Poster Abstracts - Wednesday

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Airway / Analgesia / Anesthesia /Sedation / Pain Management

W256

A COMPARISON BETWEEN ANALGESIC EFFECT OF INTRAVENOUS ACETAMINOPHEN VERSUS INTRAVENOUS MORPHINE SULFATE FOR ISOLATED DIAPHYSIAL LONG BONE FRACTURES

B. Zarmehri 1, M. Talebi Doluee 1, B. Rezvani Kakhki 1, M. Salehi 2, M. Talebi 3

1

Mashhad University Of Medical Sciences-Department Of Emergency Medicine, Mashhad, Iran, 2 Mashhad University Of Medical Sciences-Department Of Community Medicine, Mashhad, Iran, 3 Mashhad University Of Medical Sciences-Department Of Psychiatry, Mashhad, Iran Background: To compare the analgesic effect of intravenous acetaminophen with intravenous morphine sulfate in patients with traumatic diaphysial long bone fracture.

Methods: This double-blind randomised clinical trial addressed the analgesic effect of intravenous acetaminophen comparing with intravenous morphine sulfate in patients with isolated diaphysial long bone fracture in an urban trauma center of Mashhad city,Iran, for February-June 2013. The patients were 18-65 years old with isolated long bone diaphysial fracture, received acetaminophen 15 milligrams per kilograms weight or morphine sulfate 0.1 milligrams per kilograms weight randomly. The pain severity measured with visual analogue scale before drug administration and then 5 and 30 minutes after drug administration. Then the results were compared.

Results: 50 patients were recruited over 5 months. The pain severity was estimated with visual analogue scales before and 5 and 30 minutes after injection. Significant difference was observed between the group receiving intravenous acetaminophen compare with the morphine sulfate group after 5 minute of analgesic administration (P<0.0001) but there was no significant difference in pain severity after 30 minutes between two groups(P= 0.851).

Conclusions: It seems that the analgesic effect of intravenous acetaminophen is comparable with intravenous morphine sulfate in isolated diaphysial long bone fracture.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Airway / Analgesia / Anesthesia /Sedation / Pain Management

W257

A COMPERATIVE STUDY OF THE EFFECTS OF INTRAVENOUS MORPHINE AND KETROLAC ON THE PAIN CONTROL IN PATIENTS WITH LONG BONES FRACTURES

B. Masoumi 1, B. Farzaneh 1, K. Golshani 1, R. Azizkhani 1, K. Heidari 2

1

Isfahan University Of Medical Sciences, Isfahan, Iran, Tehran, Iran

2

Shahid Beheshti University Of Medical Sciences,

Background: Morphine is the most common analgesic used for pain control of patients. Such analgesics have risk of dependency and sedative effects. Ketorolac has analgesic and anti-inflammatory properties without sedative Effects. <FILE IMAGE='31_20150429012940.jpg'> Methods: This is a double-blind clinical trial study conducted in 2014 on 88 patients referring to emergency department due to long bone fractures.The pain scores before the injection and at 5 minutes, half an hour and one hour after the injection were measured and recorded for all patients.

Results: According to the T-test, the mean pain score has no significant difference in the two groups before the injection. The pain score did not differ at 5, 30, and 60 minutes after the injection in both groups too. ANOVA with repeated test also showed that the trend of changes in pain score had no significant difference in both groups (P=0.08).

During the study, 22 patients received the additional dose of the drug wherein 14 individuals belonged to the morphine group and 8 ones to the Ketorolac group (31.8% vs. 18.2%); however, according to the Chi square test, the receipt of additional dose of analgesic was not significantly different in the two groups(p=0.11).

According to the Chi square test, the incidence of complications had a significant difference in both groups (P=0.001). The complications observed in patients included nausea, vomiting, dyspnea, and hypotension in 11, 3, 2, and 3 cases, respectively that according to the Fisher's exact test, the incidence of nausea had a significant difference in both groups (P=0.024).

Conclusions: The results revealed that compared to morphine, Ketorolac is more cost-effective in pain relief in organ damage. Therefore, considering the important role of inflammatory mediators in the creation of pain and a lot of side complications of opioids, with appropriate anti-inflammatory properties and fewer side complications, Ketorolac is an appropriate replacement for the reduction of pain in patients with long bone fractures. Especially, in cases where taking opioids has the possibility to create complications, Ketorolac is an appropriate analgesic and can be used depending on the physician discretion and patient's condition.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Airway / Analgesia / Anesthesia /Sedation / Pain Management

W258

KETOPROFEN VERSUS DICLOFENAC IN IN THE TREATMENT OF RENAL COLIC: DOUBLE-BLIND RANDOMIZED FORWARD-LOOKING COMPARATIVE STUDY

C. Jebali 1, N. Ibn Hassine 1, N. Chbili 1, L. Boukadida 1, A. Zorgati 1, R. Boukef 1

1

Emergency Department Of Sahloul, Sousse, Tunisia

Background: The renal colic of the adult is a frequent lombo-abdominal painful syndrome in emergencies.

Treatment is based on nonsteroidal anti-inflammatory drug (NSAID) but the choice between different NSAIDs remains a subject of controversy. Our aim was to compare the efficiency and the tolerance of two intramuscularly NSAIDs in renal colic.

Methods: A randomized controlled clinical trial, single-center double-blind realized in emergencies service over an 8 month period. was included: Age > 16 years with a visual analogue scale (VAS) > 5 . Exclusion criteria: Pregnant, renal failure or known hepatic, known or suspected allergy to NSAIDs, known peptic ulcer, hemorrhagic. all patients was randomized in to 2 groups: GK (Ketoprofen): a 5 ml syringe with an ampoule 100 mg / 2 ml + 1 ml of S.G 5%. GD (diclofenac): a 5 mL syringe containing a bulb of 75 mg / 3 ml. The route of injection was intramuscularly. If VAS > 3 after 40 mn, 1 g of paracetamol slow intravenous was administered to the patient. Primary outcomes were successful treatment, time to resolution of pain and VAS drop percentage.

Secondary outcomes were the occurrence of side effects.

Results: We have included 80 patients. Indeed, the average age was 39 Âą 13 years for GK versus 43 Âą 14 years for GD. The mean VAS on admission was also similar in both arms. We objectified a therapeutic success rate of 92% in both groups. This success was similar in both arms with a slight tendency for the ketoprofen group. The use of rescue medication was 32.5% in the GK versus 47.5% in the GD (P=0.17). We have observed in 46% (n = 37) of the study population side effects. These effects were only minor and no major intolerance expression was registered.

Conclusions: The effect of anti-inflammatory drugs on the efficacy and tolerance in the treatment of renal colic was the same for diclofenac and ketoprofen. Other factors such cost, side effect profile, and personal preference may be taken into consideration in the choice of treatment.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Airway / Analgesia / Anesthesia /Sedation / Pain Management

W259

PREDICTIVE VALUE OF TRACHEAL RAPID ULTRASONOUND EXAM PERFORMED IN THE EMERGENCY DEPARTMENT FOR VERIFICATION OF TRACHEAL INTUBATION

B. Masoumi 1, B. Zargar Kharazi 1, K. Golshani 1, M.D. Sharifi 2, A.M. Hashemian 2

1

Isfahan University Of Medical Sciences (iums), Isfahan, Iran, (mums), Mashad, Iran

2

Mashhad University Of Medical Sciences

Background: Background: Verification of the correct placement of the endotracheal tube (ETT) has been one of the most challenging issues of air way management in the field of emergency medicine. Early detection of this oesophageal intubation through a reliable method is important for emergency physicians.

Objectives: The aim of this study was to assess the diagnostic accuracy of tracheal rapid ultrasound exam (TRUE) to assess the endotracheal tube misplacement during emergency intubation.

Methods: Methods: This was an observational prospective study being performed at the emergency department of the Alzahra tertiary referral university hospital. We included a consecutive selection of 100 patients. TRUE was performed for all these patients, and subsequently, quantitative waveform capnography have been done.

The later test was considered as the gold standard.

Results: Results: From our total 100 eligible patients, 93(93%) participants had positive TRUE results (tracheal intubation) and 7(7%) patient had negative TRUE results (esophageal intubation). Quantitative waveform capnography report of all 93 (100%) patients who had positive TRUE were positive (appropriate tracheal placement). Sensitivity, specificity, PPV and NPV of TRUE for detecting appropriate tracheal placement of ETT were 98.9%, 100%, 100% and 85.7%, respectively.

Conclusions: Conclusion: Performing TRUE is economical, convenient and feasible in approximately all emergency departments and pre-hospital settings. Based on its high predictive values, it is recommended that emergency physicians could trust more on its results and apply it as the primary method in the assessment of proper ETT placement.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Airway / Analgesia / Anesthesia /Sedation / Pain Management

W260

PREHOSPITAL TRAUMA ANALGESIA: RESULTS OF AN SURVEY ON THE TERRITORY OF PADUA SUEM-118

C. Dalla Vecchia 1, V. Pietrantonio 2

1

Mater Misericordiae University Hospital, Dublin, Ireland, 2 Università Degli Studi Di Padova, Padova, Italy

Background: Pain is a common condition in the prehospital setting and its treatment is often inefficient and not significant. Other than obvious ethic motivations an adequate and early treatment of pain in the prehospital setting guarantees a reduction of effects due to the sympathetic nervous system’s activation, all potentially harmful in an already critical patient.

Methods: we did an observational study from June 2012 to May 2013. We asked to physicians after every transport by road or helicopter of a trauma patient to fill a properly studied chart containing pain level, vital signs, analgesic therapy administered and insurgence of adverse effects such as alterations on vital signs, hypoventilation and vomit. For pain evaluation we used the Verbal Numerical Rating Score (VNRS) for conscious patients and the Critical Pain Observation Tool (CPOT) for unconscious and/or intubated patients.

Evaluations had been made on the arrival on target, after leaving the target (reevaluation) and at the arrival on the emergency department.

Results: we collected 58 charts. Analgesic therapy had been administered in 56 cases (97%). Pain passed from severe to mild-moderate in 90% of the cases evaluated with VNRS and in 89% of patients evaluated with CPOT the score was lowered at the arrival to the emergency department. The mean VNRS score dropped from 7,65 to 3,82 and the mean CPOT score passed from 5,16 to 1,78 , after pain treatment. Fentanyl was the most used drug at the median dose of 1,89 mcg/Kg with a range from 0,83 mcg/Kg to 3,07 mcg/Kg. Doses of 4 mcg/Kg had been used for intubated patients. No worsen of clinical conditions and on vital signs have been seen after therapy. Naloxone or any antiemetic drugs have never been used during the study and no adverse effects due to treatment have been seen.

Conclusions: Analgesia demonstrated to be safe and effective for trauma patients. Data encourage to follow this direction, extending the study and possibly establishing a guideline for prehospital acute pain treatment to suggest to all the personnel working in the Padua SUEM-118 emergency service’s territory.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Airway / Analgesia / Anesthesia /Sedation / Pain Management

W261

EMERGENCY DEPARTMENT FEMORAL NERVE BLOCKS FOR ACUTE HIP FRACTURE PAIN: A RANDOMIZED CONTROLLED TRIAL

K. Todd 1

1

University Of Texas Md Anderson Cancer Center, Houston, Usa

Background: Hip fractures are a significant source of morbidity and mortality among older individuals and poorly controlled pain is associated with delirium, delayed functional recovery, and increased healthcare costs. In this multicenter single-blind randomized controlled trial among older adults with acute hip fractures, we compared femoral nerve blocks (FNB) to usual care with conventional opioid therapy (COT). Outcomes included pain, opioid requirements, functional recovery, delirium, side effects, and hospital length of stay.

Methods: The study was conducted in three emergency department sites in New York City. Single shot FNBs were performed using 20 mL of 0.5% bupivacaine. All subjects were allowed intravenous opioids as needed.

Pain intensity was assessed using 11-point numerical rating scales and pain relief by six-point ordinal scales at baseline and hours two and three after enrollment. Patients were interviewed daily following admission with respect to pain at rest, pain with walking, and pain on transfers. Distance able to be walked in 2 minutes was assessed at post-operative day 3. Opioid requirements were calculated as morphine equivalents per hour using standard equianalgesic tables for conversions. Opioid-related side effects were assessed using 4-point scales (none to severe) and delirium by the Confusion Assessment Method.

Results: 161 subjects were randomized, and 153 subjects had analyzable data including 81 in the control arm and 72 in the intervention arm. COT and FNB subjects had similar baseline characteristics and reported similar average baseline pain intensities. No complications of FNB were seen. Subjects receiving FNB reported lower pain intensity and higher levels of pain relief during the ED stay. FNB subjects reported lower levels of pain, fewer opioid-related side effects, and improved mobility in the post-operative period. Improvements in FIM locomotion scores persisted at 6-weeks post hospital discharge, while analgesic outcomes were similar.

Conclusions: In the management of acute hip fractures, an approach involving early femoral nerve blocks performed by emergency physicians results in superior analgesic outcomes, reduced side effects, and improved mobility in the acute and post-operative periods when compared to conventional opioid therapy.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Airway / Analgesia / Anesthesia /Sedation / Pain Management

W262

ANALGESIC USE IN SIX URBAN EMERGENCY DEPARTMENTS: PAIN MANAGEMENT FOR PATIENTS WITH BILIARY COLIC, BOWEL OBSTRUCTION, EXTREMITY FRACTURES, MIGRAINE HEADACHE, AND RENAL COLIC

E. Sloan 1, S. Chan 2, D. Lowery-North 3, R. Zalenski 4, J. Clark 5

1

University Of Illinois College Of Medicine, Chicago, Usa, 2 Presence Resurrection Medical Center, Chicago, Usa, 3 Emory University College Of Medicine, Atlanta, Usa, 4 Wayne State University College Of Medicine, Detroit, Usa, 5 University Of California Davis College Of Medicine, Sacramento, Usa Background: Inadequate treatment of pain in the emergency department (ED) is an important ongoing patient care issue. The objective of this study was to analyze analgesic use for ED patients with presumed biliary colic, bowel obstruction, extremity fractures (upper and lower), migraine headache, and renal colic.

Methods: A retrospective review of 1,652 patient charts from six urban university-affiliated EDs was completed.

By design, approximately 17% of the patients in this series had each of the six ED discharge diagnoses.

Results: Among all patients, 78% were medicated in the ED. The mean time to first analgesic was 109 + 158 min; 47% received their first analgesic within 60 minutes of triage, and 24% received it after 120 minutes in the ED. Renal colic and extremity fracture patients were more likely to receive their first analgesic medication within 60 minutes as compared to those with the other diagnoses (p<0.008). There was no significant difference in time to first analgesic based on gender or patient-reported pain severity. Patients who entered the ED at night (0:00-7:59) had a 1.39x and 2.00x greater odds of receiving their first analgesic within 60 min (57%) as compared to patients entering the ED during the day (48%, p<.05) and evening (39%, p<.001). Caucasian patients had a 2.50 and 2.22x greater odds of receiving their first analgesic within one hour as compared to African American and Hispanic patients, respectively (p<0.004), and African American patients had a 2.68 and 1.97x greater odds of not receiving their first analgesic until after two hours as compared to Caucasian and Hispanic patients, respectively (p<0.04).

Conclusions: ED pain management predominantly utilized narcotics. Gender and patient-rated pain had no effect on medication dosing timing. Patients entering the ED at night and those with the diagnosis of renal colic or extremity fracture had increased odds of receiving analgesics at an earlier time. The analysis of the limited ethnicity data suggests that there was a difference in time to analgesic therapy based on ethnicity, requiring further analysis.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Airway / Analgesia / Anesthesia /Sedation / Pain Management

W263

A COMPARISON OF TWO LIGHTWAND INTUBATION TECHNIQUES IN PATIENTS WITH CERVICAL IMMOBILIZATION

H. Seo 1, H.P. Park 1, Y.J. Lim

1

1

Department Of Anesthesia And Pain Medicine, Seoul National University Hospital, Seoul, South Korea

Background: There are some difficulties in positioning of the lightwand in the midline of the hypopharynx or in performing the scooping movement in patients with cervical spine disorder, because manual in-line stabilization hampers free movements of the lightwand. Assistance with laryngoscope may facilitate free movements of the lightwand in the oral cavity. In this study, we tested our hypothesis that laryngoscope-assisted lightwand intubation (LALI) allows for easier and more successful endotracheal intubation than does conventional lightwand intubation in patients with cervical immobilization during intubation.

Methods: 162 patients requiring cervical immobilization during intubation for cervical spine surgery were randomly allocated to two groups. The conventional lightwand technique was used for endotracheal intubation in the control group (n=80), whereas the LALI technique for the laryngoscope-assisted (LA) group (n=82). In the LA group, a Macintosh laryngoscope was inserted into the oral cavity and advanced past the tongue until the epiglottis tip was visible. The lightwand tip was placed below the epiglottis under direct view of the epiglottis tip.

The success rate of intubation on the first attempt, intubation time, hemodynamic changes, and postoperative airway complications were evaluated.

Results: The success rate of intubation on the first attempt was higher (89% vs. 75%, p=0.034) and the median number of scooping movements was lower (0 vs. 2, p<0.001) in the LA group than in the control group. The intubation time, postoperative sore throat score, and incidences of hypertension and tachycardia, postoperative oral mucosal bleeding, and hoarseness were comparable between two groups. The number of patients with a postoperative sore throat score of >3, however, was significantly higher in the control group (40% vs. 22%, p=0.021).

Conclusions: Laryngoscope-assisted lightwand intubation allows for more successful intubation on the first attempt without increasing the intubation time or incidence of perioperative airway complications in patients with cervical immobilization during intubation compared with traditional lightwand intubation.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Airway / Analgesia / Anesthesia /Sedation / Pain Management

W264

SUCCESSFUL SEDATION VIA CHLORAL HYDRATE IN PEDIATRIC PATIENTS DURING A DIAGNOSTIC STUDY

C. Lee 1, S. Park 2

1

Hallym Univ. Dongtan Sacred Heart Hospital, Hwaseong, South Korea, Anyang, South Korea

2

Hallym Sacred Heart Hospital,

Background: Chloral hydrate (CH) is one of the most commonly used sedatives for the diagnostic radiological imaging in the pediatric emergency department. Although the half-life of CH is long, it is mostly preferred for its affordability and low complication risk in South Korea. The doses of CH that were recommended were 50~100mg/kg as per the weight of the patient.

We are aiming to determine the affecting factor on successful sedation through a diagnostic study.

Methods: A retrospective review of the medical records of 1,590 patients, who visited two emergency departments for diagnostic studies from January 2013 to December 2014, was conducted.

The definition of CH sedation success included patients who were sedated after the first CH dose. The sedation induction time was the interval between the administration of CH and transportation to the diagnostic room. All subjects were categorized into two groups, namely, successful group and failure group. We compared the two groups with respect to gender, age, weight, visitation time, and CH dose. In addition, we classified the patients’ growth levels via weight-for-age percentiles, and analyzed the effect of lower or higher weight-for-age on the sedation induction time.

Results: A total of 1,590 patients (966 boys, 624 girls) have been sedated for the diagnostic radiologic study.

The mean age was 24.8 ± 15.0 months, and the mean weight was 12.22 ± 3.2 kg. The success rate with the first dose of CH was 82.7%, and it was significantly lower under 60mg/kg dose of CH (p < 0.001). The median sedation induction time was 36.0 minutes, while the mean dosage of CH was 77.8 ± 22.3 mg/kg. Lower age, lower weight, and higher dose of CH were correlated with the successful sedation (P < 0.05). There was an earlier sedation (=<20 minutes) in patients with 10 weight-for-age percentiles and less. There was less late sedation (>= 80 minutes) in patients with weight-for-age percentiles and more.

Conclusions: We should consider at least 60mg/kg on the first dose of CH, and decide the second administration time upon consideration of the patients’ weight-for-age percentiles.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Airway / Analgesia / Anesthesia /Sedation / Pain Management

W265

COMPARISON OF ULTRASOUND AND SURFACE LANDMARKS TO DETECT THE LOCALIZATION FOR CRICOTHYROIDOTOMY

E. Göksu 1, G. Yildiz, A. Senfer, A. Kaplan

1

Akdeniz University School Of Medicine Department Of Emergency Medicine, Antalya, Turkey

Background: The surgical airway is a rarely needed and yet important procedure, as complications during this procedure may result in morbidity and mortality. Studies indicate that the incidence of difficult airway procedures is 3% and that a surgical airway is only actually required in 0.6% of these patients.

Although the cricothyroid membrane is superficial and surface landmarks are easily palpated, obese patients, patients with short necks, and secondary conditions affecting the neck region, such as subcutaneous emphysema, may all complicate the situation and may increase the complication rates of the surgical airway procedure.

Methods: In this study, we compared USG and surface landmark techniques for detecting the cricothyroid membrane in order to perform a cricothyroidotomy on healthy volunteers.

Results: Five operators and 24 models are included in this study. The cricothyroid membrane was detected accurately in 80 (66.7%) attempts with palpation, and 83 (69.2%) attempts with USG. There was no statistically significant difference in the accuracy of detecting the cricothyroid membrane with palpation and USG. The mean and median time for detecting the cricothyroid membrane with palpation was 8.25 ±4.8 seconds and 7 (IQR =5-11) seconds respectively. The mean and median time for detecting cricothyroid membrane with USG was 17 ±9.2 seconds and 14 (IQR 12-19) seconds respectively. There was a statistically significant difference in terms of the duration for detecting the cricothyroid membrane with both methods (p<0.001); the duration for detecting the localization of the cricothyroid membrane was longer with USG. Conclusions: According to the results of this study, the accuracy of USG and palpation was similar for detecting the localization of the cricothyroid membrane. The duration for detecting the cricothyroid membrane was longer with USG when compared with the palpation technique.

Keywords: Cricothyroidotomy, Ultrasound

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Airway / Analgesia / Anesthesia /Sedation / Pain Management

W266 BECK AIRWAY AIRFLOW MONITOR (BAAM) OBVIATES NEED FOR (AND RISKS) OF RSI: COMMON ED/EMS EXAMPLE CASES R. Cook 1

1

Richard Tramontina And Ruth Pauline Cook Foundation, Hershey, Usa

Background: The BAAM (Beck Airway Airflow Monitor) is an inexpensive highly versatile device to assist oral and nasal intubation. We present 5 cases in which circumstances made its use superior to commonly used alternatives.

Methods: 5 cases of representative examples of ED/EMS intubation situations that highlight the effectiveness, the safety, and indeed the superior utility of the device and techniques with which it can be used in these settings.

Results: Case Details EMS brought a morbidly obese male in respiratory failure who was positioned partly upright, and 8.0 Endotrol tube with BAAM passed thru the mouth and glottis. ETT cuff inflated less than 55 seconds after this bullnecked patient was placed on the ED stretcher.

EM physician responded to house in neighborhood where 26 yo narcotic OD female was found unresponsive, agonal respirations by family. Agonal respirations. BAAM placed on 7.0 ET tube, BAAM guided digital technique to guide/confirm 15 minutes prior to EMS. No aspiration pneumonia.

26 yo obese female dialysis pt unresponsive in urgent care waiting room. RR less than 10. clenched teeth, hypotensive. BAAM guided nasal intubation secured airway.

56 yo female hx COPD presented to urgent care in respiratory failure. With patient awake, increasing respiratory failure, ETT passed thru mouth and thru glottis guided by BAAM whistling sounds.

85 yo male in ICU respiratory failure, prior hypotension, difficult intubation was orally BAAM on ETT absent apparent discomfort, medication, or change in blood pressure, heart rate.

Conclusions: The BAAM can be used in both the ED/in hospital/in facility setting and the prehospital EMS/Air Medical setting. It can be carried in a flight suit pocket and is audible over aircraft engine noise at altitude. The techniques with which it can be used (blind oral, blind nasal, digital) don't require medications or electronic equipment. They do not risk hypotension or iatrogenic apnea. The BAAM is an inexpensive, simple to use, easily stored, extremely portable, airway adjunct that can be used to facilitate endotracheal intubation in both routine and difficult/at risk situations.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Respiratory and ENT Emergencies W267 EARLY FAILURE OF NONINVASIVE VENTILATION IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH ACUTE HYPERCAPNIC RESPIRATORY FAILURE YJ Lee 1, S Ahn 1, BS Ko 1, WY Kim 1, KS Lim 1, YS Lee 1 1

Asan Medical Center, University of Ulsan, College of Medicine, Department of Emergency Medicine, Seoul, SOUTH KOREA Background: Noninvasive ventilation (NIV) in the management of chronic obstructive pulmonary disease (COPD) patients with acute hypercapnic respiratory failure is considered a first-line therapy. However, patients who fail NIV and then require invasive mechanical ventilation have been found to have higher mortality than patients initially treated with invasive mechanical ventilation. We tried to find parameters associated with early NIV failure in patients presenting to the ED with acute exacerbation of COPD. Methods: Retrospective analysis of the medical records of 218 patients with acute exacerbation of COPD visiting Asan Medical Center and managed with NIV during their stay in the ED from January 2007 to December 2013.

Results: NIV was successful in 191 (87.6%) and 27 (12.4%) failed NIV treatment. The multivariate logistic regression analysis demonstrated that, of the variables obtained before NIV treatment, heart rate >=120/min: OR 2.8, 95% CI 1.1 – 6.8) and pH (7.25 – 7.29: OR 2.6, 95% CI 1.8 – 8.1; <7.25: OR 15.2, 95% CI 5.0 – 46.1) were significant factors associated with early NIV failure. Of the variables obtained after 1 hr of NIV treatment, heart rate (>=120/min: OR 4.0, 95% CI 1.4 – 11.5) and pH (7.25 – 7.29: OR 4.7, 95% CI 1.5 – 15.1; <7.25: OR 29.8, 95% CI 15.7 – 62.7) were still significant (Table 1). NIV failure rate was 3.7%, and 2.3% when the patient had heart rate <120/min and pH >=7.3 before and 1 hour after NIV treatment, respectively. With heart rate >=120/min and pH <7.25 before and 1 hour after the treatment, failure rate was 75.0% and 87.5% respectively (Table 2).

Conclusions: Presence of tachycardia and severe acidosis before NIV treatment were independent factors for NIV failure. The more severe the acidosis, the more likely the failure of NIV. Persistence of tachycardia and severe acidosis after 1hour of NIV treatment was associated with early NIV failure with higher odds ratios.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Respiratory and ENT Emergencies

W268

FACTORS LEADING TO AIRWAY MANAGEMENT IN BURN EMERGENCIES (FLAMBE) STUDY

D. Savaser 1, D. Benaron 1, M. Darocki 1, J. Corbett-Detig 1

1

University Of California, San Diego (ucsd), San Diego, Usa

Background: It is commonly taught that inhalation injuries frequently require rapid invasive airway intervention.

Previous studies have reported that the mortality rate associated with inhalational injuries is 45-78% and that the risk of mortality is 20% higher in patients with combined inhalation injury and cutaneous burns than in those with cutaneous burns alone. Although these statistics are alarming, they may not be applicable to all patients presenting to the emergency department (ED) with inhalational injuries. Numerous indications for invasive airway management have been documented in the literature: ranging from cyanosis, stridor to full thickness burns of the face. These clinical descriptors often overlap with the definition of inhalation injuries. No studies to date have included nasopharyngeal irritation, singed eyebrows, singed nasal hairs, or soot in the proximal airway as an indication for intubation. There is no data on patients presenting to the ED or trauma bay with specific to inhalation injuries and the need for further airway intervention.

Methods: This is a retrospective chart review of a cohort of patients presenting to the UCSD emergency department or trauma bay with inhalational injury and facial burns. Patients were identified via ICD-9 codes.

Exclusion criteria include any patient that did not present to the ED or trauma bay, and any patient without the potential ICD-9 diagnosis. The presence of indications for intubation on initial clinical presentation were evaluated. The study is ongoing.

Results: Thus far, 37 patients that presented to the UCSD emergency department or trauma bay with inhalation injury and/or facial burn were analyzed. Preliminary data is showing only three of the patients from this cohort required endotracheal intubation while 8 presented with clear indication for intubation, and 8 presented with the aforementioned study indications for intubation.

Conclusions: Over 50% of patients with clearly established indications for intubation, as well as over 50% of patients the study indications for intubation avoided an expected airway intervention. This discrepancy challenges the current dogma of invasive airway management in the face of inhalation injury and facial burn, and suggests that clinical gestalt may trump studied indications for intubation.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Respiratory and ENT Emergencies

W269

FACTORS LEADING TO AIRWAY MANAGEMENT IN BURN EMERGENCIES (FLAMBE) STUDY

D. Savaser 1, D. Benaron 1, M. Darocki 1, J. Corbett-Detig 1

1

University Of California, San Diego (ucsd), San Diego, Usa

Background: It is commonly taught that inhalation injuries frequently require rapid invasive airway intervention.

Previous studies have reported that the mortality rate associated with inhalational injuries is 45-78% and that the risk of mortality is 20% higher in patients with combined inhalation injury and cutaneous burns than in those with cutaneous burns alone. Although these statistics are alarming, they may not be applicable to all patients presenting to the emergency department (ED) with inhalational injuries. Numerous indications for invasive airway management have been documented in the literature: ranging from cyanosis, stridor to full thickness burns of the face. These clinical descriptors often overlap with the definition of inhalation injuries. No studies to date have included nasopharyngeal irritation, singed eyebrows, singed nasal hairs, or soot in the proximal airway as an indication for intubation. There is no data on patients presenting to the ED or trauma bay with specific to inhalation injuries and the need for further airway intervention.

Methods: This is a retrospective chart review of a cohort of patients presenting to the UCSD emergency department or trauma bay with inhalational injury and facial burns. Patients were identified via ICD-9 codes.

Exclusion criteria include any patient that did not present to the ED or trauma bay, and any patient without the potential ICD-9 diagnosis. The presence of indications for intubation on initial clinical presentation were evaluated. The study is ongoing.

Results: Thus far, 37 patients that presented to the UCSD emergency department or trauma bay with inhalation injury and/or facial burn were analyzed. Preliminary data is showing only three of the patients from this cohort required endotracheal intubation while 8 presented with clear indication for intubation, and 8 presented with the aforementioned study indications for intubation.

Conclusions: Over 50% of patients with clearly established indications for intubation, as well as over 50% of patients the study indications for intubation avoided an expected airway intervention. This discrepancy challenges the current dogma of invasive airway management in the face of inhalation injury and facial burn, and suggests that clinical gestalt may trump studied indications for intubation.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Respiratory and ENT Emergencies W270 THE ROL OF TRACHEOSTOMY IN CASE OF FOREIGN BODY ASPIRATION IN CHILDREN M. Alsoodany 1, M. Alsoodany 1

1

Olv Hospital, Aalst, Belgium

Background: Introduction: 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_20150608002820.png'> Methods: Clinical presentation: A 19-month-old girl, previously healthy, was founded unconscious on the floor in the day-nursery. Resuscitation was first initiated by the day care personnel and afterword by the medical emergency team. The initial rhythm was asystole and displayed difficulties during ventilation. In the hospital resuscitation was continued for more one hour until ROSC was achieved. During the oro-tracheal intubation a thumbtack between the vocal cord was visualized, 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 died later on 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: Literature 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 event more often associated with a delayed diagnosis When a severe airway compromise is encountered, it demands immediate laryngoscopy, intubation and then bronchoscopy. Tracheostomy should be performed in case of severe hypoxia, difficult ventilation and too sharp FBs that might injure the airway or too large to pass through the subglottic region.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Respiratory and ENT Emergencies

W271

A RARE CAUSE FOR ACUTE CHEST PAIN: SPONTANEOUS PNEUMOMEDIASTINUM

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

1

Fatih Sultan Mehmet Education And Research Hospital, Istanbul, Turkey

Background: Spontaneous pneumomediastinum(SPM) was described by Louis Hamman in 1939. SPM is a rare clinical identification defined as air escaping into the mediastinum without an obvious cause such as trauma. It usually develops after alveolar rupture and free air escaping into the mediastinum. The reasons of alveolar rupture for SPM are high intra-alveolar pressures, low peri-vascular pressures, or both. Clinical diagnosis is include the symptom triad, chest pain, dyspnea and subcutaneous emphysema. We reported a case of SPM, admitted to Emergency Department with acute-onset chest pain. <FILE IMAGE='209_20150710173919.jpg'> Methods: 26-year-old man presented to emergency department (ED) with acute-onset chest pain. His Glascow Coma Scale (GCS) was 15, blood pressure was 125/75 mmHg and nearly equal for left and right arm, pulse rate was 65 bpm, oxygen saturation 98% and respiration rate was 17 breaths/ minute. His upper and lower extremity pulses were normal and equal. He described the pain as knife-like on left side of his chest and radiating to his neck. Past medical history revealed nothing specific. He denied any history of trauma, drug usage, and coughing, vomiting or sportive activity. On physical examination, lungs were clear bilaterally on auscultation.

Percutaneous emphysema was picked out in the left supraclavicular area. There were no abnormality in the laboratuary results, including Troponine I. ECG was normal sinus rhythm and no pathological findings were identified. Plain chest X-ray was not descriptive (figure 1). Thorax computerized tomography (CT) revealed free air in the mediastinum and left side of the chest to neck (figure 2). The patient was followed up conservatively with parenteral antibiotics, analgesics and oxygen. On control CT, taken 10 days later, showed that the emphysematous lesions were completely disappeared.

Results: 1 Conclusions: Uncomplicated SPM is a benign condition, typically reabsorbing in two weeks and it is managed conservatively. Treatment is generally limited with analgesia, and keeping away maneuvers that increase pulmonary pressure. Patients should be followed up for possible complications like tension pneumothorax, mediastinitis, tension pneumopericardium and cardiogenic shock. The mortality rate is high because of its complications, but identified patients usually recover very quickly.

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

W272

COMPUTER TOOLS IN HEALTH CARE: A PRACTICAL EXAMPLE FOR EMERGENCIES

E. Pulido Herrero 1, S. Garcia Gutierrez 2, J. Angulo Amigo 1, M. Gallardo Rebollal 1, M. Gorordo Unzueta 3, A. Anton Ladislao 2

1

Sยบ Urgencias - Hospital Galdakao-Usansolo, Galdakao, Spain, 2 U. Investigacion - Hospital Galdakao-Usansolo / Red De Investigacion En Serv. Sanitarios Y Enferm. Cronicas (redissec), Galdakao, Spain, 3 Sยบ Neumologia Hospital Galdakao-Usansolo, Galdakao, Spain Background: The use of softwares as an aid to make decisions in medicine is a reality. It has been used in admission, administration, libraries, access to medical literature, statistics and research, accounting - billing services for pharmacy and laboratories. With less success has been directed to assist in medical decision, remaining as projects or curiosities the use of programs aimed at the same , although many of them show that the quality of care the patient is improved control over it, facilitating research, data analysis, management and cost control.

GOAL Show and define an algorithm for decision support about patients presenting to the emergency department for exacerbation of COPD in computer format, made from the emergency services for emergency physicians.

Methods: This is a multicenter observational prospective cohort study. First, by means of RAM methodology a set of explicit criteria to assess appropriateness of admission were created which the basis of an algorithm. A field work was conducted in order to apply the set of criteria created from 2007 to October 2012 at various centers in the Basque Country, Andalusia, Cantabria, Catalonia and Madrid. In this study 3091 patients attending these centers for exacerbation of COPD were included. Once this work showed in better outcomes for the patients and health systems, creation of computer software Results: ADIEPOC: An easy to use and flexible software that provides information about the severity of exacerbation at the time of consultation in the emergency room and hospital admission appropriateness validated in terms of evolution of 3000 patient two months after the exacerbation.

Conclusions: In recent years, new information has been added to medical applications such as biomedical electronic publications, telemedicine, driven by the rise of the Internet and the World Wide Web and computer records of history. ADIEPOC will provide emergency physicians of an aid in making decisions about the patients who come for exacerbation of COPD, in an easy and manageable way, will help reduce the undesirable variability and standardize the admission criteria, in addition to be a tool for learning in MIR (resident physicians).

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Pulmonary disorders W385

THE MANAGEMENT OF AN INCIDENTAL PE FINDING IN THE EMERGENCY DEPARTMENT OF AN ONCOLOGIC HOSPITAL- A RETROSPECTIVE REVIEW SR Banala; MJ Kwak; VD Page; TW Rice; K Alagappan Pulmonary Embolism (PE) is now more common than previously known. Venous thromboembolism is the second leading non-cancer cause of death among oncology patients, with infection being the first. 1-3 Mortality from an acute thrombotic event is 4 to 8 times greater in patients with cancer than for those without cancer. 4-6 Based on its high prevalence and high mortality rate, awareness of PE diagnostic approaches and treatment is particularly important in the emergency department (ED) patient with cancer. With improved ways to detect PEâ&#x20AC;&#x2122;s Emergency Physicians (EP) must now determine if this warrants an inpatient admission for anticoagulation or can the patient be managed as an outpatient.

Methods: MD Anderson is a 650 bed Cancer hospital with an ED volume of 48,283 between Jan 1, 2013 and Dec 31, 2014. All patients with a PE diagnosed at the institution were included. Many outpatients that were being staged for their cancer were found to have an incidental PE. These patients were all transferred to the ED for further care. These patients were evaluated by the EP and dispositioned accordingly. This study is a retrospective chart review.

Results: There were 2700 patients diagnosed at the institution with a PE during the study period. Of this, 260 (9.62%) patients presented to the ED with incidental PE found on staging Computed Tomography (CT) scans. Of the 260 patients 157 (60.3%) were male and 103 (39.7%) were female. 235/260 had solid tumors (90.4%) and the remaining had liquid tumors 25/260 (9.6%).

The average length of stay in the ED was 6.67 hours. In the ED, 184 (70.7%) were discharged with anti-coagulation prescription and the remaining 76 (29.3%) being admitted. Of this 76, only 1 died during that hospitalization due to multi-organ failure, the remaining 75 were discharged with anticoagulation prescription and/or post placement of Inferior Vena Cava (IVC) filter. 15 patients underwent IVC filter placement out of 76 admitted. Of the discharged, 11 returned to the ED within 30 days, out of which only 1 presented with worsening shortness of breath. The average number of days that people died after their diagnosis of incidental PE was 196. 142/270 (54.6%) patients were still alive as of 6/15/2015.

Conclusion: Many cancer patients with asymptomatic incidental PE can be safely discharged home with anticoagulation providing that other conditions do not necessitate hospitalization. No clinical guidelines or protocols were established for the disposition of the patient with PE. It was individually determined by the treating EP.

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

W273

INTRAMURAL SMALL-BOWEL AND INTRAABDOMINAL HEMATOMAS INDUCED BY ANTICOAGULANT THERAPY

M. Ince 1, Z. Kilbas 2, U. Kaldirim 1, N. Ersoz 2, O. Kozak 2

1

Gmma Emergency Dept., Ankara, Turkey, 2 Gmma Surgery Dept., Ankara, Turkey

Background: Spontaneous intramural small-bowel and intraabdominal hematoma is a rare complication of oral anticoagulation therapy. Bleeding duo to anticoagulation therapy is generally treated conservatively by nasogastric decompression and total parenteral nutrition, surgical intervention is required in patients with active bleeding, acute abdominal pain, or intestinal obstruction. The aim of our study was to review the outcomes of six patients.

Methods: The medical records and imaging of six patient were evaluated at our institution in 2014 with the diagnosis of spontaneous and nontraumatic intramural small-bowel hematoma. Ages, gender, primer disease, primer complaint, laboratory findings and treatment of patients were retrieved retrospectively from our database.

Results: Six patients (two female, mean age 67.8 years) were identificateted. All of the patients suffered from abdominal pain, five had additional symptoms. All of the patients had overdosage of warfarin sodium and had abnormal coagulation parameters. The mean duration of the patientsâ&#x20AC;&#x2122; anticoagulation was 38.5 months.

Abdominal computerized tomography showed the exact pathology which is intramural hematoma in all patients.

Five of the patients were treated, nonoperatively, and one patient underwent surgery due to necrosis and obstruction in jejunum but nonoperatively for duodenal hematoma (Table 1, 2). All patients were well at mean 21-week follow-up.

Conclusions: Intramural intestinal hematoma is a rare complication of anticoagulant therapy, however it should be considered in the differential diagnosis of acute abdomen. Firstly, nonsurgical treatment should be the treatment, but surgery is indicated if complicated patients such as generalized peritonitis, necrosis or intestinal obstruction develops.

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

W274

MANAGEMENT OF ACUTE NON TRAUMATIC ABDOMINAL PAIN IN ADULTS IN EMERGENCY DEPARTMENT. A PROSPECTIVE STUDY ABOUT 260 CASES

M. Ben Lassoued 1, H. Melki 1, R. Jebri 1, R. Hammami 1, M. Arafa 1, O. Khila 1, K. Lamine 1

1

Military Hospital Of Tunis Emergency Department, Tunis, Tunisia

Background: Non-traumatic acute abdominal pain in adults represent 5-10% of patterns in Emergency Department. Almost 40% of patients leave the emergency department without etiological diagnosis. That is to say how these symptoms remains a diagnostic problems. pragmatically speaking: the aim is not to make an accurate diagnosis but to detect the real surgical or medical emergency requiring a rapid care.

The Aim of the work was to Evaluate the management of acute non traumatic abdominal pain in adults in the emergency department: reception and triage, diagnostic approach, providing complementary examinations, providing initial therapeutic in the emergency department and providing targeted orientation Methods: Prospective observational study conducted over 2 months in the emergency department. Patients older than 14 years and with an acute non traumatic abdominal pain were included. The demographics, co-morbidities, clinical and biological data and in-hospital procedures were collected and analysed.

Results: During the study period, 260 patients were included (4.2% of all consultants). The average age was 42 Âą 17 years. The sex ratio was 1,1. The majority of patients were classified urgent (36,2%), and oriented to the consulting box in 86,2% of cases. The most common pattern was severe abdominal pain, with a visual analytic scale that ranges between 5 and 8 (41,5%). Paracetamol was the most widely prescribed analgesic treatment in 87%. A specialist opinion was sought in 34,2% of cases, mostly surgical (71,9% of cases), with an average time of care by specialist at 3 hours. The diagnosis of abdominal pain was dominated by urological etiologies (30,7%), gastroenterology (27,7%), and non-specific diagnoses (15,7%). The hospitalization rate was 28%, and the majority of patients were discharged home (70,4%). The average total time spent in the emergency department was 4 hours.

Conclusions: Acute abdominal pain is a common pattern in the emergency department. Even if the diagnostic field is broad, a good knowledge of the most frequent abdominal diseases and their potential severity criteria may lead to accurate care and urgent hospitalization.

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

W275

RIGHT ILIAC FOSA PAIN CASUISTIC IN EMERGENCY DEPARTMENT

M. Gudelis 1, J. Lacasta Garcia 1, M. Abadias Medrano 1, J. Montañes Magallon 1, J. Trujillano Cabello 1

1

Hospital Universitari Arnau De Vilanova, Lleida, Spain

Background: Introduction: Right iliac fossa (RIF) pain represents about 50% of all cases of acute abdominal pain in Emergency Department (ED). Its appearance rice the suspicion of acute appendicitis, but just in 50% of all surgery performed cases for suspected appendicitis has correct the pre-operative diagnosis.

Objectives: Describe the signs, symptoms related with RIF pain and final diagnosis.

Methods: Methods: The prospective, observational descriptive, study, which include patients, older then 14 years, with RIF pain who were admitted in Emergency Department of University Hospital Arnau de Vilnova of Lleida. The signs, symptoms, laboratory values and pathology reports of each patient were collected and evaluated. Four diagnostic groups were established: non-specific RIF pain group when the pain was remitted and the patient was discharged (NsP); AA confirmed by surgical intervention and pathological anatomy; RIF pain without inflammation (NIRIF); and RIF pain with repercussion of inflammatory process (IRIF).

Results: Results: Out of total 252 patients, 53% were males. The age ranged 33.3±16 years. Final diagnosis: 1NsP (46 %), 2 – AA (36%), 3 - NIRIF (12%), 4 - IRIF (6.0 %). 121 (48%) were hospitalized and 107 underwent the surgery. 93 were diagnosed with AA and 87,1 % presented rebound tenderness in RIF, 72% migratory pain, 82,8 % cough tenderness in RIF, 80,6% increasing pain with movement, 76,3 nauseas and vomits, 53,8% anorexia. Of 252 patients the most frequent signs and symptoms were rebound tenderness in RIF (65,9%), cough tenderness in RIF (68,3%), increasing pain with movement (65,9), nauseas and vomits (63,9%). The medium of leucocytes count (109/L) was 12±5 and in AA group 16±4. The medium C reactive protein was 60±54 and AA group 98±78.

Conclusions: Conclusions: NsP and AA are the most common pathologies, but it could be other causes of RIF pain and can be difficult to diagnose. Good management of this pathology in ED could be when the patient is admitted, observed and diagnosed. In case the patient does not need surgical treatment he could be discharged from ED.

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

W277

RECTAL FOREIGN BODY REMOVAL WITH RIGID SIGMOIDOSCOPY: A CASE REPORT

M. Ince 1, N. Ersoz 2, Z. Kilbas 2, H. Sahin 2, U. Kaldirim 1, M. Guner 2

1

Gmma Emergency Dept., Ankara, Turkey, 2 Gmma Surgery Dept., Ankara, Turkey

Background: Foreign bodies used for multiple purposes may result in complications due to uncontrolled use.

The best method of treatment is removal of foreign bodies from the anal canal. We present the removal of a foreign body from anal canal inserted into the rectum.

Methods: 24-year-old male patient put a foreign body into anal canal to eliminate itching and pain caused by hemorrhoid. While trying to remove the foreign body, patient has recognized that it has gotten more.Vital signs were stable. There was no abnormal on the examination and in laboratory. In digital rectal examination, foreign body could not be palpated.

Results: In flexible rectosigmoidoscopy, the foreign body was covered with feces in the rectosigmoid region (Figure-1). It was removed using a wider forceps (Figure-2). It was seen that foreign body was a plastic pipe-shaped and taped pieces of paper at both ends (Figure-3). There was no mucosal injury. The patient was discharged from hospital without problems.

Conclusions: Foreign bodies put into the anal canal may be in various shapes and sizes. As in our case, being atraumatic of foreign bodies can be treated without causing complications.

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

W278

SIMULTANEUOS CO-EXISTENCE OF APPENDICITIS AND PERFORATION OF MECKEL DIVERTIKULITIS IN AN OLD PATIENT

M. Ince 1, R. Senocak 2, S. Peker 2, Z. Kilbas 2

1

Gulhane Military Medical Academy, Department Of Emergency, Ankara, Turkey, 2 Gulhane Military Medical Academy, Department Of General Surgery, Ankara, Turkey, 3 Gulhane Military Medical Academy, Department Of General Surgery, Ankara, Turkey, 4 Gulhane Military Medical Academy, Department Of General Surgery, Ankara, Turkey Background: Meckel diverticulum is the most common congenital anomaly of the small intestine, occurring in about 2% - 4% of the population. The chief clinical presentation is gastrointestinal bleeding in about 25%-50% of symptomatic Meckel’s diverticulum. The other presentation is intestinal obstruction, volvulus, intussusception, and diverticulitis. We present a rare case with simultaneuos co-existence of appendicitis and perforation of Meckel divertikulitis in an old patient. <FILE IMAGE='192_20150628203712.jpg'> Methods: A 54 year-old man came to our emergency department with a 24 hour history of the gradually beginning abdominal pain. . He reported that his pain started in the middle of the abdomen, replaced left lower quadran as clasically in acute appendicitis. Abdominal ultrasound revealed a 3 cm width free abdominal liquid in lower abdomen, with a non-compressible 8.5 mm appendix diameter, increased wall thickness of terminal ileum and ceacum, suggesting perforated appendicitis. The patient underwent exploratory laparotomy. A markedly swollen and inflamed appendix were observed. After checking both large and small bowels, a 3 cm long Meckel diverticulum situated 60 cm proximal to the ileocecal valve, with inflamed and fibrinoid appearance, which adhered to pelvic peritoneum was found (Figure -1). Appendicectomy was performed, later diverticulectomy using TA stapler and irrigation were performed. Histological report indicated the presence of suppurative inflamation, segmental serositis, microperforation in Meckel diverticulum, and lymphoid hyperplasia and fecalith in appendix.

Results: After the surgery, broad-spectrum IV antibiotics was started and the patient had an uncomplicated recovery and was discharged at the 6th postoperative day.

Conclusions: Diverticulitis represents 20% of the symptomatic Meckel's diverticulum and is common in adult patients, which occurred in our patient. There are no specific physical signs or symptoms that can differentiate between Meckel’s diverticulitis and acute appendicitis. Therefore, it is not surprising, as in this case, that the clinical diagnosis of acute appendicitis was made. The literature suggests that Meckel’s diverticulum should be sought if the appendix is normal; however, if the appendix is overtly inflamed, search for Meckel’s diverticulum is controversial. It can be recommended that a search for a Meckel’s diverticulum should be routine.

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

W279

SWALLOWED FOREIGN BODIES IN ADULTS

E. Lapsekili 1, R. Senocak 1, S. Kaymak 1, M. Ince 2, T. Akyol 3, M. Yilmaz 1

1

Gulhane Military Medical Academy, Department Of General Surgery, Ankara, Turkey, 2 Gulhane Military Medical Academy, Department Of Emergency, Ankara, Turkey, 3 Corlu Military Hospital, Department Of Gastroenterology, Corlu, Turkey Background: Gastrointestinal tract (GIT) foreign bodies represent a significant clinical problem in the Emergency Department, causing a high degree of financial burden, morbidity and mortality. Foreign body ingestion can occur especially in pediatric age, but also can occur in psychiatric disorders, drug/alcohol addiction or intentional ingestion with secondary gain in olders. <FILE IMAGE='192_20150625121858.jpg'> Methods: A total of 26 young men, ranged from 20 to 30 years old applied to our hospital between January 2011 and December 2013 because of ingested foreign body. Clinical presentation, length of time before presentation, diagnosis, mode of treatment, duration of hospital stay and complications were all noted.

Results: Clinical presentation was mostly abdominal pain. Foreign body ingestion was accidental in 15 patients, deliberate in 11 patients. The median time before presentation was 2 days, (1 day-5 month). The mean length of hospital stay was 8.2 days. According to spectrum of foreign bodies, needle was detected in 20 patient (76,9%), teaspoon in 2 patients (7,7%), bottle caps in 2 patients (7,7%), toothpick in 1 patient (3,8%) and rock pieces in 1 patient (3,8%). Biplanar x-ray was the main diagnostic tool used and was positive in 26 cases. Treatment was conservative in 18 (69,2%) patients; 4 patients (15,4%) had gastroscopic retrieval. 4 (15,4%) patients underwent laparoscopy or laparotomy. 12 (%46,1) patients did not have any health problems.

Conclusions: The natural course after ingestion of a foreign body is asymptomatic in majority of cases, and the foreign body passes without problems. Endoscopic intervention or surgery is indicated in 15% cases.

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

W280

GOSSYPIBOMA: A CHALLENGING MASS IN DIFFERENTIAL DIAGNOSIS IN PATIENT WITH ABDOMINAL PAIN.

M. Ince 1, L. Ince 2, N. Yigit 3, E. Samedov 4, N. Ersoz 4

1

Gmma Emergency Dept., Ankara, Turkey, 2 Ankara Oncol. Hosp., Ankara, Turkey, Ankara, Turkey, 4 Gmma Surgery Dept, Ankara, Turkey

3

Gmma Path. Dept,

Background: Gossypiboma, also known as Textiloma, Spongioma, Gauzeoma or Retained Foreign Object (RFO), is a term used to describe a mass resulting from an accidentally left non-absorbable surgical material inside a patient's body. Although most of them can be diagnosed after a few days of surgery, remainings may persist asymptomatically during many years. <FILE IMAGE='192_20150615213559.jpg'> Methods: A 21-year-old man was admitted to surgery clinic with complaint of abdominal pain after the pilonidal sinus surgery. He also has a history of appendectomy 8 years ago. Physical examination showed a tenderness and palpable mass of the right lower abdominal quadrant. Ultrasonography revealed a lesion, containing both cystic and solid structures, measuring up to 15x12 cm. Subsequent magnetic resonance imaging identified the lesion was hypointense on T1A and hyperintense on T2A sequences with significant post-contrast enhancement on its wall (Fig). Routine blood tests were all unremarkable.

Results: The patient underwent midline laparotomy. The lesion was located within the mesentery of small intestine and attached to intestinal wall with a tiny stalk. It was observed as a well-circumscribed, mobile, and hard mass, 20x14x10 cm in dimensions. The mass was completely removed without any complication.

Pathologic examination indicated that it was entirely in cystic nature indeed and its lumen contained a big foreign material, consistent with retained surgical sponge, and yellowish, dense liquid material due to fat necrosis.

Conclusions: Gossypiboma is a rare surgical complication. Infrequently, it may cause a severe clinical presentation, morbidity or mortality. Gossypiboma should be considered in differential diagnosis for patients who previously underwent any type of surgery and subsequently have a discomfort, infection, or palpable mass in short-term or long-term follow-up period. Carefully counting all types of surgical materials, especially sponges, during operation is crucial to prevent from gossypiboma.

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

W281

A CASE OF DELAYED INTERVENTION FOR SMALL INTESTINE TORSION FOLLOWING LIVER TRANSPLANT

C. Ertan 1, I. Ozsan 2, O. Alpdogan 3, T. Karabuga 4, O. Yoldas 2, U. Aydin 2, O. Limon 1

1

Izmir University, Faculty Of Medicine, Department Of Emergency Medicine, Izmir, Turkey, 2 Izmir University, Faculty Of Medicine, Department Of General Surgery, Izmir, Turkey, 3 Bozyaka Training Hospital, Department Of General Surgery, Izmir, Turkey, 4 Karatas Hospital, Department Of General Surgery, Izmir, Turkey Background: The torsion of the intestines may end up in necrosis of the ischemic zone, if not appropriately and timely managed.

Methods: We aimed to present a liver transplant patient, who had a total torsion of small intestines and had a delayed surgical intervention, therefore had near-total small intestinal necrosis.

Results: A 50 years old female liver transplant patient, visited a hospital with sudden onset, crescendo colic pain and bilious vomiting. Laboratory work-up at that hospital revealed elevated blood glucose, urea, creatinine, potassium and liver enzymes along with leukocytosis. She was noted to have abdominal distension; increased bowel sounds and diffuse tenderness. Radiological work-up showed whirly vessels of the mesentery, which suggested intestinal herniation. The hospital referred the patient to our medical center due to their lack of experience with liver transplant patients. The patient had respiratory and circulatory failure at presentation to our ED. Abdominal examination revealed ecchymosis of the skin, distension, loss of bowel sounds and rigidity. She had acidosis, her liver enzymes were severely elevated, and SOFA score was 7. She was emergently taken to OR following fluid resuscitation. There was a near-total necrosis of the small intestine due to a total torsion of the mesentery. A near total resection was performed. The patient died due to cardiopulmonary failure at 12th post-operative day.

Conclusions: Liver transplant is the gold-standard treatment choice for end stage liver failure. Internal herniation following the procedure is rare but has a high mortality rate. Delayed surgery increases the mortality and morbidity in these patients.

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

W282

GALL BLADDER PERFORATION DUE TO HAEMOCHOLECYSTITIS

C. Ertan 1, I. Ozsan 2, O. Alpdogan 3, T. Karabuga 4, O. Yoldas 2, U. Aydin 2, D. Oray 1

1

Izmir University, Faculty Of Medicine, Department Of Emergency Medicine, Izmir, Turkey, 2 Izmir University, Faculty Of Medicine, Department Of General Surgery, Izmir, Turkey, 3 Bozyaka Training Hospital, Department Of General Surgery, Izmir, Turkey, 4 Karatas Hospital, Department Of General Surgery, Izmir, Turkey Background: Warfarin use is more common in elderly patients due to co-existing cardiac problems. <FILE IMAGE='358_20150630163241.jpg'> Methods: We aimed to present a case related to a rare complication of warfarin use.

Results: A 75 years old female attended to our Emergency Department with severe abdominal pain. The patient had a history of diabetes and hypertension, and was on warfarin for five years due to chronic atrial fibrillation.

The abdominal examination of the patient revealed diffuse tendersness, guarding and rebound tenderness. The laboratory work-up showed mild anemia, leucocytosis, elevated liver enzymes. The INR level was increased 2.5 times. Abdominal sonography showed dens fluid filling the upper abdominal area, which led to emergent surgery. The gall bladder was found to be hydropic was perforated in the fundus, was filled with hemorrhagic content, and contained multiple millimetric sized stones. There was about 1 liter of free fluid in the abdomen. A cholecystectomie was performed. Warfarin was ceased post-operatively and low-molecular weighted heparin was ordered. No post-operative complications were observed, and the patient was discharged in the fourth day.

Conclusions: Perforation and intra-abdominal hemorrhage due to non-traumatic hemorrhagic cholecystitis is a very rare occurrence. Hemorrhagic cholecystitis is also a rare complication of anti-coagulant treatment.

Cholelitiasis patients who are on warfarin and their primary care physicians, should be informed about this possible complication.

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

W283

OUTCOMES OF ABDOMINAL COMPUTED TOMOGRAPHY IN ELDERLY PATIENTS GREATER THAN AGE 85 (OLDER OLD) PRESENTING TO AN EMERGENCY DEPARTMENT IN ISRAEL

H. Rajabi 1, A. Alpert, I. Hadas

1

Shaare Zedek Medical Center, Jerusalem, Israel

Background: There is a significant influence on the healthcare system by the aging population, including increased laboratory and radiologic testing. While there have been several studies looking at outcomes of abdominal pain in the elderly which have included computed tomography (CT), none looked specifically at results of CT imaging for those greater than age 85 (older old).

Methods: : This is a retrospective chart review of all non-trauma patients aged 85 and older who presented to the Shaare Zedek Emergency Department between January 2010 through August 2014. De-identified data including demographics, clinical information, laboratory results, results of abdominal CT, as well as, length of stay, and mortality were entered into an excel spreadsheet. Statistical analysis was performed using SPSS. SPSS. Results: There were 561 patients in the study with a mean age of 89.2; 350 (62.4%) were women. The most common pathologic radiologic reports were those of intestinal obstruction-58 patients (10.3%), neoplasm-44 (7.8%), colitis-29 (5.2%), cholecystitis-22(3.9%), intestinal perforation-23 (4.1%), diverticulitis- 18 (3.2%), and mesenteric ischemia- 16 (2.9%). Other pathologic abdominal diagnoses included cholangitis, hernia, pancreatitis, renal colic, urinary retention, megacolon, volvulus, hematoma, abdominal aortic aneurysm, appendicitis, choledocholithiasis, splenic infarction, and abdominal abscess. There were important pulmonary diagnoses including pneumonia- 24 (4.3%) and pulmonary embolus- 6 (1.1%). The radiologic report was normal in 162 (29.2%) with an additional 48 patients having a report of constipation (8.6%). A significant number-126 patients (22.5%) underwent invasive procedures or an operation. A total of 83 patients (14.8%) died during their hospital stay. <FILE IMAGE='52_20150422060523.jpg'> Conclusions: Those over the age of 85 (the older old) who undergo abdominal CT represent a population at high risk for significant pathology as well as morbidity and mortality. Conversely there were a significant number of either normal CT scans or those with a benign pathology as well as 5.4% with pulmonary pathology. Other diagnoses such as those of urinary retention, cholecysititis, or cholangitis can be more rapidly diagnosed with ultrasound.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Urology Genito-urinary

W286

KETAMINE FOR RENAL COLIC IN ED

Ă&#x2013;. Yigit 1, U. Cakir 2, C. Akyol 2, M. Kesapli 2, H.I. Toksul 2

1

Akdeniz University Faculty Of Medicine Department Of Emergency Medicine, Antalya, Turkey, Research And Training Hospital Emergency Clinic, Antalya, Turkey

2

Antalya

Background: Acute renal colic pain is the sudden onset of severe flank pain often described as equal to labor pain. NSAIDs should be used as first line analgesia. However some of the patients presented with non-specified left or right sided pain and NSAIDs can be problematic because of the risk of obscuring acute abdominal conditions. There has been increasing use of ketamine in very low doses to provide analgesic effects in a wide range of acute and chronic pain settings. Here, we present a case series of 7 patients from our ED who were given intravenous infusions of ketamine for suspected renal colic pain.

Methods: This preliminary study was conducted in a tertiary care academic institution. Approval was obtained from the hospitalâ&#x20AC;&#x2122;s local ethical committee. Patients without any chronic disease or allergy who presented to ED with acute flank pain were evaluated, and seven patients were selected. These patients were informed about the preliminary study and 7 of them who approved the study medication (0.3 mg/kg Ketamine in 150 ml saline) were given the infusions. Written informed consent was taken from these patients. We measured pain intensity with visual analog scale (VAS), and monitored the vital signs of patients at the beginning and 15, 30, and 60 minutes after ketamine administration. The side effects occurred after ketamine were also observed.

Results: The patients in the series ranged between the ages of 21 and 39 years with a mean age of 30 years.

Four of them were men, and 3 were women. None of the patients experienced tachycardia, hypertension, dysphoria, nausea, vomiting, dream-like state, hallucinations, or dangerous emergence reactions. The vital signs of patients at the beginning and 15, 30, and 60 minutes were stable. None of the patients required rescue analgesia within 1 hour of ketamine administration.

Conclusions: The administration of low dose ketamine in the ED may be a safe and effective adjunct for analgesia in renal colic patients. However, prospective randomized controlled trials are needed before widespread use of ketamine for analgesia in the ED.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Urology Genito-urinary

W287

ACUTE INTERSTITIAL NEPHRITIS DUE TO FLURBIPROFEN

O. Dikme 1, A.G. Aydin 1, H. Aslan 2, E. Ars 1, C. Aktas 1

1

Koc University Hospital Emergency Department, Istanbul, Turkey, Department, Istanbul, Turkey

2

Koc University Hospital Internal Medicine

Background: Acute interstitial nephritis (AIN) presenting nephrotic syndrome and renal failure induced by Non-steroidal anti-inflammatory drugs (NSAIDs) has been recognized with increasing frequency. NSAIDs are known to affect renal function in susceptible patients by inhibiting the synthesis of vasodilating renal prostaglandins.

Methods: We described here a 36-year-old man who developed AIN after taking a single dose flurbiprofen for headache.

Results: 36-year-old man admitted to the ED with nausea, vomiting and weakness. He vomited 10 times but had nor abdominal pain neither diarrhea. In medical history he has got Hypertension for 3 years and he has used combination therapy with amlodipine, valsartan and indapamide. On admission vital signs were found as blood pressure 130/90mmHg, heart rate 104/min, respiratory rate 16/min, temperature 36C and SPO2 99%. Also physical examination was normal and he had urinary output. Same day he admitted another clinic and Creatinine found as 2 mg/dl. After eight hours later creatinine was increased twice. Urea 71mg/dl, BUN 33mg/dl, Creatinine 4mg/dl, Potassium 3.8mmol/L was found. There was no metabolic acidosis in arterial blood analysis.

Abdominal USG and non-contrast renal CT were found normal. There were no obstructive causes of nephropathy. There was no infection on urinary analysis and culture. Immunological tests were negative. He hospitalized to the ward with diagnosed acute renal failure. When the patient history reevaluated he said he used a single dose flurbiprofen for headache one day ago. All medications used were stopped and he taken IV fluid therapy, antiemetic (Metoclopramide and Ondansetron), H2 receptor blocker (Ranitidine) and steroids (Metilprednisolone). Also Nifedipine for hypertension was started on third day. Due to improvement of renal function and an increase in the amount of urine output, biopsy was not considered. After six days following, symptoms and laboratory results returned to normal and he discharged from the ward. On discharge, Urea 26 mg/dl, BUN 12 mg/dl, Creatinine 1 mg/dl, Potassium 4.6 mmol/L were found.

Conclusions: There were some cases reported in the literature of AIN that developed after flubiprofen intake. In the ED evaluation of acute renal patients this situation should be kept in mind.

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

W288

LOCALIZED ALLERGIC REACTION DUE TO ACYCLOVIR: A CASE REPORT

C. Ertan 1, F.S. Akgun 2, G. Sezgin 3, F.O. Kaya 3

1

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 Internal Medicine, Istanbul, Turkey Background: Allergic reactions to topical medication, although not rare, are usually seen following prolonged use. Here we present a case of an immediate allergic reaction to topical application of acyclovir. <FILE IMAGE='358_20150630132043.jpg'> Methods: An otherwise healthy 29-year-old female presented to emergency department with swelling and erythema of the lips and a burning sensation in the skin. She reported a 1-day history of isolated vesicular rash involving the left side of the upper lip and thus she used a topical cream containing acyclovir. She said that she didnâ&#x20AC;&#x2122;t use a similar drug and didnâ&#x20AC;&#x2122;t have allergies to any medications previously. After she used this cream, she almost immediately had swelling of the lips, erythema and a burning sensation in the skin.

Results: Blood pressure: 90/60 mmHg, heart rate: 104/min., respiratory rate: 14/min. There were no lesions except for swelling of the lips and erythema around lips. She had no edema of uvula. Owing to concern for allergic reactions, she was treated with intravenous 8 mg dexamethasone and 45,5 mg Pheniramine maleate.

The lesions decreased in emergency medicine. She was discharged to use oral antihistamine pill. The complaints improved within 2 days.

Conclusions: Allergic reactions in the Emergency Department are managed to rule out anaphylaxis. Patients are otherwise managed as outpatients following basic treatment and appropriate follow up.

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

W289

GARLIC BURN IN A PATIENT WITH LATERAL EPICONDYLITIS: A CASE REPORT

N. Tezel 1, O. Tezel 2, N. Salman 2, H. Yesil 3

1

Diskapi Research And Education Hospital Department Of Physical Therapy And Rehabilitation, Ankara, Turkey, 2 Etimesgut Military Hospital Department Of Emergency Medicine, Ankara, Turkey, 3 Etimesgut Military Hospital Department Of Dermatology, Ankara, Turkey Background: Naturopathic remedy has a long history, particularly in Eastern medicine. Garlic (Allium sativum) is one of the best-researched and best-selling herbal remedies. Many adverse effects have been reported in the literature, but there have only been a few reports of severe dermatitis, which may resemble a chemical burn. We describe a patient with a garlic burn on the lateral aspect of the elbow. <FILE IMAGE='49_20150515121740.jpg'> Methods: Case report A 35-year-old man presented to the emergency room with painful erythema and bullae on the lateral aspect of the right elbow. The patient suffered from lancinating pain on his right elbow. At the recommandation of one his friends, he had applied crushed raw garlic to his elbow and covered with occlusive bandage for approximately two hours. Physical examination revealed two 1cm x 3 cm bullaes over a 5cm x10 cm well-demarcate, erythematous patch on the lateral aspect of the right elbow (Picture).

The patient was referred to the dermatology clinic and diagnose of irritant contact dermatitis was confirmed.

Results: With the treatment of a topical corticosteroid and antibacterial cream combination twice a day, the lesion completely resolved within two weeks. After that the patient was referred to Physical Therapy and Rehabilitation because of severe elbow pain. He was diagnosed as lateral epicondylitis and treated with local steroid injections.

Conclusions: The medicinal use of herbs is becoming more common among the patients. Serious complications and side effects can occur from uncontrolled use of herbal treatment products. We present this case to increase physician awareness about the potential complications of naturopathic remedies. Cliniacians need to ask questions about naturopathic medicines in their history-taking.

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

W290

MORTALITY IN EMERGENCY DEPARTMENT: MYTH OR REALITY?

C. Jebali 1, N. Ibn Hassine 1, N. Chebili 1, L. Boukadida 1, A. Zorgati 1, R. Boukef 1

1

Emergency Department Of Sahloul, Sousse, Tunisia

Background: The study of mortality in emergencies is of high importance for emergency didactic. It is also a useful indicator for assessing the provision of care and support for patients. Our emergency department has not yet been the subject of such a study. Thus, it seemed appropriate to consider a prospective study whose objectives were to determine the characteristics of the patients died in the emergency specify the cause of death and to evaluate patients who died with the waning of the limitation or shutdown therapeutically active.

Methods: This is a prospective observational study mono centric over a period of one year including all deaths in the emergency department during the period of study. Several parameters were collected from the medical records. Then, two seniors have investigated whether the death was reversible with the waning of a medical condition, there was a concept of preventable death in severe trauma and finally, if the limitation or cessation of active treatment was formalized conduct or implicitly. Exclusion criteria inclusions were: patients already arrived dead, age <15 years, patients without medical records and patients whose medical records are unusable due to lack of data.

Results: We included ninety-four deaths in emergencies. Thus, we have objectified male predominance. The majority of death affects a young population with an average age of 61 Âą 5 years. Only 24.5% of our patients underwent a medical transport. More than half of patients have cardiovascular history. The cause of death was the most common stroke and in 29.8% of cases the etiology of death was unclear. The incidence of reversible medical death was 12.7%. We noted 17 premature deaths post-traumatic.

Conclusions: early deaths were frequent emergencies and are mainly the elderly, for which an alternative home maintenance decision could be taken. Active resuscitation measures have been taken in principle in most cases before deciding on a limitation or termination of active treatment.

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

W291

AMICI - INTERIM RESULTS OF A MULTICENTER STUDY ON THE USE OF ANTICHOLINERGIC MEDICATIONS IN PATIENTS WITH COGNITIVE IMPAIRMENT, ACUTE DELIR, OR FALLS

I. Weichert 1, T. Soe 1, J. Tolonen 2, R. Romero-Ortuno 3, C. Lebus 4, S. Choudhury 5, C. Nadarajah 5, G. Network 6

1

The Ipswich Hospital Nhs Trust - Acute Medicine Department, Ipswich, United Kingdom, 2 Helsinki University Hospital - Department Of Medicine And Rehabilitation, Helsinki, Finland, 3 Cambridge University Hospitals Nhs Foundation Trust - Addenbrooke's Hospital - Department Of Medicine For The Elderly, Cambridge, United Kingdom, 4 Cambridge University Hospitals Nhs Foundation Trust - Addenbrooke's Hospital - Acute Medicine Department, Cambridge, United Kingdom, 5 East And North Hertfordshire Nhs Trust - Lister Hospital - Acute Medicine Department, Stevenage, United Kingdom, 6 Global Research On Acute Conditions Team Background: Drugs with anticholinergic activity may worsen cognition and increase the risk of falls and mortality. Clinicians are often not aware of these potential effects. We are presenting the interim results of a multinational study which investigates physiciansâ&#x20AC;&#x2122; prescribing behaviour and the impact of hospital admission on anticholinergic burden in patients who are most at risk.

Methods: The study is a prospective comparative audit in the UK, Finland, The Netherlands, Italy, and Malaysia.

Medical patients admitted with delirium, chronic cognitive impairment, or falls were randomly selected. Using an adapted scale after Boustani et al., we recorded the anticholinergic burden on admission, during hospital stay, and on discharge, the concomitant use of acetylcholinesterase inhibitors, if a new diagnosis of dementia was made, and follow up on 30 day readmission and post discharge death. The observed anticholinergic burden in different subgroups and at different times was analyzed statistically, as well as possible changes in this burden.

The point of statistical significance was set at p <0.05. These are the preliminary results of the UK and Finnish collaborators which, between 07/09/2014 and 30/5/2015, recorded the data of 489 patients.

Results: In the cumulative data, from admission to discharge, there was no significant reduction in anticholinergic burden but a small decrease (8.93%) in the number of patients on drugs with anticholinergic properties. Subgroup analysis showed that a significant reduction in burden took place in patients with an initial score of 3 or higher, a low initial score of 1 to 2 or a diagnosis of dementia (either pre-existent or made during the index admission). This was offset by starting anticholinergic naĂŻve patients on these medications and the lack of a significant change in burden in patients not admitted with dementia, i.e. with falls or acute delirium. <FILE IMAGE='383_20150714215725.jpg'> Conclusions: These results are encouraging, particularly with regards to patients with a high burden on admission or a diagnosis of dementia. Further analysis, when all centres have contributed their data will help to develop interventions in order to improve prescribing behaviour for patients at risk of potential side effects of anticholinergic medications.

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

W292

THE BURDEN OF ELDERLY PATIENTS IN THE EMERGENCY DEPARTMENT: HEALTH CARE ASSESSMENT AND NEED OF A GERIATRIC EMERGENCY MODEL

C. Pacioni 1, A. Bianchetti 2, F. Tosoni 2, G. Ricevuti 1

1

Università Degli Studi Di Pavia, Pavia, Italy, 2 Istituto Clinico S.Anna, Brescia, Italy

Background: Elderly patients, frequently frail, with multimorbidity and polypharmacy, are at risk to receive inadequate care when admitted to Emergency Department (ED), especially if they have cognitive impairment or lack of social support. One of the factors conditioning an adequate care is the perception of health professionals of an excessive load determined by elderly patients. The aims of the study were to collect data about the admissions to our ED stratified for age, and to evaluate the perception of ED staff (physicians and nurses) upon the prevalence of >65 years old about admitted patients.

Methods: Physicians (MD) and nurses working in the ED of “Istituto Clinico S.Anna” Hospital (Brescia, Italy) were asked to rate the proportion of >65 years old among patients admitted and hospitalized. Then, data about patients admitted to the ED during 2014 were collected. Data were analyzed dividing into age group.

Results: 6 MDs and 11 nurses participated to the inquiry. The estimated percentage of the elderly admitted to ED was 50% for MDs, and 61% for nurses; the estimated percentage of the elderly among all persons hospitalized was respectively 58.3% for MDs and 61% for nurses. A total of 28.230 patients were admitted at our ED during 2014; among them, 8.274 (29.3%) were > 65 yrs old (in particular 0-17 yrs 2.9%, 18-50 yrs 51.9%, 51-64 yrs 15.9%, 65-74 yrs 11.5%, 75-84 yrs 11.4%, >85 yrs 6.4%). A total of 3.738 (13.2%) patients were hospitalized (56,4% of them were >65yrs old), mainly in Internal Medicine (30.5%), Cardiology (17.5%) and General Surgery (12.2%). Among all patients discharged, 25% were >65yrs old. A total of 34 patients died in the ED, 32 (94%) of them were >65 yrs old.

Conclusions: ED staff has an exaggerated perception of the number of the elderly admitted, which anyway represent a significant proportion. This discrepancy may reduce the quality of care provided to this vulnerable population. Thus, there is the need to develop a geriatric emergency model for frail older patients in ED in order to provide a better level of care.

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

W293

ACUTE DYSPNEA IN ELDERLY WOMAN: THE ROLE OF COMORBIDITIES

C. Bizzotto 1, M. Lucenteforte 1, V. Filippi 1, J. Forni 1, N. Marcomini 1, L. Bonomi 1, F. Siccardo 1, L. Canobbio 1, L. Bianchi 1, A. Pansa 1, E. Ragazzini 1, F. Malagoni 1, F. Rodigari 1, E. Binda 1, M. Carnovale 1, S. Frigerio 1

1

University Of Pavia - Department Of Internal Medicine And Therapeutics, Pavia, Italy

Background: Dyspnea is often associated with emergencies. It can be related to many pathological conditions, most frequently to lung pathologies.

Methods: Woman, 75, affected from diabetes mellitus, Alzheimerâ&#x20AC;&#x2122;s Syndrome, tricuspidalic and aortic insufficiency (already treated), presented acute dyspnea and gastric heartburn. Clinical examination: Bp 132/86 mmHg, Bpm 116, SpO2 74%, glycemia 200, sodium 141, potassium 3, pO2 47%, pCO2 31.8%, pH 7.48, lactic acid 2. The ECG showed a run of ventricular tachycardia with atrial fibrillation. A thoracic CT detected multiple bilateral densifications of inflammatory origin in the lungs. The patient is treated with antibiotics, oxygen, bronchodilators and iv potassium.

Results: The clinical case is an example of atypical presentation of disease, as it usually occurs in elderly people. The electrolytic imbalance has caused a severe alteration of cardiac rhythm associated with dyspnea. In turn, the dyspnea lead to the detection of the inflammatory condition affecting the lungs, not presenting its typical signs.

Conclusions: In elderly people presenting multicomorbidities, it is necessary to pay attention to the electrolytes levels and monitor metabolic and electrocardiographic alterations. A severe pulmonary condition may not present its typical signs, thus, it could be recognized by chance because of other occasional pathologies.

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

W294

ACUTE COGNITIVE DISORDER IN ELDERLY: THE ROLE OF IONIC ALTERATION

M. Lucenteforte 1, S. Moschi 1, M. Gortan 1, C. Hruby 1, E. Ragazzini 1, L. Venturini 1, G. Ricevuti 1, C. Guerini 1, F. Malagoni 1, C. Bizzotto 1, V. Casuale 1, R. Colombo 1

1

University Of Pavia - Department Of Internal Medicine And Therapeutics, Pavia, Italy

Background: Hyponatremia is the most common electrolyte imbalance observed in the elderly related to the water balance of the body. Blood sodium less than 135 mEq / L contribute to increase the incidence of mortality and morbidity. Hyponatremia may be of iatrogenic origin: medications as selective serotonin reuptake inhibitors (SSRIs) and diuretics are frequently involved in the reduction of serum sodium. In these cases, discontinuation of therapy results in the normalization of blood levels of sodium. The treatment should be evaluated according to clinical findings: the correction of 'hyponatremia should be gradual to avoid brain damages as the pontine myelinolysis.

Methods: Woman, 82, admitted due to left femur fracture treated with osteosynthesis with nail range for rehabilitation. Entrance sodium levels were normal (140mEq/l). Because of low mood, citalopram 20mg 1/2 cp was administered, later increased to 1 cp. After 15 days, blood tests showed a mild hyponatremia (134mEq/l).

As the mood improved, water restriction and administration of diuretics were evaluated as a possible solution, anyway showing no positive effects. The therapy with citalopram was suspended, solving hyponatremia and bringing blood sodium in the normal range (138mEq / l). Following the stabilization, the quetiapine therapy (25mg 1CP) was introduced and did not result in sodium alterations.

Woman, 83, suffering from hypokinetic syndrome in chronic vascular disease, FA in TAO, stenotic aortic insufficiency, admitted for rehabilitation. At the entrance, in view of low mood, paroxetine 20 mg 1/2 cp was introduced in therapy, later increased to 1 cp. Severe hyponatremia appeared after a month (128 mEq/L), SSRI administration was then interrupted. After discontinuation of treatment with SSRIs, natremia normalized (six days after 138mEq/l, 14 days after 142 mEq/l). Mirtazapine 30mg 'was then integrated, then increased to 1 1/2 cp.

Results: These cases report examples of electrolytic imbalance of iatrogenic origin, solved by the suspension of drug administration.

Conclusions: Cognitive disorders often occur in elderly. The most frequent cause is electrolytic imbalance, usually of iatrogenic origin, in particular related to neurolectics. Therefore it is necessary to pay attention in the administration of these drugs in the elderly.

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

W295

ATYPICAL PRESENTATION OF AN EMERGENCY IN AN ELDERLY WOMAN AFFECTED BY A TUMOR

C. Bizzotto 1, M. Lucenteforte 1, F. Rodigari 1, E. Binda 1, M. Baggiani 1, G. Dalla Giacoma 1, R. Maruccia 1, F. Malagoni 1

1

University Of Pavia - Department Of Internal Medicine And Therapeutics, Pavia, Italy

Background: Elderly people often have comorbidities that can generate many complications in case of an emergency.

Methods: Woman, 93, admitted due to a silent pulmonary embolism, discovered throught a CT performed to check a squamous cell carcinoma of the right cheek. Clinical examination: patient alert and oriented, absence of angor and dyspnea, absence of evident peripheral edema, bilateral signs of venous insufficiency of lower limbs, absence of clear evidence of deep venous thrombosis in progression.

The patient remained asymptomatic for angor and dyspnea. She was firstly treated with oxygen therapy and an anticoagulant. The oxygen therapy was suspended as the hemogasanalysis parameters and SpO2 improved.

An ecocolordoppler examination detected a deep venous thrombosis in the left lower limb, suggesting the continuation of the anticoagulant therapy. Subsequently the patient presented pain and swelling at the right shoulder. The rheumatological examination identified a complete rupture of the tendon of the long head of biceps brachii and hemartrosis. An arthrocentesis was thus performed and the anticoagulant therapy was temporarily suspended. Two days after she presented a transient dysarthria and a rima oris asymmetry. The neurological examination excluded damages to cranial nerves and a CT excluded intra-axial and extra-axial hemorrhages. Neurological symptoms rapidly disappeared so the anticoagulant therapy was continued.

Due to the detection of a normocytic anemia (Hb 10.3g/dl), partially due to a mild chronic renal failure with eGFR 46 ml/sec CKD-EPI (resulting in turn from arterial hypertension reported in remote patient history), it was necessary to start a therapy with recombinant erythropoietin and iron supplementation.

Results: The clinical presentation is often atypical in elderly people, also in case of an emergency. Therefore complications must be suspected even in absence of classic signs and symptoms.

Conclusions: In this case, since the patient had a tumor, it was necessary to indagate the presence of pulmonary embolism, a common complication of tumors, even if she was asymptomatic for angor and dyspnea.

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

W296

SUDDEN DEATH IN ELDERLY RELATED TO ACQUIRED LONG QT SYNDROME

M. Lucenteforte 1, E. Ragazzini 1, S. Moschi 1, M. Ceravolo 1, A. Maragoni 1, C. Riboni 1, L. Bracchitta 1, F. Conti 1, A. Apollinari 1, M. Perlato 1, G. Spennato 1, S. Soriano 1, L. Venturini 1, G. Ricevuti 1

1

University Of Pavia - Department Of Internal Medicine And Therapeutics, Pavia, Italy

Background: The development of a polymorphic ventricular tachycardia, as torsade de pointes (TdP), is associated with QTc interval prolongation on the surface electrocardiogram and can cause sudden cardiac death. Different environmental stressors can cause the Acquired Long QT Syndrome and their removal restores the physiologic condition. The drug therapy, in association with other risk factors (i.e sex, age, cardiovascular diseases), is the most common environmental stressor involved in acquired long QT syndrome.

Methods: Evaluation of the QTc interval prolongation effect in elderly subjects, considering that this category of patients is characterized by a certain number of comorbidities.

In the first six months of 2015 we analysed a large number of patients that were admitted to a rehabilitation ward. For each subjects these data were collected: age, sex, admission diagnosis, ECG QT interval values (corrected according to the Bazettâ&#x20AC;&#x2122;s formula), electrolytes values and drug therapy.

Results: At the entrance 31,80% of patients were recorded the with LQT, 18,1% of which remained unchanged.

In the total sample, 5,5% of the patients were recorded with normal ECG at admission and developed a pathological lengthening of the QTc interval during the hospital stay. In total, 22,2% deaths were recorded, 40,2% of which showed a lengthening of the QTc interval. The results showed a statistically significant association between QT prolongation, sex male (p <0.01), drug therapy (p <0.01) and death (p <0.05).

Multivariate analysis showed an OR between QT prolongation and death equal to: OR = 1.735.

Conclusions: These data suggest that the risk of sudden death is about 73% in patients with a lengthening of the QTc at hospital admission. The QT interval values monitoring, together with polypharmacy and the age, has a crucial role in the reduction of the risk of death related to QTc elongation in patient with several comorbidities.

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

W297

MANAGING PNEUMONIA IN OLDER PATIENTS IN THE EMERGENCY DEPARTMENT

S. Guerrini 1, B. Del Vecchio 2, G. Bianchi 2, M. Cavazza 1

1

Department Of Emergency Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy, Internal Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy

2

Department Of

Background: Community acquired pneumonia (CAP) represents often a â&#x20AC;&#x153;life-changing eventâ&#x20AC;? in elderly, being related with a high risk of mortality as well as functional and mental impairment. It is therefore important to define correctly the severity of pneumonia in older patients referring to the Emergency Department (ED). Furthermore, given elderly immunosenescence and comorbidities, our aim was to identify which parameters can help the emergency physician in defining the severity of community acquired pneumonia in elderly.

Methods: We performed a prospective, observational study in the Emergency Department of S. Orsola Malpighi hospital from February to May 2015. 189 patients were included. Demoghrapihcs, clinical history, comorbidities and radiological features were taken into consideration. At arrival in ED, white blood cells count, PCR and procalcitonin level together with arterial blood gas analysis were performed. Final outcome was evaluated as discharge from ED, death or admission to a long term institution.

Results: 92 patients were discharged and sent home, 40 died during hospitalization and 57 were transferred to a long term institution. We observed a statistically significant relationship between an increased risk of death or institutionalization and patients admitted at ED with a CURB-65 value superior or equal to 2, high PSI and Charlson Comorbidity Index adjusted for age. No significant relationship was identified between clinical outcome, white blood cells count and PCR level. By contrast, elevated values of procalcitonin related significantly with a high CURB-65 (3 or more). Fever or sepsis during hospitalization resulted independently related with mortality.

Similarly, age and acute related independently with the impossibility to discharge patients.

Conclusions: A high CURB-65 (3-4) score and high level of procalcitonin at admission at ED are associated with a higher risk of hospitalization for elderly with CAP. We propose the use of these two parameters to determine CAP severity in older patients in the ED setting, able to help emergency physicians in predicting clinical outcome of this vulnerable group of patients. Moreover, this study demonstrate once again the importance of clinical presentation (namely the presence of fever or acute confusion) especially in elderly

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

W298

FACTORS ASSOCIATED WITH FALLS AMONG ELDERLY PATIENTS ADMITTED TO EMERGENCY DEPARTMENT

T. Cimilli Ozturk 1, R. Ak, E. Unal Akoglu, O. Ecmel Onur

1

Fatih Sultan Mehmet Education And Research Hospital, Istanbul, Turkey

Background: Fall related injuries constitute a significant part of emergency department admissions of geriatric patients. Recurrent falls are also not uncommon. One-third of individuals over age 65 falls at least once a year and it has been shown that this ratio reached 50% over 80 years. The most important point in the prevention of falls is the identification of environmental and personal factors that give rise to falls and to take precautions against. The aim of this study is to evaluate the factors associated with falls among the elderly patients admitted to emergency department.

Methods: The study was conducted between 1st May 2014 and 31 October 2014 at a tertiary education and research hospital in Istanbul, Turkey. All the patients over 65 years who admitted to emergency department due to falls were included. Patients and/or their relatives were asked to answer the questions searching for possible factors that may interfere with their fall event. The factors that might have been associated with multiple falls were also investigated.

Results: During the study period of 6 months 308 patients over 65 years old admitted to emergency department.

51% were between 65-79 years old and 49% were > 80 years old. The women constituted the 70.1% of the cases. The majority of the cases described the mechanism of injury as stumbling and fall (72.4%). 16.6% of the cases fell after a vertiginous episode and 7.8% described syncope. Statistically significant factors related with multiple falls were as follows: being between 65-79 ages, being physically active before the fall event, having chronic cardiovascular and neurologic diseases and being on benzodiazepine medication. The most common type of injury was the minor head trauma (25%, n=77).

Conclusions: According to our results physically active and relatively younger elderly people fall more frequently. As the most commonly described mechanism was stumbling and fall, the importance of environmental risk factors is emphasized. Patients with cardiovascular and neurological diseases should be further evaluated for fall risk and indications of benzodiazepines in elderly people should be well evaluated.

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

W299

THE IMPACT OF ACCESS BLOCK IN THE EMERGENCY DEPARTMENT ON THE FUNCTIONAL STATUS OF THE OLDER PATIENT.

M. Bohane 1, L. Cogan, E. Brazil, J. Mcinerney, D. Power

1

Medicine For The Elderly, Mater Misericordiae University Hospital, Dublin, Ireland

Background: High hospital occupancy resulting in extended delays in the Emergency Department (ED) is detrimental to the health of the generality of patients. Our objective was to carry out a quantitative prospective study to assess whether older people who experience Access Block in the ED are at greater risk of functional decline.

Methods: A research pro-forma was designed for completion on all patients over 70 years old, admitted acutely through the ED of a Dublin teaching hospital.

Four assessment scales were used to assess functional status within 24 hours of presentation, daily for the next seven days, and on discharge: the Barthel Index, the Mini Mental State Exam (MMSE), the Modified Rankin Scale (mRS), and the Elderly Mobility Scale (EMS). The Charlson Co-morbidity index was also included in the baseline assessment.

Changes in the functional assessment scales were analysed from admission to day 3, from admission to discharge and were correlated with time spent in the ED awaiting inpatient admission.

Results: Fifty-two patients completed assessments of which 27 (51.9%) were female. Mean age (SD) was 82 (5.4) years (range 73 â&#x20AC;&#x201C; 93 years). Forty-two per cent of patients spent > 24 hours in the ED awaiting inpatient admission. Male patients experienced significantly longer waiting times in the ED following a decision for admission (p=0.02).

A non-significant trend for greater deterioration in the Barthel Index at day 3 and discharge (p=0.53, p=0.41) was noted for those who waited longest for admission. The majority of patients showed deteriorations in the MMSE and EMS. However, these findings did not correlate with the length of time spent in the ED (r=-0.172, r=-0.06).

Most patients, as expected, showed an improved mRS score on discharge. However, a non-significant trend towards a worsening mRS score was observed in those waiting > 48 hours in the ED (p=0.6).

Conclusions: While, this study failed to show a significant correlation between hours spent waiting in the ED and functional deterioration, it highlighted the complex needs of older patients in this setting and prompts a larger study to better evaluate the implications of Access Block.

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

W300

GERIATRIC PATIENT REVISITS TO THE EMERGENCY DEPARTMENT

S. Ravishankar 1, A. Mostafa 1

1

Hamad Medical Coorporation, Doha, Qatar

Background: There are unique challenges faced by emergency departments (ED) in providing appropriate emergency care for the elderly due to the complex nature of their presentations. This results in multiple revisits to the ED which can contribute in overwhelming the departmentâ&#x20AC;&#x2122;s capabilities. The aim of this study was to review the characteristics of all elderly patients presenting to the ED 10 times or more. <FILE IMAGE='95_20150515152448.jpg'> Methods: Setting: Hamad General Hospital is the major tertiary hospital for Qatar, population 2million people.

The ED has an average annual census of 450,000._Study Population: Elderly patients (age>65) presenting to the ED at HGH ten or more times in one year. This included 91 patients. Data collection: Retrospective chart review of all patients identified by investigators from the electronic registration log. Data items collected included age, sex, comorbidities, presenting complaint, final diagnoses, ethnicity, social aspects of residence, and method of arrival to ED. Results: In 2012 the number of patients over 65 years of age received by our ED was 12,949 out of 410,821 (3%). Of these, 91 patients came in 10 times or more during that year. There were considerable differences in the proportion of patients according to nationality, with a predominance of Qataris (68.1%), males (57.14%), patients between 65 and 75 years old (64.84%), and arrivals by private transport (65.45%). Main complaints were predominantly respiratory and gastrointestinal symptoms and they represented (38.6%) of primary complaints.

Conclusions: The geriatric population has a high frequency of ED visits in Qatar. The reasons for repeat visits were mainly respiratory and gastrointestinal complaints and depended on nationality. Certain presentations could be easily prevented by better community services such as insertion of catheters in nursing homes. In addition, identification of certain high risk presentations such as chronic obstructive airway disease and congestive heart failure, where case management may reduce re-presentation may be effective in this community. Prospective studies, including interviews with families are needed to fully understand the psychosocial reasons for the high number of visits in this at risk population.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Imaging / Imaging by Ultrasound

W301

4 WEEKS OLD GROIN/THIGH PAIN

M.A. Majeed, N. Alsukaity 1, D. Yeo 1

1

University Hospital Birmingham, Birmingham, United Kingdom

Background: Femoroacetabular impingement (FAI) is a known aetiology of premature osteoarthritis of the non-dysplastic hip in young and middle-aged adults. Groin pain is a very early complaint and its differential diagnosis is very wide. Ultrasound (US) is a cost-effective, fast and widely available technique for early detection of patients with FAI. Methods: Case report: 53 years-old gentleman presented to the Emergency Department with a four-week history of groin and thigh pain. The patient was capable of running his daily activities but had progressive difficulty. There was no history of trauma or fall prior to the onset of his symptoms.

He looked generally well and had normal observations and skin colour at the groin and the left hip area.

Bedside US was performed by the ED physician and showed an effusion of the left hip joint with anterior probe tenderness. The patient was referred to Orthopaedic surgery for further management. He had joint aspiration, which showed no features of infection. He was managed conservatively with painkillers and exercises.

Results: FAI patients can present with non-specific symptoms which makes early diagnosing more challenging.

FAI is characterized by abnormal contact between the proximal femur and rim of the acetabulum. Wisniewski reported the first case in June 2006, titled â&#x20AC;?Femoroacetabular Impingementâ&#x20AC;?. The use of bedside ultrasound by emergency physicians has dramatically increased lately and its use has led to increased speed of diagnosis, expedited disposition, and improved quality of emergency care.

Conclusions: Femororacetabular impingement causes early osteoarthritic changes of the hip joint that occur in healthy young and middle aged adults. The subtle and non-specific course of the disease represents a challenge that can lead to late diagnosis and subject patients to unnecessary treatment and functional deterioration.

Although MRI is usually the ultimate imaging to make a diagnosis of FAI, US can play a major role in early detection and management of patients. Bedside US in the ED to look for the main sonographic findings is of a great help when properly performed even with brief training.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Imaging / Imaging by Ultrasound

W302 DIAGNOSE PULMONARY EMBOLISM IN MINUTES WITH BEDSIDE ECHOCARDIOGRAPHY M. Majeed 1, A. Naveed 1

1

University Hospital Birmingham, Birmingham, United Kingdom

Background: Acute pulmonary embolism (PE) is defined as a partial or complete occlusion of the pulmonary artery branches; together with deep vein thrombosis it is a possible manifestation of the same disease: venous thromboembolism. PE is associated with high morbidity and mortality, especially when associated with signs of right ventricular (RV) dysfunction.Objective: To describe the role of bedside echo in diagnosing massive PE. Methods: We want to discuss 2 cases, which were diagnosed with bedside echo in the ED. Results: Cases: Both of our patients were female (age 35-36yrs) presenting with SOB, dizziness and collapse. On arrival they were found to be respiratory rate 25-30/min, pulse 100-120/min and BP <90 systolic with low saturation of 88-90% on air. On examination they had essentially normal chest, cardiac, abdominal and lower leg examination.

Based on the history and examination provisional diagnosis of PE was made in both the cases.

While waiting for the investigations being carried out a bedside echo was performed.

The echo showed significantly distended right ventricle and the inter-ventricular septum was pushed towards the left ventricle.

The inferior vena cava (IVC) was distended and non-collapsing (no respiratory changes).

The echo findings were clearly suggestive of massive PE confirmed by CTPA. Conclusions: Echo is a noninvasive, relatively inexpensive technique, readily available and repeatable in critically ill patients at the bedside. It helps in early diagnosis and treatment of the patients. On the other hand echo may unveil different abnormalities explaining symptoms found in a patient with suspected pulmonary embolism such as pericardial disease, aortic dissection etc.

Discussion: Patients with acute pulmonary embolism frequently have bedside echo in the current era. In patients with large pulmonary embolism, abnormalities can be seen on the transthoracic echocardiogram .

These include right ventricular dilatation and hypokinesis, abnormal motion of the inter- ventricular septum, tricuspid regurgitation, and lack of collapse of the inferior vena cava during inspiration (6). Echocardiography is useful for diagnosis in hemodynamically unstable patients with unexplained dyspnoea, syncope, or hypotension.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Imaging / Imaging by Ultrasound W303 SOLVE THE MYSTERY M. Majeed 1, A. Naveed 1

1

University Hospital Birmingham, Birmingham, United Kingdom

Background: Bedside ultrasonography has become a vital part of emergency department (ED) care. Itâ&#x20AC;&#x2122;s an increasingly important tool for emergency physicians to help solving the mysteries which canâ&#x20AC;&#x2122;t be solved with routine history and examination. It provides rapid, real time information that assists in patient care and clinical decision-making.

Methods: Case history: A 33 year old female, 9 weeks pregnant, collapsed at home. Husband called the ambulance. On ambulance arrival the patients was complaining of mild abdominal discomfort and right shoulder tip pain. She was found to have systolic blood pressure of 82, pulse of 102/min and oxygen saturation of 92% on air.

She was alerted to our Emergency Department as suspected ruptured ectopic pregnancy.

On arrival she was seen by the ED physicians who confirmed the above history and observations. She was complaining of feeling light headed and dizzy especially on trying to sit up. She had essentially normal examination except mild abdominal discomfort and above observations. She had 2 normal previous pregnancies and was normally fit and well.

Results: A bedside ultrasound confirmed intrauterine pregnancy and no free fluid was seen. Therefore the diagnosis of ruptured ectopic pregnancy was ruled out.

Echo was performed which showed distended right ventricle and inter-ventricular septum was pushed towards the left ventricle and the IVC was distended and showed no collapsibility. The deep veins showed a large DVT extending from left femoral to popliteal area.

Based on the above findings the diagnosis of massive PE was made, confirmed with CTPA and patient was started on clexane and admitted in critical care unit.

Conclusions: Initially used in trauma but with the passage of time its role has significantly expanded. It immediate availability and repeatability makes it an ideal tool for ED physicians. In the above case Bedside ultrasound changed the final diagnosis and destination of the patient. Otherwise this patient could well have been transferred to Gynecology for suspected ruptured ectopic pregnancy. This could have significantly delayed the diagnosis and possibly changed the outcome.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Imaging / Imaging by Ultrasound

W304

CONTRAST-INDUCED NEPHROPATHY IN PATIENTS CONTRAST-ENHANCED COMPUTERIZED TOMOGRAPHY Y. Kim 1, S. Ahn 1, Y. Lee 1, K. Lim 1, W. Kim

WITH

ACTIVE

CANCER

UNDERGOING

1

1

Asan Medican Center, University Of Ulsan, College Of Medicine, Department Of Emergency Medicine, Seoul, South Korea Background: This study was performed to measure the incidence and to find potential predictors of contrast-induced nephropathy (CIN) in patients with active cancer who received contrast-enhanced computerized tomography (CECT). Clinical outcomes of CIN were reported based on the RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease) classification for acute kidney injury.

Methods: A retrospective analysis of 820 cancer patients presented at our emergency department for the six-month period from October 2014 to March 2015 was done.We included adult patients (>=18 years) with active cancer who underwent CECT during their stay in the ED, and had a baseline creatinine level of 1.5 mg/dL or less. CIN were defined as an increase in creatinine concentration of >=0.5 mg/dL or a >=25% above baseline, occurring 48 to 72 hours after CECT. Results: The incidence of CIN was 8.0%. Serial CT examination (OR: 4.09, 95% CI: 1.34–12.56), hypotension before CT (OR: 3.95, 95% CI: 1.77–8.83), liver cirrhosis (OR: 2.82, 95% CI: 1.06–7.55), BUN/creatinine >20 (OR: 2.54, 95% CI: 1.44–4.46), and peritoneal carcinomatosis (OR: 1.75, 95% CI: 1.01–3.00) were independently associated with CIN. Of the 66 CIN patients, 44 met any of the severity criteria of the RIFLE classification. Five patients among them died during their hospitalization. However, only one death was related to renal failure. <FILE IMAGE='5_20150417042450.jpg'> Conclusions: Even with baseline serum creatinine is 1.5 mg/dL or less, a significant portion of patients with cancer are still in risk for CIN. Consecutive CECT examination, hypotension before CT scan, liver cirrhosis, dehydration, and peritoneal carcinomatosis seem to predispose patients to CIN. However, their clinical significance is week and additional validations of these findings are required.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Imaging / Imaging by Ultrasound

W305

DANGER IN THE SHADOWS: DON'T MISS THESE DEADLY EMERGENCY CHEST X-RAY FINDINGS

D. Manos 1, B. Das 2

1

Department Of Diagnostic Radiology, Dalhousie University, Halifax, Canada, Medicine, Dalhousie University, Halifax, Canada

2

Department Of Emergency

Background: Chest X-rays are often the initial imaging test for patients presenting to the Emergency Department with chest pain, fever, or dsypnea. Emergency Physicians are usually the first to view the radiograph and, particularly overnight, may interpret images several hours before the exam is officially reported by the Radiologist. Emergency Physicians may initiate a care plan, or discharge patients, prior to the final chest X-ray report.

Methods: This continuing medical education exhibit will present a series of Emergency Department case presentations, each illustrating important but subtle chest X-ray findings. The cases have been chosen to highlight clinical scenarios that can be associated with challenging chest X-rays. A discussion of the chest x-ray findings, the frequency of the findings and the importance of timely diagnosis for each of the clinical scenarios will be included.

Results: Pneumocystis jiroveci pneumonia, acute pericardial effusion, pneumothorax, pneumomediastinum, sternal fracture, diaphragmatic rupture, pulmonary embolus and paraspinal hematoma may be hard to diagnosis on the basis of clinical exam and history alone. However, each may present with relatively specific but sometimes subtle findings on chest X-ray. Awareness of key teaching points may improve recognition of these critical chest X-ray abnormalities and may help physicians identify which patients require further investigation such as Computed Tomography.

Conclusions: When detected, certain subtle chest X-rays findings may change the course of the Emergency patient work up and treatment plan. Failure to recognize these chest radiographic findings may delay diagnosis and lead to increased morbidity and mortality.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Imaging / Imaging by Ultrasound

W306

NOT JUST AN ABSCESS

M. Barton 1, C. Butts 1

1

Louisiana State University Health Sciences Center - Department Of Emergency Medicine, New Orleans, Usa

Background: Chief Complaint: Left thigh pain History of Present Illness: 20 year old male presented with complaint of left medial thigh pain and swelling for at least two months with acute worsening for the last five days. Patient had been stabbed in the left posterior lateral thigh by a three inch pocketknife five months prior. Patient also complained of fever and fatigue.

Past Surgical/Medical/Social History/Allergies: None Physical Exam: 38.6 degrees Celsius, 112 heart rate, 115/72 mm Hg, 16 respirations per minute Left lower extremity exam reveals a swollen, erythematous, left medial thigh with tenderness, warmth and subtle pulsatility on palpation. Well healed 1 centimeter scar noted on posterior lateral thigh. Left thigh circumference 58.5 centimeters, 1+ distal pulses, right thigh 49.5 centimeters, 2+ distal pulses Methods: Bedside ultrasound of the area revealed 6x5x5 centimeter anechoic collection with active 'to and fro' color Doppler signal. Surrounding this area was a large collection of mixed echogenicity material. This finding was highly suspicious for active pseudoaneurysm formation.

CT angiogram confirmed the diagnosis of infected hematoma with active pseudoaneurym component. <FILE IMAGE='278_20150620200435.jpg'> Results: Diagnosis of infected pseudoaneurym was confirmed. Wide spectrum antibiotics were initiated and the Vascular Surgery service was consulted. The patient was admitted and taken to the operating theater where 1.5 liters of purulent material was evacuated. Bovine patch was used for vascular repair. The patient did well postoperatively.

Conclusions: This case again shows the importance and value of using bedside ultrasound in the emergency department setting to further investigate physical exam findings. We argue that based on physical exam findings alone some would have been tempted to diagnose localized abscess and proceed with incision and drainage.

Needless to say, this would have been catastrophic. It was clear even after just a few seconds of scanning that this was not just a simple abscess and its definitive management would require the consultation of a surgeon.

Not only was possible disaster averted, a clear picture of the patientâ&#x20AC;&#x2122;s diagnosis, treatment requirements, and disposition were immediately evident after the ultrasound images were rendered.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Imaging / Imaging by Ultrasound

W307

CHILAIDITI’S SIGN: AIR UNDER RIGHT HEMIDIAPHRAGM

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

1

Fatih Sultan Mehmet Education And Research Hospital, Istanbul, Turkey

Background: Chilaiditi’s sign known as asymptomatic colonic interposition between the liver and diaphragm and is found incidentally in 0.025% to 0.28% of chest and abdominal radiographs. Chilaiditi syndrome refers only to complications in the presence of Chilaiditi's sign. These include abdominal pain, distention, nausea, vomiting, constipation, and even cardiac arrhythmias or respiratory distress. <FILE IMAGE='209_20150705152227.jpg'> Methods: A 81-year-old man was admitted to our emergency department because of diarrhea, nausea and vomiting with history of hypertension and chronic renal failure. Vital signs were as follows: 36,3°C, blood pressure: 114/69 mmHg, pulse:78 beats per minute, sp02:%96. Physical examination revealed tenderness in the periumblical area and increased bowel sounds. Electrocardiography was normal. Chest radiography suggested the presence of air below the right side of the diaphragm (Figure 1). CT scan of the abdomen revealed no evidence of obstruction or intraperitoneal free air (Figure 2). Laboratory tests were normal except blood urea nitrogen 38 mg/ dL (normal 8.9-20.6 mg/dL) and creatine 2.62 mg/dL(normal 0.72-1.25 mg/dL). Patient was treated symptomatically and observed for 6 hours. He was discharged without any intervention.

Results: 1 Conclusions: Chilaiditi's sign is generally not associated with symptoms, and is most commonly an incidental finding. It is commonly misinterpreted as pneumoperitoneum and can lead to unnecessary surgical intervention, so physicians should be aware of this benign condition.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Patient Flow / Throughput Management

W308

JOURNEY OF BOTTOM 50 TO TOP 50:

A. Habib 1, F. Khan 1

1

Doncaster Royal Infirmary, Doncaster, United Kingdom

Background: Objectives & Background: Our Trust was rated among the bottom 50 Trust across the country by the Department of Health in March 2013 on the A&E Targets. The Trust was struggling to find the right solution to improve the performance. To improve the performance of the ED Staff were taken on board by the Executive Team. In a month time the Trust Performance reached to the top 50 Trust across the country.

Methods: Methods: The Trust Executive committee conducted meetings with all the staff groups from the ED. The suggestions were listen very seriously and changes were implemented immediately. The key changes made were: Change in Leadership, Initiation of High Level Specialist Triage at Reception, Streaming of patients, fortnightly meeting between management team and ED Clinical Team, Increase work force, appointments of substantive Middle Grades, Increase Shop floor cover of Consultants, Inter departmental changes between Critical and Non Critical areas, Structuring of teams with in the department etc.

Results: Results / Conclusions: Empowering Clinical Staff in decision making, support of Executive Team resulted in the Trust to become the top 50 Trust across the country Conclusions: L

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Patient Flow / Throughput Management

W309

THE ANALYSIS OF NURSING WORKLOAD IN EMERGENCY DEPARTMENT H. Choi 1 1

Korea Hospital Nurses Association, Seoul, South Korea

Background: The standard criteria for the regional ED nurses by the emergency medical law was more than 15 people. This standard criteria didn't reflect the ED situation and the nursing workload. In case of emergency department overcrowding, the work of the ED nurses were getting increased. ED nurses' burden of the work had been reported to affect work stress, burnout, patientâ&#x20AC;&#x2122;s mortality and satisfaction. Therefore we analyzed the nursing activity in ED. Through of this we should arrange adequate nursing work distribution and provide evidence of qualified nursing.

Methods: This study was a descriptive research through the nursing activity analysis. We determined 15 nursing domain and 185 nursing activities by calculating importance rate. Nursing domain consisted of respiratory care, medication, safety, measure & observation, nutrition, excretion care, sanitation, exercise & position, comfort, education, examination care, special care, nursing management, communication, education & consult & research. This data collection was performed by the 7 nurses who worked more than 5 years in the ED. We extracted 7 days conveniently from 5th September to 2nd October 2014. Total 14 nursesâ&#x20AC;&#x2122; nursing activities observed, frequency & duration of the activities were measured by 1:1 direct observation.

Results: The observed nursing activities were total of 4,516 cases and the nursing management was highest frequency, the nutrition was lowest. Average duration was the longest in the safety (3.71 min) and the shortest in the communication (0.85 min). Showed 17.12% of total nursing activiies have been performed simultaneously.

The concurrent nursing activities were nursing record, order check, print, prescription check and intravenous injection. Among the observed 4,516 cases of nursing activities, one minute or less nursing activities were 2,367(52.41%), less than 10 seconds nursing activities were 286(6.33%), 11-30 seconds or less nursing activities were 1,107(24.51%), 31-60 seconds nursing activities were 1,260(27.90%).

Conclusions: In the ED, we founded lots of work to be done in a short time basis and a high rate of work to do at the same time. It was confirmed that a professional staff is needed in ED to facilitate ED process for patients and nurses.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Patient Flow / Throughput Management

W310

EVALUATION OF PERFORMANCE INDEXES OF EMERGENCY DEPARTMENT

A. Baratloo 1, A. Rouhipour 2, M. Forouzanfar 1, N.S. Mahdavi 3, B. Hashemi 1, F. Rahmati 1

1

Emergency Department, Shohadaye Tajrish Hospital, Shahid Beheshti University Of Medical Sciences, Tehran, Iran, 2 Pediatric Department, Valiasr Hospital, Ghazvin Medical University, Abyek, Iran, 3 Anesthesiologist And Intensive Care Specialist, Shahid Beheshti University Of Medical Sciences, Tehran, Iran Background: The importance of evaluating performance indicators in the emergency department, as one of the most important departments of hospital, is obvious to everyone. Therefore, in this study we aimed to appraise the five performance indicators, approved by the ministry of health, in Shohadaye Tajrish hospital, Tehran, Iran.

Methods: In a descriptive cross-sectional study based on the profiles of all the patients admitted to the emergency department, performance indicators in the emergency department were evaluated. The study was divided into 2 parts about the establishment of emergency medicine system and training the medical staff: the first 6 months of 1392 and the second. Then these 2 periods were compared using Mann-Whitney U test while P< 0.05 was considered as the level of significance.

Results: Of the studied indicators, mean triage time was 6.04 minutes in the first 6 months which was reduced to 1.5 minutes in the second 6 months (p=0.016). In addition, the percentage of patients who moved out of the department in 12 hours was lowered from 97.3% in the first period to 90.4% in the second (p=0.004). While, the percentage of patients who were decided upon in 6 hours (p=0.2), unsuccessful CPR percentage (p=0.34) and patients discharged against medical advice (p=0.42) showed no significant difference.

Conclusions: The results of this study showed that the establishment of the emergency medicine system in the emergency department could lead to more efficient triage. Due to the differences made after their establishment including: different pattern of the patients admitted, increased stay of the patients in the department due to their need for prolonged intensive care, a raise in patient referral to the hospital by pre-hospital services and a higher percentage of occupied hospital beds, other indicators have not shown a significant improvement.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Patient Flow / Throughput Management

W311

EMERGENCY DEPARTMENT ADMISSIONS: ACCURACY IN PREDICTING ADMISSIONS

WHO HOLDS THE KEY?

ANALYZING EM PHYSICIANS’

A. Nevel 1, J. Riordan 2

1

University Of Virginia Department Of Emergency Medicine, Charlottesville, Usa

Background: The process to admit a patient from the emergency department (ED) to an inpatient ward can vary amongst hospitals. Some emergency physicians (EPs) merely communicate a hand-off of care, while others must await confirmatory evaluation of the admitting provider/team. This variation in process can extend ED length of stay.

One factor that may weigh into the deployed process is the perceived ability of the EP to accurately determine the necessity of admission. Although this ability forms the basis of the admission process there are very few studies confirming accuracy.

This study seeks to identify the accuracy of EPs in predicting the admission of patients evaluated in the ED. Methods: This study was conducted at a university-based teaching hospital in which EPs do not have direct admitting privileges. Instead, they must request admission from the inpatient team and await evaluation/ disposition by that team. During the 3-year study period, the EPs used an electronic order (‘pre-admit’) to indicate their belief that the patient would be admitted. This could be placed at any time during the ED stay.

This study involved a retrospective review of ED encounters between 1/2012 and 12/2015. The encounter data was analyzed and time intervals of patient flow events calculated. The admission rate was then calculated for patients with pre-admit orders. This rate was then analyzed based on acuity (1 to 5 scale) and age.

Results: A total of 178,010 patient encounters were included in the analysis, with 46,332 resulting in admission (26%). Of those admitted, 28,391 (61%) had a pre-admit order placed, with 25,918 ultimately admitted to the hospital (91.3%). This increased to 94% for elderly patients (>60) with acuity level 1-3. The average time from pre-admit order to admission was 130.2 minutes.

Conclusions: This data suggests that EPs are highly accurate at predicting admission necessity of ED patients for whom they provide care (91%). This accuracy appears to improve for elderly patients with moderate-to-high acuity (94%). By requiring evaluation by the admitting team prior to acceptance of patients, hospital systems may thus be unnecessarily increasing ED length of stay.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Patient Flow / Throughput Management

W312

PATIENT FLOW CLINICAL DECISION UNIT

L. Stewart, M. Besharati, S. Das

1

West Suffolk Hospital, Burt St Edmunds, United Kingdom

Background: Clinical decision units (CDU) are observation units, separate from main Emergency Department (ED) that allow observation of patients in order to determine whether not admission is necessary. Patients are usually discharged from the clinical decision unit within 24 hours. They have the potential to provide multispecialty targeted intervention in A&Es, and avoid prolonged hospital stays. We investigated the appropriateness to patient referral to CDU. Methods: A retrospective study was carried out looking at 100 consecutive admissions to CDU in January/February 2015. For each of the patients, the electronic records were reviewed and the reason for admission, the length of stay and the outcome of the admission were recorded. Their adherence to admission criteria was assessed.

Results: 90% of the patients in the study fulfilled the CDU admission criteria. Of the 10 patients who did not fulfil the criteria, 5 had already been accepted by another specialty and 5 did not have clear management plans. 97% of the patients had a length of stay of 24 hours or less.

79% of the patients were discharged from CDU, either to their own homes or to a residential care facility. Of the remainder, 13 were admitted under the medical team, 4 were admitted under the surgeons and 4 were transferred to a psychiatric inpatient facility.

Conclusions: Analysis of this sample of patients suggests that the CDU admission criteria are being adhered to in the majority of cases. The length of stay of the majority of patients on CDU is 24 hours or less, indicating that prompt reviews are taking place and discharges are being arranged where possible. Overall most patient benefited from CDU stay and prolonged in hospital stays were prevented.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Patient Flow / Throughput Management

W313

QUALITY IMPROVEMENT TEAM PROJECT: IMPROVING THE COMMUNICATION SYSTEM WITHIN THE EMERGENCY DEPARTMENT (ED) UTILISING THE CLINICAL MICROSYSTEMS METHODOLOGY. F. Borhan 1, C. Browne, P. Martin, E. Chan, D. Melia, M. Broughall, G. Jefferies, L. Lawlor, F. Brady, E. O'conor 1

Connolly Hospital - Emergency Department, Blanchardstown, Dublin, Ireland., Dublin, Ireland

Background: To provide all Emergency department teams with a standardised approach to help with change and improvement, the National Emergency Medicine Programme in Ireland identified a methodology called â&#x20AC;&#x2DC;Clinical Microsystemsâ&#x20AC;&#x2122;, a model which evolved from work at the Institute for Health Policy and Clinical Practice, Dartmouth College, USA. We aim to improve the telecommunication system in Connolly Hospital Emergency department by utilizing the Microsystems improvement ramp. This would facilitate effective referral outcomes, improve patient-relative interactions and consequent patient care outcomes in the Emergency department.

Methods: The Connolly Hospital ED Microsystem is a multidisciplinary team including doctors, clinical nurse managers, advanced nurse practitioners, nurses, physiotherapist, care assistant, patient liaison officer, secretary and receptionist. The process began with looking into our existing telephone and bleep system. An initial audit was performed to diagnose cause of delays and unsatisfactory bleep responses. This included identifying hindrances in communication between ED with other specialties / allied health care, labs, Radiology, and patient - relative interaction. The responses to all bleeps made from Emergency department were recorded.

Communication between team members was facilitated via regular weekly meetings and emails. After analyzing the gathered data, 2 phones were introduced in the ED exclusively for the purpose of bleeping .Additionally, 2 mobile phones were allocated in ED for the purpose of patient - relative interaction. All staff working in the Emergency department were educated on appropriate usage of these phones. Subsequently, a re-audit of all bleep responses was performed.

Results: It was observed that after implementing new phones specific for bleeping and specific for patient-relative interaction, the number of successful bleep responses had increased from 23% to 64%. Failure of successful bleep response due to interruption from outside calls reduced from 45% to 16%. No response to bleep category had reduced from 15% to 8%.

Conclusions: The Dartmouth Microsystems model was applied to improve the success of bleep responses and telecommunications within Connolly Hospital Emergency department. After a systematic approach up the ramp, the number of successful bleep responses increased from 23% to 64%. This was a significant improvement.

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

W314

A MISPLACED CENTRAL LINE?

E. Davlantes 1, Z. Kazzi 1, J. Meer 1

1

Emory University Department Of Emergency Medicine, Atlanta, Usa

Background: A 65-year-old gentleman with no cardiac history presented to the ED with dyspnea. <FILE IMAGE='189_20150529183743.jpg'> Methods: Vitals were unstable and chest x-ray showed multifocal pneumonia, so he was intubated and left subclavian central line was placed for initiation of pressors. On chest x-ray to evaluate line placement, the catheter was coursing in the left chest without ever crossing to the right mediastinum.

Results: However, using the ultrasound bubble test, the ED team confirmed that the catheter was in the central venous circulation and allowed immediate use of the central line. CT chest performed hours later revealed that the line was in a duplicate left sided superior vena cava.

Conclusions: Persistent left superior vena cava is the most common thoracic venous anomaly, present in approximately 0.5% of the population. It is derived from the vein of Marshall, which is patent during early development but usually degenerates into a ligament by birth. Although this abnormality may predispose a patient to cardiac conduction abnormalities, most of the time this anatomy is clinically insignificant and is only discovered during the placement of central venous lines or pacemakers.

The bubble test is an ultrasound-guided procedure used to determine venous placement of a central line. With the probe in place, saline solution is quickly pushed through the central line. If the line is in the central venous circulation, bubbles are immediately visible in the right atrium and ventricle on ultrasound. In critically ill patients, this can allow immediate use of central line after placement and avoid inadvertent removal of the line.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Case Reports W315 AN UNUSUAL CAUSE OF SHORTNESS OF BREATH WORTH BEARING IN MIND P. Mohan 1, E. Fabris 2

1

Princess Royal University Hospital, Kings College Nhs Trust, London, United Kingdom

Background: We present the case of a 78-year old female who presented with acute dyspnea. She suffered with hypertension and chronic back pain secondary to a recent osteoporotic vertebral collapse.

On admission she was hemodynamically stable but with saturations of 58% on room air with severe type 1 respiratory failure (p02 4.2, pco2 2.67 FIO2 28%). There was no airway obstruction or obvious cyanosis but she was PROFOUNDLY dysponeic. Systemic examination and chest radiograph were unremarkable; ECG showed sinus tachycardia. Bloods were normal, apart from polycythemia (Heamoglobin-16.5).

She denied any associated symptoms. She had no risk factors for a cardiovascular disease, and an intermediate clinical probability for pulmonary embolism (Wells 4). A bedside echo revealed no signs of right ventricular compromise or increased right side pressure.

Severe respiratory distress persisted, with no improvement in saturations despite bronchodilators, steroid therapy, and trial on continuous positive pressure ventilation. With ITU support, we proceeded to thrombolysis but, an immediately subsequent CTPA showed no PE. Her saturations normalized following intubation and positive pressure ventilation for 36 hours.

During her recovery period in Coronary Care she was noted to have recurrent episodes of orthostatic de-saturation. Comparison of trans-oesophageal echocardiography echo performed in a supine and upright position revealed a right to left shunt via small intra-atrial shunt (IAS) with shunt reversal and augmentation when the patient was sat upright. This confirmed the diagnosis of platypnea-orthodoxia syndrome.

Platyponea is a rare phenomenon first described in 1957 characterized by orthostatic hypoxemia. It occurs due to the interaction between an anatomical component (e.g: intra-cardiac or pulmonary shunt) and a functional component. We postulate that the functional component in our patient could be the recent change in mediastinal anatomy (secondary to vertebral collapse) and causing raised right atrial pressure on assuming an upright position. Following surgical ASD closure, our patientâ&#x20AC;&#x2122;s symptoms have now resolved.

Methods: Results: Conclusions: Key learning points are that the first and foremost differential diagnosis to exclude in the case of severe unexplained dysponea is a pulmonary embolus, subsequently more unusual differentials such as platyponea are worth considering.

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

W316

BARIUM CONTRAST ASPIRATION CAUSING RESPIRATORY FAILURE

M. Agrait Gonzalez 1, J. Mercado 1

1

University Of Puerto Rico Emergency Medicine Department, Carolina, Puerto Rico

Background: Case of a 56 year old male who was brought in to the emergency department due to progressive shortness of breath over the previous 12 hours. On evaluation, the patient was found with severe respiratory distress, able to only communicate in one word statements and by the use of his hands. Due to distress and worsening respiratory status, the decision was made to intubate the patient. His mother arrived shortly thereafter and stated the patient had undergone a procedure in the radiology area the previous day and was told something had gone wrong. She said someone explained the situation, but she was unable to explain what procedure was performed, for what reason or what exactly the complication was.

Post intubation X-ray showed what appeared to be a right lower lobe consolidate, but instead was found to be barium contrast from an esophagram performed due to a suspected malignancy at level of the upper esophagus or vocal cords. The radiologist performing the procedure stopped it when the aspiration event was noticed, performed a chest X-ray and instructed the patient to obtain close follow up if any respiratory symptoms developed.

Barium contrast aspiration is relatively common as it is used in procedures to evaluate for possible airway or esophageal pathology and it is generally well tolerated although there are reports of complications especially in the setting of massive aspiration. This patientâ&#x20AC;&#x2122;s respiratory failure was due to a relatively small amount of contrast aspiration, but with severe resulting pneumonitis requiring a prolonged intensive care stay and eventual discharge with a tracheostomy. <FILE IMAGE='218_20150601031433.JPG'> Methods: Results: Conclusions: Barium aspirations are generally well tolerated, but patients should be monitored closely and admission should be considered if patients are at high risk for complications of aspiration pneumonitis.

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

W317

BILATERAL PNEUMOTHORACES AND RESPIRATORY DISTRESS AS THE PRESENTING MANIFESTATIONS OF PNEUMOCYSTIS PNEUMONIA IN A PREVIOUSLY HEALTHY 40 YEAR OLD FEMALE

M. Agrait Gonzalez 1, J. De Santiago 1

1

University Of Puerto Rico Department Of Emergency Medicine, Carolina, Puerto Rico

Background: A 40 year old female with a history of previously well controlled asthma is brought in to the emergency department with severe shortness of breath worsening over the previous week. The patient arrived in severe distress, afebrile, tachycardic, tachypneic, with acrocyanosis, speaking only in two word phrases.

Physical exam showed no wheezing, but diminished breath sounds bilaterally with vitals showing oxygen saturation around 70% despite 100% oxygen by mask. Non-invasive positive pressure ventilation improved saturation to 95-96%, but the patient continued with distress. Chest X-ray was obtained which showed a diffuse reticulonodular infiltrate along with bilateral pneumothoraces. On evaluation of the X-ray, the possibility of opportunistic infection was entertained and the patient was questioned about sexual behavior and prior IV drug abuse or transfusions, but repeatedly denied any high risk behaviors which would predispose her to becoming infected with HIV. Nonetheless, HIV testing was ordered with her consent and she was started on broad spectrum antibiotics including coverage for possible Pneumocystis jiroveci (formerly P. Carinii) pneumonia. The patient was managed with bilateral chest tube thoracostomy and the decision was made to intubate as her distress continued with only minimal improvement. The patient was admitted to the ICU and the next day, HIV testing returned positive along with severely elevated lactate dehydrogenase, consistent with likely Pneumocystis infection. Unfortunately, despite early recognition and aggressive treatment, the patient never recovered and died in the intensive care unit two weeks after admission.

Methods: .

Results: .

Conclusions: Pneumocystis jiroveci has been known to cause pneumothorax in around 6% of patients with confirmed infection, but there are no published cases where bilateral pneumothoraces were the presenting findings in a patient with Pneumocystis infection or in a patient without HIV risk factors. Pneumocystis infection should be in the differential for any patient with unexplained shortness of breath and hypoxia and should be high in the differential in a patient with otherwise unexplained pneumothorax (especially if bilateral) and typical X-ray and laboratory findings. If found, pneumothorax in Pneumocystis infection, presents a grave prognosis for the patient.

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

W318

EARLY RECOGNITION OF INTRAVENTRICULAR HEMORRHAGE IN THE SETTING OF THROMBOCYTOSIS IN THE EMERGENCY DEPARTMENT.

M. Charles 1, G. Sugalski, R. Fontoura

1

Rutgers New Jersey Medical University-Department Of Emergency Medicine, Newark, Nj, Usa

Background: Thrombocytosis is frequently encountered as an incidental laboratory finding. The most common etiology is reactive thrombocytosis due to infections, trauma, surgery, or occult malignancy. Even though thrombocytosis is benign and self-limiting in most cases, it can result in thrombosis or hemorrhage. Since thrombocytosis is a known risk factor for thrombosis, it is commonly a concern for ischemic stroke and myocardial infarction. Much less common, as we see in this case, are hemorrhagic events associated with thrombocytosis. <FILE IMAGE='212_20150531000051.jpg'> Methods: This is a report of an 83-year old man that presented to the emergency department with hypertension and a headache, who was found to have significant thrombocytosis and an acute right intraventricular hemorrhage without signs of neurological deficits, or evidence of vascular malformations or mass. We present this case for review and discussion amidst a dearth in data with regard to the management of thrombocytosis in the setting of acute intraventricular hemorrhage.

Results: The patient was transfused a unit of platelets and administered desmopressin for a computerized tomography scan finding of intraventricular hemorrhage and placed on a Cardene drip for blood pressure control. He was then transferred to the intensive care unit for close monitoring. As expected, platelet function tests came back low and repeat imaging showed stable intraventricular hemorrhage. Patient was managed medically, did well and was discharged to a subacte rehabilitation facility without neurological deficits on oral anti-hypertensive medications.

Conclusions: Certainly every headache does not require a head computerized tomography scan. However, we believe that early imaging in this elderly patient with thrombocytosis contributed to his favorable final outcome.

There may be a need for gathering more clinical data on current practices and outcomes of elderly patients presenting with headache and thrombocytosis in the emergency department. Furthermore, de novo research on thrombocytosis associated with intraventricular hemorrhage could provide a sound basis for formulating novel, rational clinical guidelines for these patients.

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

W319

INFERIOR DISLOCATION OF THE HIP (LUXATIO ERECTA FEMORIS); A CASE REPORT

B. Rezvani Kakhki 1, M. Saadatfar 1, S.R. Ahmadi 1, M.D. Sharifi 1, M. Talebi Doluee 1, A.M. Hashemian 1, H. Zakeri 1

1

Emergency Medicine Research Center, Faculty Of Medicine, Mashhad University Of Medical Sciences, Mashhad, Iran Background: Inferior dislocation of the hip joint is a rare disorder, especially in adults. Few cases have been reported in literature regarding the incidence and management modalities for this subtype of anterior hip dislocation. In this study, we report a case of inferior dislocation of the hip joint in an adult male.

Methods: Case Report: The patient was a 31-year-old man with severe pain in his left hip after falling off the motorbike during a road traffic injury, which he did not remember. He was unable to lift his left lower limb, which was in externally rotated position. Besides, he was unable to extent his left knee and he had lacerations and abrasion over his legs and face. His vital signs were stable and neurovascular examination was normal. Initial management was done immediately. Pelvic anteroposterior radiograph showed an inferior dislocation of the left femoral head. Close reduction of femoral head was performed under general anesthesia. Skin traction was applied following reduction. Confirmatory X-ray and CT scan of the left hip showed satisfactory results. Control CT-scans of neck revealed a fracture in second cervical vertebra, thus he was admitted to the neurosurgery ward.

Results: After a week, he was discharged with no further abnormality and the range of motion of the left hip joint was completely comparable to that of his normal right hip. The patient was educated to continue the treatment for one week, at home.

Conclusions: Inferior hip dislocations are becoming more prevalent due to the rise in road traffic injuries.

Prompt diagnostic and therapeutic measures should be taken in order to reduce the rate of neglected dislocations and avoid delayed treatments, which result in severe complications. <FILE IMAGE='50_20150531212716.jpg'>

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

W320

LIMB WEAKNESS IN SEPSIS; AN ATYPICAL PRESENTATION OF INFECTIVE ENDOCARDITIS

L. Zucco 1, E. Fabris 1

1

King's College Hospital Trust, Princess Royal University Hospital, London, United Kingdom

Background: A 54-year-old male, with a past medical history of Crohn’s disease and hypertension, presented to A&E with bilateral limb weakness and pyrexia following a two-week history of generalized flu-like symptoms. His treatment included only Mesalazine MR. Methods: He was referred to the acute medical team as possible Guillain Barre Syndrome, however a full neurological examination was in fact normal. General examination instead revealed a pansystolic murmur throughout the precordium and micro-thromboembolic phenomena in the fingers and toes. On further questioning, he admitted being diagnosed in the past with a “benign murmur”.

His ECG showed SR, LVH and LBBB. Blood tests revealed elevated inflammatory markers (CRP 318, WC 15).

He was therefore commenced on IV antibiotics for sepsis secondary to suspected infective endocarditis (IE).

Blood cultures were positive for S. aureus.

Results: An urgent bedside TTE established the presence of vegetations along the IV septum. An MRI brain revealed diffuse small infarcts with a hemorrhagic infarct in the left frontal lobe. This likely represented the effects of septic emboli thus explaining transient peripheral limb weakness on presentation.

He was later transferred to the CCU where a TOE revealed two large vegetations on the mitral valve, at the level of LVOT, in addition to the presence of a congenital sub-aortic membrane and a thickened IV septum measuring ¾ LVOT, indicating a likely history of HOCM. An urgent surgical referral was made for replacement of the mitral valve, followed by a prolonged course of IV antibiotics. He made a full recovery.

Conclusions: We are presenting an atypical case of IE presenting as bilateral leg weakness. Both HOCM and a subaortic congenital membrane can lead to LVOT obstruction (1) and it is likely that these congenital heart defects predisposed our patient to IE, while the presence of a subaortic ridge was likely the site of clot formation.

References: 1. Ahn, KT, et al. Flail Subaortic Membrane Mimicking Left Ventricular Outflow Tract Obstruction in Hypertrophic Cardiomyopathy. J Cardiovasc Ultrasound. 2013 Jun; 21(2): 90–93.

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

W321

MEDIASTINITIS DUE TO ESOPHAGEAL RUPTURE

A. Ahmadi 1, R. Azizkhani 1, K. Golshani 1

1

Emergency Department, Isfahan University Of Medical Sciences, Isfahan, Iran

Background: Mediastinitis is a critical diagnosis that should be consider in the differential diagnosis of chest pain.

Methods: A 68 years old man presented to our emergency department with chest pain, dyspnea and odynophagia. In physical examination, he was alert and cooperative. His posture was in a semi-sitting position to relief his chest pain. He had a history of viral upper respiratory tract infection and dry cough since seven days ago. His chest pain and odynophagia started four days before admission. The day before admission, he experienced hoarseness, too. In his past medical history, he had a two month history of chemotherapy because of plasma cell dyscrasia. Physical examination revealed fever (T= 39.2ยบc), cervical bilateral subcutaneous emphysema and epigastric tenderness. A diagnosis of esophageal rupture was confirmed by chest X-ray and CT scan during swallowing of water soluble oral gastrografin that showed extravasation of contrast agent and presence of free air in the mediastinal space (figure 1). The patient was successfully managed by broad spectrum antibiotics and conservative management.

Results: <FILE IMAGE='99_20150531111453.jpg'> Extravasation of gastrografin Conclusions: In cases with a history of malignancy because of an increased chance for esophageal rupture due to any valsalva-like maneuver, the diagnosis of esophageal rupture and subsequent mediastinintis should be consider in the differential diagnosis of chest pain.

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

W322

SIGMOID PERFORATION MASQUERADING AS ACUTE CYSTITIS

A. Satyam 1, S. Pothiawala 1

1

Singapore General Hospital, Singapore, Singapore

Background: Colonic diverticulosis incidence increases with age and is rarely seen under the age of 30 years.

We present a rare case where perforation of the colonic diverticulosis presented as acute cystitis.

Methods: A 40 year old man presented to the ED with complaints of suprapubic pain and dysuria since 4 days despite treated by the GP for cystitis with antibiotics.

His examination revealed moderate suprapubic tenderness and bloods showed leucocytosis. Urine had leukocytes suggestive of cystitis. His chest x-ray did not show any free air under diaphragm and abdomen x-ray did not show any obstruction or calculus. He was diagnosed as cystitis and commenced on antibiotics. He was admitted to the inpatient department in view of persistent symptoms and for intravenous antibiotics. CT scan of abdomen revealed perforation of sigmoid colon due to diverticular perforation He was operated by colorectal surgeons and then discharged uneventfully after a few days.

Results: Acute cystitis is not that common among young male population. Diverticulosis is more commonly seen in the aging population and primarily occurs in the sigmoid colon (55 to 95%) With increasing age, the diverticula increases, and they occur progressively more proximally. Structural abnormalities of the colonic wall, disordered motility, and the role of dietary fiber have been implicated in the development of diverticular disease. The risk of diverticular perforations increases as the age progresses.

We present a rare case where a middle aged patient with diverticular perforation presented with symptoms suggestive of acute cystitis. The emergency physician should always be cautious in the disposition of patients with abdominal pain. Abdomen pain has always been a challenge and chance of misdiagnosis is high as evident from this case that the suprapubic pain was not cystitis but secondary to diverticular perforation.

Conclusions: We want to highlight to the emergency physicians that if we encounter young males with symptoms of acute cystitis, we should consider alternative diagnosis as cystitis could be an atypical manifestation of underlying sigmoid perforation. This enables appropriate management of patients presenting to the ED with atypical presentations.

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

W323

SIMULTANEOUS FRACTURE OF THE HOOK OF THE HAMATE AND THE FOURTH CARPOMETACARPAL JOINTS: CASE REPORT

B. Rezvani Kakhki 1, S.R. Ahmadi 1, M.D. Sharifi 1, A.M. Hashemian 1, S.M. Sadrzadeh 1, B. Zarmehri 1, R. Akhavan 1

1

Emergency Medicine Research Center, Faculty Of Medicine, Mashhad University Of Medical Sciences, Mashhad, Iran Background: The evidence of fourth carpometacarpal joints dislocation and hammate fractures is rare, which, may be due to its difficult and sometimes miss diagnosis based on routine X-rays. Simultaneous fracture of hammate with carpometacarpal joints dislocation in the same hand is extremely rare. We report a case of a combination of a fourth carpometacarpal joints dislocation and a fracture of the hook of the hammate detected by computer tomography (CT) imaging.

Methods: The patient was a 32-year-old right-hand-dominant man, with a chief complaint of right hand pain, especially in the fourth and fifth fingers, that began immediately after punching a handle of armchair. On physical examination there was a deformity and tenderness with reduced range of movements (ROM) on the fourth metacarpal. Radiographs showed a dislocation of the fourth carpometacarpal joint and a suspicious fracture in the hook part of hammate. Then the patient underwent a CT image which indicated a dislocation of the fourth carpometacarpal joint and a fracture in the hook of hammate. An open reduction and internal fixation (ORIF) was done and the wrist and hand were immobilized for 6 weeks.

Results: In 3 months follow-up, the patient had a normal strength in his hand and he was asymptomatic.

Conclusions: Hammate fracture is often missed on initial presentation and initial X-ray, which emphasizes the need for compulsive diagnostic evaluation such as CT imaging and careful follow-up. In fact, when there is a tenderness, and a reduced ROM on the base of fourth carpometacarpal joints, CT is helpful in a more accurate diagnosis. <FILE IMAGE='50_20150531215106.jpg'>

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

W324

TENSION HEMOTHORAX IN TRAUMA

A. Rajjeh 1, M. Kalantari Meibodi 1, Y. Zeyd 1, S. Esfandiari 1

1

Shiraz Medical University, Shiraz, Iran

Background: Normal lung is important for normal breathing .then early recognizing abnormality in chest specific in trauma is very critical.

Methods: A 29 year old man has been brought following penetrating trauma (stab wound in left chest).

Initial exam revealed sharp laceration in left posterior of chest (2 cm) with decreased breathing sound in left haemithorax and dullness. But the patient remained hemodynamically stable. RR: 16, spo2 98% (on room air), BP: 110/75.

Results: First chest x ray showed left massive hemothorax with tracheal and mediastinal structure right shifting.

Left sided chest drain was placed, initial drain was 1300cc. So, the patient transferred to Operation room immediately.

Left thoracotomy is performed which showed intercostal artery cutting with active bleeding, 1000cc clot also is evacuated. Then chest is closed and chest drain is remained. 5 days later, the chest drain is discontinued and the patient is discharged home.

Conclusions: We concluded early recognizing injury in chest such as life threatening injury tension hem thorax we can treatment the patient with good prognoses

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

W325 RISK FACTORS FOR DELAYEDâ&#x20AC;?ONSET RHABDOMYOLYSIS IN PATIENTS WITH DOXYLAMINE SUCCINATE OVERDOSE H. Choi 1, Y. Choi 1

1

Ewha Womans University Mokdong Hospital, Seoul, South Korea

Background: Doxylamine is a hypnotic agent; it is widely used to control symptoms such as insomnia. Patients with doxylamine overdose mostly exhibit good outcome, but some present experience serious complication: rhabdomyolysis, convulsion, and acute renal failure.

Some patients who present with normal creatine phosphokinase (CPK) levels in the emergency department (ED) later develop rhabdomyolysis during observation. So, we investigated the factors associated with delayed-onset rhabdomyolysis in patients with doxylamine overdose.

Methods: The medical records of patients who visited the ED for doxylamine overdose between January 1, 2005 and December 31, 2014 were retrospectively reviewed. In all patients, clinical variables and initial blood samples were obtained for analysis of arterial blood gas analysis (ABGA) pH, electrolytes, CPK, blood urea nitrogen (BUN), creatinine (Cr), aspartate aminotransferase (AST), alanine aminotransferase (ALT), amylase, and lactate dehydrogenase (LDH). Urine was collected for pH and occult blood analysis was evaluated.

Follow-up samples (e.g., electrolyte, BUN, Cr, CPK) were obtained 6 hours after admission. Delayed-onset rhabdomyolysis was defined as a follow-up serum CPK level more than 5 times the upper limit of the normal value (>1000 IU/L).

Results: A total of 337 patients (66 men and 271 women) were enrolled in this study. The amount of doxylamine ingested (P = 0.000, OR = 7.002), heart rate (P = 0.003, OR = 2.809), ABGA pH (P = 0.003, OR = 2.267), and urine occult blood (P = 0.005, OR = 2.048) were found to be significant risk factors of delayed onset rhabdomyolysis.

Conclusions: Observation and laboratory follow-up are required for patients with doxylamine poisoning amount exceeds 18 mg/kg, pulse exceeds 120 beats per min, ABGA pH is less than 7.4 according to blood and urine tests, or urine occult blood is present, even if their initial creatine phosphokinase levels were normal.

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

W326

THE IMPORTANCE OF HYPERTENSION IN THE RECOGNITION OF ACUTE HEART FAILURE

D. Smith 1

1

Texas A&m College Of Medicine, College Station, Usa, 2 Baylor Scott And White, Temple, Usa

Background: A sudden increase in arterial blood pressure strains the left ventricle and may rapidly precipitate acute heart failure in susceptible individuals. Such patients commonly present to the emergency department with the appearance of a primary respiratory abnormality. This is frequently confusing because of co-morbid conditions and baseline physiological abnormalities. Naloxone has been previously described as a cause for acute congestive failure and pulmonary oedema but the setting and mechanism in which this occurs has been poorly elucidated.

Methods: The patient is a 56 year old male who resides in a nursing home where he became “dizzy and confused”. The patient was found to be “unresponsive” with an oxygen saturation of 83% on 4 litres of nasal oxygen. Ambulance providers administered naloxone. The patient regained full alertness, but developed agitation and respiratory distress. In the emergency department the patient was in severe respiratory distress with a pulse of 124 and a respiratory rate of 42. The patient’s admission blood pressure was 154/112, significantly above the patient’s baseline normal blood pressure. The patient has a history of congestive heart failure, chronic obstructive pulmonary disease, and morbid obesity. He takes numerous medications including methadone (5 mg PO bid). Physical examination was remarkable for laboured breathing with diminished breath sounds.

Results: The patient was initially treated with nebulized albuterol (5 mg) and ipratropium (0.5 mg). And non-invasive ventilation. Subsequently a chest x-ray demonstrated increasing interstitial and airspace disease.

He was given furosemide (60 mg IV) and an intravenous infusion of nitroglycerine. The patient’s condition rapidly improved and a chest x-ray done 8 hours later showed improvement.

Conclusions: Acute heart failure frequently presents with the appearance of a respiratory illness. The physical exam and chest x-ray is frequently difficult to interpret correctly because of underlying lung disease and pre-existing co-morbid conditions. Narcotic withdrawal is accompanied by catecholamine release with resulting hypertension and cardiovascular stress and is a prototypical setting for development of acute heart failure by this mechanism. Appropriate recognition and treatment in this situation depends on recognizing the cardiovascular effects as the primary abnormality.

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

W327

THE ROLE OF RADIOLOGY IN LIS FRANC INJURIES

O. Ghazanfar 1

1

Oxford University Hospitals, Oxford, United Kingdom

Background: Lis Franc injuries are sustained following a crush injury onto the mid foot in which the the metatarsal bones are displaced from the tarsus.

They commonly present to the Emergency department and more often then not require operative intervention.

Diagnosis of such injuries is often difficult and these may not be visible on plain x-rays often requiring advanced imaging which will be the focus of the poster and the case report.

Methods: A patient presented to the Emergency Department after being run over by a tractor.

The foot was clearly deformed and heavily bruised and the patient was non-weight bearing A clinical suspicion of Lis Franc injury was made and a plain xray was done .

The xray was inconclusive and a CT scan of the foot was planned.

This was a weekend and when the request was discussed with a radiologist the plain x-ray report was deemed normal and the CT request was refused.

Because of the high suspicion the patient was put in a plaster,non-weight bearing and was recalled to the trauma clinic the following day.

Results: The patient had a CT of the foot via the trauma clinic and a Lis Franc injury was confirmed and operative correction was required Conclusions: CT scan is the gold standard for diagnosing and subsequent management of Lis Franc injuries

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

W328

SUCCESSFUL TREATMENT OF ACUTE COLCHICINE INTOXICATION FROM LONG-TERM USE

S. Nakajima 1, K. Okuda 2, K. Takahoko 1, K. Hayashi 1, A. Tanpo 3, M. Nagashima 1, T. Nishiura 1, A. Kobayashi 1, M. Okada 1, N. Kokita 1, S. Fujita 1, K. Shimizu 2

1

Department Of Emergency Medicine, Asahikawa Medical University, Asahikawa, Japan, 2 Department Of Legal Medicine, Asahikawa Medical University, Asahikawa, Japan, 3 Department Of Anesthesia, Nayoro City Hospital, Nayoro, Japan Background: Acute colchicine intoxication is a potentially fatal event. Most cases result from accidental ingestion of a plant containing colchicine or from overdose by suicide attempt, but there has been no report on overdose from therapeutic colchicine intake. We report such a case with some review of literature.

Methods: A 74-year-old man was admitted to a previous hospital because of diarrhea and lethargy. From November 2013, he started taking colchicine at 1.0 mg/day for idiopathic chronic pericardial effusion. Thirteen months later, the dosage was increased to 2.0 mg/day, after which, he developed severe diarrhea and lethargy.

After admission, laboratory findings revealed pancytopenia, elevated hepatic enzymes, and renal dysfunction.

Concomitantly, his consciousness level gradually worsened and he was transferred to our hospital for further treatment on day 12. A multidisciplinary therapy was started and comprised mechanical ventilation, blood transfusion, and continuous hemodialysis. Gradually, he responded to medical treatment and his general condition eventually recovered. He was transferred to another hospital for rehabilitation on day 65. Serial measurements of serum colchicine concentration by liquid chromatography-mass spectrometry were performed on the first visit to the previous hospital, during the acme phase upon transfer to our hospital and during the convalescent phase. Toxic concentration was confirmed at fastigium (5.8 ng/ml) and reduced concentration was noted at the convalescent phase.

Results: Colchicine intoxication is a rare but potentially fatal complication. Measurement of serum colchicine concentration is useful for predicting the therapeutic effect.

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

W329

SIDE EFFECTS OF PROPAFENONE HCL; CASE REPORT

T. Korkmaz 1, N. Pekel 2, S. Yesilaras 3, D. Oray 4, C. Ertan 5

1

Izmir University Department Of Emergency, Izmir, Turkey, 2 Izmir University Department Of Cardiology, Izmir, Turkey, 3 Izmir University Department Of Emergency, Izmir, Turkey, 4 Izmir University Department Of Emergency, Izmir, Turkey, 5 Izmir University Department Of Emergency, Izmir, Turkey Background: There may be some cardiac and non-cardiac side effects of Propofenone hydrochloride (propafenone HCI) which is a class IC antiarrhythmic agent used for medical cardioversion in atrial fibrillation, atrial flatter. These properties make Propafenone an effective converting agent for up to 40-70% of patients with atrial flutter and fibrillation. Compared with other class IC agents, propafenone has a lower observed prodysrhythmic rate in therapeutic doses. Most common side effects may be listed as conduction disturbances on ECG, blurred vision, dysgeusia and dizziness.

Methods: A 74 years-old female patient with hypertension history attended to the emergency department with a complaint of tachycardia. She denied any chest pain or light-headedness, and had no history of prior palpitations, diabetes, angina or myocardial infarction. Her pulse was irregularly irregular at 158 beats/min, her blood pressure was 153/95 mm Hg, her respiratory rate was 20 breaths/min, and she was afebrile. Peroral 600mg Rytmonorm was given to the patient for rhythm control, and possible cardioversion following echocardiography examination. Conversion to sinus rhythm was achieved an hour after administration of propafenone. Thirty minutes later, sin端s bradycardia responding to atropine, swelling and numbness in the tongue, slurred speech, blurred vision, diplopia, spasm and contradiction at the right arm and leg, drowsiness and visual hallucinations lasting for 24 hours emerged.

Results: All findings were considered to be side effects related to Propafenone HCI and cardiology consultation was repeated and then the patient was taken into intensive care unit for follow-up. All side effects disappeared after 18 hours and the patient was discharged after 2 days.

Conclusions: Although administration of propafenone HCL in therapeutic dose at emergency department is considered safe, it should be considered that even a single and first dose may cause one or more side effects.

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

W330

PERIORBITAL SUBCUTANOUS EMPHYSEMA FOLLOWING NOSE BLOWING

T. Deniz 1, F. Bayram

1

1

Kirikkale University, Faculty Of Medicine, Department Of Emergency Medicine, Kirikkale, Turkey

Background: Periorbital subcutanous emphysema without maxillofacial fracture following forehead trauma is a rare occurrence. It usually develops when fracture occurs in the lamina papyracaecea due to trauma. We observed subcutaneous emphysema spread out from right periorbital region extending down to the level of the mandibula in a patient presented to emergency department without facial fracture following minor forehead trauma. A case is reported here of unilateral periorbital subcutaneous emphysema in the absence of maxillofacial skeleton fracture, in a healthy adult male following nose blowing. <FILE IMAGE='208_20150605102115.jpg'> Methods: A 59-year-old male patient presented with a sudden onset of progressive painless swelling on the right-hand side of the face following blowing the nose after minor forehead trauma. On physical examination, the patient’s vital signs were: blood pressure 147/75 mm Hg, pulse 107 beats/ min, respiratory rate 18 breaths/min, and temperature 36.5°C (97.7°F). There was no impairment of vision, double-vision or headache. There was no history nasoethmoidal and maxillary facial injuries. Patient examination revealed crepitant swelling in the right periorbital location. Otorhinolaryngologic evaluation was normal. On ophthalmologic examination, the visual acuity was normal for both eyes. Pupillary reflexs were normal. There was no palsy of the external ocular muscles. The intraocular pressure was normal and the sclera, cornea, lens, vitreous, retina, and the optic disc were bilaterally normal. Paranasal Computed tomography showed accumulation of air in the right orbit without wall fracture fragments (Figure 1). No fracture or other bony abnormality.

Results: At the week follow-up appointment, the patient’s subcutaneous emphysema and crepitus had resolved.

Conclusions: Physicians involved with forehand injuries should be aware that a trivial frontal injury may cause without fracture in orbital emphysema following nose blowing.

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

W331

AN UNCOMMON CAUSE OF ABDOMINAL PAIN IN AN ADOLESCENT GIRL

S. Chua 1

1

Kandang Kerbau Women's & Children's Hospital, Singapore, Singapore

Background: An 11 year old Chinese girl presented with lower abdominal pain for 2 days, with radiation to back and associated with dysuria for 3-4 days. There was no urinary frequency or fever, nausea or vomiting. Bowel movements were normal. She has not started menarche and is not sexually active. Upon further questioning, there was a history of similar abdominal pain 1-2 days almost monthly for the past few months. Clinical examination revealed a soft abdomen with a palpable suprapubic mass with no guarding or rebound.

Examination of the perineum revealed a firm, tender bulge at the introitus. Urine dipstick was ordered and an urgent pelvic ultrasound was performed. <FILE IMAGE='61_20150426122848.jpg'> Methods: Results: Conclusions: In a young adolescent girl presenting with lower abdominal pain secondary to acute urinary retention, a full history and physical examination including the examination of the genitalia is important, especially in girls with primary amenorrhoea. There should be a high index of suspicion of imperforate hymen especially if there is a history of cyclical abdominal pain. Bedside ultrasound may be performed for diagnostic purposes and the correct diagnosis in the emergency department will help in the appropriate disposition and guide further treatment.

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

W332

BICEPS HEMATOMA; A DIAGNOSIS WHICH SHOULD BE KEPT IN MIND

Z. Yuzgec 1, H.S. Saka 1, A. Demircan 1

1

Gazi University - Department Of Emergency Medicine, Ankara, Turkey

Background: Soft tissue injury is a common presenting complaint to emergency departments. Due to the nature of the sport, bodybuilders have tendency for muscle sprains and tears, and may present to emergency department for initial treatment. Biceps tendon injuries include a spectrum of disorders ranging from mild tendinopathy to complete tendon rupture.

Methods: Case presentation: A 24 year-old male patient presented to emergency department with upper arm pain and swelling. His pain started after training with dumbell for biceps muscle. There wasn't a history of direct trauma to his arm. He had normal vital signs, and physical examination except the swelling of his arm and limited extention at elbow joint. After physical examination, the initial diagnosis was biceps tendon rupture. Ultrasound imaging was perfomed, and the diagnosis was biceps hematoma, not biceps tendon rupture.

Results: As a result, we should also consider biceps hematoma as initial diagnosis beside biceps rupture, in patients with sports injuries.

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

W333

ANGIOEDEMA; WHICH DO NOT RESPOND TO CONVENTIONAL TREATMENT

Z. Yuzgec 1, M.E. Durak 1, M.R. Tel 2, F. Bildik 1

1

Gazi University - Department Of Emergency Medicine, Ankara, Turkey, Of Emergency Medicine, Mardin, Turkey

2

Mardin State Hospital - Department

Background: Angioedema is defined as swelling of the skin and mucous membranes, with variable symptoms.

Angioedema should be treated aggresively, and these patients should be monitored for airway compromise, as there is a potential for fatal complications.

Hereditary angioedema is a serious, chronic autosomal dominant disease that requires a highly specialized approach to treatment. Traditional treatment of histamine-induced edema with epinephrine, corticosteroids and antihistamines is still frequently used inappropriately for the treatment of hereditary angioedema, despite data demonstrating ineffectiveness of these medications. Early intubation or tracheotomy should be considered in progressive upper airway edema. The treatment of acute attack of hereditary angioedema is C1 esterase inhibitor. There are new therapeutic agents such as reversible kallikrein inhibitor or selective bradykinin B2 receptor antagonist. Fresh frozen plasma is frequently used for treatment of hereditary angioedema attacks and for short-term prophylaxis, when targeted drugs are often unavailable in emergency department.

Methods: Case presentation: 53 year-old female patient presented to emergency department with tongue swelling and shortness of breath. She had normal vital signs. She had tongue swelling, bronchospasm, difficulty at speech and swallowing on physical examination. She had no urticaria. She was given epinephrine, pheniramine, ranitidine, and methylprednisolone for angioedema. There were no improvement in her signs and symptoms. She had similar attacks in her past medical history. Hereditary angioedema was anticipated and 3 units of fresh frozen plasma was given. After fresh frozen plasma treatment, the patientâ&#x20AC;&#x2122;s symptoms regressed.

Results: Hereditary angioedema should be suspected in any patient who presents with recurrent angioedema or abdominal pain in the absence of associated urticaria, also who do not respond conventional treatment of angioedema. Fresh frozen plasma should be considered for the treatment in emergency department.

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

W334

SPLEEN AND KIDNEY INJURY DUE TO NON-PENETRATING GUNSHOT WOUND: A CASE REPORT

S. Kaymak 1, E. Lapsekili 1, M. Yilmaz 1, R. Senocak 1, N. Zeybek 1, O. Kozak 1

1

Gmma Department Of General Surgery, Ankara, Turkey

Background: In the gunshot injuries especially with high kinetic energy weapons, organs which are localized out of bullet trace could be affected because of the blast effect. We want to emphasize intraabdominal tissue and organs could be damaged by high velocity weapons’ injury, whether they do not penetrate intra-abdominal cavity. <FILE IMAGE='331_20150630211839.jpg'> Methods: 26 year old male admitted to a state hospital due to gunshot wounds.In examination entry/exit holes were observed at the posterior axiller line in the left subcostal region.He underwent an emergency surgery because of vital signs gone worse.During the operation about 500 cc of hemorrhagic fluid was found in the abomen although there was not any connection between trace of bullet and abdomen. Grade 4 injury detected at spleen and left kidney so splenectomy and nephrectomy done.In the postoperative period he was referred to our center for further follow-up. He was re-operated in our clinic due to leukocytosis (18300/microL) and disruption of vital signs.There were no itra-abdominal pathology in the exploration but skin was completely infected and detached.After excision of necrotic and infected tissues, Vacuum Assisted Closure (VAC) was applied. After subsequent applications of VAC injury site was covered with skin grafting and discharged without any complications.

Results: A large part of bullet’s energy is spent to create a temporary cavity at -high kinetic energy- gunshot wounds. Main factor of formation temporary cavity is bullet’s turning over in body. Because of this cavity tearing of tissue and vessels might be occurred.

Conclusions: Blast effect must be kept in mind at planning phase of surgical treatment especially if it is for high-velocity gunshot.

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

W335

BOWEL INJURY DUE TO LAPAROSCOPIC CHOLECYSTECTOMY

O. Hancerliogullari 1, M. Yilmaz 1, E. Lapsekili 1, Z. Kilbas 1, G. Yagci 1

1

Gmma Department Of General Surgery, Ankara, Turkey

Background: Laparoscopic cholecystectomy is accepted as a initaly method for the treatment of gallbladder disease.It has many of advantages which are related with the superiority of laparoscopic aproach like reduced cost, decreased hospital length of stay and opertation time, and increased patient satisfaction and shortness of recovery time.It also has serious complications like bile duct injury, bleeding and bowel injury. We here present a patient who had laparoscopic cholecystectomy related bowel injury. <FILE IMAGE='331_20150629111232.jpg'> Methods: 64 year old female patient admitted to our clinic with a history of laparoscopic cholecystectomy in a hospital.She is said to have primary bowel repairment due to bowel injury.Her temperature was 38째C, heart rate was 110 beats/min, respiratory rate was 22/min, and blood pressure was 160/90 mmHg. She had a rigidity and rebound tenderness at all the abdominal quadrants in examination. Her WBC count was 43.8x10/L (94 % of which were neutrophil). USG revealed with a common fluid in abdominal cavitiy.She was considered to be peritonitis and was started to take piperacillin+tazobactam 4,5 gr(3x1). She underwent a explorative laparotomy.During the exploration there was abcess formation and a leakage was detected from the sutures on bowels and irrigaiton+ ileostomy+abdominal VAC operation was performed.After administering irrigation+ VAC procedures three more times she had primary abdominal closure and discharged at 30th day. An ileostomy closure has planned for three months later.

Results: The most common complication due to laparoscopic cholecystectomy is bile duct injuries and bile leaks. While the most lethal complications are injuries to major vessels and bowel. Bowel injuries may occur as a result of puncture by the insufflation needle, trocar injury, elektrocautery mis- using.It is very imortant to be aware of bowel perforation during the operation. Early diagnose is the most important factor to decrease mortality and morbidity. In our case a simply bowel perforation can lead the patient to multiple surgical procedures.

Conclusions: We want to remind that surgeon must consider not to primary repairment if there is an intra-abdomina infection. As in this case the risk of leakage may be higher than it has ever be in these situation.

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

W336

NON-SURGICAL APPROACH IN TREATMENT OF BILE LEAK AFTER CHOLECYSTECTOMY: A CASE REPORT

M. Yilmaz 1, O. Hancerliogullari 1, I.H. Ozerhan 1, G. Yagci 1, S.D. Kahraman 1

1

Gmma Department Of General Surgery, Ankara, Turkey

Background: Laparoscopic approach to gallbladder stones is very popular and has already changed the choices of both the surgeons and the patients. Although it is considered to be a gold standard for treatment of gallbladder diseases, some complications being more frequent than with open cholecystectomy. We here present a 57 year old male who had laparoscopic cholecystectomy related bile duct injury and treated with non-surgical approach. <FILE IMAGE='331_20150628114047.jpg'> Methods: A 57 year old man was admitted to our department with a history of having a laparoscopic cholecystectomy in a state hospital after multiple attacks of cholelithiasis for five years. He was inserted a drain at gallbladder bed. On the postoperative first day 500 cc drainage came with the content of bile and he was transferred to our department. His temperature was 36.5째C, heart rate was 90 beats/min, respiratory rate was 18/min, and blood pressure was 145/80 mmHg. His examination was unremarkable and USG reveals with a fluid of 2 cm diameter at gallbladder bed and other findings were not pathologic. So he was considered with gastroenterologist and an injury was found on right bile duct with ERCP and nasobiliary drainage was inserted endoscopically. After nasobiliary drainage inserted abdominal drainage outcome decreased so nazobiliary drainage and abdominal drainwere removed at 20 and 23 day later respectively. He was discharged on 25th day without and complaint and complications.

Results: Bile duct injury could be happened after cholecystectomy. It can be resulted as an anatomic variation, accessory bile ducts, iatrogenic or malfunction of operation accessories such as clipping devices. Surgeons must be calm, careful and must make extra effort to recognize the anatomy of biliary tract when he felts difficulty in operation.

Conclusions: We think that use of nasobiliary drainage is a choice which allows us to treat with non-surgical methods. We recommend our colleagues that it must be kept in mind in selected patients with adequate multidisciplinary approach in a tertiary care center.

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

W337

PERFORATION OF THE ILEUM BY A DENTAL WIRE: CASE REPORT

E. Bayramov 1, M. Yilmaz 1, H. Sahin 1, E. Lapsekili 1, O. Hancerliogullari 1

1

Gmma Department Of General Surgery, Ankara, Turkey

Background: Ingestion of foreign bodies (FB) is not an uncommon occurrence, because most of them will pass through the gastrointestinal tract without consequences. Complication such as perforation is rare. <FILE IMAGE='331_20150628105058.jpg'> Methods: We present a case of small bowel perforation secondary to the accidental ingestion of a dental wire.

A 78-year-old woman was admitted to the clinic for emergency surgery, with a 1-day history of abrupt onset of acute abdomen with severe generalized abdominal pain. In auscultation there were no bowel sounds.Clinical examination confirmed tenderness and rebound tenderness on right lower quadrant. Plain abdominal radiography showed multiple dilated loops of small bowel, and no subdiaphragmatic free air. Abdominal ultrasound (US) showed inflammatory changes of small bowel loops, with a free fluid around intestinal loops. On CT scan revealed free air and free fluid around bowel loops. In exploration,At about 60th cm from this site we found a perforation of the ileum at the anti-mesenteric site. The perforation site primary sutured.

Results: Even that intestinal perforation by a foreign body is rare, physicians should consider possibility of intestinal perforation by a foreign body in the differential diagnosis of acute abdomen in patients presenting with abdominal pain. Biplanar x-ray is the main diagnostic tool generally showing free air under the diaphragm in perforations or opacity if the foreign bodies are radiopaque.

Conclusions: Conservative approach, gastroscopy retrieval, laparoscopy and rarely laparotomy are different treatment choice for gastrointestinal tract foreign bodies. It can be changed

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

W338

IV ADMINISTRATION OF EPINEPHRINE CAUSED VENTRICULAR DYSRHYTHMIA

Ă&#x2013;. Yigit 1, U. Cakir 2, C. Akyol 2, N. Sayrac 2

1

Akdeniz University Faculty Of Medicine Department Of Emergency Medicine, Antalya, Turkey, Research And Training Hospital Emergency Clinic, Antalya, Turkey

2

Antalya

Background: Anaphylactic reactions are defined clinically as reactions that range from mild simple urticaria to life-threatening hypotensive shock. Intravenous (IV) epinephrine only reserved for unresponsive anaphylaxis or circulatory collapse. Epinephrine can be associated with significant morbidity and potential mortality, if administered in an incorrect route or dose. We present a patient in whom ventricular dysrhythmia occurred following inadvertent IV administration of epinephrine for an anaphylactic reaction. <FILE IMAGE='304_20150623113854.jpg'> Methods: We present a patient in whom ventricular dysrhythmia occurred following inadvertent IV administration of epinephrine for an anaphylactic reaction.

Results: This case describes a 38-year-old man who presented with an acute anaphylactic reaction occurred after intramuscular penicillin injection. He was erroneously given 0.5 mg (1:1000) intravenous (IV) epinephrine and revealed severe chest pain with a wide complex tachycardia seen on ECG. The symptoms and wide complex tachycardia were resolved spontaneously after few minutes except chest pain. The troponin I level was found high, 0.3 ng/ml, (upper limit of normal testing was 0.06 ng/ml), for this reason he was consulted with cardiology clinic and hospitalized for observation. Transthoracic echocardiogram showed normal cardiac contractility and normal wall motion. The troponin levels were not elevated so much and no recurrent dysryhtmia was occurred. The patient refused coronary angiography, and he was discharged from the hospital without any sequela.

Conclusions: All guidelines recommend IM injection of epinephrine as the first-line medication of choice in anaphylaxis and there are no absolute contraindications for its usage. Serious adverse effects are very rare when it is administered at the appropriate IM doses. Because of epinephrine is a 'high-alert' medication, therefore physicians should verify the order, dose, concentrations prior the administration and adequate communication between physicians and nurses especially stressful working environment.

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

W339

ACUPUNCTURE IN ACUTE ANKLE INJURY PRELIMINARY CASE REPORT EMERGENCY DEPARTMENT

N. Tantivesruangdet 1

1

College Of Medicine Rangsit University Bangkok, Bangkok, Thailand, Thailand

2

Rajavithi Hospital Bangkok, Bangkok,

Background: Acupuncture treatment in Thailand setting under Thai Medical Council was established in 1982.

Nowaday 1,600 Thai physicians have qualified acupuncturist after graduated short-term acupuncture and moxibustion training course.1995 World Health Organization recommended that the acupuncture and moxibustion treatment can be applied for 59 kinds of diseases include musculoskeletal problem. One of the most common of musculoskeletal is acute ankle contusion and sprain. Rajavithi Hospital is the biggest supertertiary in MOPH and trauma level one of Thailand. In 2014 there have 12,000trauma cases per year, 536 cases in Emergency Department(ED) were acute ankle injury. Several treatment we used drug for analgesia. Some patient have drug allergy and time consuming to delay services. Acupuncture is Traditional Chinese Medicine commonly used in Thailand but no acupuncture treatment in ED was found. This study aim to assessment pain and swelling in acute ankle injury treatment. Short time length of stay in Rajavithi ED was also observe Methods: Traumatic Thai patient 33 year old have present twisted acute ankle injury. He had pain, swelling and difficult to walk was using assessment by Ottawa Ankle Rules (OAR).Plain radiography of ankle showed no demonstrable fracture, no subluxation or no dislocation. Pain level (on an 11-point numeric scale, ranging from 0=no pain to 10= maximum pain) Verbal Analog Scale was assessment with range of 0-10 before acupuncture treatment. Using needle size 0.25X40mm.long1.5inch.The needle was applied at KUNLUN point and QIUXU point depth0.5chun were perform and pain reassessment after 10 minutes. VAS level decrease from 8 to 4 and the patient can walk with gait aid. One week after injury the clinical of pain and swelling had improved. The ankle anterior drawer stability test showed negative. The patient satisfied in acupuncture treatment.

Results: Overall acupuncture treatment significantly. Decrease pain level VAS 8 to4 and decrease waiting time from pharmacy and drug action 30 minutes in ED. No skin infection was found in this case.

Conclusions: Acupuncture showed good clinical result and patient satisfied the treatment. Acupuncture can be used for continuous quality improvement in ED. Further study should be assessed in more case.

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

W340

FEVER AND BACK PAIN IN A KINDERGARTEN TEACHER

K. Stanford 1

1

Brigham And Women's Hospital / Massachusetts General Hospital, Boston, Ma, Usa

Background: A 29 year old female kindergarten teacher presented to the Emergency Department complaining of four days of fever to 39.2C, rigors, and back pain.

Methods: She had no other associated symptoms and denied high risk exposures such as intravenous drug use or spinal injections. Vitals were only notable for a fever of 38.2C. Physical exam revealed a well-appearing young woman with midline tenderness over the thoracic spine at the level of T5-6, without erythema or fluctuance. She had no neurologic deficits or rashes.

Results: Labs, which had been normal at a different hospital on the day of symptom onset, revealed a profound leukopenia (white blood cell count 1.6 K/uL) and thrombocytopenia (platelet count 90 K/uL) with a normal hematocrit, but otherwise were within normal limits. MRI of the spine was negative for abscess. Viral, tick, and parasitic panels were sent from the Emergency Department, which ultimately returned positive for parvovirus B19. The patient was admitted and treated with empiric antibiotics for febrile neutropenia while these results were pending, and ultimately recovered with supportive care and was discharged home.

Conclusions: Human parvovirus B19, perhaps better known as erythema infectiosum, or â&#x20AC;&#x153;fifth disease,â&#x20AC;? is a very common virus that can easily be confused with other, more dangerous, pathologies. While it usually presents as the constellation of fever, rash, and arthralgias, in rare cases it can present with isolated spinal pain and fever. Leukopenia and thrombocytopenia are uncommonly associated with the virus, and these provoke an interesting differential diagnosis, including several viral syndromes, bacterial sepsis, HIV, tick-borne illnesses, malaria, and dengue. Early recognition of both typical and atypical presentations of this common virus, to which up to 60% of adults have been exposed, allows Emergency Physicians to order the appropriate diagnostic tests early in the hospital course and potentially save patients prolonged hospital stays and unnecessary testing.

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

W341

INSULIN TREATMENT OF ACUTE PANCREATITIS CASES DUE TO HYPERTRIGLISERIDEMIA IN EMERGENCY DEPARTMENT

I. Uz, E. Ozcete, M. Songur Kodik, Y. Delice, S. Kiyan

1

Ege University Faculty Of Medicine, Emergency Department, Izmir, Turkey, 2 Ege University Faculty Of Medicine, Emergency Department, Izmir, Turkey, 3 Ege University Faculty Of Medicine, Emergency Department, Izmir, Turkey, 4 Ege University Faculty Of Medicine, Emergency Department, Izmir, Turkey, 5 Ege University Faculty Of Medicine, Emergency Department, Izmir, Turkey Background: Hypertrigliceridemia is the third frequent cause of acute pancreatitis after alcohol and biliary stones. To prevent complications due to pancreatitis and for the treatment of pancreatitis lowering of triglyceride level is important. There are several multiple choice treatment modalities such as apheresis, insulin and heparin.

In this paper the authors presents retrograde clinical observations of three cases of edematous pancreatitis due to hypertrigliceridemia which treated with insulin infusion.

Methods: Three male cases aged 42, 46 and 56 admitted with abdominal pain. With pre-diagnosis of acute pancreatitis the patients referred to ultrasonography and tomography, in none of them biliary stones obtained in biliary system. Triglyceride levels of the patients were seriously high. Insulin started with a dose of 0,1 IU/kg/ h and dextrose infused to keep the blood glucose level at about 150-200 mg/ dL.

Results: The cases presenting abdominal pain with high levels lipase, amylase with pre-diagnosis of acute pancreatitis are investigated with ultrasonography for biliary stones and with tomography diagnosis of pancreatitis and complications can be evaluated. Without history of chronic alcohol use the third reason which is frequently overlooked the high level of hypertriglyceridemia should be investigated and the treatment should be started accordingly. In these presented cases despite clinically obvious pancreatitis, lipase and amylase levels were not in high levels.

Pancreatitis to hypertriglyceridemia compared to other types is more serious and the complication rate is higher but the mortality rates are similar. The lack of complications in this case presentation may be due to the response to hypertriglyceridemia treatment. In these presented cases the preferred treatment were insulin infusion which is with less complication rates and which is easily applicable. At the 24 hours triglyceride levels were lowered half and clinical symptoms and lipase levels regressed.

Conclusions: To prevent occurring of complications in the emergency department rapid testing of triglycerides is important. The treatment of acute pancreatitis due to hypertriglyceridemia should be started in emergency department, particularly in diabetic patients insulin infusion treatment is useful even in normoglycemic patients and should be applied.

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

W342

ISOLATED RADIAL HEAD ANTERIOR DISLOCATION IN ADULT: A RARE CASE

D. Can 1, S. Bilge 1, A.A. Aydin 1, G. Aydin 1, Ă&#x2013;. Sezer 1, S. Akpancar 2

1

Gulhane Military Medical Academy Department Of Emergency Medicine, Ankara, Turkey, Medical Academy Department Of Orthopaedics And Traumatology, Ankara, Turkey

2

Gulhane Military

Background: Isolated radial head dislocation is very rare in adults, although it is often in children. It may be located in anterior or posterior. It is thought that the mechanism is related respectively hyperpronation and hipersupination of the forearm. Anterior dislocation of the radial head is often seen as part of a Monteggia lesion but isolated radial head dislocation is rarely seen. In this case report, we discussed an isolated anterior dislocation of the radial head that was occured after falling.

Methods: Case report Results: 21-year-old male was admitted to our emergency department after falling while walking. He stated that he felt a pain in the elbow and could not fully open and close. In physical examination, a palpable slight swelling on the front of the elbow and tenderness by palpation was observed. It was observed that movement of the elbow was limited and painful. In elbow radiographs, it was considered that radial head was localized to anterior but there was not fracture. Closed reduction by traction, supination, and direct compression was performed to the radial head under sedation analgesia. In control graphs radial head were seen in the joint and elbow was immobilized with long arm splint in flexion at 90 degrees.

Conclusions: Isolated radial head dislocation is frequent in children but it is very rare in adults. Anterior dislocation of the radial head is often seen as part of a Monteggia lesion but isolated radial head dislocation is rarely seen. It should be kept in mind by clinicians that isolated radial head dislocation can be seen in adults despite often occurring in children.

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

W343

CASE OF A MENINGOENCEPHALITIS ADMITTED WITH MEANINGLESS SPEAKING

D. Can 1, Ö. Sezer 1, O. Çakir 1, A.A. Aydin 1, S. Bilge 1

1

Gulhane Military Medical Academy Department Of Emergency Medicine, Ankara, Turkey

Background: There are general medical conditions in some of cases admitted to emergency department with psychiatric symptoms. Underlying cause except non-psychiatric syndromes may be trauma, medications, toxins, organ failures, intracranial hematomas or structural lesions like tumors, infections or vitamin deficiencies. We discussed a meningoencephalitis case admitted with meaningless speaking and weird behaviors.

Methods: Case report Results: A 44-year-old female was admitted to emergency department with meaningless speaking and weird behaviors. It was learned that treatment for influenza had been started five days ago and meaningless sentences, agitated and weird behaviors were occured today. In history, there was using escitalopram for depression for 12 years. In physical examination, she was conscious with faltering speech, had no cooperation and nuchal rigidity. Vital sings were stable. Biochemical tests were normal. Brain CT was evaluated as normal.

Diffusion-weighted MRI was reviewed as in favor of meningitis or encephalitis in left frontal/parietal region in suspected cortical hyperintensities. In detailed anamnesis, it was learned that case had had complaints of headache and high fever for three days and couldn’t recognize the people around her. Lomber punction was reported as cerebrospinal fluid (CSF) clear and colorless, 110 white blood cells (%96 mononuclear leucocyte, %4 polimorfonuclear leucocyte) in microscopy. The case was hospitalized in infectious disease department with diagnosis of meningoencephalitis. Aciclovir and ceftriaxone treatment was started. Electroencephalogram (EEG) was performed and reported as abnormal focal generalized teta (slow) wave paroxysms in second day of hospitalisation. Control LP was performed in third day of hospitalisation and reported as CSF clear and colorless, 25 white blood cells (%100 mononuclear leucocyte) in microscopy. After 14-day treatment, case had no active complaints was discharged with good general status, conscious and complete orientation-cooperation.

Conclusions: In most cases, central nervous system dysfunctions don’t occur with classical signs and symptoms. As in our case we mentioned, it is important to take detailed anamnesis, detailed physical examination and to look for vital sings before going towards non-psychiatric diagnosis for the right diagnosis in cases admitted to emergency department with meaningless speaking and weird behaviors.

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

W344

SIMULTANEOUS BILATERAL SPONTANEOUS PNEUMOTHORAX

Ö. Sezer 1, I. Arziman 1, M. Durusu 1

1

Gulhane Military Medical Academy Department Of Emergency Medicine, Ankara, Turkey

Background: Bilateral spontaneous pneumothorax is a quite rare situation. 1.3-1.9 % of cases with spontaneous pneumothorax are bilateral. Additionally, simultaneous bilateral spontaneous pneumothorax (SBSP) is an extremely rare clinical presentation. It occurs more frequently in males over 20 years old.

Etiologically lung diseases are seen more frequently on SBSP compared with unilateral pneumothorax. States like tuberculosis, cystic fibrosis, Marfan’s syndrome, histiocytosis X, sarcoma, mesothelioma, lymphoma, COPD have been reported as cause of SBSP. In this report, a case with simultaneous bilateral spontaneous pneumothorax is discussed.

Methods: Case report Results: 21-year-old male admitted to the emergency department with dyspnea and pleuritic chest pain which started 3 hours ago. There was not any trauma history. Vital signs were as follows: arterial blood pressure: 157/100 mmHg, heart rate: 99 pulse/min, fever: 36 ºC, sO2: 89% in room air. Breath sounds were found low bilaterally. Other systemic and neurologic examination findings were unremarkable. Lung sliding and stratosphere sign in the M-mode were found in the bedside lung USG performed by an emergency physician.

These USG findings demonstrated pneumothorax. Posterior-anterior (PA) chest radiograph was taken.

Radiological appearance was commented as bilateral pneumothorax. Tube thoracostomy was performed bilaterally by thoracic surgery physicians in the emergency department. The patient was hospitalized in the thoracic surgery clinic.

Conclusions: At first step, PA chest radiograph assists for diagnosis. Chest CT is needed in cases that diagnosis is difficult. Lung ultrasound assists to make diagnosis until PA chest radiograph is taken in emergency department. Bilateral chest tube should be urgently performed in SBSP. Additionally, surgical intervention may be considered to prevent recurrence. There is not a gold standard treatment modality that will be administered after the chest tube. Surgical pleurectomy, pleural abrasion, talk pleurodesis and bullectomy can be performed.

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

W345

A RARELY SEEN FRACTURE: HAMATUM AVULSION FRACTURE

Ö. Sezer 1, D. Can 1, S. Akpancar 2, M. Üstüner 2, M. Eryilmaz 1

1

Gulhane Military Medical Academy Department Of Emergency Medicine, Ankara, Turkey, Medical Academy Department Of Orthopaedics And Traumatology, Ankara, Turkey

2

Gulhane Military

Background: Approximately 2-4% of carpal bone fractures are hamate bone fractures. Dobyns et al examined 1621 cases with hand and wrist fracture and dislocation in a military hospital for 3 years and reported that only 3 (0.2%) cases of these were hamatum fracture. Hamatometacarpal fracture and dislocation may rarely occur after the injury of the fourth metacarp fracture and fifth carpometacarpal joint. We considered a case with hamate fracture concomitant to fourth metacarp basis fracture.

Methods: Case report Results: 32-year-old male was admitted to the emergency department with pain spreading to the wrist from the right hand back. He said that he hit his hand on the handrail firmly. It was observed that there was edema spreading to the wrist from the proximal of the 3, 4, and 5. metacarps. In physical examination, it was evaluated that there was sensitivity on the proximal of the fourth metacarp and medial of the distal row carpal bones. On the anteroposterior and lateral wrist radiographs, fracture was observed at the basis of the fourth metacarp. CT scan was performed through carpal bones could not be adequately assessed on the wrist radiographs. In CT images, avulsion fracture was found at the distal dorsal of the hamate bone in addition to the fourth metacarp fracture. Closed reduction was applied under sedation and analgesia. He discharged with a painkiller from the emergency department.

Conclusions: Hamatum fracture is seen very rarely, in addition, it cannot be assessed clearly on the standard X-ray graphs. Therefore, clinicians should keep in mind hamatum fracture and should think about performing CT to confirm the diagnosis if there is a suspicion.

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

W346

BREAD IS IT INSTALLED THE THROAT?

D. Can 1, Ă&#x2013;. Sezer 1, A.A. Aydin 1, S. Bilge 1, G. Aydin 1, C. Aydin 2, M. Eryilmaz 1

1

Gulhane Military Medical Academy Department Of Emergency Medicine, Ankara, Turkey, Hospital Department Of Internal Medicine, Ankara, Turkey

2

Etimesgut State

Background: Vertebral artery dissection is often seen after trauma whereas it may rarely occur spontaneously.

Spontaneous vertebral artery dissection is a rare cause of ischemia among the young and it can cause lateral medullary syndrome. In this paper, we discussed a spontaneous vertebral artery dissection occured in an elder and applied with atypical complaints and the occurrence of lateral medullary syndrome depending on it.

Methods: Case report Results: 57-year-old male was admitted to the emergency department in the morning with a feeling of installing bread the throat at breakfast. In his history, he has heart failure, coronary artery disease, hypertension. Systemic and neurological examinations were normal. Initial vital signs and biochemical tests were normal. Case was consulted to the ENT clinic. Right vocal cord was seen motionless in flexible nasopharingolaryngoscopic examination thereupon case was consulted to the Neurology clinic to evaluate central nervous system pathology. Vertigo, nausea, hoarseness, difficulty of swallowing occurred during the follow-up. Right central facial paralysis, dysphonia and cerebellar ataxia were detected in control examination. Acute diffusion limitation on the right medulla oblongata and cerebellum was detected in diffusion MRI. Lateral medullary syndrome was diagnosed. Dissection of the vertebral artery was detected in the neck CT angiography. Acetylsalicylic acid (300 mg) and low molecular weight heparin (LMWH) (6000 IU) treatment was started. Case was hospitalized in Neurology clinic. Miotic right pupil, extensor base skin response at right, hypoesthesia at left leg, ataxic gait to the right and lower right velum-pharyngeal reflex was assessed in neurological examination. Warfarin was started, then relief on dysphonia, ataxic gait and hypoesthesia was observed. Case was discharged nine days later with warfarin.

Conclusions: Vertebral artery dissection may be seen in the elderly as in our case, and may occur spontaneously. Considering that it appears with installing sensation in the throat and vocal cord paralysis, especially emergency physicians should be alert to the vertebral artery dissection.

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

W347

EXPECTORATION OF COIL EMBOLIZATION MATERIAL

Ă&#x2013;. Sezer 1, D. Can 1, M. Eryilmaz 1

1

Gulhane Military Medical Academy Department Of Emergency Medicine, Ankara, Turkey

Background: Coil embolization is an interventional method alternative to surgery, which is usually used in therapy of situations like aneurysm, arteriovenous malformation, tumor. In this method which is used metal coil becoming clot when it is released, occuring necrosis in tumor is provided by occluding of artery of tumor.

Complications like systemic migration of coil material, pulmonary infarction, chest pain, pleurisy may be seen. In this case report, we aimed to analyze a case presenting with expectoration of coil material which we have not found in literature until now.

Methods: Case report Results: A 54-year-old male was admitted to the emergency department because of expectoration of a filamentlike material. It was learned that coil embolization was performed 5 days ago by interventional radiology service to the case who had squamous cell lung carcinoma for one year in his history. His arterial blood pressure (ABP): 125/75 mmHg, pulse: 86 bpm, fever: 37 ÂşC, sO2: 92 % (in room air). Respiratory sounds were normal.

On chest radiography, it was commented that there was a heterogeneous opacity at right hilus. Hemoptysis occurred during follow-up in the emergency department. The material which was expectorated was considered as coil material and case was admitted to the interventional radiology department. It was decided that angiography was performed again. In imaging, it was seen that the coil in the primary branch of inferior truncus of the right main pulmonary artery was extended partially into the intratumoral cavity and trachea. Coil was taken out via bronchoscopy. It was considered that there was not indication for a new embolization. Case was discharged upon no development of any complication after he was kept in observation overnight in Thoracic Surgery.

Conclusions: In our case, it was observed that coil material localized intra-arterial invaded the trachea through intratumoral cavity. In the literature, any study has been found that it reported migration of coil material to the trachea until now. It should be paid attention for intratracheal migration of coil material after embolization.

Therefore, cases should be followed up closely after application.

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

W348

CASE REPORT - SUPERIOR MESENTERIC ARTERY SYNDROME MIMICKING BLADDER DISTENSION

S. Seol 1, W. Lee 2, S. Woo 3, D. Kim

4

1

Department Of Emergency Medicine, College Of Medicine ,st. Mary's Hospital, The Catholic University, Incheon, South Korea Background: Superior mesenteric artery (SMA) syndrome is rare disorder, which is caused by a reduction in the aorto-mesenteric angle causing a duodenal obstruction. We report SMA Syndrome Mimicking Bladder Distension.

Methods: 93 year old female patient admitted to the emergency department with problem urinary difficiulty and abdominal distension for 1days. She was failed to inserting urinary catheterization in suspected acute urethral obstruction in other hospital. She was hospitalized in the conservative care hospital because of Alzheimerâ&#x20AC;&#x2122;s disease and had a past history of femur fracture surgery. The patient complained with urinary difficulty and abdominal distension. Vital sign was normal, blood pressure 100/70, heart rate 73beat per minute, respiration rate 20/minute, body temperature 36.5°. abdomen was so distended, dull sound in percussion without tenderness or rigidity in physical examination. We tried to insert foly catheterization but failed. Urine was not drainaged. Oval shaped huge mass on abdomen was found in simple x-ray. The mass was filled with a lot of fluid and solid substances in bottom in bed side ultrasound examination. Blood test results was WBC 6220 (seg. Neutrophil 89.5%), Hb 11.9 g/dl Hct 36.4% PLT 280,000/ul, ESR 83mm/h, Na+ 141mmol/L, K+ 4.4mmol/L, Cl- 95mmol/L, amylase 33 IU/L, BUN 58.0mg/dl Creatinine 1.3mg/dl. Abdomen CT demonstrated gastric and proximal duodenal dilatation with abrupt narrowing of the third portion of the duodenum between the aorta and SMA. bladder was collapsed. Abdominal distension was became flat with 4L gastric drainage by using a nasogastric tube. And the patient could be urination by herself. The patient recovered and was discharged after Surgical consultation and conservative treatment. <FILE IMAGE='390_20150713102432.jpg'> Figure. 1 Giant oval shaped abdominal mass was found in x-ray distinguished from colorectum Results: Diagnosis of SMA syndrome is very difficult, and usually one of exclusion. Standard diagnostic exams include abdominal and pelvic computed tomography (CT) scan with oral and IV contrast, upper gastrointestinal series (UGI). Treatment may include treating the underlying cause, and small feedings or a liquid diet. If it is not effective for medical treatment, surgical treatment is considered.

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

W349

MANAGEMENT OF RIGHT MAIN BRONCHIAL TRANSSECTION WITH DOUBLE LUMEN ENDOTRACHEAL TUBE IN BLUNT CHEST TRAUMA

S. Seol 1, W. Lee 2, S. Woo 3, D. Kim

4

1

Department Of Emergency Medicine, College Of Medicine, St. Mary's Hospital, The Catholic University, Incheon, South Korea Background: Introduction Tracheobronchial disruption is one of the most severe injuries caused by blunt chest trauma. And it may cause obstruction of the airway with resulting life-threatening respiratory deficiency. We experienced a case of bronchial trans section managed with double lumen ET tube in blunt chest trauma after vehicular accident.

Methods: Case A 16 year old male who riding a bicycle was crushed by a traffic accident. He was suffering from progressive dyspnea, subcutaneous emphysema in the neck and anterior chest wall, and bilateral tension pneumothorax. He was in severe respiratory distress. A chest x-ray revealed deep neck subcutaneous emphysema and bilateral pneumothorax. Emergency needle thoracotomy, prompt chest tube drainage for suspected both sided tension pneumothorax and a tracheal intubation were performed. Shortly after the positive pressure ventilation, severe subcutaneous emphysema developed and he became impending shock. Skin incision was performed about 20cm to the Rt. chest wall to remove subcutaneous emphysema and additional chest tube insertion performed.

And the emergency bronchoscopy showed the rupture of the right main bronchus. After changed to double lumen intubation tube, condition of patient was improved. Operation was performed with tracheo â&#x20AC;&#x201C; right main bronchial end-to end anastomosis. Bronchoscopy performed post operatively showed good repair. The patient was discharged without complication. <FILE IMAGE='390_20150713100607.jpg'> Figure.1 End tip of double lumen ET tube was located in Light main bronchus(red arrow). Chest tubes located in both chest wall and diffuse pneumomediastinum and pneumoperitoneum is showing in chest wall, abdomen Results: The clinical presentations of tracheobronchial disruption are variable, and frequently difficult to diagnosis. The early diagnosis and primary repair of tracheobronchial rupture not only restores normal lung function, but also avoids the difficulties and complications associated with delayed diagnosis and repair.

Emergency bronchoscopy and selective double lumen endotracheal tube intubation is effective management of bronchial transsection in blunt chest trauma.

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

W350

ACUTE BUDD CHIARI SYNDROME IN A PEDIATRIC NEUROBLASTOMA PATIENT

D. Santiago-Haddock 1

1

University Of Puerto Rico School Of Medicine Emergency Medicine Department, Carolina, Puerto Rico

Background: Case of 2 year-old male with no known systemic illness who presented to ED for admission in order to undergo surgery for abdominal tumor resection. This patient had originally presented to the emergency department 6 months prior with suspected Chikungunya, and was diagnosed with stage 4 left adrenal neuroblastoma. During surgery, the decision was made to perform radical nephrectomy due to tumor invasion of left kidney, renal artery, and vein; afterwards the patient was transferred to the pediatric intensive care unit for post-operative monitoring. The next day the patient began to have elevated hepatic enzymes, lactate, and decreased urine output. The patient continued deteriorating, with worsening hepatic failure and hypotension requiring intubation and vasopressors. The decision was made to perform emergent laparotomy due to surgery less than 24 hours before. During surgery, he was found with extensive bowel necrosis, and was transferred to the pediatric intensive care unit after bowel resection and Bogota bag placement. The following day he continued deteriorating, with renal failure, pancreatitis, and worsening lactic acidosis. Despite aggressive resuscitation, the patient died. Autopsy was remarkable for mesenteric vein thrombosis, diffuse bowel necrosis, splenic congestion, hemorrhagic pancreas, portal vein thrombosis, and liver necrosis suggestive of acute fulminant Budd Chiari Syndrome.

Methods: .

Results: .

Conclusions: Budd Chiari Syndrome is a liver disorder secondary to hepatic venous outflow obstruction, which can present chronically or as acute hepatic failure. Acute Budd Chiari is clinically indistinguishable from acute hepatic necrosis secondary to viral infection. Classic presentation includes ascites, right upper quadrant pain, and jaundice, with coagulopathy, hyperbilirubinemia, and elevated liver enzymes. This patientâ&#x20AC;&#x2122;s sole presenting sign was acute hepatic failure, with subsequent development of multi-organ failure. Budd Chiari is almost exclusively discussed in adults, with limited information available regarding the pediatric population. When performing sonography for liver or gallbladder pathology, focus should also be placed on venous flow and parenchymal changes, as they are important radiologic signs consistent with Budd Chiari, especially in pediatric patients. This diagnosis should be considered in patients with abdominal complaints, hepatic dysfunction or hypercoagulable state, regardless of age.

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

W351

HEPATORENAL SYNDROME SECONDARY TO SPONTANEOUS BACTERIAL EMPYEMA IN A CIRRHOTIC PATIENT

D. Santiago-Haddock 1, F. Soto Torres

1

University Of Puerto Rico School Of Medicine Emergency Medicine Department, Carolina, Puerto Rico

Background: Spontaneous bacterial empyema (especially associated with hepatorenal syndrome) is a rare and under-diagnosed complication in cirrhotic patients, which can be fatal. We present the case of a 33 year-old male patient with history of chronic liver disease who presented to the emergency department with progressive shortness of breath. Past history was pertinent for a recent admission due to hepatic encephalopathy; discharged less than one week prior to arrival. Patient presented with jaundice and bilateral marked pitting edema in both lower extremities, and moderate abdominal distention but no rebound or guarding. Upon further questioning, the patient stated that since being discharged he had become progressively jaundiced, edematous, with worsening shortness of breath, chills, and tactile fevers. Initial workup was remarkable for severe hyperbilirubinemia, acute renal failure, metabolic acidosis, leukocytosis, and bandemia. Given these findings, the patient was treated with broad spectrum antibiotics due to suspected nosocomial pulmonary infection and started on non-invasive positive pressure ventilation. Despite the aggressive intervention, the patient continued with respiratory distress and was subsequently intubated. Post-intubation chest x-ray showed complete left lung opacification, most consistent with fluid accumulation. The patient later started developing hypotension and bradycardia, with multiple episodes of cardiac arrest along with hypoxemia and worsening acidosis seen on arterial blood gases. The decision was made to perform a bedside thoracentesis in order to provide symptomatic relief due to suspected respiratory failure secondary to massive hydrothorax/empyema, with drainage of grossly purulent fluid. Follow up chest x-ray showed lung re-expansion; despite this, the patient continued deteriorating, requiring multiple vasopressors due to refractory hypotension and bradycardia, and ultimately died shortly after admission to the intensive care unit. Cultures obtained from pleural fluid were positive for E. coli. <FILE IMAGE='335_20150629052209.JPG'> Methods: .

Results: .

Conclusions: Hepatorenal syndrome can develop secondary to acutely deteriorating liver function, along with a septic insult such as spontaneous bacterial empyema. Traditionally, spontaneous bacterial peritonitis has been described as the biggest risk factor for developing hepatorenal syndrome, and very limited information is available regarding hepatorenal syndrome secondary to spontaneous bacterial empyema.

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

W352

CASE REPORT: LOW BACK PAIN, NOT ALWAYS A TRIVIAL DISEASE

M. Ripoll Pons 1, S. Pairdi 1, A. Bottani 1, G. Civitavecchia 1, A. Barraco 1, G. Ricevuti 2, A. Voza 1

1

Humanitas Clinical And Research, Rozzano, Italy, 2 Ospedale Santa Margherita, Pavia, Italy

Background: Low back pain is a habitual pattern of access to the emergency department. Emergency Physician (EP) must remember some “red flags” regarding the most dangerous causes of this frequent symptom.

Methods: 53 yo man comes in the ED complaining acute dyspnea. He denies thoracic pain or fever. On arrival the patient is awake, sweaty and shortness of breath. On examination: bilateral gasps, rhythmic and tachycardic heart sounds. BP 180/140 mmHg, HR 110 bpm. SpO2 83% in room air. ABG: pO2 45, pCO2 45, SpO2 77%, lactates 1.4. Clinical US shows diffuse B-Lines and bilateral pleural effusions. Blood tests show neutrophilic leukocytosis, BNP is 1090, US-troponin is increased. The chest X-ray shows shaded right thickening. EKG is normal. Is then started NIMV (FiO2 55%) and diuretic therapy. An hour later EKG changes. A cardiologic consult is asked and echocardiography is performed: it shows middle-basal lateral ipocinesi. Because of the worsening of dyspnea, the patient is admitted in cardiology ward, with this diagnose “Acute pulmonary edema in ACS”.

During hospitalization a chest CT scan is performed and it shows a type B aortic dissection, uncomplicated.

The patient has been visited two months before for acute low back pain; in that occasion he performed blood tests and abdomen US, which resulted normal, and he was discharged with a presumptive diagnosis of renal colic.

Results: Low back pain can have different etiologies: musculoskeletal, uro-gynecological, hematological and vascular pathologies, such as abdominal aortic aneurysms.

The Stanford classification distinguishes two types of aortic dissection: Type A (75%); Type B, laceration is below the origin of the left subclavian artery (25%). It is defined as acute (less than 2 weeks), and chronic (more than 2 weeks). Clinical symptoms mainly consist of acute and intense chest or dorsal pain. Complications comprehend coronary obstruction, causing acute myocardial infarction, aortic insufficiency and acute heart failure.

Conclusions: Evaluating a patient complaining low back pain, EP must not underestimate the symptoms, especially in older patients and with risk factors such as hypertension. EP must perform a thorough clinical examination and exclude firstly potentially lethal causes.

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

W353

PATIENT WITH WEAKNESS IN LEFT LEG AND ABDOMINAL PAIN: LERICHE SYNDROME

B. Oktem 1, H. Demir 1, M. Yazol 2, M. Karamercan 1

1

Gazi University Faculty Of Medicine - Department Of Emergency Medicine, Ankara, Turkey, Faculty Of Medicine - Department Of Radiology, Ankara, Turkey

2

Gazi University

Background: Aortic occlusion is a rare but clinically important surgical emergency, due to its high morbidity and mortality. Leriche syndrome is an uncommon variant of atherosclerotic occlusive disease characterized by total occlusion in abdominal aorta and/or both iliac arteries which was first defined by Robert Graham in 1814 (1).

Typical symptoms are claudicatio in lower extremities, erectile dysfunction, weight loss and symptoms related to an arterial insufficiency of the lower extremities (2). <FILE IMAGE='394_20150715084953.jpg'> Methods: Case Presentation: A 65 year-old male patient presented in our emergency department with abdominal and both lower limbs pain, and weakness in left lower extremities. His symptoms have started about an hour ago and physical examination revealed 3/5 motor deficit in left lower extremity together with no palpable pulses on left femoral artery and its distal arteries. Pulses were also weakly palpable on right femoral artery and its distal sites. With these symptoms and physical examination findings, computed tomography (CT) scans of thorax and abdomen were taken with initial diagnosis of aortic dissection and aortic thrombosis. Together with these the patient also ordered cranial CT, to rule out any intracranial pathology that can cause motor deficit. In his toracoabdominal CT scans, it was seen that abdominal aorta was occluded in the infrarenal segment (Figure 1). Within the first hour of his attendance, Leriche syndrome was diagnosed and the patient was consulted to cardiovascular surgery. The patient was successfully managed with endareterectomy and embolectomy. His control digital subtraction angiography indicated no sign of thrombus. Patient was discharged without any sequelae after 7 days of hospitalization.

Results: Classic triad of Leriche syndrome is claudicatio in lower extremities, erectile dysfunction and decreased or absent femoral pulses (3). It has a high morbidity and mortality, and surgical revascularization is the definitive treatment (4-6). This case highlights the importance of performing a complete vascular evaluation in patients with cladicatio and emergency service doctors should keep aortic thrombosis in mind in patients with these symptoms and physical examination findings.

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

W354

A RARE COMPLICATION OF ABDOMINAL HERNIAS: SPONTANEOUS BOWEL EVISCERATION

B. Oktem 1, S. Ulusal 1, M. Karamercan 1

1

Gazi University Faculty Of Medicine - Department Of Emergency Medicine, Ankara, Turkey

Background: Spontaneous bowel evisceration is a rare, and potentially life threatening complication of abdominal hernias. Although it is mostly reported in cirrhotic patients with ascites, it can be seen in any patient with hernia. (1) <FILE IMAGE='394_20150714221235.jpg'> Methods: Case presentation: Here in we present a 75 years-old female case who attended to our emergency department with protrusion of umbilical hernia after coughing, about 30 minutes ago. She had an uncomplicated umbilical hernia for several years. Her vital sign were normal. On her physical examination, eviscerated bowel segment of umbilical hernia was seen (figure 1). The patient was consulted to general surgery department, and successfully managed with prompt surgical intervention within the first hour of her attendance.

Results: Hernia rupture is an unusual and potentially life-threatening complication of umbilical hernia.

Conditions that increase intra-abdominal pressure, such as coughing, straining can precipitate the rupture (1).

Similarly, rupture occurred after coughing in our patient. Although it is most commonly seen in incisional hernias and recurrent groin hernias, any abdominal hernia can result with evisceration, such as the case in our patient.

Evisceration of abdominal content has a risk of incarceration, infection and necrosis (3). The patients should be managed on an individual basis, balancing aggressive medical stabilization with the need for prompt surgical repair (4). ED management consists of hemodynamic stabilization and prevention of infection. The wound should be covered, and antibiotic prophylaxis should be started to prevent bacterial peritonitis (4).

This case highlights a rare and potentially fatal complication of umbilical hernia in the emergency settings.

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

W355

UNEXPECTED CAUSE OF INVERTED TAKOTSUBO CARDIOMYOPATHY: ACUTE APPENDICITIS IN A YOUNG MAN

M. Mihalcea-Danciu 1, L. Egler 1, M. Zupan 2, M. Schaenck 3, P. Bilbault 1

1

Emergency Departement, Hautepierre Hospital, Strasbourg, France, 2 Invasive Cardiology, Nouvel Hopital Civil, Strasbourg, France, 3 Intensive Care Unit, Hautepierre Hospital, Strasbourg, France Background: Takotsubo cardiomyopathy (TTC) is a stress-induced-cardiomyopathy, also known as transient left ventricular ballooning syndrome precipitated by emotional or physical stress and is characterized by normal coronary arteries and transient regional wall motion abnormalities. Variants of TTC include apical ballooning syndrome and less commonly, mid, basal, and local variants. New onset heart failure or acute coronary syndromes are common presentation of TTC. Arrhythmias such as VT, VF and torsade de pointes have also been reported.

Methods: We presented a 42-year-old man with an inverted takotsubo variant with pulmonary edema and transient accelerated idioventricular rhythm. He consulted in emergency department for acute non complicated appendicitis. Coronary angiogram showed normal coronary arteries and left ventriculography revealed this reverse variant of TTC. The patient had completely recovered. Myocarditis was ruled out by cardiac magnetic resonance imaging.

Results: To our knowledge, this case describes for the first time the occurrence of such an arrhythmia in a case of ITC, mimicking an acute coronary syndrome. Moreover, this is an extremely rare pattern in a male patient presenting with an acute stress. Interestingly, the only identifiable physical stressor was lower abdominal pain prior to presentation, confirmed to be acute appendicitis, doubled by an emotional stress caused by hearing about the necessity of surgical treatment.

Conclusions: This perioperative condition can be properly managed in the emergency department with appropriate counseling and pharmacotherapy.

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

W356

CHEST PAIN OR BACK PAIN?

S. Marra 1, G. Savioli 2, L. Pagani 1, F.G. Panizzardi 1, M. Bonzano 1, I.F. Ceresa 2, G. Ricevuti 1, M.A. Bressan 2

1

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

2

San Matteo Teaching Hospital, Emergency

Background: G.S. is a 90 years old woman, she accesses to our emergency department (DEA) for chest pain and dyspnea. When she arrived her vital signs were normal, such as EGA , chest X-ray and blood tests, including high sensitivity troponine. The patient was treated with analgesic therapy and discharged.

After 10 days she come back for persistent chest pain, increased by movements. On physical examination she appeared alert, cooperative, oriented. Chest breath sounds were reduced at the base of the right lung and the abdomen was tender at the left quadrants.

Methods: Vital parameters was: HR 101ar, BP 120/80, SO2 98%, T 37,7 °C. X-rays revealed no fractures and also the abdomen X-ray was normal. Blood tests were altered (WBC 41,05 x103/ul, Neutrophiles granulocyte 40 x103/ul, INR 2,86, PLT 376 x103/ul) The pain increased despite analgesic therapy. Patient refers lumbar and abdominal pain too. We visited her again: abdomen percussion elicited a painful response, but there were no signs of peritonism.The patient underwent abdomen CT that showed L5 on S1 spondylolisthesis, vertebral collapse of L2, D7 retrolisthesis and D8 collapse. Vacuolar degeneration of multiple intervertebral discs, with signs of discitis.

Results: Septic discitis are inflammatory process of intervertebral disc which usually involves the discovertebral junction, and may extend in to epidural space, posterior vertebral elements, paraspinal soft tissues. It may occur spontaneously, following surgery, in immunosuppressed, in systemic infections. Pyogenic spondylodiscitis are rare: concern 2–7% of all osteomyelitis.

The most important symptom is back pain that could be extended to abdomen; it is particularly severe and non-responsive to therapy. Neurological signs can develop. In the infective forms blood tests show an increase in inflammatory markers. Fever >37,5°C was documented.

Conclusions: Even if MRI is first choice examination, it is often missing in emergency departments. Soclinical examination and symptoms’ evaluation are essential, but often aspecific.

Most cases of discitis are managed with conservative therapy, including antibiotics and spinal immobilization.

Surgical therapy is reserved for neurological complications, spinal instability, deformity or when antibiotic therapy fail.

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

W357

THE USE OF NONINVASIVE VENTILATION IN HYPERCAPNIC COMA: YES WE CAN.

P. Malamani 1, G. D'antuono, L. Tabbì, M. Soccio, G. Ricevuti

1

Università Degli Sudi Di Pavia, Pavia, Italy, 2 Università Degli Sudi Di Pavia, Pavia, Italy, 3 Ospedale Di Esine, Bescia, Italy, 4 Ospedale Di Esine, Brescia, Italy, 5 Università Degli Sudi Di Pavia, Pavia, Italy Background: A controindication to the use of treatment with noninvasive mechanical ventilatio (NIV) is hypercapnic coma due to the risk of aspirative pneumonia related to lack of airways protection and the poor compliance to ventilatory treatment of confused/agitated patients.

Methods: We describe the case of hypercapnic coma that we treated with noninvasive ventilation.

The patient was dyspnoeic, hypercapnic (PaCo2 84.5 mHg), pH 7, 25,paO2 72mmHg,HCO3 36.6mmol/l .

He avoided endotracheal intubation.

The ventilator was set in the spontaneous/timed mode.

The initial inspiratory positive air way pressure was set at 5cmH2O, expiratory positive airway pressure was begun at a level of 10 cmH2O, Fio2 50%.

Patient was initially managed in emergency department for 3h and later in the respiratory ward.

Results: The patient responded to the noninvasime ventilation with clinical improvement.

Conclusions: The objective of the present case report is to show the effectiveness and safety of NIV to patient with severe neurological deterioration in hypercapnic coma.

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

W358

DANGER! MASSIVE PULMONARY EMBOLISM PRESENTING AS SYNCOPE: A CASE REPORT

T. Makker 1, B. Chang 2

1

New York-Presbyterian Hospital- Department Of Emergency Medicine, New York, Ny, Usa

Background: A 67 year-old woman presented to the emergency department (ED) with syncope. She awoke at 3am, walked to the bathroom and had nausea, chest pain and diaphoresis followed by syncope. She awoke with bowel incontinence.

On arrival, the patient was chest pain free but felt generally weak. On initial vital signs, she was afebrile, BP of 80/61, HR 100, RR 18, with an oxygen-saturation of 100% on room air. On exam, she appeared uncomfortable but was otherwise normal. <FILE IMAGE='302_20150716054900.jpg'> Methods: The initial ECG had normal axis with non-specific ST-T wave changes. Lab tests revealed guaic-positive stool, elevated troponin of 0.31 (ng/mL), leukocytosis 13.4 (U/L), and hemoglobin of 13.7 (g/dL).

The remainder of the labs including SMA-20, CBC and UA were normal. A chest-xray was concerning for left lower lobe pneumonia.

The patient was persistently hypotensive despite 2 liters fluid. This prompted a CT-angiogram which revealed bilateral saddle pulmonary embolism with significant clot burden in the right atrium and circulatory collapse. The patient was emergently taken to the OR and thrombectomy was successful.

Results: Syncope is a common complaint to the ED, accounting for nearly 3% of hospital admissions in the United States. Pulmonary embolism (PE) is one possible etiology of syncope, accounting for 100,000 deaths (0.5% of total deaths) annually in the US (1). The most common presenting symptoms include dyspnea (73%), pleuritic chest pain (44%), cough (37%), orthopnea (28%), calf/thigh pain/swelling (44%), wheezing (21%), and hemoptysis (13%). Either dyspnea, tachypnea, or pleuritic chest pain is present in 92% of patients with a PE while circulatory collapse occurs in only 8% of these patients. When circulatory collapse occurs, it is almost always accompanied by either dyspnea, tachypnea, pleuritic chest pain, or evidence of a deep vein thrombosis (2). Our patient had none of these symptoms and even maintained normal oxygen saturation on room air.

Conclusions: It is rare to see a patient with a massive PE resulting in hemodynamic compromise and syncope, but consider PE in a patient with refractory hypotension and syncope even without any of the classic symptoms.

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

W359

ACUTE, DEVASTATING, CERVICAL SPINAL CORD INFARCTION: A CASE REPORT

T. Makker 1, D. Leifer 2, R. Rao 3

1

New York-Presbyterian Hospital- Department Of Emergency Medicine, New York, Ny, Usa, 2 New York-Presbyterian Hospital- Department Of Neurology, New York, Ny, Usa, 3 New York- Presbyterian HospitalDepartment Of Emergency Medicine, New York, Ny, Usa Background: A healthy 68 year old man with a past medical history of hyperlipidemia and sarciodosis presented to the ED at New York-Presbyterian Hospital with bilateral lower extremity weakness starting 45 minutes ago. He reported profound leg weakness and urged he was â&#x20AC;&#x153;getting weaker by the minuteâ&#x20AC;?.

Vital signs were HR 54, BP 93/68, RR 18 with 98% oxygen saturation on room air, with a temperature of 36.2C. Strength testing was notable for bilateral 4/5 proximal, 2/5 right distal and 3/5 left distal upper extremity. Strength throughout the right lower extremity was 2/5 and 5/5 on the left. Sensation to pinprick and light touch was decreased below T2 on the right. The patient had absent deep tendon reflex throughout. Neurology was emergently consulted with concern for CNS infarct. <FILE IMAGE='302_20150716052234.jpg'> Methods: A noncontrast head CT was normal. Given hypotension,acute quadriparesis, and a thoracic sensory level, a CT angiogram for aortic dissection was performed and was found to be negative. MRI confirmed an acute C5-T1 spinal cord infarct. Because of progressive dyspnea with shallow respirations, he was emergently intubated. After discussion with his wife, intravenous alteplase was administered 2 hours 14 minutes after the onset of symptoms.

On transfer to an acute rehab facility one week later, he was extubated to room air. One year later, the patient reports the ability to ambulate with a walker.

Results: Spinal cord infarct is a rare condition, accounting 1% of strokes; mortality is 20-25% (1-2). Among reported cases, the majority present as ischemia during major aortic surgery and involve the Thoracic or Lumbar spine (3-7). Spontaneous spinal cord infarction is exceedingly rare and the diagnosis made clinically. Advanced neuroimaging is often confirmatory. Current treatment recommendations come from case series and expert opinion only (8). These strategies include secondary prevention of stroke. Rare case reports have reported the use of intravenous thrombolysis.

Conclusions: Spinal cord infarct should be considered in acute quadraparesis. Critical care management is crucial, particularly in cervical cord lesions. Our experience and previous case reports suggest that thrombolysis can be administered safely to patients with acute spinal cord infarcts.

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

W360

HEPARIN-INDUCED ACUTE ADVERSE REACTION – CASE REPORT OF A PATIENT WITH ACUTE TRAUMA AND A GENETIC PREDISPOSITION TO THROMBOTIC EVENTS: A CONCURRENCE OF EVENTS

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

1

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

2

Post-Graduate School In Emergency Medicine,

Background: The most common complication of heparin therapy is bleeding. Allergic reactions to heparin are rare, and the mechanisms are poorly understood.

Methods: A 57-year-old diabetic, hypertriglyceridemic and hypercholesterolemic man was admitted with a fractured right malleolus sustained while driving. He was prescribed parnaparin sodium 4250 IU subcutaneously once a day. During the third injection, the patient developed widespread pain, sickness and facial rash, followed by a state of stupor (GCS 8) and was hospitalized in Neurological Unit. He was found to be a carrier of two genetic mutations (i.e. prothrombin G20210A and MTHFR mutation) associated with an increased risk of thrombotic events. Discontinuation of parnaparin and supportive care led to a sufficient recovery of the patient to be discharged 6 days after admission.

Results: Allergic reactions to heparin are rare, and the mechanisms are poorly understood. Our patient complained of nausea and vomiting, and he developed a facial rash with a generalized sensation of warmth. So, it is possible that he had a typical allergic reaction to heparin. The Naranjo adverse drug reaction probability scale suggested that this case was probably caused by heparin (score of 5). Moreover, the possibility of a vasospastic reaction associated with an allergic one has been reported.Vasospastic reactions may develop independently of the origin of heparin, a few days after the initiation of therapy, and typically last for 4–6 h. The affected injection-site limb is painful, ischaemic and cyanosed. After repeated injections, the reaction may gradually increase to include general vasospasm with cyanosis, tachypnea, feeling of oppression and headache.

These vasospastic episodes have, in the past, been attributed to allergic reactions.This hypothesis could explain our patient’s sharp, intolerable and radiating pain, without any evidence of deep vein thrombosis (DVT).

LMWH is not a common cause of HIT but this event can occur in a post-trauma patient.

Conclusions: Clinicians should be aware of these rare but potentially serious adverse events. Prothrombin gene mutations are quite common, and guidelines on anticoagulant therapy for affected patients are needed.

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

W361

DIZZINESS AND HEADACHE: IS THERE A ROLE OF CHEST X-RAY IN THE INVESTIGATION OF POSSIBLE INTRACRANIAL LESIONS?

M. Lee 1, F. Zarisfi 2

1

Duke-Nus Graduate Medical School, Singapore, Singapore, Emergency Medicine, Singapore, Singapore

2

Singapore General Hospital Department Of

Background: In evaluating possible intracranial lesions, non-contrasted CT brain has proven its value in detecting acute life threatening emergencies such as intracranial hemorrhage. Yet it is limited in detecting intracranial tumors with similar radiodensity to normal brain parenchyma. Given that large proportion of metastatic lesions has a lung primary, we hypothesize that chest x-ray (CXR) has diagnostic value in evaluating symptoms due to possible intracranial lesions. To justify, we present a case report of a patient presenting with worsening headache and dizziness.

Methods: This is a case report following the progress of a previously healthy 62 year old Chinese gentleman, from initial presentation to the final diagnosis. He presented to the emergency department with one month of worsening non-vertiginous dizziness and frontal headache exacerbated when lying down. It was associated with nausea, vomiting and unsteady gait. He was seen at another hospital the previous week for his headache, a non-contrast CT brain was done and the radiologist reports chronic ischemic changes but otherwise no other intracranial pathology. During the week, he noted worsening symptoms. Review of system yield loss of appetite and a 4kg weight loss over the month. No significant family history was noted. On examination, there was left sided dysmetria and an inability to tandem walk. No other abnormalities were detected.

Results: Our patient was subsequently admitted. A CXR was performed. MRI brain was done to rule out stroke.

CXR revealed a suspicious solitary lung nodule. MRI brain revealed multiple hyper-intense lesions involving the leptomeninges and cerebellum. Subsequent lung biopsy revealed adenocarcinoma.

Most adult brain tumors are secondary in origin with the lung being the most common source (1). One important characteristic that increases the likelihood of metastasis and probability of detection on CXR is size (3). One study (2) has shown that 61% of metastatic intracranial lesions from lung cancer have positive CXR findings.

Conclusions: Given the low radiation and cost of CXRs it seems reasonable to include it in the initial work up for possible intracranial lesion; however as of now this is not well defined in the current literature.

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

W362

CANNABIS RELATED PARALYTIC ILEUS; CASE REPORT

S. Yesilaras 1, T. Korkmaz 1, S. Ozturk 2, A. Ugurhan 1, O. Limon 1

1

Izmir University Department Of Emergency, Izmir, Turkey, Turkey

2

Izmir University Department Of Surgery, Izmir,

Background: Paralytic ileus is intestinal paralysis condition where dilatation occurs in whole gastrointestinal system in the absence of mechanical obstruction. There are many reasons like medications, electrolyte abnormality, peritonitis and etc. According to data from Turkish Monitoring Centre for Drugs and Drug Addiction for 2013; cannabis ranks first in substance abuse rating after alcohol with a ratio of 84.1%. There are also synthetic analogs of cannabis which are used in ulcerative colitis treatment due to the inhibition of intestinal passage over CB1 receptors and anti-inflammatory effects in colon. Our case was reported as particular case since chronic cannabis usage presents and no case showing that it causes paralytic ileus in literature was found.

Methods: A 63 years old male patient applied to emergency department with abdominal pain, nausea, and vomiting and abdominal distension complaints after an episode of diarrhea. His abdominal examination revealed distended abdomen with silent bowel sounds, and abdominal x ray showed dilated and edematous bowel loops.

Air-fluid levels of the patient were detected in abdominal radiograph and with no pathological finding other than tachycardia (108/minute). No image for mass, invagination, volvulus, intra-abdominal infection which may cause obstruction was detected in contrast enhanced abdominal tomography of the patient with no previous known disease and abdominal surgery history. When the patient with suspected paralytic ileus was re-questioned, it was found out that he has not used any drugs continuously, sometimes he smokes marijuana since the age of 10 years and he did not smoked weed in the last two days. Paralytic ileus of the patient with positive THC (cannabis) in urine toxicological analysis was considered to be cannabis-related.

Results: Symptoms of the patient hospitalized in general surgery service were relieved by hydration, antibiotherapy and single dose Neostigmine methylsulfate (0.5 mg/ml) treatments after 24 hours and stool passage was observed. The patient was discharged with full recovery on 2nd day.

Conclusions: Such a commonly used substance should be kept in mind in patients with paralytic ileus and should be especially questioned.

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

W363

DRESSED IN A RASH -HISTORY IS THE KEY IN THWARTING DRESS SYNDROME

I. Sheth 1, S. Pothiawala

1

Emergency Department , Singapore General Hospital, Singapore, Singapore

Background: DRESS (drug rash with eosinophilia and systemic symptoms) syndrome is a life threatening illness with fever, exanthema, eosinophilia, atypical lymphocytes, lymphadenopathy, and hepatitis. This syndrome is difficult to diagnose, as many of its clinical features mimic those found with other serious systemic disorders.

Methods: A 45 yrs female presented to the ED with a 4 week of fever and macula-papular rash a/w nausea, sore throat and giddiness. Prescribed augmentin by the GP since the last 1 week and was also on allopurinol for hyperuriciemia before 2 weeks. Examination revealed bilateral cervical lymphadenopathy, tender hepato-splenomegaly,stomatitis. Bloods-leukocytosis with atypical mononuclear cells and deranged LFTs.Admitted to Internal medicine department. Skin biopsy-focal basal vacuolation and apoptotic keratinocytes.

CT scan of abdomen/pelvis showed gallstones with thickened edematous gallbladder /pericholecystic fat stranding and splenomegaly. . Liver biopsy -morphological picture consistent with drug induced hepatitis on a background of steatohepatitis. Started on topical corticosteroids with oral prednisolone for 2 weeks. Patient showed rapid resolution of fever, eosinophilia and progressive improvement in skin rash and liver dysfunction over a period of 2 weeks. She was discharged stable with outpatient follow-up.

Results: The mortality of DRESS is about 10%.Based on RegiSCAR criteria, patients must have three of the four following features: an acute rash, fever > 38째C, lymphadenopathy, and involvement of at least 1 internal organ, abnormalities in lymphocyte and eosinophil counts. Our patient's initial presentation of fever, cervical lymphadenopathy and progressive organ failure in the hospital setting evoked the diagnosis of intra-abdominal sepsis and infectious mononucleosis. However, no source of sepsis was identified, with bacterial cultures were negative. Our case illustrates the difficulty in diagnosing the DRESS which mimics a number of serious systemic disorders. Prompt recognition, supportive therapy, stopping the offending drug and initiation of corticosteroids, may prevent or minimize additional organ system involvement.

Conclusions: Emergency physicians should have a high index of suspicion to diagnose DRESS syndrome in patients presenting with a sepsis-like syndrome with rash and history of recent commencement on medications.

We would also like to emphasize the need for taking a detailed drug history in patients presenting with fever and rash.

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

W364

TIME IS LIMB: A CASE OF ACUTE AXILLARY ARTERY EMBOLISM

I. Sheth 1, S. Pothiawala 1, N. Yy 1

1

Emergency Department ,singapore General Hospital, Singapore, Singapore

Background: Acute Limb ischemia threatens the viability of the limb. This case report describes the clinical presentation of a middle-aged woman with acute limb ischemia mimicking as stroke.

Methods: A 58 year old female presented to the ED c/o of weakness and numbness in the left upper limb since last 1 hour. She had pain in the left upper limb with non -vertiginous giddiness. past medical history of rheumatic heart disease which was complicated by embolic stroke. She was on warfarin and digoxin since then.examination revealed weakness of the left upper limb. The limb was cold and pale and there was decreased sensation as compared to the right upper limb. The left brachial and radial pulsations were not palpable. Bedside ultrasound revealed no blood flow in the left axillary, brachial and radial arteries.diagnosed to have acute ischemia of the limb and given intravenous heparin followed by heparin infusion. She was urgently referred to the vascular . The patient went for angiography from ED which revealed an embolus in left axillary artery and in left radial artery. She underwent left brachial embolectomy. The symptoms resolved post procedure and she was discharged well from the hospital on warfarin and outpatient vascular surgery follow-up.

Results: The underlying etiology is either embolic in about 15% of cases and thrombosis in about 85% of the cases. The six classic â&#x20AC;&#x153;Pâ&#x20AC;? of acute limb ischemia with detailed examination of the affected limb is essential along with neurologic examination to differentiate stroke from signs of loss of vascular supply. The average time window is about 6 hours before the irreversible neuromuscular damage occurs. The amputation rate varies from 6-10% with the mortality rate of 6-12%. Due to threat to limb viability, the tests that localize the site of occlusion should be performed. The treatment is urgent revascularization either by endovascular or open surgical means.

Conclusions: We wish to highlight to the emergency physicians that presentation of acute limb ischemia may mimic a stroke. Early recognition of acute limb ischemia and prompt management will prevent limb loss or death.

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

W365

GIANT J (OSBORN) WAVE DUE TO BONSAI ABUSEMENT

M. Eroglu 1, M. Yalcin 2, M. Aparci 3, Z. Isilak 2, N. Ozmen 2

1

Gulhane Military Medical Academy, Haydarpasa Training Hospital, Department Of Emergency Medicine, Istanbul, Turkey, 2 Gulhane Military Medical Academy, Haydarpasa Training Hospital, Department Of Cardiology, Istanbul, Turkey, 3 Kasimpasa Military Hospital, Department Of Cardiology, Turkey Background: Osborn wave typically associated with hypothermia is currently referred as one of the J wave syndromes due to its clinical potential to develop lethal cardiac arrhythmia and rarely may be observed in a non-hypothermic setting such as cannabis abusement. Myocardial ischemia or infarction is one of the frequent mechanisms associated with cardiovascular death due to cannabis and bonsai.

We presented two young cases who presented emergency service with unconsciousness, drowsiness, and hypoxia, and also J wave on ECG due to Bonsai abuse.

Methods: Case 1 A 21 years old male was transferred to the emergency room with confusion and loss of consciousness following several hours after bonsai abusement. Body temperature was 34.4 °C On 12 lead ECG, a deflection of J wave-Osborn wave was globally observed on leads I, aVL, II, III, and aVF, and prominently on V2-V6 derivations which may be described as Type 3 pattern; early repolarization on all derivations with the highest risk for malignant arrhythmia (Figure 1, 2) Although the patient had been warmed up to 37.1 Cº for an 8 hour period it was observed that Osborn wave did not recover on ECG. We observed that Osborn wave had been disappeared on ECG at the end of the 36 hour period (Figure 3) Case 2 A 20 years old male was transferred to the emergency room in a similar clinical condition. Confusion was remarkable in his physical examination. Body temperature was 36.5 °C. J wave-Osborn wave was existed similarly on leads II, III, and aVF, and prominently on V3-V6 derivations, as Type 2 pattern (Figure 4). J wave elevation persisted at least 12 hours and then disappeared after 24 hours period (Figure 5).

Conclusion Results: .

Conclusions: Osborn wave may be a significant criterion to initiate close monitoring in coronary care unit, supportive treatment, and mechanical ventilation when necessary in those patients who abused Bonsai and became comatose. Osborn wave may be an electrocardiographic sign preceding an electrical storm in those patients unless they were managed earlier and treated effectively.

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

W366

NAVICULAR STRESS FRACTURE: A RARE TYPE OF STRESS FRACTURE OCCURRED IN A CHILD

I. Arziman 1, M. Erkencigil 1, M. Seven 2, S. Akpancar 3, L. Gurer 3, M. Durusu 1

1

Gulhane Military Medical Academy - Department Of Emergency Medicine, Anlkara, Turkey, 2 Gulhane Military Medical Academy - Department Of Emergency Medicine, Ankara, Turkey, 3 Gulhane Military Medical Academy Department Of Emergency Medicine, Ankara, Turkey Background: The aim of this study is to present a child who had navicular stress fracture occurred from rope skipping.

Methods: A case report Results: A 10-year-old female children was admitted to emergency department with complaint of left ankle pain.

At the physical examination of patient; pain and swelling were elicited along the dorsomedial border of the foot.

Pain was decreased in the rest but exacerbated by activity. The patient had no motor or sensory deficits. AP and lateral X-ray graph of ankle were completely normal. A Wide high signal intensity of bone marrow on the lateral aspect of Navicular bone which are specific findings of stress fracture determined on MRI images. Cast was applied to ankle for 21 days of immobility. After removing of case, ankle of motion was full and navicular bone was completely normal on MRI images.

Conclusions: Stress fractures are very common and most of them resulted from overuse injuries. Especially occurred in professional or recreational athletes and military recruits that subject to change in training intensity (increased), type of training or training circumstances. However, stress fractures may also develop in sedentary people if suddenly an active lifestyle is adopted. If the fractures are not properly diagnosed, considerable complaints can develop such as chronic pain, turn to fracture and reduced mobility. Emergency physicians must be aware of this situations, should examine carefully with their radiographs, and also with MRI and sintigraphy examinations, which sometimes be difficult to detect.

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

W367

A RARE FRACTURE TYPE THAT OCCURRED FROM AN ANKLE SPRAIN: AVULSION FRACTURE OF THE CUBOID

I. Arziman 1, M. Seven 2, L. Gurer 3, S. Akpancar 3, M. Erkencigil 1, M. Durusu 1

1

Gulhane Military Medical Academy - Department Of Emergency Medicine, Ankara, Turkey, 2 Gulhane Military Medical Academy - Department Of Sports Medicine, Ankara, Turkey, 3 Gulhane Military Medical Academy Department Of Orthopedics And Traumatology, Ankara, Turkey Background: The aim of study was to present a rare case of cuboid avulsion fracture, occurred from an ankle sprain.

Methods: A case report Results: A 33-year-old male sustained a supination injury of the right ankle during a football match. He instantly lost the ability to bear weight on the affected foot. He was admitted to the emergency department with complaint of ankle pain and swelling. Mobility of the right ankle was painful and reduced. His neurovascular examination was normal. Computed tomography (CT) scan was obtained for suspected cuboid avulsion fracture. The patient was treated with short leg cast. This treatment decreased pain upon weight bearing and enabled a return to work without any restrictions six week after the procedure. He was scheduled to revisit the orthopedics clinic at 3 and 6 months postoperatively.

Conclusions: The cuboid bone lies on the lateral side of the foot, in front of the calcaneus, and behind the fourth and fifth metatarsal bones. Minor fragmental avulsion fractures at ligament and capsule insertions are the most common form of cuboid injury. If the fractures are not treated properly, long-lasting conditions can develop such as chronic pain and reduced mobility. CT scan is often required to confirm the diagnosis and is usually required for assessment of the extent and nature of the injury, even when found on plain radiographs.

Clinicians must aware of these insidious fracture types for early diagnose and effective treatment.

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

W368

SLIPPED CAPITAL FEMORAL EPIPHYSIS: A RARE ORTHOPEDIC EMERGENCY

I. Arziman 1, M. Seven 2, L. Gurer 3, S. Akpancar 3, M. Erkencigil 1, M. Durusu 1

1

Gulhane Military Medical Academy - Department Of Emergency Medicine, Ankara, Turkey, 2 Gulhane Military Medical Academy - Department Of Sports Medicine, Ankara, Turkey, 3 Gulhane Military Medical Academy Department Of Orthopedics And Traumatology, Ankara, Turkey Background: Slipped capital femoral epiphysis is uncommon in children and usually occurred after high-energy trauma. We wanted to present a patient who had a slipped capital femoral epiphysis and incompatible history.

Methods: A case report Results: A 7-year-old male patient was admitted to emergency department with complaint of left hip pain limping gait. The symptoms had started 10 days before and he had no history of trauma. At the physical examination, minimal swelling and pain were detected on the left hip and pain increased with movement. Also leg length discrepancy was determined between lower extremities. The patient had no motor or sensory deficits. Slipped capital femoral epiphysis was diagnosed on the left hip with X-ray graph (figure 1, 2). After consultation to the orthopedics, the patient urgently underwent to surgery.

Conclusions: Slipped capital femoral epiphysis is uncommon in children and usually occurred after high-energy trauma. If this situation is not properly treated, considerable complaints can develop such as hip arthrosis, chronic pain, and reduced mobility. Children who admitted to the emergency departments should be questioned and examined carefully not to misdiagnose the emergency situations.

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

W369

A RARE CASE: NEWBORN FEMORAL SHAFT FRACTURE IN DELIVERY

Y. Erdem 1, S. Akpancar 1, M. Gemci 1, M. Erkencigil 2, I. Arziman 2, S. Yasar 2

1

Gulhane Military Medical Academy, Department Of Ortopedics And Traumatology, Ankara, Turkey, Military Medical Academy, Department Of Emergency Medicine, Ankara, Turkey

2

Gulhane

Background: Isolated closed femur diaphysis fracture of newborn due to birth trauma is seen rare, especially it has a high incidence in the presence of macrosomia, vaginal breech deliveries and sectio caesarea yet.

Treatment modalities vary from pelvic bandage to pelvipedal casting. We manage to present a newborn femur diaphysis fracture just after the delivery in emergency service which pelvipedal casting was applied to get the rotational stability against pelvic bandage.

Methods: A case report Results: After normal vaginal delivery of 38 th week of 2.5 kilograms newborn, obstetrician noticed an edema on newbornâ&#x20AC;&#x2122;s left thigh. Orthopedics was consulted into the emergency department. They noted that there was crepitation and no movement on his left thigh. X-rays were taken. X-ray revealed a transverse left femur diaphysis fracture (Figure 1). Pelvipedal fiberglass cast was applied on both lower extremities including the left calf extension to ankle. Control x-rays were eligible. The newborn was followed at 1st and 2nd days after cast application. Cast was removed at the end of 20th day, no complications were observed. There was a displacement on x-rays, but callus formation was observed adequately (Figure 2). On the 5th month control graph, displacement was disappeared and there was no shortness. Also fully hip and knee range of motion was observed.

Conclusions: Femur diaphysis fracture can be seen in any traumatic deliveries. Clinicians should be suspicious of a fracture if there was a immobile thigh. On the other hand clinicians should be calm enough and apply pelvipedal cast in a position of bilateral hip abducted and flexed in such a case. Pelvic bandage is another treatment option; however it cannot probably provide rotational alignment. Control x-rays should be considered at the appropriate limits either a fracture site displacement. Clinicians should not worry about angulation and displacement except rotation, because new bone formation and callus undergoes remodeling.

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

W370

NECROTIZING FASCIITIS: A DEVASTATING TISSUE INFECTION COULD BE OCCURRED FROM A SIMPLE PINPRICK

Y. Erdem 1, S. Akpancar 1, M. Gemci 1, M. Erkencigil 2, I. Arziman 2, S. Yasar 2

1

Gulhane Military Medical Academy, Department Of Orthopedics And Traumatology, Ankara, Turkey, Military Medical Academy, Department Of Emergency Medicine, Ankara, Turkey

2

Gulhane

Background: We wanted to share a patient who had necrotizing fasciitis and underwent hip disarticulation.

Methods: A case report Results: A 22-year-old male admitted to emergency department with the complaint of pain and local reddening due to pinprick injury. There was not any soft tissue swelling and erythema. Pulses of dorsalis pedis and tibialis posterior arteries were palpable. Leucocytes, sedimentation rates and C-reactive protein values were out of range and minimally elevated. He was consulted to infectious diseases clinic where intravenous antibiotherapy was started. Excessive swelling and erythema began three days after antibiotherapy. Infection advanced quickly, pulses were weakly palpable. Urgent debridement and irrigation were performed. Hip disarticulation was needed because of the spread infection and severely impaired tissue perfusion.

Conclusions: Necrotizing fasciitis is a serious skin infection that spreads quickly and kills the body's soft tissue.

Rapid and accurate diagnosis prior to appropriate treatment with antibiotics is important to stop this fatal infection. If needed superficial wound debridement should be applied in a short time. Physicians must be careful in foreign bodies injuries such as nail and pinprick, also they have to questionize the history of symptoms carefully in a manner and use further laboratory examinations.

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

W371

FIRST-TIME PATELLAR DISLOCATION: CONSERVATIVE TREATMENT IN EMERGENCY SERVICE

Y. Erdem 1, S. Akpancar 1, M. Gemci 1, M. Erkencigil 2, I. Arziman 2, S. Yasar 2

1

Gulhane Military Medical Academy, Department Of Orthopedics And Traumatology, Ankara, Turkey, Military Medical Academy, Department Of Emergency Medicine, Ankara, Turkey

2

Gulhane

Background: Acute traumatic patellar dislocation is the second most common cause of knee hemarthrosis. This injury is mostly associated with participation in sports and physical activity.

We aimed to present a first-time patellar dislocation of a young recruit who was admitted to emergency service with severe knee pain and swelling.

Methods: A case report Results: A 21-year-old recruit presented to emergency service with knee pain, swelling and deformity. On his anamnesis he declared that he had a severe pain while kicking ball in a football match. Then he could not walk because of knee pain. His knee was in flexed position and severe edema was observed. He could not extend his knee because of severe pain. X-rays revealed lateral patellar dislocation of left knee (Fig.1). Then minimal sedation anesthesia was applied before the reduction maneuver. Reduction was achieved in knee extended position. Jones bandage extent to ankle joint was applied. Control x-rays were taken, patella was seen in trochlear groove (Fig.2). Sports activities were restricted at least 3 months.

Conclusions: Patellar dislocations usually occur to lateral direction with trauma while kneeling and squatting. It is also reported that patella alta can cause this scenario. In this case it was occurred without any trauma, only by kicking. These findings suggest to us that he had probably congenital patella alta. In such cases in emergency services reduction should be applied with light sedation not to damage patellar and trochlear joint surfaces which cause a complication of patellofemoral degenerative arthritis in the future. Clinicians should take care of this subject.

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

W372

DELAYED DIAGNOSIS OF AN INTRACRANIAL LESION BY A SERIAL CRANIAL MAGNETIC RESONANCE: ARE WE ON THE SAFE SIDE?

A. Denizbasi 1, E. Salcin 1, C. Ulubay 1, O. Onur 1, S. Eroglu 1, H. Akoglu 1

1

Marmara University Department Of Emergency Medicine, Istanbul, Turkey

Background: Objective: The aim of the case presentation is to discuss a patient in whom we have diagnosed an intracranial hemorrhage of an intracranial lesion at the second Magnetic Resonance Imaging (MRI) while we are observing the patient at the Emergency Service.

Methods: Case: 81 year old male is presented to the Emergency Service after he has fallen down and hit his head. After the incident he has new onset of disartria, and a new onset indifference to the environment. In his personal medical records he is already diagnosed to have hypertension, diabetes, and a past cerebrovascular event which is almost fully recovered so that he is independent for the personal activities. After his arrival, his full evaluation is done to rule out any syncope or seizure etiology. First cranial CT is performed to rule out intracranial hemorrhage due to trauma in which no bleeding is noted. After that a diffusion MRI is done to document new ischemic stroke in which, however, there is no new pathology. While the patient is being observed in the emergency service, he begins to deteriorate and becomes unresponsive. After consultation to the neurology and three hour observation period, he has second MRI performed.

Results: Result: The second MRI shows that he has an intracranial lesion with 2 cm in diameter in the right frontal cortex of the brain that has bled. The blood in the lesion has augmented the contour of the lesion to be seen on the MRI. The patient is admitted to Neurosurgery for treatment.

Conclusions: Conclusion: Although MRI is an expensive technique, it is extremely helpful to diagnose any ischemia or any unidentified cranial lesion. When there is a doubt about the clinical state of the patient to clarify the diagnosis, MRI techniques must be performed again even in the emergency setting to stay on the safe side to avoid misdiagnosis. The fact that a patient is old or has an underlying disease may be the worst reason to continue further evaluation.

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

W373

POSTICTAL ST SEGMENT ELEVATION: IS IT POSSIBLE THAT MYOCARDIAL INFARCTION?

T. Deniz 1, M. Koksal, O. Eroglu, U. Aciksoz, F. Coskun

1

Kirikkale University, Faculty Of Medicine, Department Of Emergency Medicine, Kirikkale, Turkey

Background: Epilepsy is a clinical condition characterized by recurrent seizures. The aim of this presentation is to emphasize that can be changes as hyperacute myocardial enfarctus in electrocardiogram after epileptic seizures. <FILE IMAGE='208_20150609222006.jpg'> Methods: 43-years-old male patient was admitted to the emergency department following a generalized tonic窶田lonic seizure. The patient about 30 years ago, received a diagnosis of epilepsy after a head trauma.

Carbamazepine had been changed to sodium valproate a month ago. There was no history of alcohol excess or drug abuse. His postictal state was characterized by mute confusion and agitation. On physical examination, blood pressure was 110/70 mmHg, pulse rate 105/min regularly, respiration rate 20/min. and temperature 36,7 C while the heart and lungs showed no abnormalities. Neurologic examination was unremarkable except for moderate memory difficulties.

Results: Electrocardiogram was taken due to the rhythm of change. The electrocardiogram showed a normal sinus rhythm with a normal AV conduction time and normal QRS duration. There was elevation of the ST segments in leads II, III and aVF and ST segments depresion in leads aVR and aVL. It was observed ST-segment resolution during the electrocardiogram (Figure 1). Cardiac specific enzymes (CK-MB, troponins) were all within normal limits. All other biochemical and haematological investigations were normal. He was referred to the catheterization laboratory for coronary angiography (CAG). Coronary artery disease was excluded by coronary angiography.

Conclusions: Transient myocardial infarction electrocardiogram findings can be detected after seizures in the early period without coronary abnormality. There is need for further studies on electrocardiographic changes after epileptic seizures.

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

W374

A CASE OF PATENT FORAMEN OVALE AND ATRIAL SEPTAL ANEURISM

A. Comaglio 1, V. Gagliardi 1, L. Sabbadini 1, M. Francini 1, C. Corbellini 2, M.L. Muiesan 1

1

UniversitĂ Degli Studi Di Brescia, Brescia, Italy, 2 Clinica Medica - Spedali Civili Di Brescia, Brescia, Italy

Background: An 85-year-old woman was admitted to our hospital because of frequent episodes of desaturation (76-83% despite O2 therapy in nasal cannulae). The clinical suspicion of pulmonary embolism was confirmed at the chest CT scan performed in the ED. Methods: At admission, the patient complained of mild dyspnoea at rest and platypnea; the clinical examination was normal, except for the presence of digital clubbing and a mild hypostenia of the left inferior limb (as a consequence of a recent relapse of ischemic stroke localized at the brainstem, possibly caused by a right persistent trigeminal artery. A few hours after admission, because of the persistence of desaturation despite O2 15L/min, we started non-invasive ventilation (NIV) and heparin treatment before starting oral anticoagulation.

Venous dopplersonography of the inferior limbs, pulmonary scintigraphy and spirometry, performed after admission, resulted normal. Despite these results oxygen saturation was persistently low ant the patient needed high-flow O2 therapy (15L/min mask with reservoir). We then looked for the presence of a right-to-left shunt explaining the persistence of oxygen desaturation that worsened passing from supine to the upright position (platypnea-ortodeoxya syndrome).

Results: The patient underwent a Trans-Esophageal Echocardiography that showed a huge right-to-left shunt due to a wide patency of the fossa ovalis associated with an atrial septal aneurism. The cardiac catheterization showed normal pressure values in the pulmonary arteries and low pulmonary resistances, confirming the presence of the atrial septal defect. Therefore, after an unsuccessful attempt with medical therapy (Sildenafil 20 mg x3/die), the patient underwent a percutaneous closure of the defect with an Amplatzer device. Immediately after the closure procedure SaO2 values improved and remained in normal range.

Conclusions: The patient was dismissed completely asymptomatic for dyspnoea, palpitations and/or chest pain.

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

W375

A USUAL ABDOMINAL PAIN, WITH UNUSUAL FINDINGS…

A. Rigatelli 1, G.A. Soardi 2, G. Ricci 1, C. Caroselli 1

1

Azienda Ospedaliero Universitaria Integrata Verona, U.O.C. Pronto Soccorso, Verona, Italy, Ospedaliero Universitaria Integrata Verona, U.O.C. Radiologia, Verona, Italy

2

Azienda

Background: Large bowel obstruction is a frequent cause of admission in ED especially among elderly patients.

Intestinal obstruction is a blockage of normal transit of the fluids and digested foods.

Bowel obstruction (BO) if untreated may evolve in ischaemia, peritonitis or perforation.

Methods: A 89-years-old, presented in ED with abdominal pain and acute urine retention, started slowly few days before presentation. He referred also progressive abdominal distension and constipation. Clinical History reported trans-urethral prostate resection and a colectomy 30 years before. Objective examination was negative for relevant findings and bladder volume seemed almost normal at ultrasound scan.

Results: Chemistry was in the range of normality, not CRP elevation or Leucocytosis. X-Ray of abdomen showed air-fluid levels (Figure 1) but was required to perform abdomen CT-scan that revealed a picture of small intestine and large intestine obstruction. Without relevant findings despite of clinical presentation we hypothesized a chronic intestinal pseudo-obstruction (CIP) or a Ogilvie’s syndrome. A rectal probe was placed with immediate pain relief, admission to floor was disposed. A control CT of abdomen assessed that the occlusion was chronic, lab tests performed once ammitted were unchanged, with the exception of al mild renal impairment 125 µmol/L. A rectal-sigmoidal-endoscopy was performed revealing ileus dilated for a length of 140 cm, ileo-cholic and terminal anastomosis were regular. After liquid-feed therapy and electrolitic supply for ten day normal bowel function was restored and renal function become normal. At discharge the diagnosis was of bowel obstruction probably due to motorial disease in patient with previous sub-total resection of colon. <FILE IMAGE='376_20150707223645.JPG'> Conclusions: Ogilvie’ s syndrome is a dilation of the gut in absence of mechanical obstruction, generally affecting patients over 60 years-old. It may occur after major surgery or develop after drugs administration like: amphetamines, steroids, anticholinergics, narcotics, clonidine, phenothiazines. Symptoms are characterized from: abdominal distension, bowel movements disorders (constipation and diarrhoea), and diffuse abdominal pain. Usually Ogilvie’s treatment is conservative. The objective is to remove the possibile causes.

In many cases is necessary and effective a colonscopic decompression or a pharmacological treatment using neostigmine.

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

W376

A FATAL COMBINATION OF SITUS INVERSUS, PREGNANCY, CARDIAC ARREST AND INAPPROPRIATE SHOCKS BY AN AUTOMATED EXTERNAL DEFIBRILLATOR

S. Calle 1, M. De Leeuw 1,2, N. Mpotos 1,3,4, P. Calle 1,5

1

Ghent University - Faculty Of Medicine And Health Sciences, Ghent, Belgium, 2 Ghent University Hospital Forensic Pathology Department, Ghent, Belgium, 3 Sint Lukas General Hospital - Department Of Emergency Medicine, Ghent, Belgium, 4 University Of Antwerp - Faculty Of Medicine And Health Sciences, Wilrijk, Belgium, 5 Maria Middelares General Hospital - Department Of Emergency Medicine, Ghent, Belgium Background: A 34 years old female suddenly felt down and remained comatose. She was 6 months pregnant.

Information on previous medical problems could not be obtained (due to language barriers). Upon arrival of the first tier ambulance she was unresponsive with a pulse of 30 per minute. A few minutes later, no pulse could be detected and basic life support was started with an automated external defibrillator. Self-adhesive pads were placed in the conventional sternal-apical position. The first and second rhythm analysis led to a correct no-shock decision (figure 1). The third and fourth analysis gave rise to wrongful shocks, probably because the tachyarrhytmia with QRS complexes of low amplitude were considered to be ventricular fibrillation (figure 2).

About 25 minutes after the collapse, the patient was transferred to the hospital with ongoing advanced cardiac life support and taken to the delivery room. Caesarean section was performed about 1 hour after the collapse.

Maternal and newborn resuscitation were unsuccessful. Forensic autopsy revealed situs inversus, but no apparent cause of death. <FILE IMAGE='142_20150706212432.jpg'> Methods: not applicable Results: not applicable Conclusions: 1. Intriguingly, no cause of death could be detected on autopsy. Therefore, further research on the cardiac arrest risk stratification in dextrocardia in general, and during pregnancy in particular is needed.

2. In a known dextrocardia case, the conventional sternal-apical position for electrodes should be changed to bi-axillary placement or a mirror-like approach (i.e. placement to the left of the sternum and in the right mid-axillary line). This case also argues against the use of the above-mentioned mirror-like approach in a standard cardiac arrest patient with a medical device implanted below the right clavicle.

3. The inappropriate shocks delivered in this case underscores the need for review of each automated external defibrillator use and feedback to manufacturers to improve the accuracy of the rhythm analysis algorithms.

4. Additional training for prehospital care providers may improve the outcome of mother and child. Emphasis should be put on manual displacement of the uterus to the left and left lateral tilt to remove caval compression, and on emergency Caesarian section.

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

W377

CASE REPORT: SPONTANEOUS RUPTURE OF LEFT FEMORAL ARTERIAL PSEUDOANEURISM

A. Bottani 1, A. Barraco 2, A. Popovich 3, S. Paiardi 2, M. Ripoll Pons 1, G. Civitavecchia 1, G. Ricevuti 1, A. Voza 2

1

Postgraduate School Of Emergency Medicine, University Of Pavia, Pavia, Italy, 2 Emergency Department, Humanitas Clinical And Research Center, Rozzano, Milano, Italy, 3 Vascular Surgery Unit, Humanitas Clinical And Research Center, Milano, Italy Background: Aterosclerotic aneurism of superficial femural artery are quite rare. Usually these aneurisms are asymptomatic and undiagnosed until the rupture complications.

It is not well described if femoral artery aneurism behave like aorto-iliac aneurism, with high percentage of rupture, or if they behave like popliteal aneurism, with frequent embolic or trombotic complications.

Methods: CASE REPORT An 85 yo man, nursing home resident, comes into the ED complaining a massive left leg swelling with pain, he is awake but uncooperative. His PMH comprehends diabetes, COPD, prostatic cancer, previous TIA, previous extradural hematoma, parkinsonism, cognitive impairment. AThe left leg is swollen, with cutaneus erythema. No DVT clinical signs. BP is 120/74 mmHg, HR is 55 bpm, SpO2 is 93%. Blood tests show leucocitosis with neuprophilia, CRP level is elevated, D-dimer 340 ng/ml. A dermatologist consult is asked: stasis dermatitis with possible initial erisipela. An abdominal US is then performed: left iliac artery aneurism (diameter 33 mm) with diffuse parietal calcification. The patient is kept in the ED for observation and the day after a vascular US is performed: left femural artery rupture with pseudoaneurism (diameter 38 mm) with partial compression of left femural vein. Bilateral peripheral pulses are present and a left femoral pulsatile mass is palpable.

The patient is then subjected to urgent surgical suture of arterial rupture.

Results: Peripheral arterial aneurisms can be associated to many conditions, such as syphylis, inflammatory or immunological arteritis, Ehlers-Danlos syndrome and others.

Most of these remains without clear etiology, and are classified as aterosclerotic aneurisms.

Femural aneurism can be bilateral in 18% of cases and are associated to abdominal or peripheral aneurism in a percentage ranging from 27% to 69%.

Conclusions: Generally femural artery aneurism rupture is well tolerated from the patient, due to the tamponage of nearby muscular structures. This mechanism allows in most cases to have enough time to plan a precise therapeutic strategy. In our patient the pain, and probably the aneurism rupture, is started the day before the access in the ED and the muscular tamponage mantained an emodinamically stable situation.

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

W378

A RAPID EVOLUTION HEAD TRAUMA CASE

M. Bonzano 1, F.G. Panizzardi 1, S. Marra 1, L. Pagani 1, M.A. Bressan 2, G. Ricevuti 1

1

Scuola Di Specializzazione In Medicina D'emergenza E Urgenza, UniversitĂ Degli Studi Di Pavia, Pavia, Italy, D.E.A. -Pronto Soccorso, Irccs Policlinico San Matteo, Pavia, Italy

2

Background: <FILE IMAGE='315_20150715190520.jpeg'> Methods: M.A, male, 81 years old, came to attention of emergency room for an accidental fall from a stair at 12:00 p.m.

Medical history: Atrial fibrillation in oral anticoagulant therapy, hypertension, diabetes.

At the physical examination the patient presented cranial contusion, left orbital bruise and left collarbone fracture, the cardiopulmonary examination was normal, the patient was well responsive with a brief amnesic period of the event with neither motion deficit and nor sensitive deficit.

First head CT-scan showed no intracranial bleedings or hematomas.

Laboratory exams were normal except for INR 2,74 due to the warfarin therapy.

The patient underwent oculist, orthopaedic and neurologic specialist visits and he was moved to observation room for a 24 hours observation cause the cranial contusion and oral anticoagulant therapy.

During the first hours the patient was complaining only pain at the collarbone and the neurological examination was still negative.

At midnight, twelfth hour from the trauma, suddenly the patient became confused, restless and uncooperative.

A second head CT-scan showed bilateral temporal, parietal and frontal intraparenchymal hematomas and a bilateral thin subarachnoid bleeding (Fig.1-2).

At 2:00 a.m. the patient was taken in the neurosurgical ward for observation and conservative therapy (suspension of oral anticoagulant therapy).

A third CT-scan of the head showed a progression of the hematomas bilaterally (Fig.3).

After 3 days from trauma the patients became unresponsive and he died the day after.

Results: Since the patient was asymptomatic and the first CT-scan was negative, there wasnâ&#x20AC;&#x2122;t any indication to recoagulant therapy for a patient with head trauma and oral anticoagulant therapy; despite this facts, the clinic manifestations appeared so dramatically fast that any therapy was any more effective after the radiological results.

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

W379

DIGITALIS TOXICITY

F.G. Panizzardi 1, M. Bonzano 1, S. Marra 1, L. Pagani 1, M.A. Bressan 2, G. Ricevuti 1

1

Scuola Di Specializzazione In Medicina D'emergenza E Urgenza, UniversitĂ Degli Studi Di Pavia, Pavia, Italy, D.E.A. -Pronto Soccorso, Irccs Policlinico San Matteo, Pavia, Italy

2

Background: Digoxin blocks the sodium/potassium ATPase pump. Intracellular calcium within the cardiac myocytes is increased by digoxin resulting in increased contractility. Digoxin toxicity causes hyperkalemia. The sodium/potassium ATPase pump normally causes sodium to leave cells and potassium to enter cells. Blocking this mechanism results in higher serum potassium levels. Digoxin toxicity is worsened in states of hypokalemia since digoxin normally binds to the ATPase pump on the same site as potassium. When potassium levels are low, digoxin can more easily bind to the ATPase pump exerting the inhibitory effects, so the membrane calcium channels open resulting in increase calcium influx into cells. <FILE IMAGE='315_20150715185216.jpg'> Methods: V.T, male, 75 years old came to attention of emergency room for asthenia and dizziness with low cardiac rate. The patient was affected by persistent atrial fibrillation treated with digoxin and sotalol.

The cardiopulmonary examination and neurological examination were normal, cardiac rate 32 bpm (Fig. 1), blood pressure was 140/70 mmHg and oximetry was 98% and laboratory exams were normal, in particular the electrolytes. Suspecting a digoxin intoxication a sample for serum digoxin levels was collected.

The test revealed 1,74ng/ml (therapeutic range: 0,5-1 ng/ml).

The patient was admitted to observation room for monitoring vital signs, hydratation and suspention of digoxin therapy. After 16 hour the serum digoxin level was 1,39 ng/ml, the heart rate was 60 bpm. The patient was asynthomatic and discharged after 19 hours.

Results: In the setting of digoxin toxicity and hyperkalemia, giving IV calcium may be potentially fatal. The massive influx of calcium into myocytes after the IV calcium is given has been theorized to induce a non-contractile state and has been termed 'Stone Heart'. There is no evidence to validate this theory and some reports have shown safe administration of calcium during digoxin toxicity in isolated cases. If hemodynamic compromise is present or serious arrhythmia manifests from digoxin toxicity, the mainstay of treatment is digoxin specific antibody. Indications: -Life threatening arrhythmia including ventricular arrhythmias, asystole, complete or high grade AV block or other symptomatic bradycardia.

-Evidence of end-organ dysfunction.

-Significant hyperkalemia.

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

W380

A RARE DIAGNOSIS OF UPPER ABDOMEN: SPLENIC CYST HYDATID

G. Berikol 1, G. Berikol 2, Y. Kurucay 3, M.S. Yurdakul 1, T. Ă&#x2013;nge 1

1

Karaman Public Hospital-Department Of Emergency Medicine, Karaman, Turkey, 2 Karaman Public Hospital-Department Of Neurosurgery, Karaman, Turkey, 3 Karaman Public Hospital-Department Of General Surgery, Karaman, Turkey Background: Spleen is known as third common organ of cyst hydatid disease. Not only it diagnosed difficulty, but also delayed diagnosis can present serious symptoms as anaphylaxis. Epigastric pain and upper quadrant sensitivity has differential diagnosis like perforation, peptic ulcus, cholelytiasis, hepatitis, pancreatitis.

Methods: Twenty seven year old patient has appealed emergency service with epigastric pain. She has been suffered symptoms for one day. She has left shoulder and back pain for two years and consulted to physiotherapy for a year. She has been prescribed analgesics, antiinflamatory drugs, proton pump inhibitors and antacid drugs.Her physical examination was normal but a sensitivity at upper quadrants of abdomen. She has been observed in emergency service for two hours. Pantoprozole and hydration was given. Her symptoms were deceased and discharged with recommendations. Twelve hours later she reapplied to emergency service with same complaints. Her blood tests were taken and abdomen computer tomography was done.

Results: Laboratory findings are CRP 140,7 mg/L, AST 23 U/L, ALT 18 U/l, Direct bilirubin 0,50mg/dl, K+ 4,1mmol/L, WBC 9200, LYM 7100. Abdominal computerized tomography was reported as spleen size was increased (152 mm), a hypodense cystic lesion (14*8cm) in parachyme seperated with internal membrane.

There is diffuse free fluid at perihepatic, bilateral paracolic and pelvic. Diagnosed of perforated splenic cyst hydatid, she has operated by general surgeon, and discharged from hospital after three days with albendazole. <FILE IMAGE='379_20150706195233.jpg'> Conclusions: %30 of patients are asymptomatic and only symptom can be epigastric pain and dyspepsia due to its slow growing nature. More sensitive than ultrasound, computer tomography has an important role in diagnosis. In emergency service, splenic cyst hydatid should be kept in mind in patients with abdominal pain.

Especially perforated cyst hydatid should be consultated to general surgeon, taken open or laparoscopic surgery beside antihelmintic treatment.

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

W381

CAN MILD HEAD INJURY CAUSE ISCHAEMIC STROKE IN CHILDREN?

S. Eraybar Pozam, G. Torun, O. Aydin, Y. Kati, Y. Nencioglu

1

Uludag University Faculty Of Medicine Hospital, Bursa, Turkey, Hospital, Bursa, Turkey

2

Sevket Yilmaz Research And Training

Background: Trauma can cause many vascular complications and can lead to cerebral infarction. Recognation of childhood stroke is difficult and ischemic stroke after minor head trauma is a major clinical problem and in children under 18 months is rare eventually. <FILE IMAGE='385_20150710100921.jpg'> Methods: A girl aged 18 months was referred to our observation following a head injury involving the left zygomatic region. She fell while running onto a thinly carpeted floor. The child did not lose consciousness and had no history of seizures. After 6 hours her parents recognized weakness of her left arm and leg. Clinical examination confirmed a left hemiparesis with 3/5 muscle tone and pozitif babinsky reflex on left site.Immediately cerebral CT and extremity graphies showed no abnormalities.Further imaging studies were obtained to find the etiology of hemiparesis.Brain MRI showed an enfarct affecting the caudat nucleus and corona radiata on the right cerebral hemisphere. Diffusion weighted images showed a sharply demarked high signal intensity lesion in similar area on T2 weighted and fluid attenuated inversion recovery sequences images(Fig端re:1-2).

Results: In childhood, ischemic stroke due to mild headtrauma is an exceedingly rare event and each year 5 /100000 children are affected (1).Children are particularly vulnerable for translating, stretching and shearing effects on the vessels because of the high moment of inertia.The obstruction causes ischemia of cerebral parenchyma with clinical symptoms after a symptomless latency period (2) Common conditions predisposing to stroke include embolism associated with congenital or acquired heart disease, or arteriel malformations as in the Ehler Danlos sendrom, and fibromuscular dysplasia.

Conclusions: Mildhead injuries may cause serebral infarction at the internal capsula due to mechanical vasospasm or thrombosis of the perforating vessels, although ischemic symptoms are not so severe and tend to dissappear in the early period by conservative theraphy.Rapid reversal or attenuation of neurological symptoms may be attributed to the resolution of vasospasm. (4,5). Emergency physicians must be aware of lenticulostriat infarction as a rare complication of mildtrauma in young children and early diagnosis can prevent possible permenant neurological damage.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Case Reports W391 RUPTURE OF THE LEFT ATRIUM DUE TO BLUNT TRAUMA Nursah Basol1, Ilker Akar2, Abdullah Dogan2, Nuray Alt覺ndeger2, Ali Kablan1 1-

Gaziosmanpasa University, Faculty of Medicine, Department of Emergency Medicine

2-

Gaziosmanpasa University, Faculty of Medicine, Department of Cardiovascular Surgery

Cardiac rupture due to blunt thoracic trauma is generally mortal in a short time, therefore it is rarely seen in emergency department (ED). The incidence of blunt traumatic cardiac rupture is reported the range of 0.16% to 2% in literature. It is aimed to present a cardiac rupture case with no marked clinical signs due to take attention to this issue in ED.

Case: A 51-year-old male patient was brought to ED after a fall from height. On arrival, he was unconscious and his Glasgow Coma Scale rate was 12. His blood pressure was 100/60 mmHg, pulse rate was 92 beats per minute, respiratory rate was 22 breaths per minute and the oxygen saturation (SpO 2) was 90 on pulse-oximeter.

The left supraorbital area was ecchymotic and there was skin incision. In auscultation, respiratory sounds were decreased on left hemithorax. The hearth sounds were distant. There was minimal abdominal tenderness. His laboratory results were revealed the following: hemoglobin 13.9 gr/dL, hematocrit 42.5, platelet 204000 繕L. ALT 332 U/L, AST 409 U/L, BUN 28.4 mg/dL, creatinin 1.05 mg/dL and glucose 231 mg/dL. In echocardiography, there was markedly pericardial effusion. In thoracal computed angiography tomography (CAT), the hemopericardium, left hemothorax and bilateral loculated pneumothorax were detected (Figure 1). Additionally, liver laceration and contusion were seen in abdominal CAT (Figure 2). Under the diagnosis of cardiac rupture the patient was taken to the operation room by cardiovascular and general surgeons. Perioperatively, left atrial rupture was detected (Figure 3). Under partial cardiopulmonary bypass, the defect was sutured. Besides, general surgeons were interfered to liver laceration. The patient was dead after 6 hours of the surgery due to multiple organ failure.

Conclusion: Blunt chest trauma patient presenting with no marked clinical signs, the diagnosis is hard. In this case, cardiac rupture was diagnosed by CAT and it was supported at echocardiography. Emergency physicians should be aware of cardiac trauma possibility without external wound in blunt trauma patients and they should not avoid further diagnostic tests in any suspicious.

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

W383

ASSESSMENT OF AEROPHAGIA IN THE EMERGENCY DEPARTMENT

N. Salman 1, O. Er 2, O. Tezel 1

1

Etimesgut Military Hospital Department Of Emergency Medicine, Ankara, Turkey, Department Of Psychiatry, Ankara, Turkey

2

Etimesgut Military Hospital

Background: Aerophagia is a functional gastrointestinal disorder defined with the accumulation of air in stomach and intestines. Although presence of some air in intestines is normal, excessive volumes of air can be both the reason and the result of some pathological processes. <FILE IMAGE='49_20150528220927.jpg'> Methods: CASE A 22 year old man admitted to the emergency department with the complaints of sore throat and cough. Physical examination results presented hyperemia of pharynx, normal breath sounds and pyrexia (38.2°C).

Posteroanterior chest radiograph presented aerophagia and then the air accumulation was verified with abdominal radiograph (Figure). Our patient reported that he had bloating and abdominal distension for about seven years.The general surgery and internal medicine consultations resulted with normal assessment. Hospital anxiety and depression scale was performed at emergency department and resulted with an increase at depression scale. At psychiatric consultation, Minnesota multiphasic personality inventory of the patient presented increase at hysteric scale. After the detailed evaluation, the patient was discharged with pharyngitis therapy and suggestions for psychiatric follow-up.

Results: There are scarce case studies and clinical surveys reviewing aerophagia in current literature. We observed that most of them are about gastrointestinal symptoms and belching has been reported to be the most common symptom of adult aerophagia patients. We consider that absence of belching may result to underestimating of aerophagia at clinical assessment as in our case. However itâ&#x20AC;&#x2122;s reported that gastrointestinal symptoms are even more common in patients with a diagnosis of an anxiety or depressive disorder, further psychiatric evaluation and follow-up should be performed for the exploration of pathological reasons.

Conclusions: At emergency department settings, assessment of the aerophagia requires the psychiatric assessment of the patients after observation of organic pathologies and surgical conditions. Hospital anxiety and depression scale is a simple and reliable tool for the first step for the assessment of the psychiatric disorders.

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

T212

A RANDOMIZED CONTROLLED TRIAL OF LISTENING TO LIVE SAX MUSIC FOR HAEMODIALYSIS PATIENTS

F. Burrai 1, V. Micheluzzi 2

1

University Of Bologna.Aosp Of Bologna, Bologna, Italy, 2 Villa Della Salute Hospital., Bologna, Italy

Background: Objective.The research hypothesis were:hemodialysis patients of the intervention group will have better mood, better systolic and diastolic blood pressure, better pulse rate,better glycaemia, higher oxygen saturation, lower pain and lower itching than patients of the control group.

Methods: A mono-centre randomized controlled trial with two parallel arms was conducted.The experimental arm was involved in live sax music listening,while the control arm received standard care only.Participants were recruited from Hemodialysis Unit Stefoni AOSP of Bologna.Sample size calculation.The sample size was based on the primary outcome of mood, measured by Visual Analogic Scale for Mood.Considering two balanced groups (n1 = n2), a medium effect size (d = 0.5), alpha error of 5% and power of 80% to detect differences between groups, was necessary to enroll a total of 124 (n1 = n2 = 62) patients.Assuming a drop-out of 10% for group, it was needed to enroll a total of 112 patients, 56 subjects per group.Patients were blinded than data collectors and outcome assessors. Intervention.Patients assigned to the music group listened to live sax music for 30 minutes, played by a nurse saxophonist during hemodialysis treatment.Patients could choose pieces among a playlist of 100 songs of different styles (including relaxing, cheerful and lively pieces) and genres (pop, classical, folk and jazz). Data collectors, collected the baseline before the 30 minutes of music intervention and the outcome assessors collected the data post-test after the music intervention.

Results: Significant differences were found between the control and experimental groups in the post-test (p = 0.000) in the oxygen saturation. Pain, mood and itching levels were found statistically significantly different in the music group (p < 0.05) and between the two groups in the post-test (p < 0.05). Itching level showed a statistically significant reduction of 75.7% (p =0.000), mood level a significant reduction of 70%, and pain level a significant reduction of 48.1% (p = 0.000).

Conclusions: Live sax music could reduce the pain and itching levels, increasing oxygen saturation and improving mood. This intervention showed no negative side effects and could be administered in patients undergoing hemodialysis.

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

T243

CELL TOXICITY AND PAIN RESPONSE FOR TOXIN OF C.PACIFICA

Y. Kang 1, S. Jung, Y. Yang

1

School Of Medicine, Jeju National University, Jeju, South Korea

Background: Jelly fishes have flourished in Jeju Island according to climate warming in South Korea. The exposure and injuries by jelly fish also have increase. C.pacifica is one of common jelly fishes has severe toxin and found in southern sea of South Korea.

Authors want to know the toxic effect of venom of C.pacifica(CpV) in pain mechanism. <FILE IMAGE='372_20150709011829.jpg'> Methods: Venom preparation: C.pacifica were collected in the east coast of South Korea. The tentacles were dissected and their nematocysts were isolated using the method described by Bloom et al.

Cell culture: HT-22 were cultured in DMEM. Cortical primary cultures: Primary cortical neuron was obtained from 1-day-old postnatal Sprague-Dawley rats.

Measurement of cell viability: MTT was used to evaluate the effects of CpV on cell viability. The neuronal viability was obtained by reading absorbance at 550 nm using a microplate reader.

Morphological analysis of cell viability: The degree of apoptosis was determined by nuclear staining with Hoechst 33342. Cells were observed under a IX-71 fluorescent microscope.

Measurement of intracellular reactive oxygen species (ROS): After the addition of 50 uM of DCF-DA, fluorometric analysis was conducted at an excitation/emission wavelength of 485 nm/535 nm using a microplate reader.

Behavioral Testing: Mechanical sensitivity was assessed using von Frey filaments on the plantar surface.

Allodynia was characterized as the number of paw withdrawals, and was tested on 0.5, 2, 24, 48 hrs and 1 week after injection of 50 ?g CpV with/without any reagent. For thermal sensitivity test, paw withdrawal latencies were determined using the technique described by Hargreaves et al.

Results: CpV decreased neuronal viability 50% significantly in HT22 comparing the bell.

Antioxidant woud decrease the neurotoxicity induced by CpV. EDTA also decrease neurotoxicity induced by CpV in cortial neuron.

EGTA increase threshold of pain by CpV. Conclusions: CpV has the neuronal toxicity and decrease cell viability.

EDTA and EGTA can decrease the toxicy by C.pacifica effectively.