Oral Abstracts - Tuesday

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

Topic: Critical Care

T47 POST-GRADUATE TRAINING OF FACULTY AT NATIONAL EMERGENCY MEDICINE – CRITICAL CARE MEDICINE CONFERENCES J. Shiber 1, E. Fontane 1 1 Uf College Of Medicine, Jacksonville, Usa Background: There are numerous conferences advertised as some combination of Emergency Medicine and Critical Care Medicine (EM-CCM) but the background and qualifications of the speakers at these conferences is not well known <FILE IMAGE='137_20150524150431.jpg'> Methods: Review of the course programs for the training and background of the faculty speakers at seven prominent national EM-CCM conferences from 2009 -2012: ACEP Scientific Assembly – CCM Tract, Critical Points: Emergency Critical Care, The Weil Symposium on Critical Care and Emergency Medicine, Emergency and Critical Care Medicine -The Cutting Edge, Florida Emergency Physicians Symposium on Critical Care in the Emergency Department, U. MD – The Crashing Patient, and Resuscitation. Confirmation of post-graduate training was performed by on-line research. We compared the percentage of speakers trained in both EM and CCM with the post-graduate training of the speakers at the ACEP Pediatric Emergency Medicine Assembly who have training in both Pediatrics and Emergency Medicine as compared to Emergency Medicine or Pediatrics alone. Results: There were a total of 221 speakers at the seven studied EM-CCM conferences from 2009-2012: faculty trained in EM-CCM 42 (19.1%) and trained in EM alone 179 (80.9%). There were 58 speakers at the ACEP Pediatric Emergency Medicine Assembly from 2010-2012: faculty trained in Peds-EM 29 (50.0%), Pediatrics plus subspecialty [critical care, cardiology, dermatology, etc.] 23 (39.6%), EM plus subspecialty [ultrasound, toxicology, etc.] 4 (6.9%), Pediatrics alone 1 (1.7%), and EM alone 1 (1.7%). Conclusions: In the included EM-CCM conferences, less than 1/5 of speakers were trained in both EM and CCM with the overwhelming majority trained in only EM. Using the ACEP Pediatric EM Assembly as a comparison model, there were a much larger percentage of dually trained speakers in either Peds-EM or Peds Subspecialty, with only a very small percentage of speakers trained in EM alone or Peds alone. We believe that conference directors should be encouraged to invite speakers who have the appropriate training (additional residency or fellowship) in the area of the specific conference so that the audience can benefit from those presenters with the most formal education and expertise in their respective specialty.


Topic: Cardiovascular / CPR / Resuscitation

T48 FEASIBILITY OF ALS AT SCENE ASSISTED BY VIDEO CALL WITH PHYSICIAN IN REPUBLIC OF KOREA S. Park 1, Y. Oh 1 1 Hallym University Medical Center Hallym University Sacred Heart Hospital, Anyang-Si, South Korea Background: In Republic of Korea, in average, the EMS(Emergency medical service) team arrive in 7 min on the scene. In other study, the survival rate would be 7.5%, but actually only 4.8% of out of cardiac arrest victims are survived in Korea. In USA, EMS team do advanced life support(ALS) for longer than 20min. In contrast, Korean EMS team do basic life support(BLS) for only 5min and transport to nearest hospital. We hypothesized that ALS longer than 20min at scene may decrease mortality and neurological morbidity. So, we conducted the study that ALS performed by EMS team advised by emergency physician with video call at scene for longer than 20min. <FILE IMAGE='69_20150511160112.jpg'> Methods: This study is a prospective cohort study conducted in between July 1, 2014 and December 31, 2014. We conducted study in an urban city had a million population, thirteen ambulance, 75 paramedics and 3.7% of scene return of spontaneous circulation record in the same period of previous year. In Korea, the EMS is organized on a provincial basis with a single call center that answers all patients’ phone calls to 119. Just after activate EMS system by bystander, two ambulance and six paramedics rush to the scene, first class paramedic who had emergency medical technician(EMT) perform video call to doctor who had both of emergency medicine board and certification of EMS supervision. ALS was performed by paramedics as physician ordered in real time. All out of cardiac arrest patients are enrolled. Trauma, pediatrics, refusal of cardiopulmonary resuscitation(CPR), missing data and a clear sign of death are excluded. We evaluated prehospital ROSC, survival rate at discharge, favorable neurological outcome(cerebral performance category 1-2) at discharge and compared the same period of previous year. Results: Total 251 cardiac arrest had occurred and 124 patients were excluded and 127 patients were included. There are statistical significance in prehospital ROSC(4.3% vs 24.4%), survival rate at discharge(2.6% vs 11.8%), and favorable neurological outcome(0.9% vs 8.7%). Conclusions: In prehospital setting, video call-assisted ALS for longer than 20min showed more favorable survival rate and neurological outcome at discharge.


Topic: Infectious Disease & Sepsis

T50 EVALUATION OF A “SEPSIS ALERT” SYSTEM FOR DIRECTION OF PATIENT CARE RESOURCES TO EMERGENCY PATIENTS IDENTIFIED WITH SEVERE SEPSIS J. Perkins 1, D. Krakauer 1, L. Long 1, A. Lucas 1 1 Virginia Tech Carilion School Of Medicine, Roanoke, Usa Background: Three landmark trials have recently established that a protocol-driven approach to management of patients with severe sepsis is not required. These trials did affirm, however, that early antibiotic administration and aggressive fluid resuscitation of these patients is essential to optimize outcomes. We therefore developed a “sepsis alert” (SA) system to direct resources to emergency department (ED) severe sepsis patients with the goal of delivering early antibiotics and aggressive fluid resuscitation in a non-protocolized manner. We hypothesized that the presence of the SA system would reduce time to antibiotics, ED length of stay (LOS), hospital LOS, and would be associated with a concordant reduction for in-hospital mortality in patients with severe sepsis. Methods: The SA system was instituted at a large, tertiary care center with an annual ED volume of 90,000 patients. Interventions specific to the SA included a dedicated ED nurse assigned for unique care for 60 minutes, early identification of an intensive care unit bed, and commitment of the admitting physician to be at bedside in the ED for patient care within 60 minutes of SA activation. A cohort of patients managed with the SA during a predefined period were compared to historical controls (HC) who were previously coded as having severe sepsis at the time of ED admission. Cohort comparison with identified outcome variables were analyzed for significant differences with a generalized linear model (mortality) and wilcoxon rank sum test (all others). Results: Historical controls for 207 patients were compared to 30 SA patients. There was no significant difference between the two groups in mortality or hospital length of stay. Significant differences were demonstrated for time to antibiotics (HC=166 minutes, SA=100 minutes; p<0.05) and ED LOS (HC=8.2 hours, SA=6.2 hours; p<0.05). Conclusions: A focused SA system for ED patients provoked meaningful reductions in ED LOS and time to antibiotics for ED patients with severe sepsis. Although no reductions in mortality or hospital LOS were demonstrated in this limited cohort, an ongoing larger cohort and future trials are merited to evaluate the impact of this non-protocolized SA approach.


Topic: Infectious Disease & Sepsis

T51 ARE SCORING SYSTEMS SUFFICIENT FOR PREDICTING MORTALITY IN SEPSIS PATIENTS IN THE EMERGENCY DEPARTMENT? M. Gunes Ozaydin 1, O. Guneysel 2, V. Ozaydin 3 1 Dr. Lutfi Kirdar Kartal Training And Research Hospital, Istanbul, Turkey, 2 Dr. Lutfi Kirdar Kartal Training And Research Hospital, Istanbul, Turkey, 3 Goztepe Training And Research Hospital, Istanbul, Turkey Background: Scoring systems have been used to risk stratify in intensive care units (ICU), but they are not routinely used in emergency departments. The aim of this study was to determine accuracy for predicting mortality in emergency medicine with scoring systems, Sequential Organ Failure Assessment (SOFA), Mortality in ED Sepsis (MEDS) score and Simplified Acute Physiology Score (SAPSII). <FILE IMAGE='128_20150527062538.jpg'> Methods: A prospective observational study was planned to enroll all patients with evidence of sepsis. SAPSII, MEDS, and SOFA scores were calculated. Analysis compared areas under the receiver operator characteristic (ROC) curves for 28-day mortality. Results: Two-hundred patients were included in the study; consisting of 31 (14.3%) septic shock,138 (69%) severe sepsis without shock and 31 (15.5%) infection with no organ dysfunction. Fifty-three (26.5%) patients died within 28 days of presentation. Area under the ROC curve for mortality was 0.76 for MEDS (95% CI = 0.69 to 0.82), 0.70 for SAPSII (95% CI = 0.62 to 0.78); and 0.68 for SOFA (95% CI = 0.60 to 0.76) scores. Pairwise comparisons of the AUC were as follows: MEDS versus SOFA p < 0.005; MEDS versus SAPSII, p <0.005; and SAPSII versus SOFA p < 0.005. Mortality rate increased with increasing scores (Figure). Conclusions: The MEDS performed better than the SOFA and SAPS II score for predicting mortality in severe sepsis patients.


Topic: Cardiovascular / Non-CPR/Non-Resuscitation

T52 ANTICOAGULATION THERAPY FOR PATIENTS WITH NON VALVULAR ATRIAL FIBRILLATION: EVALUATION OF THE ORAL ANTICOAGULANTS PRESCRIPTION BY EMERGENCY PHYSICIANS H. Ghazali 1, J. Essid, S. Souissi, H. Aouni, A. Yahmadi, M. Mougaida, M. Chkir, M. Mguidich 1 Regional Hospital, Emergency Department, Ben Arous, Tunisia Background: Objectives: Assess vitamin k antagonists prescription in eligible non-valvular atrial fibrillation patients and determine criteria associated with an under-prescription of this therapy in emergency department. Methods: Prospective, observational, over two years study. Inclusion: patients (age> 18 years), with non-valvular atrial fibrillation eligible for anticoagulation. Non-inclusion: atrial fibrillation treated by vitamin k antagonists, contra-indications to vitamin k antagonists. Collection of epidemiological and clinical parameters, classification of non-valvular atrial fibrillation, calculation of ischemic risk: CHA2DS2-VASc (Congestive heart failure, Hypertension, Age75 years, Diabetes, Stroke, Vascular disease, Age 65 -74 years, Sex category) and bleeding risk: HAS-BLED (Hypertension ,Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly, Drugs/alcohol concomitantly) scores. Patients divided into two groups: Group (vitamin K antagonists +): patients received vitamin K antagonists and Group (vitamin K antagonists -). Multivariate analysis by multiple logistic regressions was performed to know the parameters significantly and independently associated with under prescription of the vitamin K antagonists. Results: Inclusion of 176 patients. Mean age: 67±13 years. Sex-ratio=0.5. Cardiovascular comorbidities were present in 68% cases. Atrial fibrillation classification: paroxysmal n=114, permanent n=47 and persistent n=15. The mean CHA2DS2VASc Score was 2.88 ± 1.55 and the mean HASBLED score was 1.52 ± 1.05. Vitamin K antagonists prescription rate: 36%. In multivariate analysis, age >70 years (odds ratio adjusted =1.59, 95% confidence interval (1.11-2,21), p<0.001), creatinine level >= 110 µmol/l(odds ratio adjusted =2,54, 95% confidence interval (1,20–5,37), p=0,01) and aspirine use (odds ratio adjusted =1,7, 95% confidence interval (1,08-2,67), p=0,02) were independently associated with non-prescription vitamin K antagonists. The main causes of vitamin K antagonists underuse reported by the emergency physicians were: factors related to patient characteristics n=38, factors related to emergency physician n=62, factors related to the patient environment n=20 and factors related to the drug n=22. Conclusions: The vitamin K antagonists prescription rate of was 36%. To optimize this rate, the prescription of vitamin K antagonists must be in a socio-medical perspective taking account the socio-economic conditions of each patient.


Topic: Medical Education (Undergraduate, Graduate, and CPD )

T53 HOW COUNTERTRASNFERENCE AFFECTS MEDICAL DECISION-MAKING: COMPARING EMERGENCY MEDICINE VERSUS PSYCHIATRY RESIDENTS- IN-TRAINING N. Moukaddam 1, A. Shah, L. Laufman, V. Tucci 1 Baylor College Of Medicine, Houston, Usa Background: Medical decision-making is not an objective process, despite the presence of medical algorithms for work-up and diagnosis. The reason for difficult patient-provider interactions can be due to the patient the provider. Bias in medical decision making can cause costly mistakes in treatment, and has been linked to race, gender, socio-economic status, but does not fully explain fluctuations in how providers make decisions. Countertransference, the psychodynamic concept representing feelings of providers towards patients, has been reported anecdotally to affect decision-making. Modern countertransference is operationalized into eight dimensions: overwhelmed/disorganized, helpless/inadequate, positive, special/overinvolved, sexualized, disengaged, parental/protective, and criticized/mistreated. In this study, we explore how countertransference affects medical decision making and compare Emergency medicine vs Psychiatry residents in that respect Methods: Psychiatry and Emergency Medicine residents were asked to view five (standardized) patient encounters: 1- a likeable nurse presenting with chest pain, 2- young man with drug addiction and chest pain, inability to walk more than a few steps, marginally cooperative 3- young woman with borderline, histrionic personality c/o chest pain and palpitations (has pulmonary embolism), 4-Entitled patient with acute cholecystitis who is insulting to housestaff & 5- young man presenting with sleepiness- has an overbearing, overly controlling mother- patient has a knife in his belt buckle; presents very differently when interviewed alone.Residents were shown the vignettes, asked what workup they would order for the patient, their top three differential diagnoses, then asked to fill out a countertransference questionnaire. Results: CT influenced medical decision making. CT elicited by patient vignettes were consistent with projected hypotheses, varied with training levels. There were differences between Psychiatry and Emergency Medicine residents in CT scores and in tests ordered. Conclusions: To our knowledge, this is the first study linking countertransference to how resident providers made medical decisions. There are specialty-specific differences. CT affects adherence to recommended algorithms. The effect is most prominent when the criticized/mistreated, helpless/inadequate dimensions are activated. These findings offer an opportunity for intervention and training



T54 A CRITICAL ANALYSIS OF FACTORS THAT INFLUENCE EMERGENCY MEDICINE CONSULTANTS IN THEIR CAREERS: WHY HAVE CONSULTANTS CHOSEN EMERGENCY MEDICINE, WHY DO THEY STAY & WHY MIGHT THEY GO? F. James 1, F. Gerrard 1 1 Cardiff University, Cardiff, United Kingdom Background: Emergency departments (ED) are currently facing experiencing intense pressures, which are resulting in many senior doctors leaving and decreasing the attractiveness of emergency medicine (EM) for junior doctors. The reduced workforce is seeing increased patient numbers resulting in over-stretched EM trainees, leading to further attrition. This research aims to understand why current EM consultants in Welsh EDs pursued a career and remain in EM amidst this negativity. This information will be used to identify methods of increasing the popularity of EM to medical students and junior doctors, most of whom have very limited exposure to EM. Methods: Narrative semi-structured interviews were conducted with 10 EM consultants, focusing on how and why they began their career in EM, why they choose to remain in EM and factors that might influence them to leave the specialty. Interviews were audio recorded and transcribed verbatim. Common themes were identified and thematic analysis used for data analysis. Results: The challenge of the undifferentiated patient, and generalist nature of EM was a motivating factor for the majority of consultants. Another strong motivating factor was having a positive effect on patient’s lives and maintains their enthusiasm for EM. EM is well suited to flexible training and participants were strong advocates for this. Consultants inability to perform their job effectively due to exit block is a significant barrier to job satisfaction. The majority of consultants’ enthusiasm stemmed from passionate role models on EM placements as undergraduates or junior doctors. Inability to provide patients with the best possible standard of care created a sense of failure amongst participants. Increased awareness is required of the suitability of EM for family life to increase the attractiveness of EM. Conclusions: This study reinforces the need for dedicated undergraduate EM placements, thus enabling the development of positive EM role models to stimulate interest and encourage EM aspirations. Improving the physical work environment for current EM staff would improve their ability to do their job effectively and increase retention of current staff. Further research is required to determine if these viewpoints are universal amongst UK EM consultants.


Topic: Education

T55 WHAT THE RESIDENTS DON’T KNOW CAN HURT THEM: THE 2015 PATIENT SATISFACTION EDUCATIONAL NEEDS ASSESSMENT K. London 1, J. Druck 2, M. Silver 3, D. Finefrock 4 1 Thomas Jefferson University, Philadelphia, Usa, 2 University Of Colorado, Denver, Usa, 3 Kaiser Permanente, San Diego, Usa, 4 Hackensack University Medical Center, Hackensack, Usa Background: Since the adoption of the Affordable Care Act in 2010 and arguably earlier, Patient Satisfaction (PS) has become a metric that can profoundly affect the careers of individual physicians, the functioning of entire departments and the fiscal balance of most hospitals. While government and hospital mandates demonstrate the prominence of PS as a quality measure, no such mandate exists for its education. The objective of this study was to determine the education and evaluation landscape for PS in categorical Emergency Medicine (EM) residencies. Methods: This was a prospective survey analysis of the Council of Residency Directors (CORD) membership. Program directors (PDs), assistant PDs and core faculty who are part of the CORD listserv were sent an email link to a brief, anonymous electronic survey. Respondents were asked their position in the residency, the name of their department and questions regarding the presence and types of PS evaluative data and education they provid Results: 168 responses were obtained from 138 individual residencies, representing 71% of all categorical EM residencies. 27% of responding residencies provide PS data to their residents. Of that 27%, 38% provide third party acquired data specifically about residents, 36% provide third party attending data on cases with resident participation, 33% provide internally acquired quantitative data with others providing simulation scores, anecdotes and other modalities. 37% of residencies have organized PS curricula. 95% of those utilize formal didactics, but others also use small group sessions (48%), simulation (47%), asynchronous materials (30%) and standardized patient encounters (24%). Most residencies with curricula explain techniques that can improve PS scores (95%) but only 47% explain the differences between surveys residents may be evaluated with upon graduation. Conclusions: The majority of categorical EM residencies do not provide either PS data or any organized PS curriculum. Those that do utilize a heterogeneous set of data collection modalities and educational techniques. Further work is needed improve education given the high stakes of PS in EM careers.


Topic: Education

T56 EFFECT OF A NOVEL ENGAGEMENT STRATEGY USING TWITTER ON TEST PREFORMANCE B. Adkins 1, K. Barnett, N. Patel, C. Doty, M. Silverberg, S. Morehead, S. Stearley 1 University Of Kentucky College Of Medicine, Lexington, Ky, Usa, 2 University Of Kentucky College Of Medicine, Lexington, Ky, Usa, 3 University Of Kentucky College Of Medicine, Lexington, Ky, Usa, 4 University Of Kentucky College Of Medicine, Lexington, Ky, Usa, 5 Suny-Downstate, New York City, Ny, Usa, 6 University Of Kentucky College Of Medicine, Lexington, Ky, Usa, 7 University Of Kentucky College Of Medicine, Lexington, Ky, Usa Background: Medical educators in recent years have been using social media for more penetrance to technologically-savvy learners. Medical students utilize social media platforms for discussion, learning, and collaboration in medical learning. The utility of using Twitter for curriculum content delivery has not been studied. We attempted to test if participation in a didactic program of quizzing identification of visual pathologies via twitter would improve student performance on a test of clinical images at the end of the semester. <FILE IMAGE='22_20150316193627.jpg'> Methods: 116 second year medical students were enrolled in the Introduction to Clinical Medicine II course. In the testable course content, several clinical images of physical examination findings were presented as part of the lecture series. An optional weekly assessment was also performed using Twitter. Each week, a photograph of a physical examination finding not covered in the course lectures was distributed from the class Twitter account. Over 80 students participated to some extent in this social media assessment of ungraded material. At semester end, 116 students were tested over their recognition of 24 clinical images revealed for 30 seconds each in a slideshow. 12 images were from the course lecture content and 12 images were from the twitter quizzes. Results: Students active on the twitter feed scored significantly higher on the overall and twitter portions of the quiz (Doty Fig 1 and 2). There was no significant difference in the classroom portion of the quiz between the students who were active on the twitter feed and those who were not (p=0.124). Conclusions: Medical students are utilizing social media more often in professional learning environments. Our data supports that using twitter assisted the students in image recognition even if they did not participate in Twitter all the time. This finding did reach statistical significance. The statistically significant effect present in the combined image questions (classroom and twitter images) might be due to the fact that twitter users scores are better on the twitter exclusive images. While limited, our study shows that social media content delivery might serve as a novel engagement tool for tech savvy learners.


Topic: Education

T57 THE EFFECTIVENESS OF ULTRASONOGRAPHIC EDUCATION CONDUCTED ON THE MEDICAL COLLEGE STUDENTS J. Seo 2, H. Doh 1, S. Lee 4, J. Lee 5, K. Oh 3 1 Dongguk University Ilsan Hospital, Goyang-Si, South Korea, 2 Dongguk University Ilsan Hospital, Goyang-Si, South Korea, 3 Dongguk University Ilsan Hospital, Goyang-Si, South Korea, 4 Dongguk University Ilsan Hospital, Goyang-Si, South Korea, 5 Dongguk University Ilsan Hospital, Goyang-Si, South Korea Background: Sonographic examinations such as Extended Focused Assessment with Sonography for Trauma (eFAST) are widely used in the emergency department due to its rapidness and convenience. Many medical college programs do not include sonography in its curriculum making sonography a rare skill. This study is designed to determine student achievement by teaching students eFAST and by thus, evaluating the efficacy of sonographic educations. Methods: Thirty eight participants in their 4th grade of medical school were enrolled in the study. They underwent training with two emergency medicine physicians about eFAST. 2 hours were used to teach students the theory of the eFAST and 4 hours were spent in practical training. Student achievement was tested through a theory test and their level of comprehension was examined using a questionnaire. Results: Thirty eight students were involved in the study. The examination consisted of 11 items including an aorta scan. When a student acquires an adequate picture, the item was considered a success. The overall success rate was 88.5% and the adaquecy of the ultrasound technology was 96.7%. The average of the time taken to acquire the entire image was 313.7 seconds. The students felt that finding the seashore sign in lung sonography easy, whereas items including finding the pericardium, hepatorenal recess and splenorenal recess hard. Conclusions: This study was devised to determine the student achievement through 6 hours of training. According to this study, as students show a high success rate in most of the items, ultrasonography education may be well used in the future curriculum.


Topic: Academics / Resident Education

T58 GENDER BIAS AT AN ACADEMIC EMERGENCY MEDICINE DEPARTMENT L. Mcdougald, L. Walter 1 University Of Alabama Birmingham, Birmingham, Usa Background: While comprising half of medical school and Emergency Medicine residency graduates, women EM physicians report earning less money and having fewer opportunities for promotion or leadership compared with similarly qualified male counterparts. We sought to determine if gender disparities exist within an academic EM department and residency training program. <FILE IMAGE='98_20150514093039.jpg'> Methods: We surveyed current faculty, residents and residency graduates at an academic Emergency Medicine department. The survey assessed perceived gender bias in numerous aspect of clinical and administrative practice within EM. Respondents also rated perceived subsequent effects from gender bias, including salary discrimination, barriers to career advancement and satisfaction, as well as strained social interactions within one’s group. Survey responses consisted of Likert scale ratings (1-5 scale). The survey was administered by email. We analyzed the data using descriptive statistics and chi-square. Results: Of 141 surveys, we received 55 total responses, including 41 attending physicians and 14 residents. Respondents included 39 men (39.8% response rate) and 16 women (37.2% response rate). Female respondents were more likely to perceive gender specific barriers to career satisfaction (68.8% women, 36.2% men, p < 0.05) and were more likely to have experienced gender bias within their EM career (75% women, 11.1% men, p<0.05). Female respondents were more likely to experience gender bias from patients (100% women, 20% men, p<0.05), nursing staff (87.5% women, 14.3%, men, p<0.05), consults (75% women, 8.3% men, p<0.05), colleagues (56.3% women, 11.4% men, p<0.05) and medical director/leadership (37.5% women, 5.8% men, p<0.05). Female respondents were more likely report barriers to career advancement and leadership opportunities due to perceived gender bias (20% women, 2.9% men, p<0.05). Female respondents reported salary discrimination due to perceived gender bias (26.7% women, 0% men, p<0.05). One-third of female respondents reported a lower sense of social belonging within their department/group because of perceived gender bias (31.3% women, 0% men, p<0.05). One-fifth reported trouble developing relationships within the department/group due to perceived gender bias (18.8% women, 2.9% men, p<0.05). Conclusions: In this academic EM department, female Emergency Medicine physicians reported gender bias across all realms of their professional careers.


Topic: Substance abuse

T59 ETHNOBOTANICAL PRODUCTS: A STEP BETWEEN ENTERTAINMENT AND DANGER C. Cimpoesu 1, M. Corlade Andrei 1, E. Butnaru 1 1 Umf Gr.T.Popa Iasi, Iasi, Romania Background: Nowadays, more than 220 million people worldwide are drug addicts. In the present-day society, there is a greater access to ethno-botanical drugs and a growing trend among the youngsters to experiment with these products. The study was performed to analyse the profile and to identify the risk factors in the use of ethno-botanical substances, clinical and paraclinical changes caused by the consumption of these products. Methods: This study included all patients who consumed in various ways ethnobotanical substances and visited the ED of Saint Spiridon Hospital of Iasi, Romania, over a period of 5 years (2010- 2014). The ethno-botanical products were analysed by gas chromatography coupled with mass spectrometry. Results: Data from 168 patients poisoned with ethno-botanical substances were included in the final analyses. Statistically higher poisoning was associated with male sex 86.9% and the most frequent age was 19 years old. 60.11% of the patients were brought to the hospital by ambulance and most emergencies were recorded during holiday. The main symptoms were psychomotor agitation, disorder, chest pain accompanied by palpitations, visual and auditory hallucinations, chills, nausea and vomiting, abdominal pain, diarrhoea. There were two cases with autolytic injuries and one case of Quincke oedema. On ECG we detected with higher frequency (90.27%) tachyarrhythmia. Qualitative analysis of urine (the only diagnostic method available in ED) revealed: THC, THC and barbiturates, THC and benzodiazepines. All the patients received treatment- i.v. fluids, oxygen, benzodiazepines, blood glucose correction. The time spend in ED was between 2 - 16 h, the admission rate was 6.2%. The mortality rate was 0. After examination of the ethno-botanical products, there was identified MDPBP (3,4-methylenedioxy-alfa-pyrrolidinobutiophenone), MDPV(methylenedioxypyrovalerone) and JWH-203 [1-pentyl-3- (2-chlorophenyl) indole)], banned substances in our country and in many other countries. Conclusions: For Romania, ethno-botanical products abuse it’s a new pathology, the symptoms and the treatment also are non specific and depend largely on how quickly it’s correctly diagnosed by anamnesis. Ethno-botanical products considered as no risk, contained dangerous substances with harmful effects, which, in the absence of immediate treatment, can lead to death.



T60 HEROIN OVERDOSE AND THE EFFECT OF A “REAL-TIME” CONTROLLED SUBSTANCE MONITORING SYSTEM B. Adkins 1, B. Kostelnik, S. Stearley, M. Greene 1 University Of Kentucky College Of Medicine, Lexington, Ky, Usa, 2 University Of Kentucky College Of Medicine, Lexington, Ky, Usa, 3 University Of Kentucky College Of Medicine, Lexington, Ky, Usa, 4 University Of Kentucky College Of Medicine, Lexington, Ky, Usa Background: KASPER, also known as the “Kentucky All Schedule Prescription Electronic Reporting” law, serves to monitor controlled substance prescriptions that are dispensed within the state of Kentucky. Kentucky was the first state in the nation to establish such a system, which has evolved through the years. A KASPER report can be used by physicians, pharmacists, and law enforcement as well as regulatory agencies to identify all scheduled prescriptions, prescribers, and dispensers over a specific time period. As of July 20th, 2012, Enhanced KASPER, eKASPER, was an upgraded version to provided real-time web based information in a further attempt to help address the misuse, abuse, and diversion of controlled substances. This retrospective study investigates the number of heroin overdose patients admitted to the University of Kentucky Emergency Department two years before and two years after the introduction of the eKASPER. By investigating the frequency of heroin overdoses (patient admission, discharge, and expiration), we hope to develop a better understanding of the effect of drug monitoring systems on patient drug use and patient outcomes. Methods: Three ICD 9 codes were searched by the Emergency Medicine research department at the University of Kentucky, 2 years prior to the introduction of eKASPER, July 20th,2012, and 2 years after. Specifically, the ICD 9 codes, which used were: 965.01, E950.0, E850. Results: From July 20th, 2010 through July 19th, 2012, there were 85 heroin overdoses identified prior to eKASPER. From July 20th 2012 through July 19th 2014, 216 heroin overdoses were identified. This results in a 254% increase in the number of cases identified by ICD 9 Coding. Conclusions: With the addition of the eKASPER system in Kentucky, there was a 254% increase in the number of heroin overdoses seen in the Emergency Department at the University of Kentucky in a two year period. As there is decreased access to prescription pills from practitioners having real-time data during patient encounters, some patients may have a more difficult time acquiring a prescription for controlled substances, and thus may seek alternative forms of cheap opiates such as heroin.



T61 MEDICAL PROBLEMS AND SEARCH FOR NEW PSYCHO-ACTIVE SUBSTANCES AT A LARGE INDOOR DANCE EVENT IN GHENT (BELGIUM) N. Sundahl 1, K. Maudens 2, S. Wille 3, A. Hautekiet 1, K. De Graeve 4, S. Gogaert 5, P. De Paepe 6, D. Devriese 7, G. Arno 8, P. Blanckaert 9, P. Calle 1, 10 1 Ghent University, Ghent, Belgium, 2 Toxicological Centre, University Of Antwerp, Antwerp, Belgium, 3 National Institute Of Criminalistics And Criminology, Brussels, Belgium, 4 Emergency Department, General Hospital Jan Palfijn, Ghent, Belgium, 5 Belgian Red Cross, Belgium, 6 Emergency Department, University Hospital, Ghent, Belgium, 7 Emergency Department, General Hospital Saint Lucas, Ghent, Belgium, 8 Federal Public Service Health, Food Chain Safety And Environment, Brussels, Belgium, 9 Belgian Early Warning System On Drugs, Scientific Institute Of Public Health, Brussels, Belgium, 10 Emergency Department, General Hospital Maria Middelares, Ghent, Belgium Background: I Love Techno is an annual indoor dance event with 30,000 attendants. We report on the medical problems encountered in 2013 and 2014. In patients with severe drug-related problems, screening for drug use was performed on blood and urinary samples, with a focus on new psychoactive substances. Methods: Statistics on the medical problems were retrieved from the Red Cross first aid interventions database. Data on drug use were based on information from the patient (or a bystander), the clinical presentation and/or toxicological screening. Samples were screened using a variety of methods based on gas or liquid chromatography coupled to (high resolution) mass spectrometry or PhotoDiodeArray/Fluorescence detection. Approval for this prospective study with an opting-out design was obtained from the ethics committee of all participating hospitals. Results: In the on-site medical station, 264 and 222 patients were treated in 2013 and 2014 respectively. The most frequent reasons for encounter were trauma (86/85), headache (19/17), gastro-intestinal problems (24/20) and intoxication (88/71). Thirty-eight and 31 patients were transferred to a hospital, including 31 and 23 with severe drug-related symptoms. Analysis of the 67 and 45 retrieved blood samples detected ethanol (59/40), MDMA (22/13), cannabis (19/19), cocaine (3/6), amphetamine (2/1) and GHB (1/0) alone or in combination. In 2014, the neuroleptic drug clozapine was found in 3 cases and ketamine in one. Additional analyses were performed in 9 cases from 2013 with suspected discrepancy between history/clinical presentation and toxicological data. Only in 1 agitated patient the new psychedelic research chemicals 25B-NBOMe and 25C-NBOMe were found. The results of the additional toxicological work up in 11 cases from 2014 will be presented at the congress. Conclusions: Our findings demonstrate a considerable number of patients in need of on-site medical treatment and transfer to a hospital because of drug use. Ethanol is the most consumed (legal) drug, yet classical illicit recreational drugs are also frequently (co-)ingested. Although it can be assumed that new psychoactive substances are increasingly being used on Belgian dance events, this phenomenon is hard to detect via toxicological analyses.



T62 THE EFFECTIVENESS OF BRIEF SMOKING CESSATION INTERVENTIONS BY HEALTH CARE PROVIDERS IN THE EMERGENCY DEPARTMENT B. Becker 1, E. Jennings 2, R. Martin 2, K. Walaska 2, E. Boudreaux 3, B. Bock 2 1 Department Of Emergency Medicine, Warren Alpert Medical School At Brown University, Providence, Ri, Usa, 2 Department Of Psychiatry And Behavioral Medicine, Warren Alpert Medical School At Brown University, Providence, Ri, Usa, 3 Department Of Emergency Medicine, University Of Massachusetts Medical School, Worcester, Ma, Usa Background: More than 119 million patients are treated each year in ED’s in the U.S.; 30-40% of these ED patients smoke. Many of the illnesses treated in the ED are caused or made worse by smoking. Brief smoking cessation interventions delivered in health care delivery settings have been shown to increase quit rates among smokers. This study assesses the rates of smoking cessation interventions provided by ED health care providers and the subsequent quit rates of patients receiving these interventions. Methods: This was prospective observational cohort study of a convenience sample of smoking patients and the smoking cessation services provided to them in two large academic ED's. Trained RA's conducted post-discharge interviews by phone at 24 hours, 1, 3, and 6 months after ED discharge to determine patients’ self-reported perception of health care providers’ delivery of smoking cessation counseling (Ask, Advise, and Refer) and the patients’ 7-day point-prevalence abstinence. Intent-to-treat analyses were employed for smoking outcomes and provider delivery results were calculated using Chi-Squares. Results: 351 smokers were contacted at 24 hours. 126 were Asked about their smoking, 156 were Advised to quit, and 69 were Referred to an smoking cessation program. Those just asked reported a median conversation time of 10 seconds, those advised to quit - 1 minute, and those referred - 3 minutes. The quit rates for those Advised were 13.7%, 21.4%, and 21.1% at 1,3,and 6 months with Odds Ratio of Smoking 0.456, 0.280, and 0.530, and 95% CI's (0.211-=0.986), (0.132-0.594), and (0.286-0.980) respectively. Conclusions: Very brief ( < 1 min) smoking cessation interventions given by providers in the ED can be effective. Smokers treated in ED's who were Asked about their smoking and Advised to quit had quit rates four times greater than the 5% rates of spontaneous quits historically reported in the literature. Programs that increase the likelihood of ED smoking interventions by providers may reach many smokers increasing their quit rates dramatically.



T63 RETROSPECTIVE SURVEY OF EMERGENCY DEPARTMENT VISITS DUE TO ACUTE ALCOHOL INTOXICATION IN GHENT AND SINT-NIKLAAS (BELGIUM) A. Hautekiet 1, C. Simon 1, H. Francois 2, C. Cornelis 1, N. Sundahl 1, P. De Paepe 1,3, N. Mpotos 1,4,5, J. Damen 2, K. De Graeve 6, P. Calle 1,7 1 Faculty Of Medicine And Health Sciences - Ghent University, Ghent, Belgium, 2 Emergency Department - Nikolaas General Hospital, Sint-Niklaas, Belgium, 3 Emergency Department - University Hospital Ghent, Ghent, Belgium, 4 Emergency Department - Sint Lucas General Hospital, Ghent, Belgium, 5 Faculty Of Medicine And Health Sciences - University Of Antwerp, Wilrijk, Belgium, 6 Emergency Department - Jan Palfijn General Hospital, Ghent, Belgium, 7 Emergency Department - Maria Middelares General Hospital, Ghent, Belgium Background: Alcohol abuse is a major health concern. Our objectives were to measure the number of emergency department visits due to acute alcohol intoxication, and to collect data about clinical parameters. Methods: Between 01/09/2013 and 31/08/2014, patients with a blood alcohol concentration of at least 0.5g/L were identified from the laboratory databases of all hospitals of 2 distinct areas (with 600,000 inhabitants). Clinical data were collected retrospectively from the patient chart. Results: Of the 3918 included patients, only 1255 (32%) were female. The age distribution is shown in the figure. Blood alcohol concentrations (given as percentiles 10, 50 and 90 and highest concentration) were 1.10, 2.30, 3.60 and 5.80g/L respectively. There was a high preponderance of weekends and night time. The context of the alcohol intoxication was related to some kind of festivity in 29%, mental problems in 18% and chronic abuse in 54%. The patients were transported to the hospital by emergency medical services in 69% and by police in 6%. The dispatch centre also sent out a second tier unit in 26% of the emergency medical services interventions. The main symptom was depressed level of consciousness in 20%, psychological/psychiatric problems in 29%, traumatic lesions in 27%. and aggression in 4%. Co-ingestion of illicit drugs or medication was found in 6% and 9% respectively. Outcome data were: discharge within 24 hours in 50%, admission to an intensive care unit in 5%, admission or referral to a psychiatric service in 28%, and taken into custody by police in 1%. Five patients died in-hospital. <FILE IMAGE='147_20150526234155.jpg'> Conclusions: This study clearly indicates that acute alcohol intoxications are a major health problem. It concerns both sexes and all age groups, mainly men and people between 46 and 55 years. Although our study design (i.e. retrospective data gathering and only inclusion via measurement of blood alcohol concentration in an emergency department) is bias-prone, our figures point to an urgent need of a global national alcohol plan.



T64 WOMEN PRESENTING TO EMERGENCY DEPARTMENTS WITH ACUTE ALCOHOL INTOXICATION IN GHENT AND SINT-NIKLAAS (BELGIUM): ARE THEY DIFFERENT FROM MEN? C. Cornelis 1, N. Sundahl 1, H. Francois 2, A. Hautekiet 1, S. Calle 1, J. Damen 2, N. Mpotos 3, P. De Paepe 4, K. De Graeve 5, P. Calle 6 1 Ghent University, De Pintelaan 185, Ghent, Belgium, Ghent, Belgium, 2 Az Sint Nikolaas, Department Of Emergency Medicine, Moerlandstraat 1, Sint-Niklaas, Belgium, Gent, Belgium, 3 Az Sint Lucas, Department Of Emergency Medicine, Groenebriel 1, Ghent, Belgium, Ghent, Belgium, 4 Uz Gent, Department Of Emergency Medicine, De Pintelaan 185, Ghent, Belgium, Ghent, Belgium, 5 Az Jan Palfijn, Department Of Emergency Medicine, Watersportlaan 5, Ghent, Belgium, Ghent, Belgium, 6 Az Maria Middelares, Department Of Emergency Medicine, Kliniekstraat 27, Ghent, Belgium, Ghent, Belgium Background: This study examines gender differences in emergency department admissions due to acute alcohol intoxication. Methods: For the period 01/09/2013 - 31/08/2014, patients with a blood alcohol concentration of at least 0.5g/L were identified from the laboratory databases of all hospitals of two distinct areas (with 600,000 inhabitants). Clinical data were collected retrospectively from the patient chart. Results: Of the 3918 included patients, only 1255 (32%) were female. The male/female ratio in the different age categories ranged from 1.49 (group < 18 years) to 2.73 (group 26-35 years). The highest number of cases was found between 46 and 55 years in females (293/1255; 23.3%) and males (630/2663; 23.7%). Blood alcohol concentrations (given as percentiles 10, 50 and 90 and highest concentration) were 1.00, 2.19, 3.44 and 5.80g/L in females and 1.14, 2.35, 3.60 and 5.47g/L in males. The preponderance of weekends and night time was slightly higher in females. Women were transported to the hospital by emergency medical services in 70.9% (vs 67.7% in men). The dispatch centre also sent out a second tier unit in 25.7% of the interventions in females (vs 25.8% in males). The main symptom in females was depressed level of consciousness in 20.1% (vs 20.4% in males), psychological/psychiatric problems in 31.8% (vs 27.3%) and traumatic lesions in 24.6% (vs 28.7%). Co-ingestion of illicit drugs or medication was found in 3.7% and 14.4% respectively in females (vs 6.5% and 6.7% in males). Outcome data in females and males respectively were: discharge within 24 hours in 48.0% and 50.7%, admission to an intensive care unit in 4.8% and 6.0%, admission or referral to a psychiatric service in 30.4% and 26.5%, and taken into custody by police in 0.7% and 0.9%. Of the five patients who died in-hospital, only one was female. Conclusions: Acute alcohol intoxication is much more frequent among men than among women. However, most of the clinical features we investigated are not gender-specific. The most important differences seem to be related to the reason for admission and the co-ingestion of illicit drugs and medication.



T65 UTILIZING SIMULATIONS TO DEVELOP AND ASSESS SOCIO-BEHAVIORAL COMPETENCY IN AN EMERGENCY MEDICINE RESIDENCY PROGRAM: A PILOT PROJECT P. Rega 1 1 University Of Toledo College Of Medicine, Toledo, Ohio, Usa Background: Emergency Medicine residency programs have a responsibility to ensure that its residents not only have the requisite clinical skills but also the necessary socio-behavioral skills that will ensure a successful and long career in Emergency Medicine. A well-planned simulation medical program can properly teach and assess clinical skills, but oftentimes, the socio-behavioral talents assume secondary importance. This lack of prioritization may lead to worsening communication skills, improper interdisciplinary behavior, malignant patient encounters, and, ultimately, a threat to patient care and job security. An intense socio-behavioral simulation functional exercise was created to explore its limits and to define the required logistical issues. Methods: A series of scenarios (8) was created emphasizing the socio-behavioral challenges of Emergency Medicine: 1) The derisive consultant; 2) The verbally abusive patient; 3) The sarcastic and demeaning nurse; 4) The drug-seeker and the medically inappropriate senior medical colleague; 5) The medically dangerous consultant; 6) Emergency department command and control pending arrival of three motor vehicle victims; 7) A consultant’s inappropriate imaging demands for a pediatric patient; 8) Notification of parents following the death of their baby. The scenarios and logistics were discussed with the technical staff and volunteer actors. The resident-subject was unaware of the specific cases other than the general objectives. Results: The preparatory phase required 8 hours (4 hours: scenario development; 2 hours: meetings; 2 hours: human patient simulator prep). The execution phase lasted 2.5 hours as the resident managed each scenario consecutively (0.5 hours briefing, 1.5 hours of consecutive or simultaneous scenarios, and 0.5 hours de-briefing). The number of faculty and staff personnel involved: 3 staff, 3 actors, 2 faculty. The entire exercise was recorded. The project was assessed from the viewpoints of the subject, the residency director, and the simulation technicians. Conclusions: The general consensus was that the project required a significant amount of time and resources. However, given the importance of the objectives, it was a successful enterprise and worthy of consideration as part of the overall residency program, in terms of education, assessment, and remediation.



T66 USING PATIENT VOICE TO CONSTRUCT AN EMERGENCY MEDICINE CLERKSHIP CURRICULUM C. Peterson 1 1 New York Presbyterian Hospital, New York, Usa, 2 Weill Cornell Medical Center, New York, Usa Background: Past decades brought significant advances in Emergency Medicine, these advances occurred within a healthcare system comprised of complex bureaucracies organized more for the benefit of service providers than healthcare consumers. Economic incentives and legal considerations have assumed tremendous importance in the delivery of emergency care in the United States. Methods: This curriculum is distinguished by an attentiveness to patient voice, designed to integrate varied aspects of emergency care delivery and explore, analyze the dynamics of illness from multiple perspectives. Participation in multi-disciplinary collaborative partnerships with patients and clinicians realistically illustrates the complex skills required to identify and overcome barriers and create micro-systems of care functioning with integrated attention to the macro-systems in which they operate. . Utilizing techniques of ethnographic research with focus on areas of communication, patient rights, power dynamics, cultural sensitivity and case-based problem solving tutorials sensitizing students to the ethical and legal dilemmas encountered in the emergency setting. Didactic sessions expand the scope and diversity of knowledge by exploring the historical evolution and the broad social and cultural forces which shape patterns of health, medicine, disease and illness. Examining the social implications of power inequities, technology and scientific research, understanding legislative and regulatory systems relevant to Emergency Medicine illustrate how systems affect the healthcare of individuals and drive institutional change. Results: Subjective evaluation has shown effective facilitation of learning and professional growth in a way which ensures a theory-practice dynamic, affords the opportunity to acquire essential skills such as empathic communication, negotiation, conflict resolution and collaborative problem solving. Conclusions: Emergency Medicine educators are in a unique position to question whether current trends best serve patient interests and to move the system to a patient centered focus where delivery of emergency care is attuned to patient voice and issues of empowerment, autonomy, access are integral to the delivery of care, to design a curriculum which accentuates the dynamic interaction between patient and provider as well as acknowledges the tension between academic study and the actual practice of Emergency Medicine.



T67 ASSESSING THE QUALITY OF ELECTRONIC DOCUMENTATION OF A COMMON CHIEF COMPLAINT AMONG EMERGENCY MEDICINE RESIDENTS _IN TEACHING HOSPITALS L. Juarbe Rivera 1, J. Mercado 2 1 University Of Puerto Rico Medical Science Campus, San Juan, Puerto Rico, 2 Hospital Upr Dr. Federico Trilla, Carolina, Puerto Rico Background: The patients’ medical record is an essential part of patient care in emergency medicine. Numerous studies show that the standard of medical record keeping cannot predict quality of care or patient outcome, thus the standard of medical documentation is an important quality assurance issue (Murphy JG). The medical record is also a source of information for third parties such as hospital administrators, malpractice lawyers and, most importantly, for other healthcare professionals involved in the patients' care (Humphreys, T). Thus, leaving a residency program without a clear understanding of the impact of poor documentation can be considered a failure of the residency program to prepare their graduates for real-world emergency medicine practice (Weizberg). Methods: The study was performed at the Emergency Department (ED) of the UPR Hospital. The study was done via chart review. Chart that presented abdominal pain as the chief complaint during July 1st, 2013 to July 30th, 2014 were used. The 21 participants in the study were categorized into three groups which were classified by the year of residency of our EM residents. All charts of a non-traumatic chief complaint of abdominal pain were included. All charts of traumatic chief complaint of abdominal pain, record written by attending and record written by Non-ER Resident were excluded. Results: There were 111 variables expected to be complete. None of the groups met the number of variables expected. The groups fluctuate between 34 and 76 variables completed. 1st year residents completed the most variables while 3rd year residents completed the least variables. First year residents obtained a median of 57.17 with an SD of 11.13 of variables completed. Second year residents obtained a median of 49.75 with an SD of 14.21 of variables completed. Third year residents obtained a median of 48.57 with an SD of 6.68 of variables completed. Conclusions: Since there was no difference between the groups, and neither of them met the required 70% cutoff value, there has to be an intervention with the residents of all levels to improve the EMR documentation in which the chief complaint is abdominal pain.



T68 SATISFACTION OF THE EMERGENCY RESIDENTS WITH THE WEB-BASED COMMUNICATION GROUP FOR EDUCATION. D. Alfaraj 1 1 University Of Dammam, Khubar, Saudi Arabia Background: Because of the busy shift environment of the emergency department, the teaching opportunities for residents are sometimes reduced. As the use of smartphones and social media is widespread, in this study we use a chat group application to enable greater communication between residents and senior doctors to better allow the exchange of knowledge and experience. In this study we aim to measure the satisfaction of emergency residents regarding their involvement with this new tool in the residency training program. Methods: We chose a chat application available on smartphones. We then invited all ER residents and consultants to participate, with residents discussing one to two cases per day with consultants for training and teaching purposes. We sent questionnaires to the group participants via a link using SurveyMonkey to measure the satisfaction of emergency residents. This study will also serve as a pilot study. Results: The data was analyzed using SurveyMonkey. We used a ranking scale (1–5) to measure residents’ satisfaction regarding the organization of the group discussions (3.24), supervision by consultants (3.32), new medical information (4.2), and the application as a useful learning tool (4.04). Overall, the residents were satisfied with their experience in the group (3.72). Conclusions: The use of smartphone group chat applications is a useful method to overcome the busy environment of emergency departments and the lack of teaching opportunities during shifts. Regarding residents’ satisfaction levels, larger prospective studies are required to confirm this observation.



T69 FOURTH-YEAR MEDICAL STUDENTS DO NOT PERFORM A FOCUSED PHYSICAL EXAM DURING A CASE-BASED SIMULATION SCENARIO L. Bilello 1, N. Dubosh 1, J. Fisher 1, J. Lewis 1, D. Schoenfeld 1, E. Ullman 1 1 Beth Israel Deaconess Medical Center, Boston, Usa Background: High-fidelity simulation is becoming an increasingly more popular means of teaching and evaluating medical students on clinical competencies. The validity of case-based simulations for various clinical performance measures is unclear. We sought to determine the utility of using a cardiac case-based simulation scenario to assess physical exam skills of fourth-year medical students during an emergency medicine (EM) rotation. Methods: Fourth-year medical students enrolled in a four-week EM clerkship at an academic medical center were prospectively evaluated on their performance in a case-based simulation scenario using the Laerdal SimMan. The case involved a patient presenting with chest pain that evolves into cardiac arrest. All simulations were video recorded for teaching and evaluation purposes. All videos were reviewed by one of three EM physicians who underwent a 30-minute group training session on simulation evaluation. The reviewers recorded whether or not each student completed the following components of a physical exam: auscultation of the heart, auscultation of the lungs, pulse and extremity exam, and abdominal exam. Proportions and confidence intervals (CI) were calculated using GraphPad. Results: Twenty-seven students participated in the case-based simulation. The percentage of students completing each of the four components of the focused physical exam was as follows: cardiac auscultation 33.3% (95% CI 18.5 -52.3), lung auscultation 29.6% (95% CI 15.7-48.7), pulse and extremity exam 55.6% (95% CI 37.3-72.4), abdominal exam 3.70% (95% CI 0- 19.8). None of the students completed all four of the physical exam components. Conclusions: The majority of the medical students neglected to perform a focused physical exam during a case-based simulation scenario. The utility of case-based simulation to assess global medical student competencies may be limited. Future studies are needed to determine why omission of the physical exam occurs and to investigate other ways in which simulation can be used to evaluate this competency.



T70 ASSESSMENT OF MEDICAL STUDENT MILESTONES IN EMERGENCY MEDICINE USING CASE-BASED SIMULATION L. Bilello 1, N. Dubosh 1, J. Fisher 1, J. Lewis 1, D. Schoenfeld 1, E. Ullman 1 1 Beth Israel Deaconess Medical Center, Boston, Usa Background: The movement toward competency-based assessment in medical education has led to the development of medical student milestones in emergency medicine (EM). Twenty-four competency-based milestones for fourth-year medical students completing their EM clerkships were recently published. The means by which students should be evaluated on these, however, remains unclear. The goal of this study was to determine the feasibility of using case-based simulation to assess a subset of these milestones. <FILE IMAGE='89_20150529171623.jpg'> Methods: Fourth-year medial students enrolled in a four-week EM clerkship at an academic, tertiary medical center participated in a case-based simulation scenario using the Laerdal SimMan. The case involved a patient presenting with chest pain that evolved into cardiac arrest. All simulations were recorded for teaching and evaluation purposes. After undergoing a 30-minute group training session, five emergency physicians (EP) independently reviewed the simulation videos and rated each student on ten of the EM medical student milestones using a 1-5 Likert scale, with 1 being unsatisfactory and 5 being outstanding (Table 1). Median scores were calculated for each milestone. A likert score of 3, 4 or 5 was consider as meeting the milestone. A Cohen’s Kappa was calculated to examine inter-rater reliability. Results: Twenty-seven fourth-year medical students completed the simulation scenario over a four-month period and were scored by 2 reviewers. The results are shown in Table 1. The overall Cohen’s kappa for meeting the milestone was 0.26 Conclusions: Case-based simulation is a feasible method for assessing fourth-year medical students on ten of the emergency medicine milestones. There was fair inter-rater agreement. Further studies are needed to determine how performance on these milestones compares with other methods of evaluation including direct clinical observation and standardized tests.


Topic: International Emergency Medicine

T71 GLOBAL IMPLEMENTATION OF QUALITY IMPROVEMENT: IMPACT OF EDUCATIONAL INTERVENTIONS ON PRESCRIBING PATTERNS OF ED PHYSICIANS IN ABU DHABI X. Anton 1, K. Balhara 2, N. Nassif 1, Y. Hsieh 2, T. Hassan 1, S. Mousa 1, D. Abbashar 1, M. Moghazi 1, S. Stewart De Ramirez 1 Al Rahba Hospital, Department Of Emergency Medicine, Abu Dhabi, United Arab Emirates, 2 Johns Hopkins University School Of Medicine, Department Of Emergency Medicine, Baltimore, Usa Background: Appropriate, cost-effective medication prescribing is an important focus in quality improvement aimed at physicians. IV acetaminophen is equally effective as oral acetaminophen, but is much costlier. Physicians may be unaware of its cost and may order it for inappropriate indications. This study aimed to examine the volume and appropriateness of intravenous (IV) acetaminophen orders in the emergency department (ED) and to implement a physician-based educational intervention about IV acetaminophen use. Methods: A retrospective chart review was conducted in the Al-Rahba hospital ED in the UAE from July-December 2012 to assess volume of IV acetaminophen orders. Additionally, orders from 100 randomly selected charts were assessed for appropriateness (considered appropriate if patients had nausea/vomiting, were receiving opioids or were in severe pain, or had persistent fever >1 day despite antipyretics). Appropriate indications, best practice data, and current usage trends were reviewed with physicians in an educational intervention supplemented by individual feedback sessions targeted at frequent prescribers. Volume and appropriateness of use were assessed after the intervention from April-August 2013. 3 separate educational and feedback sessions were subsequently conducted, each followed by a 3-month volume assessment period. Preceding assessment data were included in each session to demonstrate real-time improvements and evolving usage trends. Results: Initially, on average, 211 patients received IV acetaminophen each month. 60% of sampled orders were inappropriate. After the first educational session, on average, 167 patients received IV acetaminophen per month. Only 35% of sampled orders were inappropriate (p=0.002). The initial and subsequent interventions correlated with a 41% overall decrease in rate of IV acetaminophen prescription (95% CI: 38% to 46%). A sustained and significant trend towards decreased prescribing of IV acetaminophen was seen over the repeat audit periods (p<0.001) (fig 1).<FILE IMAGE='138_20150529235204.jpg'> Conclusions: Repeated educational interventions were correlated with decrease in overall and inappropriate use of IV acetaminophen. This study demonstrates the utility of ongoing direct physician feedback in sustainably modifying physician behavior. It highlights the need for physician awareness of cost and indications for frequently-prescribed medications.



T72 OBSERVATION MEDICINE IN NOVEL SETTINGS: ASSESSMENT OF UTILIZATION PATTERNS LEADING TO PROLONGED OBSERVATION UNIT STAYS IN THE UAE K. Balhara 1, S. Stewart De Ramirez 1, I. Othman 2, P. Hill 1, S. Figueroa 1, J. Scheulen 1, X. Anton 2 1 Johns Hopkins University School Of Medicine, Department Of Emergency Medicine, Baltimore, Usa, 2 Al Rahba Hospital, Department Of Emergency Medicine, Abu Dhabi, United Arab Emirates Background: Emergency department observation units (EDOUs) are important in addressing ED overcrowding and preventing avoidable admissions. However, literature on EDOU use in regions where emergency medicine is a relatively new specialty, such as the Middle East, is limited. Our study based in an EDOU in a United Arab Emirates hospital offers a unique description of EDOU utilization by specifically studying patients with prolonged EDOU stays. Methods: Trained abstractors performed retrospective chart reviews of EDOU patients over a two-month period. Patients with overall ED LOS > 18 hours were included; this was chosen as the cut-off as it comprises one change of shift and is greater than the average 15-hour LOS for EDOU patients often cited in the literature. Visit diagnosis, LOS in EDOU itself, reason for observation, and disposition were analyzed for these visits. Results: The Al Rahba Hospital EDOU is an 8-bed hybrid unit contiguous to the 27-bed ED and is staffed by 2 nurses. ED providers retain responsibility for patients they originally saw. A monthly average of 7905 patients was seen in the ED during the study period. Patients held to await admission beds had longer EDOU LOS compared to those placed in observation status. (Table 1) The EDOU also accommodated in-patients who needed electrolyte repletion but were not on monitored floors. Overall discharge rates for observation patients were 58% for pediatrics and 59% for adults. Pediatric patients with gastrointestinal upset and adult patients needing rule-out for acute coronary syndrome comprised the majority of observation patients.<FILE IMAGE='138_20150529201255.jpg'> Conclusions: This study describes EDOU utilization in a setting where observation medicine is a new specialty and identifies use patterns leading to prolonged LOS. Frequent reasons prompting prolonged stays were serial troponins and hydration; this knowledge could guide specific protocol development. Discharge rates for prolonged stay observation patients were lower than overall rates typically cited for EDOU patients (75-85%); many were eventually admitted, indicating a need for reevaluation of admission criteria to facilitate disposition decisions. Prolonged EDOU use for boarding patients and patients needing cardiac monitoring highlights a need for more short-stay and telemetry beds.



T73 AN EVALUATION OF DEFINITIVE CARE HOSPITALS REFUSAL TO ACCEPT PATIENT TRANSFER REQUESTS FROM AN OUTPATIENT CLINIC IN RURAL HAITI B. Nicholson 1, H. Dhindsa 2, J. Lovelady 2 1 Boston Medical Center - Department Of Emergency Medicine, Boston, Usa, 2 Virgina Commonwealth University - Department Of Emergency Medicine, Richmond, Usa Background: Developing world medical infrastructure limitations as well as unique social and economic factors, require that patients are transferred from health clinics only when the patient care needs exceed the level of care at the clinic. This study sought to determine what type of barriers to care prevented transfer of patients from a daytime only general clinic in rural Haiti to an urban hospital in Port-au-Prince. Methods: Design – Prospective observational review of all patients for which transfer to a hospital were requested or for which the clinic’s ambulance was requested to an offsite location to assist with patient care. Setting – Monday through Friday, 8:00 AM to 3:00 PM, private, non-profit general outpatient clinic in Titanyen, Haiti that sees seventy to one hundred patients per day. Participants/Subjects – Convenience sample consisting of a consecutive series of all patients for whom transfer to another healthcare facility or for whom an ambulance was requested during the time period of 11/22/2010 – 12/14/2010 and 3/28/2011 – 5/13/2011. Observations – Observations focused on the barriers to patient transfer Results: Requests were made to transfer a total of thirty-seven patients during the observation periods. Eighteen (48.6%) patients were successfully transferred to public hospitals that have a policy of not refusing any patients who present at their facility. In order to reduce the burden on these hospitals, attempts were generally made to transfer patients to other facilities before transferring them to these public hospitals. Eleven (29.7%) patients were transferred without incident to the first facility contacted. Political unrest prevented the transfer of four (10.8%) patients. Patient or family refusal of transfer occurred in three (8.1%) cases. Conclusions: Barriers to patient transfer occurred to some degree in twenty-six (70.3%) cases making this a serious concern in the Haitian healthcare system. Efforts to improve appropriate and efficient patient transfer to ensure the best utilization of limited resources for optimal patient outcomes needs further study and evaluation.



T74 RECORDING ‘PRESENTING COMPLAINT’ IN THE ED – A PAN-EUROPEAN REVIEW OF METHODS. K. Janssens 1, J. Ryan, R.L. Drew 1 St. Vincent's University Hospital, Dublin, Ireland Background: In Europe, diagnosis-related group (DRG) systems are used to understand hospital admissions. The emergency department (ED) is unique from other departments, because most patients are not admitted and the majority of encounters are directly initiated by the patient with their reason for encounter rather than a diagnosis, is the precipitant. While ‘presenting complaint’ (PC) forms the axis of practice for most ED physicians, there lacks a standardized method for recording this parameter. In Ireland, a program is underway to compare data regarding GP attendances, including PC data, across multiple centres using different data collection systems. The objective of this study is to explore how PC is recorded in ED’s in across Europe, comparing it to our hospital, and to explore opportunities for international comparison. Methods: For each of the 20 most populous countries in Europe, Pubmed searches for the terms “complaint”, “emergency department” and country name were undertaken. Publications were included if they reported on patterns of complaints. An attempt was made to contact authors for each article to (1) clarify methods and (2) to gauge their interest in data comparison. In order to explore a model for inter-center comparison, we attempted to re-categorise one year of PC data from a Dublin hospital (40462 visits) into the various methods used across Europe. Results: 22 articles were included from 15 countries (Germany, England, France, Italy, Spain, Poland, Netherlands, Belgium, Greece, Portugal, Sweden Switzerland, Denmark, Finland, Norway). A PC categorization method was evident in 15: 3 used free-text, 6 local lists, and 6 used internationally standardized codes. Our hospital uses an internally generated 68-item list. Equivalent codes were sought for these in each coding systems with degrees success varying from 53% (MTS) to 77% (ICD-10). Of the authors contacted, 5 responded and were interested in opportunities for collaboration. A meeting has been arranged at the 8th MEMC in Rome. Conclusions: Data regarding PC in the ED can be compared between countries using different systems. There is an international appetite to do so and a working model of how this might happen is available.



T75 STATE OF EMERGENCY MEDICAL CARE IN SINGAPORE H.C. Lim 1, M. Mahadevan 2, J.J. Oh 3 1 Changi General Hospital, Singapore, Singapore, 2 National University Hospital, Singapore, Singapore, 3 Singapore General Hospital, Singapore, Singapore Background: In late 2011, The College of Emergency Physicians (Academy of Medicine Singapore) and The Society for Emergency Medicine in Singapore commissioned a Workgroup to describe the emergency care system in Singapore, identify future challenges, and chart the directions to achieving the vision by recommending strategic thrusts and best ways to organize emergency medical care in Singapore. The findings and recommendations were finalised this year in 2015. Methods: Main and sub-committees were established to address different topics such as ageing population, manpower, comprehensive emergency preparedness, paediatric emergency medicine, education and research in emergency medicine. Discussions were held within committees, among focused-groups and panel discussions during the Society’s Annual Scientific Meetings. Results: Singapore faces a high burden of medical emergencies. In 2013, emergency departments (EDs) in Singapore received above 1 million attenders. Last year, the number of ambulance calls received by the Singapore Civil Defence Force went up 3.7% to around 155 000. 95.4% of those calls were for emergencies. Providing emergency care for a rapidly ageing population is a big challenge. Elderly attenders make up around ¼ of ED visits. They have an estimated 65% admission rate. Together with an increasing prevalence of chronic diseases and access block, the ability to deliver timely, integrated care is threatened. Recommendations include engagement and enabling of primary care physicians who form an important part of the emergency care continuum to right-site patients. Integrating care at the ED with community and home-based resources aid to reduce unnecessary hospital bed occupancy. Conclusions: Emergency care systems in Singapore aim to deliver timely and integrated care. By holding to a patient-centric approach when implementing services, quality care may be provided in an integrated, efficient and evidence-based manner.


Topic: Paediatrics

T76 DOES PEDIATRIC EMERGENCY SEDATION WITH COMBINED KETAMINE/PROPOFOL (KETOFOL) RESULT IN FEWER ADVERSE EVENTS THAN KETAMINE OR PROPOFOL ALONE? R. Hoffman 1, G. Barnett 2 1 Sidra Medical And Research Institute, Doha, Qatar, 2 Sheih Khalifa Medical City, Abu Dhabi, United Arab Emirates Background: Ketamine and propofol are commonly used for procedural sedation of children in the ED. Each works by a different mechanism and has different adverse effects. The rationale for combining ketamine and propofol is that each drug may counterbalance or offset the adverse effects of the other and combined use permits administration of a lower dose of either drug. This study seeks to determine if sedation with ketofol in pediatric patients has fewer adverse effects than sedation with ketamine or propofol alone. Methods: By retrospective review data was extracted from charts of 43 pediatric patients who underwent ketofol sedation in the ED of an urban, academic medical center staffed by board-certified emergency and pediatric emergency physicians from the USA, Canada and UK. The incidence of the following adverse reactions was compared: hypoxia, hypotension, respiratory depression, vomiting, and agitation/emergence reaction. The specific aim is to determine if these adverse events with ketofol occur in a lower incidence than withketamine or propofol alone. Results: Forty-three children were included in this study. Vomiting was the only adverse event noted, in 4.6% (2/43) of patients. Each propofol-associated adverse event, respiratory depression, and hypotension, occurred less frequently with with ketofol. With regard to ketamine-associated adverse events, emergence reaction occurred less frequently and there was no statistical difference in the incidence of vomiting. Conclusions: Use of ketofol in children results in fewer adverse reactions than from propofol alone. Regarding ketamine adverse effects, use of ketofol results in a lower incidence of emergence reaction, but no difference in incidence of vomiting than ketamine alone. Clinicians who use either or both of these sedating agents should consider using combined ketamine/propofol in children for the purpose of lessening the chance of the most common adverse events from these medications.


Topic: Patients at the core

T77 AWARENESS AND PRACTICE OF PEDIATRIC FIRST-AID AMONG SAUDI ARABIAN PARENTS: A CROSS SECTIONAL STUDY A. Almass Ahmad 1, B. Alshahrani, A. Almweisheer, A. Alshlewi 1 King Saud University-King Khalid University Hospital, Riyadh, Saudi Arabia Background: Childhood injuries are the leading cause of death for children worldwide. No studies have been done regarding assessment of pediatric first-aid knowledge among Saudi parents and related childhood injuries and there prevention. Methods: This cross-sectional study was performed among Saudi adult parents who attended tertiary patient care center at King Khalid University Hospital, Riyadh, Saudi Arabia during August 2012 to February 2013. A survey questionnaire regarding pediatric first-aid knowledge based on the guidelines of American Academy of Pediatrics was employed. Descriptive statistics, Chi-square and Pearson correlation tests were used to analyzed the data. Results: A total of 383 subjects including 50.9% males and 49.1% females were surveyed. More than 80% (males and females) of them had high school level education. Only 12% males and 22% females had previous formal training in pediatric first-aid. Most of the Saudi parents gathered the first-aid knowledge from the media and interested in formal training (p=0.03). However, the knowledge about specific guidelines ranged between 16.4 to 93%. The correct knowledge among males and females regarding the first-aid of stings and bites (55.0 and 54.0%; p=0.013), fever (72.25 and 66.50%; p=0.023), cuts and scrapes (71.42 and 68.28%; p=0.001), burns (66.33 and 60.0%; p=0.002), nose-bleeding (66.33 and 60.0%; p=0.002) and choking (42.25 and 41.75%; p=0.013) were bit significant. However, difference between the first-aid knowledge of poisoning (62.0 and 53.0%; p=0.140), eye injuries (73.40 and 68.40%; p=0.056), fracture (72.75 and 70.25%; p=0.086), convulsion and seizure (74.80 and 76.20; p=0.193) were insignificant among the males and females. Surprisingly, most parents lack knowledge regarding the use of ice on the burns (only 27.9% aware), keep the child in a sitting position with the head tilted slightly backward (16.4% aware), induce vomiting in case of swallowed poisoning (18.0% aware) and to remove foreign body in case of choking (22.2% aware). Conclusions: Dedicated/structured education/awareness program is needed for parents to save human life and children safety and health. Beside media and internet, healthcare professionals should play more active role by providing information on child safety.


Topic: Toxicology / Environmental Injury

T78 SPECIFIC ISSUES OF THE CLINICAL PICTURE AND EVOLUTION IN ACUTE TOXIC METHEMOGLOBINEMIA IN CHILDREN V. Nitescu 1, D. Boghitoiu 1, C. Ulmeanu 1 1 Pediatric Poisoning Centre Emergency Clinical Hospital For Childrengrigore Alexandrescu, Bucharest, Romania Background: Acute toxic methemoglobinemia is a severe entity in children related to xenobiotic oxidative stress. Methods: Objective: To assess the specific aspects of the clinical picture and evolution in cases with acute toxic methemoglobinemia admitted to a pediatric emergency hospital. Methods: We performed a retrospective study of cases with acute toxic methemoglobinemia admitted in our hospital during a 5 year period (2010 to 2014). The following criteria were taken into consideration, etiology, age, gender, symptoms and evolution under treatment Results: Out of the total number of 3,087 poisoned children admitted to our hospital in the study period, 61 cases (1.97%) were reported with acute toxic methemoglobinemia. Regarding the age we noted two peaks of incidence, less than 1-year-old (45.90%, n=28) and 1 to 5-years-old (42.62%, n=26). The rate of male patients was slightly higher than female (55.73% vs. 44.26%). Well water contaminated with nitrates used in the preparation of food was implicated in the majority of cases (83.60%, n=51). A new entity was noted. Acute severe methemoglobinemia in patients with severe burns treated with topical benzocaine occurred in 9 cases (16.39%). Pentaerythritol tetranitrate poisoning was implicated in 1 case (1.63%). Generalized cyanosis, chocolate-brown blood obtained from venipuncture and impaired clinical status was noted in all cases. Other clinical signs included acute respiratory failure in all cases with serum methemoglobinemia above 50% (16.39%), seizures in 2 cases (3.27% with methemoglobinemia above 70%), vomiting 8 cases (13.11%) and tachycardia 10 patients (16.39%). Methylene blue was administered in all cases. The clinical condition and serum concentration of methemoglobinemia normalized after one dose in 51 children (83.60%). Multiple (two or three) administrations of methylene blue was required in 10 patients (16.39%) with methemoglobinemia above 50%. One death was reported in 6-week-old premature infant who was admitted 12 hours after onset of symptoms Conclusions: Acute toxic methemoglobinemia is rare but potentially fatal event in children. Acute toxic methemoglobinemia due to topical benzocaine is a particular severe entity reported in large burned patients. Methylene blue, the antidote is very efficient if given in time, sometimes requiring repeated administration


Topic: Paediatrics

T79 UTILITY OF ULTRASONOGRAPHY AS ADJUNCTS IN RISK STRATIFICATION FOR PEDIATRIC SEPTIC ARTHRITIS L. Cochon 1, P. Shashikant Patel 3, A. Baez 2 1 Universitat De Barcelona, Barcelona, Spain, 2 Jackson Memorial Hospital, Miami, Usa, 3 University Of Florida Gainesville, Gainesville, Usa Background: Differentiation between septic arthritis and transient synovitis of the hip in children can be difficult given their similar, non-traumatic presentations. Because of the high morbidity associated with septic arthritis, it is important to make this diagnosis in a timely manner. The Kocher criteria were derived to identify factors important in distinguishing septic arthritis and transient synovitis.The objective was to determine whether the imaging modalities of ultrasonography, plain film radiography and magnetic resonance imaging (MRI) can improve the pretest probability of the Kocher criteria. Methods: The Kocher criteria consists of four clinical yes/no questions: 1) ability to weight bear, 2) fever, 3) ESR>40mm/hr and 4)WBC > 12,000 cell/mm3. The pretest probability of having septic arthritis ranges from 3% for 1 point to 99% for 4 points. Using these pretest probabilities, a Bayesian nomogram was constructed using pooled sensitivity and specificity estimates for plain radiography, ultrasonography, and magnetic resonance imaging, in order to derive post test probabilities for each imaging modality. Results: The pooled sensitivity, specificity, positive and negative likelihood ratios for plain radiography were 59%, 79%, 2.81 and 0.52. For ultrasonography, they were 86.4%, 89.7%, 8.30, and 0.15. For MRI, they were 79%, 100%, 790, and 0.21. Each of the imaging studies helped to improve the pretest probability, and the most incremental gain was seen in the moderate risk category (2 points on Kocher criteria), which clinically is most helpful. Of the 3 imaging modalities, ultrasonography provided the best relative gain using the negative likelihood ratio. Specifically, ultrasonography decreased the pretest probability from 40% to 7%, representing a relative gain of 77%. Conclusions: Patients with a moderate Kocher score present the biggest diagnostic dilemma. In this group, performing an ultrasound of the hip significantly improved the ability to rule out septic arthritis.


Topic: Paediatrics

T80 A BRIEF EDUCATIONAL INTERVENTION TO IMPROVE HEALTHCARE PROVIDERS KNOWLEDGE ABOUT PEDIATRIC CERVICAL SPINE INJURIES C. Zeretzke 1, S. Alwood, P. Mcmahon, S. Herskovitz 1 University Of Florida, Gainesville, Usa, 2 Our Lady Of The Lake Regional Medical Center, Baton Rouge, Usa Background: Cervical Spine Injury (CSI) occurs in <1% of children presenting to ED with trauma. Children are unnecessarily exposed to radiation. CT radiation doses are 100 - 500 times higher than conventional radiography and lead to increased risk of cancer. Radiation exposure may be reduced by developing clinical pathways limiting CT scanning and encouraging alternate modalities. Methods: Surveys were administered to pediatric emergency medicine physicians, trauma surgeons, pediatric and EM residents, and pediatric EM nurses. Education sessions occurred for each group in the study population. Topics included: prevalence of SCIs in children, risks associated with radiation exposure, determination of imaging, details about a new protocol for clearing spinal injuries that minimizes radiation exposure. A pre- and post- survey was administered before and after the education session. Results: The overall mean number of knowledge items answered correctly at pretest was 6.73 (SD = 1.41) out of 10. Following the brief educational intervention, the overall mean number of knowledge items answered correctly was 9.23 (SD = .97) out of 10. All items were answered correctly by more than 75% of the respondents on the post-test. There was a statistically significant increase in knowledge following the intervention (F(1,66) = 193.39, P<.0001). There were also significant differences among groups regarding knowledge (F(3,66) = 7.41, P <.0001). Post-hoc analyses using the Tukey Honest Significant Difference Test determined that nurses had significantly lower knowledge scores than did the combined group of attending physicians (P <.0001), emergency medicine residents (P =.02), and pediatric residents (P <.05). The other three groups did not differ significantly from one another. Conclusions: It is unlikely providers will embrace new protocols for clearing the cervical spine without addressing knowledge gaps. A brief education program improved knowledge about CSIs . All items were answered correctly at posttest by at least 75% of participants. Attending physicians demonstrated the greatest knowledge concerning CSIs. EM and pediatric residents had the same knowledge level, and nurses with less than physician groups. Education regarding limited radiation to clear the cervical spine was gained by educational interventions in all groups.


Topic: Disaster Medicine

T81 GEOGRAPHICAL RELATION OF RITN CENTERS TO MEDICAL TOXICOLOGY RESOURCES E. Davlantes 1, Z. Kazzi 1, J. Venero 2, S. Shartar 3, A. Steck 1, A. Langston 4 1 Emory University Department Of Emergency Medicine, Atlanta, Usa, 2 Radiation Injury Treatment Network, Minneapolis, Usa, 3 Emory University Office Of Critical Event Preparedness And Response, Atlanta, Usa, 4 Emory University Department Of Hematology And Oncology, Atlanta, Usa Background: The Radiation Injury Treatment Network (RITN) consists of 59 centers across the United States that are poised to care for victims of a radiation emergency. The network is organized around bone marrow transplant centers because these facilities have expertise both in radiation medicine and in the care of patients with severe bone marrow depression. A radiation emergency may cause not only irradiation from an external source but also internal contamination with radioactive material. Because medical toxicologists possess training in radiation injury management and expertise in the management of internal contamination, RITN centers may benefit from partnership with medical toxicology (MT) resources, which may be located at an academic medical center, a hospital inpatient clinical service, an outpatient clinic, or a poison center. <FILE IMAGE='189_20150529184824.jpg'> Methods: We examined the geographic location of MT resources with regards to existing RITN centers. Data were derived from public sources. Results: The majority of RITN centers do not have a MT residency, an inpatient MT service, or an outpatient MT clinic within the same institution. However, 57% of RITN centers have at least one of these resources located in the same city, and 73% of RITN centers have at least one of these resources or a poison center within the same city (Table 1). Conclusions: As MT resources can supplement the capabilities of RITN centers in a radiation emergency, medical toxicologists and RITN centers should collaborate during further planning and response efforts. The majority of RITN centers have at least one MT resource in the same city. Centers that do not, can explore other ways to collaborate with these resources like partnering with ones located in neighboring cities or connecting through a national network.


Topic: Metabolic and endocrine disorders

T82 RISK OF RE-HOSPITALIZATION IN PATIENTS ATTENDING THE EMERGENCY DEPARTMENT FOR ACUTE ALCOHOL INTOXICATION: AN OBSERVATIONAL RETROSPECTIVE STUDY S. Guerrini 1, A. Grignaschi 1, M. Cavazza 1 1 Department Of Emergency Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy Background: Acute alcohol intoxication (AAI) is a frequent cause of admission to the emergency department (ED). Patients with several admission in ED because of AAI may present alcohol use disorders (AUDs) and therefore need specific evaluation and therapy. Aims if this retrspective study was to identify factor associated to risk of readmission in ED for AAI patients. <FILE IMAGE='167_20150529113842.png'> Methods: An observational retrospective study was performed at the S. Orsola-Malpighi University Hospital. Patients admitted to ED in 2014 were screened for study enrollment. Inclusion criteria were diagnosis of AAI at admission. Results: Five-hundred-seventy-six patients were enrolled in this study. Mean age was 35±15 years, 368 (67%) were male. Patients with more than one admission to ED were 72 (13%). Factors associated to re-admission at univariate analysis were age, eastern countries nationality, psychiatric disorders, social discomfort, anamnesis of AUDs, drug addiction and homelessness (Figure1). At multivariate analysis AUDs (OR 5,2; CI 2,9-9,2; p<0,001), social discomfort (OR 3,7; CI 2,0-6,8; p<0,001), psychiatric disorders (OR 3,6; CI 2,9-9,2; p<0,001) and European eastern country nationality (OR 1,5; CI 1,1-2,1; p=0,015) were independent predictors of re-hospitalization (Figure 2). Basing on the multivariate model results we develop a risk-score for re-hospitalization in which one point for each risk factor was attributed (score range 0 to 4). The ROC curve analysis showed that the score we developed have a good discriminating performance against the risk of re-hospitalization (AUROC 0,809; CI 0,754-0,864). Conclusions: The present study demonstrated that simple parameters may stratify the risk of readmission in ED for AAI and may identify patients needing specific therapeutic support.



T83 EPIDEMIC SYNTHETIC CANNABINOID POISONING: A CASE SERIES E. Eustice 1, B. Bailey 1, A. Leonetti 1, K. Katz 1 1 Lehigh Valley Health Network- Department Of Emergency Medicine, Allentown, Usa Background: There has been a recent emergence in the popularity of synthetic marijuana usage across the country. The product being abused are made in clandestine labs in countries outside of the United States. Chemicals used in the manufacturing process of these drugs are changing constantly to evade law enforcement, which leads to unknown harmful effects. There are also specific ingredients which can cause clinical harm to those who ingest. Methods: We evaluated and treated 13 patients over a 1 week time period at Lehigh Valley Health Network. These patients were admitted to the ICU for reported synthetic cannabinoid use/overdose. In all of these patients, synthetic cannabinoid confirmation was sent to outside laboratory for testing and further evaluation of the parent compounds in these drugs. We attempted to objectively identify a linking chemical substance in the 13 patient cases, causing similar presentations and clinical side effects. This is a case series reviewing and evaluating patients admitted to Lehigh Valley Health Network during April of 2015. Serum laboratory samples were taken from all patients and sent to NMS toxicology laboratory. Results: Laboratory testing is currently pending on all of the current cases in the series. The results of these tests would confirm patients included in the series had used synthetic cannabinoids, contributing to the clinical effects in these patients. Recent preliminary testing performed by law enforcement officials have found a chemical called ADB- CHMINACA and FUB-PB-22. These chemicals were identified as synthetic cannabinoids. According to our literature search results, there appears to be no current records of clinical testing for these compounds in serum samples from patients. Conclusions: Our study will evaluate the recent trend and increases in the usage of synthetic marijuana. We will then have the ability to identify new compounds in an emerging drug market. This will provide a link between measured drug amounts and clinical effects seen in patients.



T84 VITAMIN E IN THE TREATMENT OF ACUTE ALUMINUM PHOSPHIDE POISONING AS A NOVEL THERAPY: A RANDOMIZED CLINICAL TRIAL S. Shadnia 1, Z. Halvaie 2, H. Tehrani 2, K. Soltanienjad 3, M. Abdollahi 4, G. Sasanian 4 1 Clinical Toxicology Department, Loghman Hakim Hospital Poison Center, Shahid Beheshti University Of Medical Sciences, Tehran, Iran, 2 Faculty Of Pharmacy, Islamic Azad University Of Medical Sciences, Tehran, Iran, 3 Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran, 4 Faculty Of Pharmacy, Tehran University Of Medical Sciences, Tehran, Iran Background: Aluminium phosphide is commonly used as a fumigant in developing countries. In contact with moisture, it produces phosphine gas. Induction of oxidative stress is one of the most important mechanisms for its toxicity. In this regard, and considering that there is no specific antidote for its treatment, the aim of this study was to evaluate the effect of vitamin E in the treatment of acute aluminium phosphide poisoning. Methods: This was a prospective, randomized, control open label trial on acute aluminium phosphide intoxicated cases in the Medical Toxicology Intensive Care Unit during one-year period. The diagnosis was based on history of exposure, clinical manifestations, laboratory findings and other circumstantial evidences such as availability of a poison bottle or a label. In fatal cases, the toxicological analysis and histopathological examination were performed. All the patients received gastric decontamination with sodium bicarbonate, permanganate potassium, and activated charcoal. They were treated with magnesium sulfate, calcium gluconate, hydration, and vasopressor based on the clinical toxicology department protocols. In treatment group, vitamin E (400 IU/IM, every 12 hours) was administered up to 72 hours. Level of malondialdehyde and total antioxidant capacity of plasma were measured. Results: In the present study, 36 patients were included, of whom 20 were the treatment, and 16 were controls. The route of exposure was deliberate ingestion in all patients. There was no significant difference between two groups according to demographic, clinical, paraclinical, and SAPSII score on admission. The results showed significant difference between two groups with regard to diastolic blood pressure (p<0.05), blood pH (p<0.001) and serum bicarbonate (p<0.05), 24 hours after onset of poisoning. Total antioxidant capacity and malondialdehyde level of plasma in control group was significantly higher than treatment group (p<0.05), 24-hour after onset of poisoning. Vitamin E administration significantly decreased necessity and duration of intubation and mechanical ventilation (p<0.05). In addition, significantly reduced the mortality rate in treatment group compare to control (15% vs. 50%, p=0.02). Conclusions: Vitamin E along with supportive treatment could have a therapeutic effect in acute aluminium phosphide poisoning.


Topic: Cardiovascular / Non-CPR/Non-Resuscitation

T85 TREATMENT OF COCAINE CARDIOVASCULAR TOXICITY: A SYSTEMATIC REVIEW E. Laurin 1, J. Richards 1, D. Garber 1, T. Albertson 1, R. Derlet 1, E. Amsterdam 1, K. Olson 2, E. Ramoska 3, R. Lange 4 1 University Of California, Davis Medical Center, Sacramento, Usa, 2 University Of California, San Francisco, San Francisco, Usa, 3 Drexel University, Philadelphia, Usa, 4 Texas Tech University, El Paso, Usa Background: Cocaine abuse is a major worldwide health problem. Cocaine cardiovascular toxicity requires urgent treatment for hyperadrenergic symptoms, leading to pathologic sequelae such as ACS. The objective is to review the current evidence for pharmacologic treatment of cocaine cardiovascular toxicity. Methods: MEDLINE, PsycINFO, DARE, and the Cochrane Library were systematically searched. Evidence was graded using CEBM levels. Treatment recommendations were compared to current ACC/AHA guidelines. Special attention was given to adverse drug events or treatment failure. Results: The search identified 1,848 articles with 104 eligible involving 2,334 human subjects. There were 5 high-quality (Level I/II) studies, 3 Level III, and 18 case series/reports (Level IV/V) for benzodiazepines in 224 subjects, with 5 treatment failures. For calcium channel blockers: 8 Level I/II, one Level III, and 6 Level IV/V studies, 113 subjects, and 2 treatment failures. For nitric oxide-mediated vasodilators such as nitroglycerin and nitroprusside: 6 Level I/II, one Level III, and 22 Level IV/V studies, 231 subjects, 10 treatment failures, and one adverse drug event. There was a smaller number of studies for α1-blockers such as phentolamine and doxazosin: 2 Level I studies and 3 case reports. Nitric-oxide-mediated vasodilators, calcium channel and α1-blockers were effective at mitigating hypertension but not tachycardia. There were 8 Level I/II, 7 Level III, and 25 Level IV/V studies of β-blockers, 1,711 subjects, 7 adverse drug events, and 3 treatment failures. No adverse events were reported for combined β/α-blockers, such as labetalol and carvedilol, which were effective in attenuating both hypertension and tachycardia. There were 2 high-quality studies and one case report detailing the successful use of dexmedetomidine. Other pharmacologic agents included antipsychotics and intravenous lipid emulsion. Conclusions: High-quality evidence for pharmacologic treatment of cocaine cardiovascular toxicity is limited but can guide acute management of associated hypertension, tachycardia and agitation. Benzodiazepines are recommended as first-line treatment. For control of cocaine-associated hypertension, the use of calcium channel blockers, nitroglycerine/nitroprusside, and α1-blockers are each recommended. Combined β/α-blockers are recommended for control of concomitant tachycardia and hypertension. Future trials are needed to evaluate new agents and define optimal treatment.



T86 THE EFFECTS OF SUGAMMADEX IN TRICYCLIC ANTIDEPRESSANT TOXICITY H. Alp 1, A. Bayir 2, H. Kara 3, A. Unlu 4, M. Yilmaz 5, M. Alp 1 Kastamonu State Hospital Emergency Department, Kastamonu, Turkey, 2 Selcuk Universty Hospital Emergency Department, Konya, Turkey, 3 Selcuk Universty Hospital Emergency Department, Konya, Turkey, 4 Selcuk Universty Hospital Biochemistry Department, Konya, Turkey, 5 Selcuk Universty Hospital Histology Department, Konya, Turkey, 6 Selcuk Universty Hospital Physiology Department, Konya, Turkey Background: Sugammadex is a gamma-cyclodextrin effects by encapsulating lipophilic molecules. The goal of this study to research the treatment effect of sugammadex in an experimental rabbit model of Tricyclic Antidepressant toxicity and to compare with the effect of Sodium Bicarbonate. Methods: 32 New Zelland rabbits divided into four groups as control (n = 8), intoxication (n = 8), bicarbonate (n = 8) and sugammadex group (n = 8). After anesthesia, for each subject the ECG, respiration and heart rate, mean arterial pressure and oxygen saturation were recorded at 0, 30, 60 and 120 minutes. Orogastric tube was applied to all groups except the control group and were given 70 mg / kg a single dose of amitriptyline. We regarded as intoxication occurred when blood pressure was decreased to half of an initial value (0 min). To the bicarbonate group, after intoxication, 4 ml / kg initial dose of 8.4% Sodium Bicarbonate was given iv at 5. minute,and the maintenance dose of 4 ml / kg / hr was given until the end of experiment. To the sugammadex group, 5 min after intoxication 15mg / kg sugammadex was administered intravenously. We took 5 ml blood from each subject to assess venous blood gases, level of troponin, amitriptyline and nortriptyline at 0, 1 and 2. hours. At the end of the second hour surviving subjects were sacrificed. Than heart and brain tissues were removed to assess apoptotic index. Results: Nortriptyline levels of Bicarbonate and Sugammadex groups were significantly higher than Control group at 0, 60 and 120. minutes. (Bicarbonate: p <0.001; 0.03; <0.001 sugammadex: p = 0.03; 0.02; 0.02). Apoptotic index of the heart and brain tissue of Sugammadex group was significantly lower than intoxication and bicarbonate groups (p<0,05). The survival of Sugammadex group was significantly higher than intoxication and bicarbonate group (p <0.05). There was no significant difference in survival between the control group and the sugammadex group. Conclusions: Sugammadex has positive effects especially on tissue survival and prognosis. More experimental and clinical studies are needed to support the availability of using as an antidote.


Topic: Orthopaedic Emergencies

T87 RAPID INTERVENTION AND DISCHARGE OF SHOULDER DISLOCATIONS A. Habib 1, S. Carr 2 1 Doncaster Royal Infirmary, Doncaster, United Kingdom, 2 Galway Regional Hospitals, Galway, Ireland Background: INTRODUCTION: Shoulder dislocations are a common problem presenting to the Emergency Department with an incidence in the region of 12 per 100,000 per year. We identified significant delays from presentation through to discharge of these patients including: • Time waiting assessment • Time waiting x-ray (pre- and post-reduction) • Limited availability of monitoring areas • Up to 4 hours monitoring post sedation With increasing workloads on Emergency Departments combined with a painful condition there are obvious merits to a rapid safe treatment algorithm. Methods: Methods / Results: Emergency Department doctors were instructed on the use of the slump technique for the reduction of anterior dislocation. Doctors chose between either the slump technique or a different technique. Of 73 patients presenting with acutely dislocated shoulder 36 patients were manipulated using the slump technique. Of the 36 patients 29 patients were successfully reduced using the slump technique representing an 80% success rate which compares favorably to a 70-80% published success rates of the Kocher method. Results: a Conclusions: Conclusion: The utilization of the slump technique as it offers the following advantages: • Markedly reduced analgesic requirements • Well tolerated without sedation and hence monitoring • Patients can be discharged immediately post procedure without the need for post sedation observation • Favorable success rates compared with other methods


Topic: Trauma

T89 PREHOSPITAL SYSTOLIC BLOOD PRESSURE AND MORTALITY IN MAJOR TRAUMATIC BRAIN INJURY: IS THERE A HYPOTENSION THRESHOLD? D. Spaite 1, C. Hu 1, 2, B. Bobrow 1, 3, V. Chikani 1, 3, B. Barnhart 1, D. Sherrill 2, J. Gaither 1, C. Viscusi 1, K. Denninghoff 1, U. Stolz 1 1 Arizona Emergency Medicine Research Center, University Of Arizona, Phoenix, Usa, 2 College Of Public Health, University Of Arizona, Tucson, Usa, 3 Arizona Department Of Health Services, Phoenix, Usa Background: Current Prehospital Traumatic Brain Injury (TBI) Guidelines utilize a Systolic Blood Pressure (SBP) threshold of <90mmHg for treating hypotension in patients >=10 years. This is supported by literature showing higher mortality when cohorts of patients with SBP <90mmHg versus >=90mmHg are compared. However, the published guidelines forthrightly acknowledge that the evidence supporting this threshold is very weak. Objective: In a statewide, multisystem study of major TBI, we evaluated whether any statistically-supportable SBP versus mortality cut-point/threshold emerges from the data when assessed a priori, without reference to any given definition for hypotension. <FILE IMAGE='146_20150528225936.jpg'> Methods: All moderate/severe TBI cases (Barell Matrix-Type-1 and/or International Classification of Disease-9 head-region severity >=3 and/or Abbreviated Injury Scale head-region severity >=3) in the pre-implementation cohort of the Excellence in Prehospital Injury Care (EPIC) TBI Study (NIH/NINDS-1R01NS071049; ClinicalTrials.gov-#NCT01339702; 1/1/07-3/31/14) were evaluated. Exclusions-Age<10, transfers, prehospital death, missing prehospital SBP and/or other risk measures-2.9%. Patients with lowest prehospital SBP between 40 and 119mmHg (study population) were assessed using the generalized additive model and logistic regression to determine the relationship between SBP and mortality, adjusting for significant/important confounders. Results: 3844 patients were included. The best model (controlling for ISS, ICD-head, injury type, prehospital airway management, age, sex, race, ethnicity, payor), chosen by the Generalized Cross-Validation Criterion, showed an essentially-linear relationship between SBP and probability of death (Figure). Each five-point increase of SBP decreased the adjusted odds of death by 11.1% (aOR=0.889-95% confidence interval: 0.853-0.926) across the entire SBP range from 40 to 119mmHg. Conclusions: In major TBI, we found a linear relationship between lowest prehospital SBP and severity-adjusted probability of mortality across an exceptionally wide range. For example, the odds of death increase as much for a 10-point drop from 120 to 110mmHg, or from 110 to 100mmHg, as for 100 to 90mmHg. This suggests that the optimal treatment threshold may be higher than 90mmHg. Summary: 1) The concept that 90mmHg represents a unique/important “cut-point” may be wrong, 2) For the injured brain, clinically meaningful “hypotension” may not be as low as current guidelines suggest, 3) Specific trials comparing various SBP treatment thresholds are needed.


Topic: Trauma

T90 SUSPECT PELVIC INJURIES BASED ON MECHANISM ALONE OR IN CONJUGATION WITH PHYSIOLOGICAL PARAMETERS M. Majeed 1, A. Naveed 1 1 University Hospital Birmingham, Birmingham, United Kingdom Background: Pelvic fractures represent 3%-6% of all fractures in adults and occur in up to 20% of all polytrauma cases. Unstable pelvic fracture is estimated to occur in up to 20% of pelvic fractures. The common causes include road traffic accidents, falls from height and sports injuries. Early mortality in relation to pelvic fracture is due to associated injuries or catastrophic haemorrhage. About 10% of hemodynamically unstable fractures of the pelvis patients will die. For patients with pelvic and acetabular injury, two-thirds have other significant injuries to their skeleton or other body systems. Objective: To estimate, the predictive value (positive and negative) of mechanism in isolation or in combination with physiological parameters, identifying pelvic fractures. Methods: We did the retrospective analysis of 540 Major trauma patients who attended out hospital from January 2013 to June 2013. Inclusion: All major trauma patients who were suspected to have pelvic injuries based on mechanism were included in this study. Exclusion: Patients with age < 16yrs and not suspected to have pelvic injuries were excluded. Settings and Methodology: This study was done in the Emergency Department (ED) of University hospital Birmingham. A retrospective analysis of the Major trauma cases was performed. Results: We found the mechanism to be good tool to exclude (negative predictive value= 98.77% (CI: 93.29-99.79%) pelvic injuries but extremely poor to diagnose them (positive predictive value was 15.24% (11.17-20.10%). When combined with physiological parameters the PPV= 56%, 43-68% and NPV (99.29, 96-99.9%) had significantly improved. Similarly the specificity had improved from 25% to 84%. Conclusions: Trauma triage tool is widely used by the pre hospital teams to divert patients to the major trauma centers. The step 3 of this tool has got suspected pelvic fracture as one of the trigger. It is evident from our results that mechanism on its own is a poor indicator to diagnose pelvic fracture. We believe its diagnostic accuracy will improve when joint together with physiological triggers. Limitations: Our study has a small sample size and been performed in a single center.


Topic: Trauma

T91 RISK FACTORS FOR UNDERTRIAGE OF SERIOUS TRAUMA IN PATIENTS AGED 65 AND OLDER PRESENTING TO THE EMERGENCY DEPARTMENT R. Dickason 1, A. Ourian 2, Z. Ali 1, M. Zimmerman 2, J. Torres 1, J. Sample 2, S. Jazarevic 2, M. Radeos 1 1 New York Hospital Queens, Department Of Emergency Medicine, Flushing, Usa, 2 New York Hospital Queens, Department Of Surgery, Flushing, Usa Background: The 2012 Eastern Association for the Surgery of Trauma guidelines recommend lowering the threshold for triaging elderly, 65 years or older, trauma patients to higher levels of trauma care. We studied if our injured elderly patients are triaged in accordance with these guidelines. Methods: We performed a retrospective study of consecutive elderly patients with ICD-9 codes from 800-959 indicating “injury.” Within this group serious trauma comprised multiple rib fractures, pneumo- or hemothorax, intracranial bleed, long bone fracture, spinal cord injury, or vertebral fracture or dislocation. Our primary outcome was serious trauma with no prehospital trauma notification (PTN), full trauma team activation (FTTA), or trauma consult (TC) (collectively called “trauma care”). Secondary outcomes were risk factors for undertriage. We present results as odds ratios (OR) with 95% confidence intervals (95%CI). Statistical significance was set at p=0.05. We used Stata for all analyses (version 13, Stata Corp., College Station, TX). Results: 395 patients were included with a median age of 83 years (IQR 75-89). There were 229(58%) females; 276(70%) white, 89(23%) Asian, 22(6%) black, and 8(2%) other; 42(11%) were Hispanic. Serious trauma was present in 259(66%) of patients. Of these, 122(47%) received no trauma care. 330(85%) patients were brought by EMS; 84(25%) of these patients received PTN. FTTA occurred in 83(25%). Of 246(75%) patients who came in via EMS without PTN, 18(7%) received FTTA, 50(20%) received TC, and 178(72%) received no trauma care. Of 60(15%) patients who arrived by private vehicle, 3(5%) received FTTA, 21(35%) received TC, and 36(60%) received no trauma care. In the model adjusted for age, sex, race, and mechanism of injury (MOI), the odds of no trauma care for patients with serious trauma decreased with age, OR 0.96(0.93-0.99), arrival by private means, OR 2.1(1.2-3.8) and any MOI excluding stairs or being a pedestrian or cyclist struck, OR 4.0(2.3-6.9). Conclusions: Elderly trauma patients are undertriaged. Risk factors are private transport, and uncommon MOI. Increasing age is protective. Educational initiatives to lower the threshold of activating a trauma team for elderly patients may improve patient outcomes.


Topic: Trauma

T92 THE ACUTE CARE DIAGNOSTICS COLLABORATION (ACDC): PERFORMANCE ASSESSMENT OF CONTRAST ENHANCED ULTRASOUND COMPARED TO ABDOMINAL CT AND CONVENTIONAL ULTRASOUND IN AN EMERGENCY TRAUMA L. Cochon 1, M. Supino 2, A.A. Baez 2 1 Universitat De Barcelona, Barcelona, Spain, 2 Jackson Memorial Hospital, Miami, Usa Background: Objective was to evaluate the clinical diagnostic impact of Contrast Enhanced Ultrasound (CEDUS) compared to traditional Abdominal Computed Tomography (CT) and standard ultrasound (US) in a Bayesian Clinical Decision Scheme integrating the Emergency Trauma Score (EMTRAS). Methods: For the purposes of our model the EMTRAS was used as pretest probability and stratified as: Low Risk (0-3 points=10%), Moderate risk (4-6 points=42%) High risk (7-12 points=80%) based on mortality risk. Sensitivity (Se) and specificity (Sp) for US, CT and CEUS was obtained from pooled data and used to calculate negative (-) and Positive (+) likelihood ratios (LRs). EMTRAS percentage risk used as pretest probability and likelihood ratios were charted into the Bayesian nomogram to obtain posttest probabilities. Results: Data for Se, Sp, LR+ and LR- were obtained (table-1) for Ultrasound Se=45.7%, Sp=91.8%, LR+= 5.57, LR-=0.59 CEUS (Se 91.4%, Sp 100% LR+91, LR- 0.09) and CT (Se=94.8 %, SP=98.7%, LR+=73, LR-=0.05). Ultrasound LR+ model results showed Low Risk posttest probability of 38%, RDG of 28% and ADG of 280%, US Moderate risk Posttest of 80%, RDG of 38%, and ADG of 90.5%, whereas for High risk posttest of 96%, RDG of 16% and ADG of 20%. CEUS model results for LR+, yielded Low Risk Post Test Probability of 91% ADG of 81.0% and RDG of 810.0%, for Moderate risk Posttest probability of 99.0% ADG of 57.0% and RDG of 135.7%, whereas for High risk Posttest probability of 100.0%, RDG of 20.0%, and RDG of 25.0%. CT LR+ results were Low Risk Posttest of 89%, RDG of 79% and ADG of 790%, Moderate risk posttest of 98%, RDG of 56%, and ADG of 133.3%, whereas for High risk scores, posttest of 100%, RDG of 20% and ADG of 25%. Comparison of CT vs CEUS did not yield statistically significant differences for LR+, (P=0.9811) Conclusions: CEUS performed statistically similar to traditional abdominal CT in an EMTRAS Bayesian Clinical Decision Scheme. The greatest incremental gain was obtained for low pre-test positive Likelyhood Ratio groups, further validation of this model is needed as well as cost benefit analysis.

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