom is responsible for the complex response of organism of bitten person including local painful swelling, bruising and systemic 'anaphylactic ' symptoms like hypotension, nausea, vomiting, abdominal colic, urticaria, bronchospasm and angioneurotic oedema. Signs of neurotoxicity were also reported. Vipera berus venom displayed in vitro proteolytic, fibrinolytic, anticoagulant, and phospholipase A2 activities. Methods: We would like to present a case report of 42 years old woman who suffered Vipera berus snakebite envenoming in the region of Northern Bohemia. She developed surprisingly severe coagulopathy detected and followed using repeated trombelastometry (ROTEM 速) studies. Results: As the picture indicates, ROTEM study performed at admission revealed coagulopathy with obvious hyperfibrinolysis (confirmed by APTEM) <FILE IMAGE='284_20150714150637.jpg'> Loading dose of tranexamic acid 1,0 i.v. with continuos infusion of 1,0g over the next 8 hours was given as a part of symptomatic treatment. Because of shock state progression despite volumotherapy antivenom was administred. Signs of hyperfibrinolysis then diappeared, remained hypofibrinogenemia, profound trombocytopenia developed in the next days. Conclusions: Vipera berus snakebite envenoving has a potential to cause venom induced coagulopathy. We suppose that VIC reflects severity of envenoming and should be taken into account in decision making about antivenom administration. Trombelastometry (ROTEM 速) is excellent tool for diagnostics and treatment guidance.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T242

HEMATOLOGICAL PARAMETERTERS PREDICTING COMPLICATIONS OF CAUSTIC INGESTION: A RETROSPECTIVE STUDY

J. Kim 1, J. Park 2, M. Kim 3, K. Kim 4, J. Park 5, D. Shin 6, H. Kim 7, W. Jeon 8, H. Kim 9, J. Choi 10

Department Of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea, Of Emergency Medicine, Yonsei University College Of Medicine, Seoul, South Korea

Department

Background: In addition to chemical burn of the alimentary tract, caustic ingestion can cause severe complications including esophageal perforation, airway edema, esophageal stricture, and death. Hematological parameters have been reported to be useful inflammatory markers predicting prognoses in various clinical situations where oxidative stress is increased. We hypothesized that hematological parameters might be useful to predict prognoses after caustic ingestion. <FILE IMAGE='257_20150622043310.jpg'> Methods: We performed a retrospective analysis of patients admitted to our Emergency Department after caustic ingestion. The numbers of leukocytes, neutrophils, lymphocytes, and monocytes; and the neutrophil-lymphocyte ratio, were compared between uncomplicated and complicated patient groups. Receiver operating characteristic curve analysis was conducted for parameters that differed between the two groups. Subgroup analysis was performed according to the substance ingested, thus acid or alkali. Results: Thirty-seven patients were included in our study and eight had complications. Leukocyte and neutrophil counts, and the neutrophil-lymphocyte ratio, of the complicated group were higher than those of the uncomplicated group. The areas under the receiver operating characteristic curves of leukocyte counts, neutrophil counts, and the neutrophil-lymphocyte ratio, were 0.819, 0.832, and 0.750, respectively. The cut-off values of these parameters for prediction of complications were 12 060/uL, 9607/uL, and 2.72, respectively. Upon subgroup analysis, the leukocyte and neutrophil counts, and the neutrophil-lymphocyte ratio of complicated patients who had ingested alkali, were higher than those of the uncomplicated group. Conclusions: Leukocyte counts, neutrophil counts, and the neutrophil-lymphocyte ratio might serve as useful predictors of complications after ingestion of caustic substances.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T245

CHARACTERISTICS AND OUTCOMES OF SNAKEBITES AT A TERTIARY CARE HOSPITAL IN LEBANON.

M. El Sayed 1, T. El Zahran 1, A. Al-Hajj Chehadeh 1, Z. Kazzi 2

American University Of Beirut Medical Center,department Of Emergency Medicine, Beirut, Lebanon, University, Department Of Emergency Medicine, Atlanta, Usa

Emory

Background: It is estimated that 5.5 million people are victims of snakebites yearly worldwide resulting in about 125,000 deaths. Few reports of snakebites in the Eastern Mediterranean region exist in the literature. This study describes demographic and clinical characteristics, treatment modalities and outcomes of confirmed cases of snakebite victims treated at a tertiary care hospital in Beirut, Lebanon. <FILE IMAGE='299_20150628215238.jpg'> Methods: We performed a retrospective chart review of patients who presented to the Emergency Department (ED) during the study period (1/1/2000 to 9/30/2014) with a chief complaint of snakebite. Investigators extracted the following data: date of bite, patient’s age and gender, geographical area where the bite occurred, time elapsed from bite until ED presentation, body location of injury, systemic and local manifestations, laboratory findings, severity of envenomation, complications and antivenin administration. Descriptive statistics and frequencies were performed. Results: A total of 24 patients were included in the study. The mean age was 34.6 (± 16.4) years with 58.3 % of male gender. Local manifestations were documented in 15 (62.5%) patients, systemic effects in 10 (41.7%), hematologic abnormalities in 10 (41.7%) and neurologic effects in 4 (16.7%) patients (Table). Nine patients (37.5%) received antivenin (Polyvalent Antivenom-2). The median amount of antivenin administered was 40 ml or 4 vials (1–8 vials). Twelve patients (50%) were admitted to the hospital with 9 (75%) to an intensive care unit and 3 (25%) to a regular bed. All were discharged home with a mean length of stay in hospital of 10.2 (± 14.4) days. Among those admitted, seven patients (58.3%) had at least one documented complication during their inpatient stay, including: compartment syndrome (33.3%), fasciotomy (25%), airway compromise requiring intubation (16.6%), deep vein thrombosis (16.6%), disseminated intravascular coagulopathy (16.6%), acute respiratory distress syndrome (8.3%), sepsis (8.3%), congestive heart failure (8.3%), cellulitis (8.3%), upper gastrointestinal bleed (8.3%) and vaginal bleed (8.3%). Conclusions: In this study, victims of snakebites developed local, systemic, hematological or neurological manifestations. Antivenin was administrated. Complications from the snakebite were frequent. Larger studies are needed to establish better guidelines for the treatment of snakebites in Lebanon.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T246

CONCIOUS PATIENT WITH LETHAL CARBOXYHEMOGLOBINE LEVEL

N.R. Disel 1, E.Ă&#x2021;. Direk 1, A. Sebe 1, A.A. Akpinar 1, S. Acele 2

Cukurova University Faculty Of Medicine, Department Of Emergency Medicine, Adana, Turkey, Government Hospital, Emergency Service, Adana, Turkey

Cukurova

Background: Carbonmonoxide poisoning (COP) is a serious condition which is usually underdiagnosed, especially when exposure is not well questioned by the clinician. Delays in diagnose and treatment may be life-threatening. Here, we present a case with extremely high carboxyhemoglobine levels, to the best of our knowledge, the highest ever reported in a conscious patient. Methods: Case report: A-37-year-old woman was admitted to emergency department with the complaint of dyspnea. She was conscious with normal skin colour and appearance. Her physical examination was normal with normal vitals. She was a heavy smoker (20 pack-year history of smoking) and previously healthy adult without any chronic respiratory diseases. When questioned deeply, it was learned that she was working in a small unventilated room near to a working power generator for the last 6 hours. Her arterial blood gase analyse revealed 80% COHb with a control confirmation. Her chest X-ray and ECGs were normal. She was started 100% oxygen by a nonrebreathable mask and hospitalized for further evaluation and hydration. Her blood tests were in normal limits and her complaints resolved in the following three hours. The patient was discharged with COHb 6% before planned, when she felt better and wanted to go. Results: Discussion:Carbonmonoxide poisoning may not be diagnosed when patients do not give proper anamnesis of exposure. Questioning patients with chest pain, headache, dizziness, dyspnea, nausea, vomiting, seizures and altered mental status may help more patients to be diagnosed as COP. Although carboxyhemoglobine level alone do not correlate with clinical status of patients, levels >70% are classified as severe toxicity that cause consioussness, seizures and fatalities. Victims with COHb levels higher than 40% (> 25% in pregnants) are candidates for hyperbaric oxygen treatment. Despite the literature and previously reported cases, our patient had extremely high level of COHb with relatively little discomfort and complaints. Conclusions: COP should be kept in mind in patients complaining dyspnea. This case has the highest ever reported COHb level without any mental, cardiac or systemic abnormality.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T247

ROLE OF INTRAVENOUS LIPID EMULSIONS IN THE MANAGEMENT OF CALCIUM CHANNEL BLOCKER AND BETA BLOCKER OVERDOSE: THREE YEARS EXPERIENCE OF A UNIVERSITY HOSPITAL

A. Sebe 1, N.R. Disel 1, A.A. Akpinar 1, E. Karakoc 2, M.G. Karanlik

Cukurova University, School Of Medicine, Emergency Medicine, Adana, Turkey, 2 Cukurova University, School Of Medicine, Internal Medicine, Intensive Care Unit, Adana, Turkey, 3 Ceyhan Government Hospital,emergency Clinic, Adana, Turkey Background: The objective of this study was to assess the efficacy of lipid emulsion as antidotal therapy in severe calcium channel blocker (CCB) and beta blocker (BB) intoxications. <FILE IMAGE='338_20150629125120.jpg'> Methods: This is a retrospective study in which we have summarized data of patients who were admitted to a university-based emergency department in a period of 3 years and were given intravenous lipid emulsion (ILE) to manage cardiogenic shock due to CCB and BB overdose. Results: We identified 15 patients who received ILE therapy for CCB and BB toxicity. Hospitalization durations variated between 3 and 33 days (mean 7.46 Âą 7.41 days). Drug exposures included CCBs (n = 8, 53.3%), CCBs and paracetamol (n = 1, 6.6%), and BBs (n = 6, 40%). ILE therapy was effective in 12 patients (80%). Three patients (20%) had resistant hypotension, one of whom progressed to pulmonary edema. Adverse effects of ILE therapy were seen in three patients (20%). Two patients underwent mechanical ventilation. Two patients developed hypoxic ischemic encephalopathy, one patient died, and 14 patients (93.3%) were discharged from hospital. Conclusions: There was 93.3% survival in patients receiving ILE for drug-induced cardiovascular collapse. Clinically significant adverse effects were uncommon. We suggest ILE administration for the treatment of cardiogenic shock due to CCB and BB overdose.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T248

THERAUPETHIC PLASMA EXCHANGE IN POISONING: SEVEN YEARSâ&#x20AC;&#x2122; EXPERIENCE OF A UNIVERSITY HOSPITAL

N. Disel 1, A.A. Akpinar 1, A. Sebe 1, E. Karakoc 2, S. Surer 1, S. Matyar 3

Cukurova University Faculty Of Medicine, Department Of Emergency Medicine, Adana, Turkey, 2 Cukurova University Faculty Of Medicine, Department Of Internal Medicine, Intensive Care Unit, Adana, Turkey, 3 Cukurova University Faculty Of Medicine, Biochemistry Division Of Central Laboratory, Adana, Turkey Background: This study examined the extracorporeal methods for the elimination of toxic substances in poisoning patients that are used by clinicians taking care of such patients. Here we present our experience in the utilization of theraupeutic plasma exchange (TPE). To the best of our knowledge, this is the largest number of poisoning cases ever reported in a study. <FILE IMAGE='338_20150629121204.jpg'> Methods: This is a retrospective study conducted at the Ă&#x2021;ukurova University Faculty of Medicine, Department of Emergency Medicine, with the permission of the ethical committee of the medical faculty. The study includes patients who had undergone TPE because of poisoning between January 2007 and May 2015. We summarize the clinical data and outcomes of the patients with available files. Results: A total of 36 cases among the 42 patients who underwent TPE in this seven-year period were included in the study. More than 20 identified toxic substances, the majority of which were pesticides, were found to be the causes of poisoning. Twenty-three healthy discharges, and twelve deaths, are discussed in the study. Conclusions: We believe that our study reports the largest ever number of poisoning cases treated with TPE in the literature. When applicable, TPE may be a promising extracorporeal elimination and treatment technique in poisoning patients when performed in selected cases.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T249

UNA FONTE OCCULTA DI CATECOLAMINE

E. Colonetti 1, G. Maruelli 1, A. Lamera 1, A. Comaglio 1, L. Verzeri 1, A. Paini 2, M. Salvetti 1, M.L. Muiesan 1

Università Degli Studi Di Brescia, Brescia, Italy, 2 Spedali Civili Di Brescia, Brescia, Italy

Background: Una donna di 23 anni, viene trasferita presso la nostra Divisione Medica proveniente da un ospedale di medie dimensioni della provincia di Brescia con diagnosi di sospetto paraganglioma/feocromocitoma. Methods: La paziente era stata ricoverata per episodi ricorrenti di tachicardia parossistica sopraventricolare e/o dolore toracico, ipokaliemia, rialzi glicemici transitori e riscontro ripetuto di valori di pressione arteriosa (PA) superiori alla norma (valutazioni ripetute presso ambulatorio ipertensione della stessa azienda ospedaliera). Alcuni mesi prima era stata ricoverata presso lo stesso ospedale per insufficienza ventricolare sinistra acuta con alterazioni ECG, elevazione dei valori di troponina I e quadro di grave compromissione della funzione VS con EF 15 %, trattata con contropulsatore aortico; una coronarografia aveva evidenziato coronarie angiograficamente indenni. I valori di PA erano risultati per lo più entro i limiti di norma durante la degenza, con tendenza ad ipotensione nel periodo con disfunzione sistolica VS acuta. In occasione di tale ricovero riscontro di adrenalina urinaria 56 mcg/24h (le altre catecolamine e metanefrine entro i limiti). Una RM dell’addome non aveva evidenziato masse compatibili con feocromocitoma o paraganglioma. Results: Durante il ricovero presso la nostra Divisione la scintigrafia con MIBG risulta negativa e la paziente viene dimessa in attesa dei risultati relativi ad ulteriori dosaggi di catecolamine e metanefrine urinarie (precedenti dosaggi forse eseguiti dopo labetalolo) che pervengono alcuni giorni dopo e mostrano valori superiori alla norma di adrenalina e metanefrina urinarie. La paziente viene perciò nuovamente ricoverata presso il nostro reparto ed al monitor si rilevano episodi di tachicardia sinusale e, in prima mattina, un episodio di verosimile TPSV. Il nuovo dosaggio di catecolamine e metanefrine evidenzierà valori elevati di adrenalina 0.101 mg/24h e metanefrina 0.473, con normali livelli di cromogranina. Una TC multislice dell’addome risulta normale. In occasione di un colloquio privato si sottolinea alla paziente la incongruenza dei dati bioumorali con quelli derivati dall’imaging e si ottiene il consenso ad ispezionare congiuntamente gli effetti personali, si rinviene una scatola contenente fiale di adrenalina parzialmente utilizzate. Conclusions: La fonte occulta di catecolamine? L’armadietto della paziente

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T250

CHARACTERISTICS OF ELECTROCARDIOGRAPHIC CHANGES IN MYOCARDIAL INJURY WITH ACUTE CARBON MONOXIDE POISONING

H. Choi 1, H. Park 1, J. Ryu 1, I. Choi 1

Dankook Univrtsity Hospital, Cheonan, South Korea

Background: Electrocardiographic findings such as Tp-Te interval, Tp-Te dispersion, and Tp-Te/QT ratio, could be used to predict the dysrhythmic events as to any kind of toxic materials. We investigated the prevalence of cardiac toxicity related to acute carbon monoxide (CO) poisoning and the characteristics of electrocardiographic changes correspondence to the severity of intoxication. Methods: This retrospective observational study was conducted with 113 patients of acute CO poisoning from May, 2013 to July, 2014. Myocardial injury (MI) was determined based on an elevation of serum troponin T within the first 24 hours of ED visit. Study population was classified according to an Acute Neuropsychiatric Status (ANS) scoring: a mild intoxication group (ANS scores were 0 and 1) and a severe intoxication group (ANS scores were 2 and 3). Results: Prevalence of MI was higher in the severe intoxication group of acute CO poisoning (p<0.001). QTc was significantly prolonged in the MI group (p=0.007). But there were no differences on other electrocardiographic parameters between MI group and non-MI group. <FILE IMAGE='352_20150630055046.jpg'> Conclusions: Myocardial injury was combined more frequently with a severe intoxication group of acute CO poisoning compared to a mild intoxication group. Specific feature of eletrocardiogram in the myocardial injury with acute CO poisoning was a QTc prolongation.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T251

INTRALIPID THERAPY: A RAPID REVERSAL IN BISOPROLOL AND ESCITALOPRAM TOXICITY

Y. Eyinc, F. Doganay, A.D. Kocaturk, M. Buyukkal, E. Unal Akoglu, O. Ecmel Onur, R. Ak

Fatih Sultan Mehmet Education And Research Hospital, Istanbul, Turkey

Background: Escitalopram is an antidepressant of SSRI and Bisoprolol is a drug belonging to the group of beta-blockers. While escitalopram has metabolites which causes QT prolongation, bisoprolol has both lipid and water-soluble properties and it’s overdose is also associated with a number of predictable adverse effects including bradycardia, hypotension and prolongation of QT interval, even at therapeutic doses. We report a suicidal attempt with both bisoprolol and escitalopram overdose, which has prolonged QTc, hypotension, low GCS and treated succesfully with intralipid therapy. Methods: A 48 years old woman presented to emergency deparment approximately 30 minutes after intentionally ingesting 10 of 10mg bisoprolol and 14 of 20mg escitalopram tablets in a suicide attempt. The medication was prescribed to her for treatment of depression and hypertension. Vital signs were as follows: 36,5°C, blood pressure: 133/82 mmHg, pulse:60bpm, respiratory rate: 20 per minute, sp02:%98. Physical examination revealed an alert and oriented woman with Glasgow coma scale score of 15. The remainder of the physical examination was unremarkable. The initial electrocardiogram (ECG) revealed sinus rhythm of 69 with no ischemic changes and a prolonged QTc (510 msec). Initial laboratory investigations showed no remarkable results. Routine toxicology screening was normal. Gastric lavage was performed and the patient was given 50 grams of activated charcoal by NG tube. During 2 hour follow-ups in ED, her GCS score decreased by 5 points (E2M5V3), BP was 91/55 and heart rate was 50bpm. In her stay she was only treated with IV saline and intralipid without any further medication. After administrating %20 intralipid with a boluse dose of 100 ml and infusion of 0.25ml/kg/min for 30 minutes, her ECG revealed a sinus rhythm with QTc (387 msec), BP of 145/88 mmHg, pulse: 83 bpm and her GCS score improved to 15. She was admitted to the intensive care unit for further monitoring and supportive treatment. Results: 1 Conclusions: As intralipid fat emulsions provide a fast-acting and effective “Lipid Sink” for fat-soluble drugs, they may be considered as first-line treatment rather than the classical regimen of atropine, vasopressors and high-dose insulin.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T252

A NEW APPROACH TO SYNTHETIC CANNABINOID TOXICITY

F. Doganay, R. Ak, Y. Eyinc, E. Unal Akoglu, O. Ecmel Onur

Fatih Sultan Mehmet Education And Research Hospital, Istanbul, Turkey

Background: Synthetic cannabinoids have been popular since 2004 in Europe, and were first reported in the U.S. in December 2008. Acute intoxication with synthetic cannabinoids is a clinical diagnosis. Synthetic cannabinoids have serious neuropsychiatric toxicity potential, like hallucinations, delirium, psychosis, agitation and seizures. Intravenous lipid emulsion therapy (iv lipid) has been used for nutrition support in the past. Since 1998, iv lipid has also been used as a resuscitative agent for cardiac and/or neurologic toxicity of xenobiotics. This case illustrates resolving neurologic toxicity of Synthetic cannabinoids with only iv lipid. Methods: A 47-year-old man presented to the emergency department (ED) with altered mental status after using a synthetic cannabinoid named as Bonzai. There was no remarkable past medication history.Blood pressure was 110/70 mmHg , pulse rate was 91 beats per minutes, body temperature was 36,8째C, oxygen saturation was 95%. He had a Glascow Coma Scale (GCS) score of 8. In his physical exam, there was no pathology except low GCS score. His Electrocardiography and his laboratory results were normal. We decided to give only iv lipid. No other medications were given. 1,25 ml/kg bolus of %20 lipid and followed with infusion of 0,5ml/kg/minute for 40 minutes. After iv lipid infusion, his GCS score improved to 15 in forty minutes, The patient did not have any symptoms of synthetic cannabinoids toxicity in his follow-ups for 24 hours in the ED. Results: 1 Conclusions: There is no specific antidote for intoxication with synthetic cannabinoids. iv lipid available for the patients with cardiac and/or neurologic toxicity of SC intoxication.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T253

VENLAFAXINE OVERDOSE: CAN INTRALIPID THERAPY REDUCE THE QTC?

R. Ak, Y. Eyinc, F. Doganay, E. Unal Akoglu, H. Demir, T. Cimilli Ozturk, O. Ecmel Onur

Fatih Sultan Mehmet Education And Research Hospital, Istanbul, Turkey

Background: Venlafaxine, a bicyclic hydroxycycloalkylphenylethylamine derivative antidepresant, has serotonin, norepinephrine, and dopaminergic reuptake inhibition properties. Most patients overdosing with venlafaxine develop only mild symptoms. It is associated with a number of predictable adverse effects that are generally mild, including tachycardia, increased blood pressure, fatigue, headache, dizziness and dry mouth. In healthy young adults, venlafaxine is capable of prolonging the QT interval, particularly at doses >200 mg daily. We report a venlafaxine overdose which has a prolonged QTc and treated succesfully with intralipid therapy. Methods: A 41 years old woman presented to emergency deparment approximately 30 minutes after intentionally ingesting twenty tablets containing 150 mg venlafaxine/tb in a suicide attempt. The medication was prescribed to her for treatment of depression. She had no other medical problems and took no other medications. Vital signs were as follows: 36,5째C, blood pressure: 140/85 mmHg, pulse:119 beats per minute, sp02:%98. Physical examination revealed an alert woman in no distress with clear lungs, a soft abdomen, and a non-focal neurologic examination. Cardiac exam revealed tachycardia with a regular rhythm. Fifty grams of activated charcoal was administered orally. The initial electrocardiogram (ECG) revealed sinus tachycardia with no ischemic changes and a prolonged QTc (511 msec). Hemogram, biochemistry and cardiac panel was normal. After administration a boluse dose of 100 ml %20 intralipid, an ECG revealed sinus rhythm with a QTc (456 msec). She was admitted to the intensive care unit for further monitoring and supportive treatment. Results: 1 Conclusions: Venlafaxine poisoning is associated with a high prevalence of cardiovascular adverse events. There is no spesific antidote for venlafaxine overdose, so intralipid therapy can be an effective antidote for venlafaxine such as other lipophilic drug intoxication.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T254

ACUTE CLENBUTEROL INGESTION RESULTING IN CARDIAC TOXICITY

D. Ageib 1, W. A

Imam Abdulrahman Bin Faisal National Guard Hospital, Dammam, Saudi Arabia

Background: BACKGROUND: Clenbuterol is a long-acting beta2-adrenergic agonist mainly used in veterinary medicine in the United States. Recently, it has become a common drug of abuse by body builders due to its known lipolytic and anabolic effects. We are presenting a case of a patient demonstrating cardiac toxicity associated with acute clenbuterol ingestion. Methods: CASE REPORT: A 20 year-old man presented to our emergency department approximately one hour after drinking a juice mixed with an unknown amount of Clenbuterol offered to him by his friend to increase his muscle mass. The patient’s father brought the drug with him to the physician and the patient denied any current use of anabolic medication or steroids. He presented with complaints of palpitations, shortness of breath and vomiting. Vital signs upon examination were as follows: blood pressure, 141/59 mmHg; heart rate 149 bpm; respiratory rate, 24 bpm; Temperature was normal; and oxygen saturation, 99% on ambient air. His electrocardiogram demonstrated sinus tachycardia with a heart rate 149 bpm. Laboratory studies showed a high troponin I, 0.84 ug/L; and creatinine phosphokinase, 2223U/L. The rest of the results including potassium, magnesium, phosphorus, serum glucose, creatinine, hemoglobin and liver enzymes were all normal. The patient's urine toxicology screening was negative for any drugs of abuse. Clenbuterol levels were not obtained as it was not available. Although, the patient’s creatinine phosphokinase was high, the renal function and potassium were normal all the time. A transthoracic echocardiogram was normal and the patient was discharge home 48 hours later after he has been treated with intravenous fluids and metoprolol and his troponin decreased. Results: Clenbuterol is approved for use in some countries as a bronchodilator for the treatment of acute asthma exacerbations. However, it’s over dose and abuse has been associated with many adverse effects including the cardiac toxicity. Conclusions: CONCLUSION: Considering Clenbuterol as a new emerging drug of abuse, physicians need to know more information about its toxicology.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Toxicology / Environmental Injury

T255

IDENTIFICATION OF AN INDEPENDENT PROGNOSTIC MARKER IN PATIENTS WITH SEVERE METFORMIN POISONING.

T. Valobra 1, G. Acquistapace 1, 2, M. Rossi 1, 2, A. Manelli 1, S. Paglia 1, G. Ricevuti 2

Ao Lodi - Usc Pronto Soccorso, Lodi, Italy, 2 Emergency Medicine School, Pavia, Italy

Background: Metformin is a biguanide anti-hyperglycemic agent that decreases insulin resistance. Itâ&#x20AC;&#x2122;s removed through renal mechanisms and its clearance is reduced in renal failure. Metformin ingestion should always be considered in the differential diagnosis of any patient with metabolic acidosis and increased lactate level. The main objective of the study is identificate a prognostic marker for metformin-intoxicated patients, useful to identify the level of intensity of care most suitable for this type of patients. Methods: A retrospective study on metformin-intoxicated patients treated in the Emergency Department (ED) of Lodi and Niguarda was conducted. 16 patients with lactic acidosis and acute renal failure were included. Patients were divided for outcome (alive or dead at 15 days to ED access). Results: As historically documented, renal function, pH, lactate and metformin concentration well as age, comorbidities and presenting access symptoms donâ&#x20AC;&#x2122;t correlate with the short-term prognosis of our patients. Otherwise the monitoring of vital signs throught New Early Warning Score (NEWS) is significantly associated with patient outcomes both to the access (p=0.003) and to the pre-dialysis evaluation (p=0.0002). Moreover, time elapsed between ED access and first gasanalysis (EGA) execution (defined for us as diagnosis time) inversely correlates with prognosis. Finally, the difference between first and second NEWS evaluation and the difference between time of ED access and first EGA execution significantly associate (p=0.002), showing that an early suspected diagnosis will positively affect patient clinical evolution, decreasing the possibility of adverse events. <FILE IMAGE='345_20150629235952.jpg'> Conclusions: In metformin intoxication, the early diagnosis plays a particular importance. Our study confirms the correlation between the earliness of suspicion and prognosis, emphasizing the importance of the identification of lactic acidosis by EGA. A NEWS calculated on the first ED parameter greater than 7, similar to those documented in other clinical settings, significantly correlated with adverse prognosis in these patients. We also documented a linear relation between the increase of the first and last NEWS evaluation and the time elapsed before EGA, indirectly confirming how the diagnostic delay correlates with a worse prognosis. NEWS correlates significantly with the prognosis both at presentation and for evolution.