Day 1 :
Keynote Forum
John J. Kelly
Emergency Medicine Physician in Einstein Medical Center Philadelphia
Keynote: Electronic Trigger Tool Improves Early Identification, Management, and Survivorship of Emergency Department Severe Sepsis Patients
Time : .
Biography:
John J. Kelly is an Emergency Medicine Physician in Einstein Medical Center Philadelphia Department of Emergency Medicine 5501 Old York Road Philadelphia.
Abstract:
Background: Sepsis identification and timely management is critical, yet it can be difficult to efficiently assess the individual vital signs and lab values that indicate sepsis, as data may arrive at disparate times. We implemented an electronic sepsis tool as part of our EMR triggered by SIRS and sepsis organ dysfunction criteria. The purpose of our study is to determine if our electronic tool will result in increased identification of patients with sepsis, successful completion of the 3-hour bundle (blood cultures drawn, antibiotics given, 30cc/kg normal saline), and improved survivorship compared to previous bedside checklist.
Methods: We performed a prospective, observational study of patients in our ED between March 2016 and December 2017, before and after the implementation of an electronic screening tool in January 2016. In 2016, providers screened for evidence of SIRS/Sepsis and completed the 3-hour bundle using a bedside checklist tool. In January 2017, an electronic sepsis alert was implemented using: (Temp >38.4°C or < 36°C; HR >110; Resp Rate >28, WBC > 12,000/mm³, < 4,000/mm³, or > 10% bands), lactate level >2 mmol/l, Δ Creatinine ≥ 0.5, INR ≥ 2.0, and bilirubin >2.1 mg/dcl. The alert would prompt the use of an electronic checklist consisting of the 3-hour bundle requirements. Outcomes measured included: the number of patients identified use of the electronic sepsis tool, confirmed cases of sepsis, compliance with the 3-hour bundle, in addition to survivorship.
Results: Between March 2016 and December 2016, a bedside checklist identified 143 patients meeting SIRS criteria, and 137 patients were confirmed sepsis (96%). During this period, 63 (44%) had the 3-hour bundle completed. Between January 2017 and December 2017, the implementation of an electronic trigger tool identified 760 patients meeting sepsis alert criteria; 520 (68%) were confirmed cases of sepsis, and 401 (77%) were compliant with the 3-hour bundle. Prior to the implementation of the electronic trigger tool survivorship for severe sepsis and/or septic shock was 65.23%. Following the implementation of the trigger tool survivorship improved to 73.25%.
Conclusion: The implementation of an electronic screening tool at our institution substantially increased identification of patients with potential and confirmed sepsis, increased compliance in the 3-hour bundle, and survivorship. Based on our study, the electronic sepsis tool is a superior screening tool over a bedside tool and traditional reliance on providers’ awareness and identification of patients with possible sepsis
Keynote Forum
Au Kin Heng Constantine
Medical Director, Emergency Care Training, Hong Kong and Shenzhen
Keynote: Medical Coverage in Rugby 7, Nanjing 2014 Youth Olympics (YOG)
Time : .
Biography:
Au Kin Heng Constantine is an emergency specialist from Hong Kong who used to work at Queen Elizabeth Hospital, Hong Kong. Together with Dr. Gary Chu, Constantine founded the emergency room at the University of Hong Kong-Shenzhen Hospital, Shenzhen. Constantine is now the Medical Director of ECT-HK/SZ. In terms of experience in medical coverage, Constantine served in the Oxfam Trailwalker, Hong Kong, from 2002 to 2010, the Beijing 2008 Summer Olympic Games (Equestrian Event), the East Asian Games 2009 (Hong Kong), the 16th Asian Games (Guangzhou, 2010) and Rugby 7, Nanjing 2014 Youth Olympics (YOG).
Abstract:
Medical coverage at mass events, especially sports events, is a popular sub-branch of care among emergency physicians and emergency nurses in Hong Kong. There is often a misconception that sports event coverage depends on the expertise of orthopedic surgeons. As generalists, emergency physicians and emergency nurses can handle medical emergencies such as exercise-induced asthma, cardiac arrest and gastroenteritis outbreak, and traumas such as joint dislocation and wounds. In addition, emergency physicians and emergency nurses are familiar with both prehospital care service and emergency room service. The Hong Kong College of Emergency Medicine has established a Sports Medicine Subcommittee for more than ten years. In terms of work, medical coverage involves the pre-event stage, the event stage and the post-event stage. The pre-event stage involves recruitment of personnel, training and drills and preparation of equipment. The event stage involves skills beyond those found in the emergency room. The most important concept is to take care of the sick but not to overcrowd an already busy emergency room. The post-event stage involves evaluation and improvement of service. In terms of mentality, medical coverage involves consideration of clinical needs, logistics and politics (power and relationships). Clinical consideration is relatively easy for emergency physicians and emergency nurses. With respect to logistics and politics, things are not that straightforward. I would like to share my experience in the medical coverage of the Rugby 7, Nanjing 2014 Youth Olympics (YOG).
Keynote Forum
Mehrdad Soltani Delgosha
Emergency Medicine in Karaj Emam Ali hospital.
Keynote: The prognostic role of ECG in brain trauma injuries at emergency department
Time : .
Biography:
Mehrdad Soltani Delgosha is a Specialist of Emergency Medicine in Karaj Emam Ali hospital.
Abstract:
Background; Electrocardiograph (ECG) changes along with brain trauma injuries have been reported in many studies. The brain injuries accompanied with ECG abnormalities had more mortality rate. The aim of study is assessing the relationship between electrocardiograph (ECG) changes and GCS among patients with traumatic brain injury.
Methods; This cross-sectional study was performed on the brain trauma patients admitted to the Emergency Department (ED) of Imam Hossein Hospital, Tehran, Iran during January 2015 to February 2016. After stabilization of the patients, according to the inclusion criteria, GCS was determined and ECG was taken. This process was repeated three times with the interval of two hours, and the relation between GCS and ECG changes was determined and reported. After one year the Glasgow outcome score (GOS) was measured by telephone the patients and getting the history.
Results; After consideration of the inclusion criteria, 200 patients were assessed (168 males and 32 females). During the first ECG assessment, 42% of the patients had ST alteration, while in the second and third ECG assessments, 46% of the patients had ST changes, which was in relation to lower GCS and severity of the brain injury. According to the analysis, there was also a direct association between QT correction (QTc), QT dispersion (QTd (and GCS, GOS.
Conclusion; The ECG changes would be in association with the GCS and GOS, therefore, the evaluation of ECG parameters can be useful in determining the early outcome of patients.
Keynote Forum
Sofia Lokman Cavill
Northwest London Hospital NHS Trust, London, United Kingdom
Keynote: Do-Not-Attempt-Cardiopulmonary-Resuscitation practices in acute care for older adults – a qualitative study
Time : .
Biography:
Dr Sofia Cavill has completed her medical school training at Guy’s Kings & St Thomas’ School of Medicine, London where she achieved an honours in her MBBS degree. She then went on to complete her postgraduate studies at Kings College London where she obtained an MSc in Gerontology and Ageing in 2017, as well as a Post-graduate diploma (PGDip) in Clinical Dermatology from Queen Mary University London (QMUL) in 2015. She is currently a Senior Specialist Registrar in Acute and General Internal Medicine with a special interest in Frailty and Geriatrics in the Acute Medical Unit and is a member of the Royal College of Physicians (MRCP (UK)).
Abstract:
Background: Older adults are more likely to receive Do-not-attempt-cardiopulmonary-resuscitation (DNACRP) orders when they are admitted to hospitals compared to younger patients, yet little is known of the impact these orders have on the every day care of older patients.
Objectives: To understand staff perceptions on issues surrounding current DNACPR practices involving older adults in the acute setting, and elicit the influences of DNACPR decisions on care for older adults.
Design: A qualitative approach was used. Semi-structured interviews were conducted with 15 health professionals from multiple disciplines, working in geriatric medicine wards, in a district general National Health Service (NHS) hospital in the United Kingdom (UK).
Results: All participants supported the use of DNACPR orders in older adults but agree on the unintended repercussions to care beyond what the order stipulates. Four key themes have been identified surrounding DNACPR practices in older adults including: complex decision-making, challenging discussions, staff’s reflections of its impact on care and its benefits to geriatric medicine.
Conclusion: Hospital DNACPR practices in older adults can be variable with DNACPR decisions having unintended negative influences to care. Nevertheless, staff in geriatric medicine strongly support its use in older adults which staff felt led to a more holistic care with discussions often used as platforms for conversations on wider aspects of care. Perhaps incorporating DNACPR decisions into formal care plans, and increasing staff education on resuscitation policies may help standardize practices and remedy its negative influence on care.
- Neurological Emergencies
Session Introduction
Segundo Mesa Castillo
Psychiatric Hospital of Havana
Title: Direct evidence of viral infection and mitochondrial alterations in the brain of fetuses at high risk for schizophrenia
Biography:
Segundo Mesa Castillo. As Specialist in Neurology, he worked for 10 years in the Institute of Neurology of Havana, Cuba. He has worked in Electron Microscopic Studies on Schizophrenia for 32 years. He was awarded with the International Price of the Stanley Foundation Award Program and for the Professional Committee to work as a fellowship position in the Laboratory of the Central Nervous System Studies, National Institute of Neurological Diseases and Stroke under Dr. Joseph Gibbs for a period of 6 months, National Institute of Health, Bethesda, Maryland, Washington D.C. USA, June 5, 1990. At present he is member of the Scientific Board of the Psychiatric Hospital of Havana and give lectures to residents in psychiatry.
Abstract:
There is increasing evidences that favor the prenatal beginning of schizophrenia. These evidences point toward intra-uterine environmental factors that act specifically during the second pregnancy trimester producing a direct damage of the brain of the fetus. The current available technology doesn't allow observing what is happening at cellular level since the human brain is not exposed to a direct analysis in that stage of the life in subjects at high risk of developing schizophrenia. Methods. In 1977 we began a direct electron microscopic research of the brain of fetuses at high risk from schizophrenic mothers in order to finding differences at cellular level in relation to controls. Results. In these studies we have observed within the nuclei of neurons the presence of complete and incomplete viral particles that reacted in positive form with antibodies to herpes simplex hominis type I [HSV1] virus, and mitochondria alterations. Conclusion. The importance of these findings can have practical applications in the prevention of the illness keeping in mind its direct relation to the aetiology and physiopathology of schizophrenia. A study of the gametes or the amniotic fluid cells in women at risk of having a schizophrenic offspring is considered. Of being observed the same alterations that those observed previously in the cells of the brain of the studied foetuses, it would intend to these women in risk of having a schizophrenia descendant, previous information of the results, the voluntary medical interruption of the pregnancy or an early anti HSV1 viral treatment as preventive measure of the later development of the illness.
Mehrdad Soltani Delgosha
Emergency Medicine in Karaj Emam Ali hospital
Title: The prognostic role of ECG in brain trauma injuries at emergency department
Biography:
Mehrdad Soltani Delgosha is a Specialist of Emergency Medicine in Karaj Emam Ali hospital.
Abstract:
Background; Electrocardiograph (ECG) changes along with brain trauma injuries have been reported in many studies. The brain injuries accompanied with ECG abnormalities had more mortality rate. The aim of study is assessing the relationship between electrocardiograph (ECG) changes and GCS among patients with traumatic brain injury.
Methods; This cross-sectional study was performed on the brain trauma patients admitted to the Emergency Department (ED) of Imam Hossein Hospital, Tehran, Iran during January 2015 to February 2016. After stabilization of the patients, according to the inclusion criteria, GCS was determined and ECG was taken. This process was repeated three times with the interval of two hours, and the relation between GCS and ECG changes was determined and reported. After one year the Glasgow outcome score (GOS) was measured by telephone the patients and getting the history.
Results; After consideration of the inclusion criteria, 200 patients were assessed (168 males and 32 females). During the first ECG assessment, 42% of the patients had ST alteration, while in the second and third ECG assessments, 46% of the patients had ST changes, which was in relation to lower GCS and severity of the brain injury. According to the analysis, there was also a direct association between QT correction (QTc), QT dispersion (QTd (and GCS, GOS.
Conclusion; The ECG changes would be in association with the GCS and GOS, therefore, the evaluation of ECG parameters can be useful in determining the early outcome of patients.
Byoungseok, Yoon
Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
Title: The effect of ‘time target’ on overcrowding and clinical outcomes in ED : A systematic review and Meta-analysis
Biography:
Byoungseok Yoon has completed his bachelor’s degree at the age of 22 from Yonsei Unieversity, Bio-engineering department, Seoul, Korea and MD at the age of 26 years from Gachon University, School of Medicine. He is working in residency at Yonsei University, School of Medicine, Emergency Department, Severance hospital, Seoul, Korea.
Abstract:
Many studies have reported the effectiveness of ‘time target’ on reducing emergency department (ED) overcrowding and improving clinical quality. We investigated the effect of introducing ‘time target’ on ED overcrowding and clinical quality using meta-analysis.
We searched electronic databases including PubMed, Cochrane Library and Embase until June 2017. Search keywords were including time target, national emergency access target, four hour rule, and shorter stays in ED. Two investigators selected and reviewed articles according to predefined inclusion and exclusion criteria. The quality of articles were evaluated by RoBANS checklist. Data were abstracted by a predetermined criteria and performed meta-analysis using RevMan software.
Out of 721 articles, 16 studies were included in the final analysis. A meta-analysis of four studies on ED length of stay (LOS) showed that the mean EDLOS was reduced by 0.64 hours (95% CI, 0.34~0.94) since the introduction of the “time target”. Other studies also showed that EDLOS was reduced. There was no definite trend for hospital admission rate. A meta-analysis of nine studies on the clinical quality. Showed that the total odds ratio was 1.02 (95% CI, 0.74~1.32). Time taken until the visitation of a doctor and the ainitiation of treatment were both reduced. The rate of “left without being seen” was decreased.
EDLOS was reduced and no significant association was seen between mortality and the application of ‘time target’ since the introduction of ‘time target’. “Rate of revisiting”, “time to clinician”, “time to treatment” and “rate of left without being seen” was reduced.
Sanjeev Pratap
Department of Emergency Medicine Kauvery Hospital, Trichy, India.
Title: Phosphorous poisoning: An Indian experience
Biography:
Following my graduation from Christian Medical College, Vellore, India, I took up the challenge of working in a rural hospital with limited facilities. That experience inspired me to pursue a career in Emergency Medicine which was in its infancy in India at that time. After completing my Fellowship in Accident and Emergency Medicine from CMC Vellore, I was sponsored to train in the NHS by the Royal College of Emergency Medicine, UK. After completing my Fellowship, I returned to India and took over as Head of Department of Emergency Medicine at Kauvery Hospital, Trichy, India.
Abstract:
Statement of the Problem:
Ratol paste is an easily available cheap rodenticide which is contains 3% yellow phosphorus. It’s easy availability over the counter has led to its use for deliberate self-harm. Accidental poisoning in children have also been reported. It is a general protoplasmic poison with high mortality rate. No specific antidote is available and treatment is mainly supportive. There is paucity of published literature on its management and treatment varies from centre to centre.
Methodology:
A retrospective audit of patients presenting to a tertiary hospital with history of Ratol paste poisoning was done. The laboratory investigations and treatment given were analysed to derive treatment recommendations.
Findings:
The leading cause of death is due to fulminant hepatic failure. Multi-system involvement is common. Presentation to hospital is often delayed due to early asymptomatic phase. Early initiation of supportive treatment helps in preventing hepatic encephalopathy and reduces mortality and duration of hospitalisation.
Conclusions:
In the absence of a specific antidote, early initiation of supportive management and close clinical monitoring is the way forward in its treatment.
Hemanshu K Warrier
Max Hospital, India
Title: Chest Ultrasound : More sensitive and specific than Chest X-ray in diagnosing pneumonia
Biography:
Dr. Hemanshu K Warrier is an MBBS Graduate from P.R China. He has also completed the Membership of Royal College of Emergency Medicine, RCEM, UK & Masters in Emergency Medicine from The George Washington University, USA.He has rich experience of over 7 years to his credit with reputed Institutes such as Moolchand Hospital, Lok nayak Hospital in New Delhi and is currently heading the department of emergency at Max Hospital, Gurgaon,
Abstract:
Statement of the Problem: Community-acquired pneumonia is a common and serious illness worldwide. It is the main cause of mortality, which particularly targets young patients, elderly patients and those with co morbid conditions. Most patients with pneumonia are managed in the outpatient setting but patient admitted in the hospital due to pneumonia have a high mortality. Chest ultrasound (CUS) is being increasingly utilized in emergency and critical settings. Aim of this study was to compare the sensitivity and specificity of chest ultrasound and chest x-ray. Methodology & Theoretical Orientation: This was a prospective clinical study. We aimed for a sample size of 96 patients. Patients were enrolled every alternate day to randomise the study. Informed written consent was taken from all enrolled patients or their immediate relatives. The result of chest computerized tomography scan was taken as gold standard. The duration of study was 6 months(from September’16 to February’16). 100 patients were included in the study. Findings: Chest Ultrasound was found to have a higher sensitivity of 0.96 (95% CI 0.85 – 0.99) compared to x-ray which had a sensitivity of 0.57 (95% CI 0.42 – 0.70). Also a higher specificity was found in Chest Ultrasound compared to chest x-ray, 0.95 (95% CI 0.84-0.99) vs 0.85 (95% CI 0.71-0.93). Chest ultrasound was found to have a perfect agreement with the final diagnosis i.e k=0.91 compared to a moderate agreement between chest x-ray and the final diagnosis i.e k=0.42 . The two tailed p value was 0.02 and by conventional criteria, this difference was found to be statistically significant. Conclusion & Significance: We concluded that chest ultrasound is more sensitive and specific the chest x-ray in diagnosing patients with pneumonia. Chest ultrasound is easily available, less expensive, faster and gives off no radiation when compared to chest x-ray. We recommend that with adequate training chest ultrasound should be preferred over chest x-ray for patients in a critical care setting.
- Emergency and Acute Care Medicine
Session Introduction
Mehrdad Soltani Delgosha
Emergency Medicine in Karaj Emam Ali hospital.
Title: The prognostic role of ECG in brain trauma injuries at emergency department
Biography:
Mehrdad Soltani Delgosha is a Specialist of Emergency Medicine in Karaj Emam Ali hospital.
Abstract:
Background; Electrocardiograph (ECG) changes along with brain trauma injuries have been reported in many studies. The brain injuries accompanied with ECG abnormalities had more mortality rate. The aim of study is assessing the relationship between electrocardiograph (ECG) changes and GCS among patients with traumatic brain injury.
Methods; This cross-sectional study was performed on the brain trauma patients admitted to the Emergency Department (ED) of Imam Hossein Hospital, Tehran, Iran during January 2015 to February 2016. After stabilization of the patients, according to the inclusion criteria, GCS was determined and ECG was taken. This process was repeated three times with the interval of two hours, and the relation between GCS and ECG changes was determined and reported. After one year the Glasgow outcome score (GOS) was measured by telephone the patients and getting the history.
Results; After consideration of the inclusion criteria, 200 patients were assessed (168 males and 32 females). During the first ECG assessment, 42% of the patients had ST alteration, while in the second and third ECG assessments, 46% of the patients had ST changes, which was in relation to lower GCS and severity of the brain injury. According to the analysis, there was also a direct association between QT correction (QTc), QT dispersion (QTd (and GCS, GOS.
Conclusion; The ECG changes would be in association with the GCS and GOS, therefore, the evaluation of ECG parameters can be useful in determining the early outcome of patients.
- Toxicological Emergencies
Session Introduction
Sanjeev Pratap
Department of Emergency Medicine Kauvery Hospital, Trichy, India.
Title: Phosphorous poisoning: An Indian experience
Biography:
Following my graduation from Christian Medical College, Vellore, India, I took up the challenge of working in a rural hospital with limited facilities. That experience inspired me to pursue a career in Emergency Medicine which was in its infancy in India at that time. After completing my Fellowship in Accident and Emergency Medicine from CMC Vellore, I was sponsored to train in the NHS by the Royal College of Emergency Medicine, UK. After completing my Fellowship, I returned to India and took over as Head of Department of Emergency Medicine at Kauvery Hospital, Trichy, India.
Abstract:
Statement of the Problem: Ratol paste is an easily available cheap rodenticide which is contains 3% yellow phosphorus. It’s easy availability over the counter has led to its use for deliberate self-harm. Accidental poisoning in children have also been reported. It is a general protoplasmic poison with high mortality rate. No specific antidote is available and treatment is mainly supportive. There is paucity of published literature on its management and treatment varies from centre to centre.
Methodology: A retrospective audit of patients presenting to a tertiary hospital with history of Ratol paste poisoning was done. The laboratory investigations and treatment given were analysed to derive treatment recommendations.
Findings: The leading cause of death is due to fulminant hepatic failure. Multi-system involvement is common. Presentation to hospital is often delayed due to early asymptomatic phase. Early initiation of supportive treatment helps in preventing hepatic encephalopathy and reduces mortality and duration of hospitalisation.
Conclusions: In the absence of a specific antidote, early initiation of supportive management and close clinical monitoring is the way forward in its treatment.
- Emergency Imaging
Session Introduction
Hemanshu K Warrier
Max Hospital, India
Title: Chest Ultrasound : More sensitive and specific than Chest X-ray in diagnosing pneumonia
Biography:
Dr. Hemanshu K Warrier is an MBBS Graduate from P.R China. He has also completed the Membership of Royal College of Emergency Medicine, RCEM, UK & Masters in Emergency Medicine from The George Washington University, USA.He has rich experience of over 7 years to his credit with reputed Institutes such as Moolchand Hospital, Lok nayak Hospital in New Delhi and is currently heading the department of emergency at Max Hospital, Gurgaon.
Abstract:
Statement of the Problem: Community-acquired pneumonia is a common and serious illness worldwide. It is the main cause of mortality, which particularly targets young patients, elderly patients and those with co morbid conditions. Most patients with pneumonia are managed in the outpatient setting but patient admitted in the hospital due to pneumonia have a high mortality. Chest ultrasound (CUS) is being increasingly utilized in emergency and critical settings. Aim of this study was to compare the sensitivity and specificity of chest ultrasound and chest x-ray. Methodology & Theoretical Orientation: This was a prospective clinical study. We aimed for a sample size of 96 patients. Patients were enrolled every alternate day to randomise the study. Informed written consent was taken from all enrolled patients or their immediate relatives. The result of chest computerized tomography scan was taken as gold standard. The duration of study was 6 months(from September’16 to February’16). 100 patients were included in the study. Findings: Chest Ultrasound was found to have a higher sensitivity of 0.96 (95% CI 0.85 – 0.99) compared to x-ray which had a sensitivity of 0.57 (95% CI 0.42 – 0.70). Also a higher specificity was found in Chest Ultrasound compared to chest x-ray, 0.95 (95% CI 0.84-0.99) vs 0.85 (95% CI 0.71-0.93). Chest ultrasound was found to have a perfect agreement with the final diagnosis i.e k=0.91 compared to a moderate agreement between chest x-ray and the final diagnosis i.e k=0.42 . The two tailed p value was 0.02 and by conventional criteria, this difference was found to be statistically significant. Conclusion & Significance: We concluded that chest ultrasound is more sensitive and specific the chest x-ray in diagnosing patients with pneumonia. Chest ultrasound is easily available, less expensive, faster and gives off no radiation when compared to chest x-ray. We recommend that with adequate training chest ultrasound should be preferred over chest x-ray for patients in a critical care setting.